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By Victoria Espinoza

For Huntington residents, going to the emergency room just got a little less painful.

Huntington Hospital unveiled its new $53 million emergency department Dec. 13, which is capable of handling 64,000 patient visits per year. The department starts treating patients Jan. 3.

The new ED is more than double the size of the old. In total it’s 28,000 square feet, with 47 treatment spots and 12 private waiting stations where patients receive results. The facility was designed with a mission to significantly improve patient care.

“Efficiency is the idea behind this whole department,” Michael Recupero, director of patient care services in the ED said at the opening.

An entirely new system was put in place for dealing with patients from the moment they enter the building, to ensure their stay is as short and effective as possible.

Michael Recupero shows how the lighting system will works. Photo by Victoria Espinoza.
Michael Recupero shows how the lighting system will works. Photo by Victoria Espinoza.

Under the new method, patients are immediately seen by a nurse to determine if they need instant treatment in the main ED or treatment in one of the four intake rooms. The intake rooms are what Recupero calls “the game changers.”

“Traditionally you’d come in and be seen by a triage nurse, then you’d sit and wait in the waiting room for an undisclosed period of time, and then be brought to a room where you would wait some more,” he said. “Finally you’re seen by a doctor. But with this model, you’re seen by a nurse and then immediately placed in one of the intake rooms where a doctor will see you.”

The intake rooms feature a brand new lighting system that helps staff learn what step of care each patient in a room is at. The system, created by the University of Colorado, runs similar to a traffic light, but with four colors. If the light above an intake room is red, the patient is in the room and needs their vitals checked. If the red light is flashing that means vital check is complete. When the light is yellow, a provider is in the room and when flashing yellow, the provider completed their exam and the patient is ready to move. A green light indicates the room needs cleaning and flashing green means the room is clean and ready for the next patient. When flashing blue, the patient needs an EKG test done.

“It’s really amazing,” Recupero said. “With visual queues, we don’t even have to have a conversation. [A doctor] can see what’s happening in each room without anybody telling [him or her].”

On the wall of every intake room is a whip-off board with a checklist of certain tests a doctor may order.

“Within the first five minutes you’re getting orders done,” Recupero said.

One of the private waiting results stations. Photo by Victoria Espinoza.
One of the private waiting results stations. Photo by Victoria Espinoza.

He explained the ED is spilt into half of an emergency department and half of an urgent care center. Patients with less serious illnesses are taken to “super track” spaces where they quickly get antibiotics, or an X-ray, and are then sent to one of the 12 results waiting areas, which are private cubicles with lounging chairs and floor to ceiling windows.

The main part of the department will be divided into an east wing and a west wing, with a nurse’s assistant, doctor and three nurses on each side. Another doctor is designated to the trauma area, which deals exclusively with patients in extreme conditions.

Recupero said other standout features in the new ED are a pediatric wing that can treat up to nine children at once, a radiology section exclusively for the ED — meaning no other departments are allowed to take time away from ED patients to use the machine — a dedicated Ob/Gyn area and a behavioral health area.

Michael J. Dowling, the CEO of NorthWell Health, of which the hospital is a member, said the hospital plans to apply for level three trauma designation in 2017.

“It’s a new beginning here,” he said at the opening. “This is just a wonderful example of what you can do when a lot of people put their efforts together and have the communities and patients interests forefront.”

Leonardo Huertas, chairman of emergency services for the hospital, said the new treatment style at Huntington Hospital will be a win for patients.

“The emergency department leadership has envisioned a way to best care and manage our patients,” Huertas said. “The new ED was designed with an eye for innovation. We wanted to change the traditional sequential process which is riddled with bottlenecks and delays.”

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File photo from WMHO

As part of the Young at Heart Alzheimer’s & Dementia Program, St. George Productions will present “The I Love Lucy Story: Birth of the Modern Day Sitcom” on Wednesday, Dec. 21 from 1 to 3 p.m. at the Ward Melville Heritage Organization’s Educational & Cultural Center, 97P Main St., Stony Brook located in the rear of the Village Center.

The program will include a lecture and a video led by a facilitator who specializes in geriatrics and a certified nurse will be present. Cost is $20 for guest and caregiver; light refreshments will be served. Sponsors include Stony Brook Medicine, Stony Brook University, CVS Health, Bristal Assisted Living, Aging Flower and Village Chemists of Setauket. Reservations are required by calling 631-751-2244 or by visiting www.stonybrookvillage.com.

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Putting one foot in front of the other never looked so inspiring.

A freak sledding accident in Vermont in 2009 left Greg Durso, 31, of Stony Brook unable to use his lower body from his stomach muscles down. With the help of St. Charles Hospital’s rehabilitation center, he stood and walked across a room Dec. 13 in front of his family and dozens of hospital personnel for the first time since his accident.

Greg Durso, who is paraplegic, walks at St. Charles Hospital Dec. 13 with help from an Indego exoskeleton. Photo by Alex Petroski
Greg Durso, who is paraplegic, walks at St. Charles Hospital Dec. 13 with help from an Indego exoskeleton. Photo by Alex Petroski

Durso was aided by a clinical trial product called the Indego exoskeleton, which is a wearable robotic frame. St. Charles is one of nine hospitals in the United States conducting the clinical trial, and the only one on Long Island. Durso is the first patient at the hospital to take the technology for a spin.

“It’s just an incredible feeling to be up there and be walking again — putting weight on your legs,” Durso said after his groundbreaking stroll. “Each step is kind of like a leap of faith … a month ago I probably couldn’t have told you I’d be here today, so when I heard about this, I was so happy to have the opportunity to do this.”

Indego is the second FDA-approved exoskeleton device used for lower limbs. The device weighs about 26 pounds, and requires no backpack or external wires, as other similar devices have in the past. Currently the machine is operated by Durso’s chest muscles, but future incarnations of the device will allow electrical stimulation in the muscles so that a patient’s own legs will make the machine work, according to St. Charles Physical Medicine and Rehabilitation Medical Director Jennifer Semel. The FDA gave the machine clearance in March.

“The future is really limitless,” Semel said in an interview. “It’s really exciting to see people who haven’t been able to stand up in several years not only to be at the same height as their peers, but to be able to walk. It’s really uplifting.”

Semel said Durso has been using the device for about a month, and last week required a walker in addition to the exoskeleton to get around. He progressed to crutches for his Dec. 13 walk. Semel said the plan is for Durso to continue using the device for several months to gain a better understanding of the health benefits and the impact it has on a patient’s gait.

“I think I was a little skeptical because you realize people always tell you there’s going to be advances, there’s going to be this and that in the future,” Durso said. “But when you see this — I actually get up, I actually walk, I gave my sister a hug for the first time in eight years face to face — it’s pretty emotional and empowering, and it’s just exciting to see where the future is going to go with this technology.”

It was an emotional day for the members of the Durso family in attendance. Durso’s older sister, Jessica Giovan, fought back tears trying to describe seeing her brother walk again for the first time in eight years.

‘It’s just an incredible feeling to be up there and be walking again — putting weight on your legs … each step is kind of like a leap of faith.’

— Greg Durso

“I just saw him look so proud and happy,” she said. “He works so hard at everything he does, so to see him put one foot in front of the other, literally, was just unbelievable … the person you see now is the person he has always been. He has not, for one second, wavered in his personality since the accident. In fact, he has only increased his perseverance and his humor, and he lives everyday to make everyone around him feel like it’s okay.”

His dad, Richard Durso, said he couldn’t have imagined he’d be sitting where he was, watching his son walk, when he heard the news of the accident eight years ago. He credited his son’s positive attitude for keeping him on track. His mom, Jean Durso, called what she saw “unbelievable.”

Durso has competed in Iron Man races and marathons in his life — the former both pre and post accident — and said he hopes to be able to regain some of that lifestyle in the future.

“I love to do athletic things. I mean, it could be anything. I just want to be out there, have fun and live my life the way I want to do it,” he said. “For me that’s enough.”

The Indego devices cost about $80,000 each.

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Dementia symptoms include impairments in thinking, communicating, and memory. Stock photo

By David Dunaief, M.D.

When you hear the word dementia, what is your reaction? Is it fear, anxiety or an association with a family member or friend? The majority of dementia is Alzheimer’s, which comprises about 60 to 80 percent of dementia incidence (1). There is also vascular dementia and Parkinson’s-induced dementia, as well as others. Then there are precursors to dementia, such as mild cognitive impairment, that have a high risk of leading to this disorder.

Dr. David Dunaief
Dr. David Dunaief

Encouraging data

There is good news! A recent study, the Health and Retirement Study (HRS), a prospective (forward-looking) observational study, suggested that dementia incidence has declined (2). This was a big surprise, since predictions were for significant growth. Dementia declined by 24 percent from 2000 to 2012. There were over 10,000 participants 65 years old and older at both the 2000 and 2012 comparison surveys. There was also a decrease in mild cognitive impairment that was statistically significant. However, the reason for the decline is not clear. The researchers can only point to more education as the predominant factor. They surmise that more treatment and prevention of risk factors for cardiovascular disease may have played a role.

So how is dementia defined?

According to the American Psychiatric Association’s DSM-5 (“Diagnostic and Statistical Manual of Mental Disorders,” Fifth Edition), dementia is a decline in cognition involving one or more cognitive domains. In addition to memory, these domains can include learning, executive function, language, social cognition, perceptual-motor and complex attention (3).

What can be done to further reduce dementia’s prevalence?

Knowing some of the factors that may increase and decrease dementia risk is a good start. Those that raise the risk of dementia include higher blood pressure (hypertension), higher heart rate, depression, calcium supplements in stroke patients and prostate cancer treatment with androgen deprivation therapy (ADT).

What abates risk?

This includes lifestyle modifications with diet and exercise. A diet shown to be effective in prevention and treatment of dementia is referred to as the MIND (Mediterranean–DASH intervention for neurodegenerative delay) diet, which is a combination of the Mediterranean-type and Dietary Approaches to Stop Hypertension (DASH) diets. Surprisingly, there is also a cocktail of supplements that may have beneficial effects.

How does medication to treat dementia, specifically Alzheimer’s, fit into this paradigm?

It is not that I was ignoring this issue. Our present medications are not effective enough to slow the disease progression by clinically significant outcomes. But what about the medications in the pipeline? The two hottest areas are focusing on tau tangles and amyloid plaques. Recently, drugs targeting tau tangles from TauRx Therapeutics and amyloid plaques from Eli Lilly failed to achieve their primary clinical end points during trials. There may be hope for these different classes of drugs, but don’t hold your breath. The plaques and tangles may be signs of Alzheimer’s dementia rather than causes. Several experts in the field are not surprised by the results.

Let’s look at the evidence.

The quandary that is blood pressure

If ever you needed a reason to control high blood pressure, the fact that it may contribute to dementia should be a motivator. In the recent Framingham Heart Study, Offspring Cohort, a prospective observational study, results showed that high blood pressure in midlife — looking specifically at systolic (top number) blood pressure (SBP) — increased the risk for dementia by 70 percent (4). Even worse, those who were controlled with blood pressure medications in midlife also had significant risk for dementia.

There were 1,440 patients involved in the study over a 16-year period with an examination every four years. Then, those patients who were free of dementia were examined for another eight years. Results showed a 107-patient incidence of dementia, of which half were on blood pressure medications. And when there was a rapid drop in SBP from midlife to late in life, there was a 62 percent increased risk, to boot. Thus, the moral of the story is that lifestyle changes to either prevent high blood pressure or to get off medications may be the most appropriate route to reducing this risk factor.

Prostate cancer inflates dementia risk

Actually, the title above does not do justice to prostate cancer. It is not the prostate cancer, but the treatment for prostate cancer, androgen deprivation therapy (ADT), that may increase the risk of dementia by greater than twofold (5). Treatment duration played a role: those who had a year or more of ADT were at higher risk. ADT suppresses production of the male hormones testosterone and dihydrotestosterone. The study involved over 9,000 men with a 3.4-year mean duration; however, it was a retrospective (backward-looking) analysis and requires a more rigorous prospective study design to confirm the results. Thus, though the results are only suggestive, they are intriguing.

Calcium supplements — not so good

In terms of dementia, the Prospective Population Study of Women and H70 Birth Cohort trial has shown that calcium supplements, especially when given to patients who have a history of stroke, increase the risk of dementia by greater than sixfold (6). Those who had white matter lesions in the brain also had an increased risk. The population involved 700 elderly women, with 98 given calcium supplements. How do we reduce this risk? Easy: Don’t give calcium supplements to those who have had a stroke. This brings more controversy to taking calcium supplements, especially for women. You are better off getting calcium from foods, especially plant-based foods.

The MIND diet to the rescue

In a recent study, results showed that the MIND diet reduced the risk of Alzheimer’s dementia by 53 percent in those who were adherent. It also showed a greater than one-third reduction in dementia risk in those who only partially followed the diet (7). There were over 900 participants between the ages of 58 and 98 in the study, which had a 4.5-year duration. When we talk about lifestyle modifications, the problem is that sometimes patients find diets too difficult to follow. The MIND diet was ranked one of the easiest to follow. It involves a very modest amount of predominantly plant-based foods, such as two servings of vegetables daily — one green leafy. If that is not enough, the MIND diet has shown the ability to slow the progression of cognitive decline in those individuals who do not have full-blown dementia (8).

Supplement cocktail

To whet your appetite, a recent study involving transgenic growth hormone mice (which have accelerated aging and demonstrate cognitive decline) showed a cocktail of supplements helped decrease the risk of brain deterioration and function usually seen with aging and in severe Alzheimer’s dementia (9). The cocktail contained vitamins, minerals and nutraceuticals, such as bioflavonoids, garlic, cod liver oil, beta carotene, green tea extract and flax seed. Each compound by itself is not considered to be significant, but taken together they seem to have beneficial effects for dementia prevention in mice.

The reasons for dementia may involve mitochondrial dysfunction, oxidative stress and inflammation that are potentially being modified by these supplements. Hopefully, there will be more to come on this subject. It comes down to the fact that lifestyle modifications, whether in terms of reducing risk or slowing the progression of the disease, trump current medications and those furthest along in the drug pipeline. There may also be a role for a supplement cocktail, though it’s too early to tell. The MIND diet has shown some impressive results that suggest powerful effects.

References: (1) uptodate.com. (2) JAMA Intern Med. online Nov. 21, 2016. (3) uptodate.com. (4) American Neurological Association (ANA) 2016 Annual Meeting. Abstract M148. (5) JAMA Oncol. online Oct. 13, 2016. (6) Neurology. online Aug. 17, 2016. (7) Alzheimers Dement. 2015;11:1007-1014. (8) Alzheimers Dement. 2015;11:1015-1022. (9) Environ Mol Mutagen. online May 20, 2016.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Rheumatoid arthritis causes pain, stiffness and swelling of the joints.

By David Dunaief, M.D.

Rheumatoid arthritis (RA) is one of many autoimmune diseases where the body’s immune system begins to attack the body’s own tissue. RA results in systemic (throughout the body) inflammation, which initially affects the synovium (lining) of the small joints in both the hand and the feet bilaterally, as well as the wrists and ankles (1). It causes pain, stiffness and swelling of the joints.

RA, like most autoimmune diseases, affects significantly more women than men and can be incredibly debilitating (2). It affects approximately 1 percent of the U.S. population (3). Fortunately, treatments have helped to significantly improve sufferers’ quality of life.

Dr. David Dunaief
Dr. David Dunaief

RA may be treated initially with acetaminophen and NSAIDs (such as ibuprofen), depending on its severity. To help stop progression and preserve the joints, disease-modifying anti-rheumatic drugs (known as DMARDs) may be used. They are considered the gold standard of treatment for RA and include methotrexate, which has been around the longest and is a first-line therapy; plaquenil (hydroxycholorquine); and TNF inhibitors, such as Enbrel (etanercept), Humira (adalimumab) and Remicade (infliximab).

DMARDs work by reducing inflammation and acting as immunosuppressives, basically tamping down or suppressing the immune system. These drugs have helped RA patients improve their quality of life, preserving joint integrity and causing RA to go into remission. The goal of these drugs is to reduce synovitis, or inflammation in the joints, helping to lessen joint damage. They can be quite effective. Unfortunately, compliance can be an issue. In addition, corticosteroids can be used to suppress inflammation.

The yin and yang of medications

In a meta-analysis (a group of 28 studies), the results showed that DMARDs reduced the risk of cardiovascular events by up to 30 percent, while NSAIDs and corticosteroids increased the risk (4). However, oral steroids have been found to increase the risk of heart complications, approximately a 50 percent rise in risk. This may be one reason rheumatologists encourage their RA patients to discontinue oral steroid treatments as quickly as possible.

In an observational study, the results reaffirmed that corticosteroids increased the risk of a heart attack in RA patients, this time by 68 percent (5). The study involved over 8,000 patients with a follow-up of nine years. Interestingly, there was a dose-response curve. In other words, the results also showed that for every 5-mg increase in dosage, there was a corresponding 14 percent increase in heart attack risk.

The downside of using immunosuppressive drugs

Unfortunately, DMARDs have significant adverse effects. In 2011, the FDA found there were 100 cases of Listeria and Legionella pneumonia infections associated with these drugs. Therefore, a black-box warning was placed on all TNF inhibitors cautioning about serious or life-threatening side effects, such as opportunistic infections — more likely in combination with other immunosuppressives — and malignancy. The median duration that patients were on the drugs when they experienced infections was about 10 months. However, most patients were also on methotrexate and steroids at the time of infection.

Anecdotally, I had a patient who had previously developed pneumonia twice, multiple basal-cell carcinomas and one episode of melanoma. These were all attributed to use of a TNF inhibitor.

Skin cancer risk

In 2009, the FDA warned that there is an increased risk of cancer after about 30 months of treatment, especially with TNF inhibitors. A 2011 meta-analysis (a group of 28 studies) found that TNF inhibitors may increase the risk of cancers, including skin cancers (6). In four of the studies, there was a 45 percent elevated risk of developing skin cancer other than melanoma. However, in data pooled from two of the studies, there was a 79 percent greater chance of developing melanoma. All the studies in this analysis were observational studies, and the absolute risk of developing cancer is small. The good news is that this analysis did not appear to show increased risk of lymphoma.

Cardiovascular disease

Patients with RA are at a threefold increased risk of developing coronary artery disease, compared to the general population (7). Those RA patients who stopped taking statins for high cholesterol and/or heart disease had a 60 percent increased risk of cardiovascular mortality and a 79 percent increased risk of all-cause death after three months (8). Though statins have their pitfalls, they can be potentially lifesaving in the right context. Don’t discontinue statins before consulting your physician.

Additional complications from RA

RA can also affect organs and the surrounding tissue. Thus, complications from RA include heart disease, stroke, atrial fibrillation, chronic obstructive pulmonary disease, fracture risk, as well as uveitis and scleritis (inflammatory disorders of the eye).

Nonpharmacologic approaches

Exercise and fish oil have shown reductions in symptomatology and joint inflammation. In a meta-analysis (a group of 17 trials), omega-3 fish oil reduced joint pain intensity, as reported by patients, minutes of morning stiffness, number of painful joints and NSAID use significantly (9). The dose was at least 2.7 g of EPA plus DHA in the omega-3 fish oil and took at least 12 weeks of treatment to see a benefit. Exercise is also important to relieve joint pain and stiffness. In a meta-analysis of 14 studies, there was a 69 percent reduction in pain with aerobic exercise (10). Understandably, however, a study found that 42 percent of RA patients don’t work out at the recommended minimum of 10 minutes of moderate exercise daily (11). The reasons were that half were either not motivated or believed that exercise had no benefit.

Prevention

In the Iowa Women’s Health Study, results showed that supplemental vitamin D decreased the risk of RA by 34 percent (12). This study involved almost 30,000 women followed over an 11-year period.

The best way to treat an autoimmune disease like rheumatoid arthritis is to prevent it with an anti-inflammatory diet, exercise and omega-3 fish oil. Barring that, however, it is encouraging that DMARD treatments may be effective at half the dose once the disease has been suppressed significantly. Therefore, a low-dose pharmacological approach coupled with nonpharmacological lifestyle adjustments may produce the best outcomes with the fewest adverse reactions.

References: (1) www.ncbi.nlm.nih.gov. (2) www.mayoclinic.com. (3) Arthritis Rheum. 2008;58:15-25. (4) Ann Rheum Dis 2015;74(3):480-489. (5) Rheumatology 2013;52:68-75. (6) Ann Rheum Dis. 2011 Nov;70(11):1895-1904. (7) Ann Rheum Dis. 2007;66(1):70. (8) Arthritis Care Res [Hoboken]. 2012 Mar 29. (9) Pain. 2007 May;129(1-2):210-223. (10) Br J Sports Med. 2011;45(12):1008-1009. (11) Arthritis Care Res [Hoboken]. 2012 Apr;64(4):488-493. (12) Arthritis Rheum. 2004 Jan;50(1):72-77.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Consuming white fleshy fruits such as pears may decrease ischemic stroke risk by as much as 52 percent.

By David Dunaief, M.D.

Stroke remains one of the top five causes of mortality and morbidity in the United States (1). As a result, we have a wealth of studies that inform us on issues ranging from identifying chronic diseases that increase stroke risk to examining the roles of medications and lifestyle in managing risk.

Impact of chronic diseases

There are several studies that show chronic diseases — such as age-related macular degeneration, rheumatoid arthritis and migraine with aura — increase the risk for stroke. Therefore, patients with these diseases must be monitored.

In the ARIC study, stroke risk was approximately 50 percent greater in patients who had AMD compared to those who did not — 7.6 percent versus 4.9 percent, respectively (2). This increase was seen in both types of stroke: ischemic (complete blockage of blood flow in the brain) and hemorrhagic (bleeding in the brain). The risk was greater for hemorrhagic stroke than for ischemic, 2.64 vs. 1.42 times increased risk.

However, there was a smaller overall number of hemorrhagic strokes, which may have skewed the results. This was a 13-year observational study involving 591 patients, ages 45 to 64, who were diagnosed with AMD. Most patients had early AMD. If you have AMD, you should be followed closely by both an ophthalmologist and a primary care physician.

Rheumatoid arthritis (RA)

In an observational study, patients with RA had a 30 percent increased risk of stroke, and those under 50 years old with RA had a threefold elevated risk (3). This study involved 18,247 patients followed for a 13-year period. There was also a 40 percent increased risk of atrial fibrillation (AF), a type of arrhythmia or irregular heartbeat. Generally, AF causes increased stroke risk; however, the authors were not sure if AF contributed to the increased risk of stroke seen here. They suggested checking regularly for AF in RA patients, and they surmised that inflammation may be an underlying cause for the higher number of stroke events.

Migraine with aura

In the Women’s Health Study, an observational study, the risk of stroke increased twofold in women who had migraine with aura (4). Only about 20 percent of migraines include an aura, and the incidence of stroke in this population is still rather rare, so put this in context (5).

Medications with beneficial effects

Two medications have shown positive impacts on reducing stroke risk: statins and valsartan. Statins are used to lower cholesterol and inflammation, and valsartan is used to treat high blood pressure. Statins do have side effects, such as increased risks of diabetes, cognitive impairment and myopathy (muscle pain). However, used in the right setting, statins are very effective. In one study, there was reduced mortality from stroke in patients who were on statins at the time of the event (6). Patients who were on a statin to treat high cholesterol had an almost sixfold reduction in mortality, compared to those with high cholesterol who were not on therapy.

There was also significant mortality reduction in those on a statin without high cholesterol, but with diabetes or heart disease. The authors surmise that this result might be from an anti-inflammatory effect of the statins. Of course, if you have side effects, you should contact your physician immediately.

Valsartan is an angiotensin II receptor blocker that works on the kidney to reduce blood pressure. However, in the post-hoc analysis (looking back at a completed trial) of the Kyoto Heart Study data, valsartan used as an add-on to other blood pressure medications showed a significant reduction, 41 percent, in the risk of stroke and other cardiovascular events for patients who have coronary artery disease (7).

It is important to recognize that chronic disease increases stroke risk. High blood pressure and high cholesterol are two of the most significant risk factors. Fortunately, statins can reduce cholesterol, and valsartan may be a valuable add-on to prevent stroke in those patients with coronary artery disease.

Medication combination: negative impact

There are two anti-platelet medications that are sometimes given together in the hopes of reducing stroke recurrence — aspirin and Plavix (clopidogrel). The assumption is that these medications together will work better than either alone. However, in a randomized controlled trial, the gold standard of studies, this combination not only didn’t demonstrate efficacy improvement but significantly increased the risk of major bleed and death (8, 9).

Major bleeding risk was 2.1 percent with the combination versus 1.1 percent with aspirin alone, an almost twofold increase. In addition, there was a 50 percent increased risk of all-cause death with the combination, compared to aspirin alone. Patients were given 325 mg of aspirin and either a placebo or 75 mg of Plavix. The study was halted due to these deleterious effects. The American Heart Association recommends monotherapy for the prevention of recurrent stroke. If you are on this combination of drugs, please consult your physician.

Aspirin: low dose vs. high dose

Greater hemorrhagic (bleed) risk is also a concern with daily aspirin regimens greater than 81 mg, which is the equivalent of a single baby aspirin. Aspirin’s effects are cumulative; therefore, a lower dose is better over the long term. Even 100 mg taken every other day was shown to be effective in trials. There are about 50 million patients who take aspirin chronically in the United States. If these patients all took 325 mg of aspirin per day — an adult dose — it would result in 900,000 major bleeding events per year (10).

Lifestyle modifications

A prospective study of 20,000 participants showed that consuming white fleshy fruits — apples, pears, bananas, etc. — and vegetables — cauliflower, mushrooms, etc. — decreased ischemic stroke risk by 52 percent (11). Additionally, the Nurses’ Health Study showed that foods with flavanones, found mainly in citrus fruits, decreased the risk of ischemic stroke by 19 percent (12). The authors suggest that the reasons for the reduction may have to do with the ability of flavanones to reduce inflammation and/or improve blood vessel function. I mention both of these trials together because of the importance of fruits in prevention of ischemic (clot-based) stroke.

Fiber’s important role

Fiber also plays a key role in reducing the risk of a hemorrhagic stroke. In a study involving over 78,000 women, those who consumed the most fiber had a total stroke risk reduction of 34 percent and a 49 percent risk reduction in hemorrhagic stroke. The type of fiber used in this study was cereal fiber, or fiber from whole grains.

Refined grains, however, increased the risk of hemorrhagic stroke twofold (13). When eating grains, it is important to have whole grains. Read labels carefully, since some products that claim to have whole grains contain unbleached or bleached wheat flour, which is refined.

Fortunately, there are many options to help reduce the risk or the recurrence of a stroke. Ideally, the best option would involve lifestyle modifications. Some patients may need to take statins, even with lifestyle modifications. However, statins’ side effect profile is dose related. Therefore, if you need to take a statin, lifestyle changes may help lower your dose and avoid harsh side effects. Once you have had a stroke, it is likely that you will remain on at least one medication — low-dose aspirin — since the risk of a second stroke is high.

References: (1) cdc.gov. (2) Stroke online April 2012. (3) BMJ 2012; Mar 8;344:e1257. (4) Neurology 2008 Aug 12; 71:505. (5) Neurology. 2009;73(8):576. (6) AAN conference: April 2012. (7) Am J Cardiol 2012; 109(9):1308-1314. (8) ISC 2012; Abstract LB 9-4504; (9) www.clinicaltrials.gov NCT00059306. (10) JAMA 2007;297:2018-2024. (11) Stroke. 2011; 42: 3190-3195. (12) J. Nutr. 2011;141(8):1552-1558. (13) Am J Epidemiol. 2005 Jan 15;161(2):161-169.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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Providing care for a family member in need is an act of kindness, love and loyalty.

Editors Note: Having recently recognized the dedication of family caregivers nationwide, we offer a timely suggestion for this season. Holiday gatherings are also an ideal opportunity to take note of any changing needs for loved ones that we may see infrequently, and a chance to plan proactively for them in the coming year.

“My wife has dementia and I am going to do what I can to keep her at home.”

“My father died recently and Mom needs our help.”

“My 90-year-old uncle lives across town all alone, so someone in our family visits him every day.”

Family caregivers are some of our nation’s most dedicated heroes — devoted men and women who tirelessly attend to loved ones with an illness, disability or limitations of aging. Each November, America celebrates National Family Caregivers Month to recognize and honor family caregivers across our country. From metropolitan brownstones and urban care facilities to rolling farmsteads and rural assisted living centers, family caregivers compassionately assist parents, spouses, extended family, friends and neighbors.

The Centers for Disease Control and Prevention estimates that 34 million unpaid caregivers nationwide care for someone age 18 or older who is dealing with sickness or disability. These millions represent roughly 21 percent of all U.S. households.

Family caregivers come from diverse backgrounds and care circumstances. She may be the granddaughter stopping by her grandparents’ home twice a week with fresh produce, or the son driving 300 miles every other week to take his father to his cancer treatments. Fueled by love and sacrifice, the role of a volunteer caregiver knows few limits.

Fortunately, a plethora of national and local organizations and online resources are available to family caregivers. For a local list of services and organizations, caregivers can contact federal, county and state government agencies including the U.S. Health and Human Services Department, social services departments and public health departments. The social services department of local hospitals and medical clinics or adult daycare centers and faith-based agencies are other avenues for learning about services and programs available to family caregivers and care recipients.

The following is a summary list of national family caregiver resources:

Family Caregiver Alliance offers services and publications based on caregiver needs at the local, state and national levels. The group’s www.caregiver.org website offers a wealth of helpful information from caregiving tips and fact sheets to personal stories and newsletters.

National Alliance for Caregiving is a nonprofit coalition of national organizations whose www.caregiving.org website connects family caregivers with information, videos, books and more that the alliance reviews and approves as providing beneficial information for caregivers.

Medicare.gov, the official U.S. government site for Medicare, presents easy access to useful information about Medicare and other proven resources to help with family caregiving. The site includes links to partner organizations and essential caregiver information, such as “What type of care is best for your loved one?” and “What every caregiver needs to know.”

This information was provided by Jamie Robinson, president of Right at Home In Home Care and Assistance of Miller Place.

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Parents listen to learn ways to discuss depression and suicide prevention with their kids during a seminar at Shoreham Wading River High School Nov. 30. Photo by Kevin Redding

“We need to change the way we think about mental health and teen depression .. .and we can start in our homes by keeping an open and honest communication and letting our kids know that it’s okay to say that they’re not okay.”

Ann Morrison, Long Island director for the American Foundation for Suicide Prevention, addresses parents in the Shoreham Wading River school district during a seminar Nov. 30. Photo by Kevin Redding
Ann Morrison, Long Island director for the American Foundation for Suicide Prevention, addresses parents in the Shoreham Wading River school district during a seminar Nov. 30. Photo by Kevin Redding

That’s what Ann Morrison, Long Island director for the American Foundation for Suicide Prevention, told an audience of parents at a seminar at Shoreham-Wading River High School Nov. 30, to help identify warning signs and risk factors for suicide in teens, understand the role of treatment in reducing risk and open a dialogue with their children about the topic.

The school district was impacted by two separate incidents of suicide in October and November. Both were high school freshmen. The school’s administration has been doing all it can to raise awareness and education for both students and parents alike ever since.

The AFSP gives different versions of the seminar throughout the country. Morrison’s presentation spoke specifically to parents. Those in attendance said it was much needed.

“It’s important with all the things that have been going on here,” Thomas McClintock said. “I know they wanted to address it with the children, but it’s good for the parents too, because a lot of us are in the dark on this type of thing. It’s not something you expect or anticipate in your own child.”

Morrison explained suicide has become the second leading cause of death among youth between the ages 10 and 24 in the U.S. after accidental injuries and yet, she said, “we aren’t really talking about it.”

“That’s where a lot of the issue is,” Morrison said. “We need to be more comfortable talking about one of the leading causes of death and why this is happening and how we can prevent it. This isn’t meant to frighten anybody, but to let you know the scope of the problem.”

According to the National Youth Risk Behavior Survey, conducted by the Centers for Disease Control and Prevention to monitor health risk behaviors that contribute to causes of death for teens, 17 percent of high school students reported having seriously considered attempting suicide in the previous year — 13.6 percent reported having made a plan for a suicide attempt in the previous year, and eight percent reported having attempted suicide one or more times in the last year.

“We need to be more comfortable talking about one of the leading causes of death and why this is happening and how we can prevent it. This isn’t meant to frighten anybody, but to let you know the scope of the problem.”

— Ann Morrison

Morrison said suicide is a mental health issue and marginally preventable.
The thought comes about when multiple factors come together, so it’s not related to just one cause, but underlying risk signals to look out for in teens are out-of-character bouts of depression, anxiety, aggression and agitation.

She said parents must act if they notice drastic changes in their children’s behavior, which might include withdrawal from activities they normally enjoy, isolation from friends or social media, changes in sleep patterns and appetite, unexplained rage, or giving away their prized possessions — something that commonly happens when someone is preparing to commit suicide.

“It can be very easy sometimes to mistake mental health symptoms for typical adolescent behaviors,” she said.

Also listen for statements like “I should go kill myself,” “I have no reason to live” and “everybody would be better off without me.”

Morrison stressed to the parents the key to helping prevent suicide among teens is to have a strong and supportive home, where it’s okay to reach out for help.

“You have to be a role model and let them know that in your home, it’s okay for open communication no matter what it is that they want to talk about,” she said. “We need to not be afraid to reach out and ask them if they’re okay. … Make sure you talk to them in private, [and] not at the dinner table, in front of siblings or handled very nonchalantly. Listen to their story, get them comfortable to talk to you, express care and concern. Don’t dismiss their feelings. What we think is a small problem to them might be a bigger problem in their mind.”

Debra Caputo, counselor at the Long Island Crisis Center, addresses parents in the Shoreham Wading River school district during a seminar Nov. 30. Photo by Kevin Redding
Debra Caputo, counselor at the Long Island Crisis Center, addresses parents in the Shoreham Wading River school district during a seminar Nov. 30. Photo by Kevin Redding

Debra Caputo, who works as a counselor at the Long Island Crisis Center, echoed the importance of listening. As someone who answers crisis calls on the National Suicide Prevention Lifeline, she said just simply listening to someone wrestling with mental health issues is helpful to them.

“When people call, we’re basically just listening and validating their feelings,” she said. “What they’re feeling is real. If we listen non-judgmentally and understand what they’re going through, it can make a world of difference. We want to reassure them they’re not alone and help is available.”

Morrison said that if there’s a true feeling that a child may be at risk or having suicidal thoughts, it’s okay to directly ask them if they are.

“It’s a scary question to ask or think about asking, but we know that when we ask, it opens that conversation,” Morrison said. “And should a child actually have those thoughts, in most cases, they’re going to feel comfortable telling you. Thank them for having the courage to talk to you and contact a mental health professional for an evaluation. Take it seriously. Don’t wait to act. Be calm. Listen to them.”

If you or your child is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). The hotline is available 24 hours a day.

For more information about the American Foundation for Suicide Prevention and their services, visit afsp.org.

You can watch “More Than Sad,” a film presented by the AFSP that dramatizes four situations of high school depression, at www.afsp.org/our-work/education/more-than-sad/.

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Setauket residents continue a Renaissance Technologies tradition

Stony Brook Cancer Center. File photo

Generosity, particularly towards Stony Brook University, runs in the family at Renaissance Technologies.

Lalit Bahl, a veteran of the hedge fund, and his wife Kavita, who are Setauket residents, recently agreed to donate $10 million to a new translational research program that will complement Stony Brook’s effort to understand and conquer cancer. The financial gift, which will support a metabolomics and imaging center that will provide individualized cancer care, comes two years after the Bahls donated $3.5 million to a similar effort.

Bahl said he was following a long-established tradition.

“Many of my colleagues at Renaissance have donated significant amounts to Stony Brook and in particular the medical side over the years,” Bahl said. “I’ve heard from some of them about some of the projects that they have been involved in. I’m sure that played some part in my decision to make this donation.”

Another compelling factor in that decision, Bahl said, was the prevalence of cancer in his family.

Jim Simons, former chairman of the Mathematics Department at Stony Brook, founded Renaissance Technologies, bringing in a range of expertise to understand and predict movements in the stock market. Simons and his wife Marilyn have made significant contributions to Stony Brook that have helped bring in talented staff.

Indeed, in 2012 the school recruited distinguished scientists Yusuf Hannun, the director of the Cancer Center and Lina Obeid, the dean for research and professor of medicine. Hannun and Obeid, with the support of other senior faculty in the Cancer Center, will help oversee the creation of an advanced metabolomics and imaging center in the new Medical and Research Translation building when it opens in 2018.

Lalit and Kavita Bahl pledge $10 million to new cancer research program. Photo from Stony Brook University
Lalit and Kavita Bahl pledge $10 million to new cancer research program. Photo from Stony Brook University

“We have high-powered, brilliant investigations in cancer medicine,” Hannun said. “This creates the capability that will allow them to take their work to the next level, in developing new therapeutics as well as in imaging studies.”

The new facilities include a cyclotron, which is used to create novel tracer molecules for PET scanning, hot labs that produce radioactive tracers for the cyclotron, two PET scanners and research labs.

Imaging will enable doctors to monitor patients, in some cases without excising a tissue sample or performing surgery.

The imaging will “distinguish between a tumor [that] is necrotic and dying [and one] that’s metabolically active,” said Obeid. That will help track and monitor the patient’s response to various medicines and chemotherapy in a noninvasive way.

Metabolomics is the study of the small molecules or metabolites that help cells function. Some of those metabolites provide energy while others could act as signaling molecules, and still others could be involved in other structural or functional effects.

In addition to new equipment, Stony Brook will add new scientists to its fight against cancer. During the first phase, the school will recruit an oncological imaging researcher, a matrix-assisted laser desorption ionization researcher and a magnetic resonance spectroscopy researcher. In the second phase, Stony Brook will hire a new scientist in experimental therapeutics.

Ken Kaushansky, the dean of the School of Medicine, appreciates the progress the school is making in cancer research and is energized by the combination of philanthropic gifts and investments from the university.

“There’s something remarkably catalytic about a brand new building,” Kaushansky said. He said he’s had regular discussions with people who want an opportunity to work in the new facility.

While the broader goal is, and continues to be, to make important discoveries that will help in the prevention, diagnosis and treatment of cancer, Kaushansky reiterated the school’s desire to earn a National Cancer Institute designation. This designation, which has been given to 69 institutions throughout the United States, raises its visibility and increases the opportunities to become part of research initiatives, while it also improves the chances that an individual scientist will obtain research funding from the National Cancer Institute, according to that organization’s web site.

“We have far surpassed the threshold of cancer research needed to acquire an NCI designation,” Kaushanksy said, which he attributes to Hannun’s efforts. Stony Brook is “now focusing on building up our clinical research prowess. That’s the second major component. I like our chances.”

The next area Stony Brook hopes to build is cardiovascular imaging, Kaushansky said.

“We have some remarkable cardiovascular surgeons and some terrific cardiovascular biologists,” Kaushansky said. “We need some outstanding cardiovascular imagers to work with [them]. We can use the incredible tools that we are building to do to cardiovascular medicine what we are doing to cancer.”

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Stony Brook Univeristy surgeon James Vosswinkel, left, is recognized prior to the Dec. 5 New York Jets game at Metlife Stadium. Photo from Melissa Weir

A lifelong New York Jets fan and Stony Brook University Hospital surgeon had the chance to take the field with the team.

The Suffolk County Police Department showed its gratitude to SBU Hospital Chief Trauma Surgeon Dr. James Vosswinkel at a surprise press conference at the hospital Nov. 29, with a little help from the Jets.

Vosswinkel, a Jets fan who saved the lives of two SCPD officers critically injured in the line of duty, said he was “completely overwhelmed” to learn that he and 20 members of his staff were to be honored at the Jets’ Annual First Responder Appreciation Night at Metlife Stadium before the game Monday, Dec. 5.

“I don’t think either one of us would be standing here today as full capacity police officers if it wasn’t for the doctor and his care.”

— Nicholas Guerrero

SCPD Commissioner Tim Sini and Military & First Responder Liaison for the team, Steve Castleton, along with members of the police department and staff from the hospital, were present to announce the news to the trauma surgeon.

Alongside members of police and fire departments from across the tri-state area including the SCPD, NYPD and FDNY, Vosswinkel served as honorary team captain and helped with the coin toss before the Jets squared off against the Indianapolis Colts on “Monday Night Football.” Unfortunately the Jets were defeated by a 41-10 final score.

Vosswinkel said the honor is as much about the efforts of the hospital as it is about him.

“I may be the guy that’s most visible right now, but this is not about me,” Vosswinkel said. “This is about Stony Brook. Stony Brook cares. It excels in so many areas. It’s a true team here that truly cares about their patients. They put the extra time in; we go out to the community to try to prevent trauma. Everybody deserves credit here. We’re very happy when our patients do well.”

L. Reuven Pasternak, chief executive officer at the hospital, said at the press conference trauma is the leading cause of death for all Americans before age 45 and, in terms of trauma care, every second counts.

Vosswinkel leads the hospital’s trauma program, which is the only Regional Level 1 trauma center for Suffolk County, according to the New York State Department of Health. The center has been recognized as the top-ranked center in the care of pedestrian trauma and has some of the highest survival rates anywhere in the nation and state.

The two SCPD officers are on their feet again thanks to the emergency surgery done by Vosswinkel. Mark Collins and Nicholas Guerrero made sure their surgeon was invited to the event as they wanted to do something special as a thanks for giving them a second chance at life.

“I don’t think either one of us would be standing here today as full capacity police officers if it wasn’t for the doctor and his care,” Guerrero said.

Collins said he and Guerrero are thankful for each day they wake up.

Guerrero, a four-year veteran of the SCPD, was under Vosswinkel’s care for weeks in a medically induced coma after suffering a critical head injury when a hit-and-run driver in Huntington struck him in September 2014.

According to Vosswinkel at the time of the officer’s discharge from the hospital, Guerrero had “only a one in three chances of surviving.” Collins, a member of SCPD’s gang unit and a 12-year veteran, was rushed to the hospital in March 2015 after he was shot in the neck and hip while pursuing a suspect in Huntington. He was discharged only four days after the shooting occurred.

If it wasn’t for the immediate action of Vosswinkel and his team, the injuries could have been fatal.

Nicholas Guerrero, left, and Mark Collins, right, honor James Vosswinkel, who performed life-saving surgery on each of the police officers, at a surprise press conference Nov. 29. Photo by Kevin Redding
Nicholas Guerrero, left, and Mark Collins, right, honor James Vosswinkel, who performed life-saving surgery on each of the police officers, at a surprise press conference Nov. 29. Photo by Kevin Redding

According to Sini, the partnership between the SCPD and SBU Hospital is integral to the law enforcement mission. He said the department relies on the hospital in the wake of unfortunate circumstances, and many officers wouldn’t be alive if it weren’t for “the man sitting to my left,” referring to Vosswinkel.

“We call him Voss and he’s part of our family,” Sini said. “You’ve saved families from extreme tragedy; you’ve saved this department from extreme tragedy; and you’ve allowed two officers to continue to serve the department. We can’t thank you enough for that. What we can do is do our best to express our gratitude. But from the bottom of my heart, on behalf of the SCPD and on behalf of Suffolk County, thank you very much.”

Castleton was introduced to make the big announcement, which Sini referred to as a small token of appreciation.

Castleton said when the announcement was being planned, he heard some “crazy” stories about Vosswinkel, like he often wears a Jets shirt under his scrubs and even repainted his office in the team’s colors. He spoke on behalf of the Jets organization and said it was extremely important to recognize medical staff.

“A lot of people forget that doctors and nurses are first responders … it’s not just policemen, EMTs, and paramedics,” Castleton said.

According to Castleton, the Jets players were insistent that members of the surgeon’s staff join them in running out of the stadium tunnel before the start of the game.

 

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