Monday, January 2, 2023

The Major Occupational Hazard of Post Traumatic Recall (PTSD) - part 1


Updated 1/2/2023 (original feature published 8/15/2019)

INTRODUCTION:
High risk professions like law enforcement, military service, healthcare and emergency response are known to have exposure to some of the most extreme levels of trauma - both physically and psychologically.  They range in effects from manageable symptoms to crippling disorders.  Over time, most people overcome disturbing or traumatic experiences and continue to work and live their lives. But others who get affected by traumatic experiences may trigger a reaction that can last for months or even years. This is called Post-traumatic Stress Disorder, or PTSD. Proportionately, studies have shown a lower percentage of retirees from such challenging careers acquire PTSD (from 15-20%) while an estimated 30-40% who suffer from PTSD associated symptoms go undetected or do not register as full cases. A larger percentage ‘on the job’ might be able to maintain the expected work standards throughout their career and even make it to retirement without visible signs. But “POST traumatic recall” leading to fully blown PTSD occurs when repeated exposure to trauma compounds on the tolerance capacity that eventually, one’s coping ability collapses.  The individual may feel stages of grief, depression, anxiety, guilt or anger from uncontrollable issues like recurring flashbacks and nightmares. [1]


REVIEW OF POST TRAUMATIC RECALL (A field report by: Jessica Glynn, CSW)
PTSD can occur in all different extremes with at-risk professionals (like cops, responders and veterans). The trauma that they experience are above the ordinary that they could cause extreme flashbacks, anxiety and depression—heavily affecting their quality of life. The average civilian is also prone to this disorder starting with MICRO-TRAUMAS that can happen to everybody throughout any point in their lifetime.  Usually stemmed from childhood issues, micro-traumas actually shape the way an individual reacts to other people. As an example, child bullying may lead to developing a protective or defensive personality disorder.  Anytime they feel disrespected or embarrassed by others, feelings of extreme uncontrollable anger may arise without knowing the source of the hurt or why they're acting in that way.  This dilemma often causes problems in relationships.

Similarly, a first responder who experiences extreme traumas like horrendous disasters may stick with them in a much harsher way that could lead to flashbacks that are hallucinatory.  If gone unchecked or untreated, these symptoms (including auditory hallucinations) can get increasingly more intense and expand to other symptoms that can affect their daily functions.  A common way that anxiety can debilitate a sufferer is from recurrent lack of sleep disrupted by bad dreams triggered by the traumatic event.

Enduring trauma is different and unique for everyone. Some cases are event-specific (having intense auditory impact or visual intensity of a terrifying event) while other cases are contingent upon the tolerance of an individual. There are people who are more emotionally expressive than others- and that might help with if they talk about the trauma that they've been through. A latent emotional disorder like PTSD symptoms can come out over time just like anything that is suppressed or repressed. It could take some time for somebody who came back from combat or a first responder who has been in a traumatic event to show signs of disturbance. They could be holding it in and repeatedly thinking about it privately (or ruminating over it) allowing the disturbing memories to get more intense by the day.  This can often be a coping mechanism- protecting themselves from dark or negative feelings for a while, but eventually it builds up and can become symptomatic like flashbacks and anxiety, then leading to an eventual explosion.  Meanwhile, some people just have flashbacks right after the experience because of the way that everybody's brain processes differently. Others obsess over thoughts that keep popping up over and over again. It really just depends on the person.

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SIGNS AND SYMPTOMS

Not every traumatized person develops ongoing (chronic) or even short-term (acute) PTSD. Not everyone with PTSD has been through a dangerous event. Some experiences, like the sudden, unexpected death of a loved one, can also cause PTSD. Symptoms usually begin early, within 3 months of the traumatic incident, but sometimes they begin years afterward. Symptoms must last more than a month and be severe enough to interfere with relationships or work to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic. A doctor who has experience helping people with mental illnesses, such as a psychiatrist or psychologist, can diagnose PTSD.

To be diagnosed with PTSD, an adult must have all of the following for at least 1 month:
• At least one re-experiencing symptom
• At least one avoidance symptom
• At least two arousal and reactivity symptoms
• At least two cognition and mood symptoms

Re-experiencing symptoms include:
• Flashbacks/Bad dreams - reliving the trauma over and over, including physical symptoms like a racing heart or sweating
• Frightening thoughts

Re-experiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms.

Avoidance symptoms include:
• Staying away from places, events, or objects that are reminders of the traumatic experience
• Avoiding thoughts or feelings related to the traumatic event
• Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.


Arousal and reactivity symptoms include:
• Being easily startled
• Feeling tense or “on edge”
• Having difficulty sleeping
• Having angry outbursts

Arousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to do daily tasks, such as sleeping, eating, or concentrating.





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HOW STRESS CAN MAKE YOU SICK
For our well-being, stress is so powerful that it can affect just about every function in our bodies right down to our cells. Stress can cause major weight gain, headaches, hair loss, dental problems, major fatigue, respiratory issues, digestive problems, psychological & focal disorders.  It is also known to affect the performance of our immune system - allowing for skin issues, colds, allergies and a host of chronic diseases. Stress management is important for more than psychological health; stress can greatly affect immune functioning, inflammation and even hormonal balance. Studies have shown that stress can reduce natural killer cell function. These are normally the cells that attack foreign invaders including viruses, bacteria and fungi. They are also the cells that patrol the body as the first line of defense against the development of cancer. 

Stress links to Cancer
When stressed, the body responds to physical, mental, or emotional pressure by releasing stress hormones (such as CORTISOL, EPINEPHRINE AND NOREPINEPHRINE) that increase blood pressure, speed heart rate, and raise blood sugar levels. When chronically elevated, these stress hormones can corrupt the performance (and even paralyze) our immune system which can lead to osteoporosis, weight gain (especially the dangerous visceral fat), high blood pressure, cardiovascular disease and cancer. These stress hormones are known to bind with cancer cells and stimulate angiogenesis, cell migration and invasion, leading to increased tumor growth and progression. Long term stress also increases blood supply that adds to the growth of cancerous tumors.

See complete article at IMMUNOLOGY TODAY
Also see video on "THE PITTS- 5 Elements that Affect the Immune System"



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TRANSCRANIAL NEURO-IMAGING FOR STRESS RELATED DISORDERS
By Dr. Robert L. Bard

Emotional traumas and stress influencers are scientifically aligned with anxiety, depression, behavioral disorders, drug/alcohol abuse and a wide list of physiological health issues.  These symptoms are typically diagnosed by mental health professionals through observational science and behavioral analysis.  But within the past 15 years, global advancements in transcranial imaging pioneered the ability to detect trauma-related issues in the brain through neurological imaging. Now, neurological stress can be identified clinically by monitoring chronic imbalance and changes in the neurochemical structure (or circuitry).  The shift in memory performance - specifically the hippocampus and the medial prefrontal cortex is one indicator of this imbalance whereby a stressful event can show images with signs of neuronal dysfunction.

Neuro-imaging measures brain thought activity which has known chemical tissue changes by observing the alterations in capillary blood vessels in the retina located in close proximity to the main emotional center of the anterior brain. Functional MRI (fMRI) is currently used to show brain chemical changes with cognitive commands such as “death vs freedom.” Most recognizable patterns with suicide occur in the anterior cingulate cortex of the brain which lies directly behind the globe and is vascularized by orbital branches of the anterior cerebral artery. Functional near infrared imaging (fNIR) devices show changes in brain oxygenation linked to suicide.

Another imaging innovation is the TRANSCRANIAL DOPPLER (TCD) - a type of sonogram that is a non‐invasive, non‐ionizing, inexpensive, portable and safe technique that uses a pulsed Doppler transducer for assessment of the blood flow in the anterior cerebral arterial circulation. This technology has been used to evaluate intracranial steno‐occlusive disease, subarachnoid hemorrhage, and extracranial diseases (including carotid artery disease and subclavian steal syndrome), detection of microembolic signals and acute strokes. [5] The Transcranial Doppler has been used to examine the mean speed of blood circulation of patients to validate and monitor treatment efficacy by tracking cranial blood vessels and vertebrobasilar flow vasospasm.  (See complete report from Military Medicine)

Another device used by imaging specialists to detect mental distress is through an EYE SONOGRAM or  Real Time Sonofluoroscopy of the orbital soft tissues of the eyes.  This process is performed in multiple scan planes with varying transducer configurations and frequencies.  Power and color Doppler use angle 0 degrees and PRF at 0.9 at the optic nerve head. 3D imaging of optic nerve and carotid, central retinal arteries and superficial posterior ciliary arteries performed in erect position before & after verbal communication and  orbital muscle tissue contractions may be observed as a precursor to visual changes in facial expression. Retinal arterial directional flow is also measured with peak systolic and diastolic values. Bulging of the optic nerve head is checked as increased intracranial pressure may be demonstrable in this condition. Other innovations such as the TRANSORBITAL DOPPLER, 3D/4D VESSEL DENSITY HISTOGRAM and the RETINAL OCT (optical coherence tomography) are also being explored in the pursuit of studying brain performance through the eyes.  An expanded review on these solutions will be available in part 2 of this report.

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CONTRIBUTORS /  EDITORIAL TEAM


ROBERT L. BARD, MD, PC, DABR, FASLMS - Advanced Imaging & Diagnostic Specialist
Having paved the way for the study of various cancers both clinically and academically, Dr. Robert Bard co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital Imaging technology has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered Sonograms, Spectral Doppler, sonofluoroscopy, 3D/4D Image Reconstruction and the Spectral Doppler are safe, noninvasive, and does not use ionizing radiation. It is used as a complement to find anomalies and help diagnose the causes of pain, swelling and infection in the body’s internal organs while allowing the diagnostician the ability to zoom and ‘travel’ deep into the body for maximum exploration.

JESSE STOFF, MD, HMD, FAAFP - Cancer Immunologist / Publisher of Wellness Programs
Dr. Stoff is a highly-credentialed medical expert studying all medical remedies in pursuit of resolving the most challenging health issues of our time. In many circles, he is recognized for his 35+ years of dedicated work in immunology and advanced clinical research in modern CANCER treatments. He has spoken worldwide in some of the most sought-after medical conferences about his experiences and analyses on the study of human disease. His integrative practice (INTEGRATIVE MEDICINE OF NY, Westbury, NY) has been continually providing all patients with the many comprehensive clinical options and modalities available- including "ONCO-IMMUNOLOGY", the science of battling cancer cells and reversing pre-cancerous conditions through a complete prevention program that has earned him great success in this field.  For more information, visit: www.Dr.JesseStoff.com

JESSICA A. GLYNN, LMSW, CPC, CEC - Responders' Mental Health Program
As a therapist and coach, a lot of my work with clients is helping to manage symptoms of anxiety and panic- that which manifests in physical, often frightening and alarming ways. We can experience things like racing heartbeat, shortness of breath, numbness in arms and legs which can all make us feel like we are out control of our bodies and our surrounding world. When we have experienced a traumatic event in our lives, these feelings can be even more severe and heightened. The trauma and residually related fear is one that is very close to my heart and a reason I can provide empathy and understanding to clients that have been affected by the horrific day. When we work to process physical emotions that arise from trauma, the hope is that one day we can be less affected by it and live more presently to enjoy life’s fulfilling moments. I work with clients to slowly pull apart the physical emotions we experience from the thoughts that we are having and process them in a more self-aware and grounded way., visit her website- www.jagtheracoach.com



** SIGNS AND SYMPTOMS segment is sourced from The National Institute of Mental Health website: www.nimh.nih.gov










References
1) https://www.rcpsych.ac.uk/mental-health/problems-disorders/post-traumatic-stress-disorder
2) https://www.psychologytoday.com/us/blog/cop-doc/201811/cops-and-ptsd
3) https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729089/
5) Transcranial Doppler: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2659960/
6) Transcranial Doppler 2: https://www.ncbi.nlm.nih.gov/pubmed/11725323
7) Design and Validation of an FPGA-Based Configurable Transcranial Doppler Neurofeedback System for Chronic Pain Patients https://europepmc.org/articles/pmc6069097
8) https://academic.oup.com/milmed/article/166/11/955/4819466
9) PTSD Diagnosis Aided By New Imaging Techniques  https://www.psychiatryadvisor.com/home/topics/anxiety/ptsd-trauma-and-stressor-related/ptsd-diagnosis-aided-by-new-imaging-techniques/
10) https://psychcentral.com/news/2014/12/02/imaging-studies-differentiate-ptsd-mild-brain-injury/78060.html
11) https://www.psychologytoday.com/us/blog/the-many-faces-anxiety-and-trauma/201904/how-do-we-diagnose-ptsd





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Wednesday, December 7, 2022

NEUROPLASTICITY: Eight Reasons We All Need to Learn About Brain Health

 Written by: Marilyn Abrahamson, MA,CCC-SLP - CBHC (Certified Brain Health Coach)

NEUROPLASTICITY is defined as the ability of the nervous system to change its activity in response to intrinsic or extrinsic stimuli by reorganizing its structure, functions, or connections after injuries, such as a stroke or traumatic brain injury (TBI) - NIH.GOV


The word Neuroplasticity ignites a feeling of hope. For clinicians and therapists working with patients with all types of brain injuries, understanding neuroplasticity is crucial. Because neuroplasticity is the brain’s ability to change and adapt in response to new learning and new experiences, it can change both a clinician's choice of therapeutic techniques as well as the duration of the patient’s therapeutic program. 
 
We now know that, even in the absence of brain injury or illness, teaching people how to help their brain to more easily adapt, change and grow as we age is the key to maintaining cognitive health. That’s how we remain sharp and resilient into our advanced years, but there’s more to it than that.  The answers to the following seven questions will help us to better understand why brain health education is so very important to all of us. 
 
Why is it so important for people to teach others about brain health?  The brain is what makes us who we are, producing our every thought, and every action. It stores all of our memories, feelings, and experiences.

The brain resides quietly in our heads, is relatively low maintenance, and is grossly taken for granted. Teaching people about brain health raises their awareness of the need to take a more active role in preserving the health and wellness of this amazing resource.

Knowing that there are actionable tasks, such as adjusting lifestyle choices and habits to support a healthier brain, can offer the clarity and the direction people need to begin to make those adjustments.
 
Decline is a natural aspect of normal aging, but how do we know what’s normal and what should spark concern? Age-related decline is normal for any part of the body, but when talking about normal brain-aging, many believe that the word “decline” implies the presence of impairment. With that in mind, a more appropriate word to use could be  “change” to describe the process of brain aging. People with brain injuries, memory disorders and neurodegenerative diseases may ultimately enter a state of “decline”, where functionality gradually wanes over time. If a person in decline is going to improve, it takes exceptionally hard work for rehabilitation of skills to take place.

With general age-related “change”, many of us can simply compensate and adjust how we use our brain by implementing strategies and targeted techniques for better memory, organization and completion of more complicated tasks.  Compensatory strategies and techniques allow us to work around change by doing tasks differently, more mindfully and more efficiently. By adjusting our habits  and learning to roll with the changes, we can help our memory and thinking skills to work well again - in many cases, as well as they worked before.

With that being said, there are aspects of cognition that do naturally change with age, and one of the first is processing speed. For example, if you’re watching a game show, such as Jeopardy and you know the answer, but the buzzer rings before you can say it, your processing speed may be starting to slow down. This is considered normal. Attention also becomes more elusive as the brain ages and it may become more difficult to focus and pay attention. Reduced attention may cause us to miss parts of conversation, particularly if we’re in a distracting environment. This can also be contributed to by other sensory changes that occur as we get older such as problems with vision and hearing, both of which allow us to acquire information from the environment around us.

When do “lapses in memory” become more of a concern? People generally worry about things that should be less of a concern. Word finding and name recall are the most bothersome aspects of brain-aging, and what people complain about the most. This problem tends to start at a young age, with many beginning in their 40’s.  It is considered normal, especially if we’re able to retrieve the correct name shortly after. Problems with word finding and name recall become more of a concerning issue if we find ourselves persistently calling people and objects by generic names such as “honey” or “whatchamacallit”. But if this is not a pattern, it’s generally nothing serious.

People also tell me that they are concerned because they frequently misplace personal items.
Misplacing items, even if this happens frequently, is not necessarily a cause for concern. This habit is not exclusive to the aging population. We’ve been misplacing things since childhood. If you have children, you know they misplace things every day. After putting in minimal effort to find their lost belongings, they called you (their parents) to find the items for them. Interestingly, as parents, we generally always knew where they were!

However, if misplacing items occurs persistently, AND the objects are ultimately found in locations that show a mindful placement of the item in a grossly inappropriate place, it may be a sign of something more serious.  Taking the time to place a basket of freshly folded laundry in the kitchen pantry would likely not occur unless there was cause for concern. This would warrant a visit to the doctor.
Misplacing items, and later finding them placed mistakenly on a table or in a jacket pocket, would likely just call for mindfulness exercises, a memory strategy and better habits to help keep track of them.

(To be continued)



"5 Negative Antigen Tests Do Not Match How OFF I Feel..."
An IPHA Editorial Submission

In August of 2021, David (last name withheld) arrived home from his job at the local hardware store and within minutes of entering the front door, collapsed with a most unusual set of symptoms including acute exhaustion. Following the national guidelines, taking a PCR test showed that he was 
hit with the Coronavirus Delta Variant! The flu-like symptoms all hit simultaneously in full force.  David saw stars for most of his recuperation period while taste and smell were completely shut down. For 1 week, David quarantined in his office - armed with every super-food, every kind of soup and immune booster his support team could find.  Being fully vaccinated only meant he had a better chance of NOT DYING, but as the world was only a year into the data collection, there was still so much left to understand about the recuperation period as well as its long standing effects.

FAST FORWARD to the fall of 2022. Life goes on and regular rapid  (home) testing says David was negative every time. Tracking the latest in covid news reports, the idea of lingering symptoms is in the back of everyone's- especially those who got hit at least once with the virus.  But HOW or WHERE in the body is it?  To over-think this does not make one a hypochondriac- only someone surrendered to the realities of our times, meaning 'if it doesn't kill you, the viral load may have the tendency to linger, causing  potential organ damage, failure or dysfunction.


MEMORY LOSS:
They say that you shouldn't worry about getting dementia or Alzheimer's- once you have it, you won't know it. Well this is not completely true. We can attribute forgetting a name here and there as a natural, normal age-related wear down. But forgetting EVERY name is not the same.  It's as if someone stole or deleted specific data from your brain, and when it's time to withdraw those names to compose a sentence, all there is is an empty shelf where that name was expected to be.  The simplest proper nouns that David once quickly referenced and freely spoken about all his life- including names of product brands, movie and song titles, artists- even celebrities are now GONE- or perhaps buried in the back yard somewhere!

If "it is (in fact) what it is",  David expressed his disbelief that the CDC or the WHO are pressing to come up with Long Haul therapies. "There's still so much to go with perfecting the vaccination to control the global surge. We can choose to fight the erosion in our brain with mind optimizers, exercises, better sleep and every protocol to improve brain performance.  But this very insidious aftermath of the virus that buried itself into my brain is now aging me, starting with my memory, my processing speed and if the data out there is right, my waning cognitive functions. "





(Continued from top feature)

Can we control or change our risk for getting Alzheimer’s disease or other types of dementia? Yes, and this is what brain health education is all about. Engaging in brain-healthy lifestyle habits can help to reduce the risk factors for Alzheimer’s disease and other types of dementia.
 Age-related cognitive changes are directly influenced by brain size. Keeping neural pathways active, and engaging in habits such as lifelong learning, can help sustain healthy brain volume and contribute to the development of cognitive reserve.

What is cognitive reserve and how can we get it by modifying lifestyle choices?  Cognitive reserve is the brain’s ability to be resilient against damage or disease. A prestigious longitudinal research study showed that people who lived a healthy lifestyle and had no apparent symptoms of dementia were found to have brain changes consistent with dementia and advanced Alzheimer's disease on autopsy. This is likely to have been a result of high levels of cognitive reserve, which served to offset the damage, allowing them to function well in life.

Would these people have eventually developed symptoms of dementia had they lived long enough? 
There is a high probability that they would have. Cognitive reserve offers the gift of additional years before the onset of symptoms.  

What lifestyle habits facilitate the development of cognitive reserve and how do they reduce the risk for Alzheimer’s disease and other types of dementia?

        Exercise: The brain is the greediest organ in the body in terms of the need for blood flow and oxygen. Exercise helps to provide the brain with those nutrients, and also facilitates the release of a protein called BDNF (Brain Derived Neurotrophic Factor). BDNF is instrumental in supporting the birth of new neurons in the hippocampus, the brain region primarily responsible for new learning and memory storage.

        A Brain-Healthy Diet: The Mediterranean Diet and the MIND diet ( a combination of the Mediterranean Diet and the Dash Diet) have been proven to support healthy brain function. This is most likely because of their generous inclusion of antioxidants and Omega 3 fatty acids.

         Sleep: Sleep is important for optimal brain function and for consolidation (movement into storage) of information acquired during the previous day into long term memory. Additionally, sleep is the time that the brain is cleared of plaques that build up throughout the day.

         Stress Management: Effectively managing stress is essential to maintain healthy levels of cortisol which, in large quantities, is destructive to the brain and organs throughout the body.

         Lifelong Learning: Learning something new and interesting every day is essential to activate existing neural pathways and connections throughout the brain and for development of new ones. The more activated neural connections and pathways you have, the bigger and more voluminous your brain will remain!

         Enjoyable Activities: As a bonus, finding something that you love to do and getting excited about it will give your brain an instant boost of motivation to keep learning and growing, in addition to adding a spark of joy each time you do it.

Changing life-long habits is undeniably hard, especially when there are several changes that need to be made. What’s the best way to tackle them and how do we decide what to do first? Change is difficult for people, even when they are keenly aware of the benefits of following through.

To begin, you need to have clarity for why you want to make these changes. Knowing your reasons for doing something is essential before starting. Otherwise, you’re likely to give up if things get tough. Once you’re ready to begin, it is important not to attempt too many changes at once. Make a list of the lifestyle habits you want to change and then choose the most do-able first.  Giving yourself the boost of dopamine associated with accomplishment will be helpful to get the ball rolling. As you begin to engage in these new habits, gradually add one, then another and another.
 
 
ABOUT THE AUTHOR-

MARILYN ABRAHAMSON, MA, CCC-SLP : As a Brain Health Education Specialist at Ceresti Health, Marilyn offers initiatives that supports education and empowerment of family caregivers. She also writes for and edits the Ceresti’s monthly newsletter and produces all brain health education and brain-health coaching programs for caregivers.  Marilyn's prior work is as a NJ Licensed Speech-Language Pathologist since 1987 and is an Amen Clinics Certified Brain Health Coach.


 





10/25/2022- HEALING, STRESS AND THE PARASYMPATHETIC SYSTEM:  Analyzing STRESS & ANXIETY from a holistic point of view means identifying the body’s interconnected systems (ie. circulatory, cardiovascular, nervous, lymphatic, endocrine etc.) and its many touch points for stimulation.   This analysis should also offer a comprehensive breakdown of the body's HEALING capacity- which includes our hormones, digestive system, immune system, brain, heart-- all the way down to our cells and mitochondria.   Stress is part of life, and comes in many forms including physical, emotional, mental and environmental. Foods we eat, unhealthy relationships, difficulties at work, toxins in our environment, even poor posture or lack of sunshine can all create stress on our bodies. (See complete report by: Dr. Roberta Kline)


9/14/2022 - ADDRESSING BURNOUT: RECHARGING FOR CAREGIVERS: During the Covid-19 surge, interviews with emergency medical professionals showed dramatic cases of ICU and ER responders exposed to major signs of advanced fatigue and risk of burnout.  This significantly raised major risks to their work performance where lives are to be affected, including theirs.  Over time, double and triple shifts resulted in "a different type of pandemic" on a national scale- where this level of exhaustion and overwhelm.  (See full report by Dr. Leslie Valle & Dave Dachinger)





Copyright Notice: The materials provided on this website/web-based article are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and The AngioFoundation). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.
















Tuesday, November 15, 2022

Early Detection: The Risk of Being "Too Young for a Mammogram"


 A major concern is the presence of breast cancer in underserved communities, including those TOO YOUNG FOR A MAMMOGRAM.  Whereby the medical community touts the recommended (and legal/billable status) of getting a mammo scan should be between 40-50, what happens to the many women who do not fit this age criteria?  How would they even know to get checked without the support of their clinicians or an alarm from family history?

Decades into the battle against breast cancer, clinicians and the public are much more educated about EARLY DETECTION, PREVENTION and the current protocols and modalities available to save lives.  Recent headlines on DENSE BREAST and the advancements in ULTRASOUND SCANNING supports a major part of this battle.

UNDERSERVED AGE FOR EARLY DETECTION

By Dr. Robert L. Bard and Joe Cappello of AreYouDense.org

According to Breastcancer.org, "Where mammography is available, ultrasound should be seen as a supplemental test for women with dense breasts who do not meet high-risk criteria for screening [with] MRI and for high-risk women with dense breasts who are unable to tolerate MRI... but if mammography isn’t available, then ultrasound seems to be a good alternative for breast cancer screening."

Doppler Sonography offers clinical accuracy and access
to breast imaging evaluation (www.breastcancernyc.com
)


A recent cohort study is underway under a partnership between Molloy College and AreYouDense.org  to publish new findings about low BMI patients and younger women about the presence of dense breast tissue.  This same review also covers the advantages of ultrasound use where mammography is not available.

Mammography is the current standard for breast cancer early detection for women 40 & older. Recent studies have shown nearly half of all women who get mammograms are found to have dense breasts, exposing this population to the risk that mammograms may miss potentially cancerous tumors concealed by dense breast tissue.  Dr. Cutter's initial concepts to target LOW BMI (bet 12-22% body fat) was personally inspired.  As an active TRIATHLETE, her own diagnosis sparked her survey and inquiry throughout the athletic community where she uncovered a significant trend that became the basis for this research. She wishes to target younger women, athletes and members of underserved communities. "Younger women may be more likely to have dense breasts... also I find athletes with LOWER BMI (body mass index) or those with  less body fat are more likely to have more dense breast tissue compared with women who are obese." (See complete feature article)


VIEWPOINT 
WHAT ABOUT IF YOU'RE TOO YOUNG FOR A MAMMOGRAM?   I went to my doctor for a lump I felt in my breast and she gave me a response that set off red flags: "don't worry about it". Being a researcher involved in breast density and breast cancer, I knew that I had to take action; I was fortunate enough to have my breast ultrasound training with Dr. Robert Bard (cancer imaging specialist, NYC) upcoming in the next week. Dr. Bard showed me how to use the ultrasound to help me find two benign tumors in my breasts, and it was there that he reported that I have dense breasts. Had I not taken action in getting screened at the young age of 22, I would have never known that I should be getting screened via ultrasound every 6 months (because having dense breasts puts me at a higher risk for breast cancer), nor would I have known that I had benign breast tumors. 

- ALEXANDRA FIEDERLEIN, 22
Cancer Researcher/ Graduate- Molloy Univ.



NEWS FROM THE FIELD 

Click to see NEWS
The DENSE BREAST TISSUE / CANCER CONNECTION is a topic that has finally achieved proper recognition in our community. Thanks to organizations like The 'ARE YOU DENSE?' Foundation, awareness of this health concern has now shed light to the risk to 40+% of the national women's population whereby more clinicians are now recognizing the need to state a patient's dense breast status.  Research crusaders like  Dr. Noelle Cutter and research associate Alexandra Fiederlein from Molloy University are underway the 2022 National Survey of Dense Breast Studies by bringing ultrasound access to underserved members of the women's community. 

In a recent episode of SPOTLIGHT ON AMERICA, Dr. Bard spoke as the clinical expert in the report "Millions of women have this breast cancer risk factors... why aren't they being informed?" -- TND REPORT/Spotlight on America is pressing to ensure women have access to a crucial health fact that could save their lives. According to the Centers for Disease Control and Prevention, 40% of women have dense breast tissue, which is a risk factor for cancer. The TND team first highlighted this issue in October 2021, and more than a year later, we expose how some women are still being left in the dark about their density, and federal health bodies are failing to make sure they’re informed.




2022 REVIEW ON WOMEN'S EARLY DETECTION STANDARDS 
Excerpt from the 2021 NYCRA Dense Breast Diagnostic Conference By: Dr. Roberta Kline

Breast cancer is still one of the most common cancers in women, and the leading cause of cancer mortality. While mammography is considered the standard imaging for early detection, it falls short for many – including those with dense breasts. Approximately 40% of women have dense breasts, which we now know is associated with an increased risk of breast cancer. On top of this increased risk, mammogram is less sensitive for early detection – up to 50% less for women with the highest breast density. [1] As a result many women are not diagnosed until they have a much later stage cancer – and a worse prognosis. [2]

The State of Connecticut passed legislation requiring notification of breast density in 2009, after having passed legislation requiring insurance coverage for ultrasound for dense breasts in 2005. As an ObGyn physician practicing in CT at the time, I remember the discussions with colleagues and patients around this issue although at the time there were no formal efforts to raise awareness or update guidelines from our national specialty organization, the American College of Obstetricians and Gynecologists (ACOG). 


PERSPECTIVE: PERSONAL FINDINGS BY A CLINICAL PROFESSIONAL
I was fortunate to have benefited personally from this effort when I had my first screening mammogram shortly after the law went into effect. The reading radiologist personally informed me of my high breast density immediately after the mammogram, and after recommending a breast ultrasound for further evaluation this was done right then and there. I walked away from my appointment feeling well informed, and any potential anxiety relieved by the prompt additional imaging and results. I also knew that I needed a different approach for my screenings going forward.

Between 2009 and 2019, 37 other states and D.C. passed legislation requiring notification of breast density, one of the last being my new home state of New Mexico. In 2019 a federal law was passed to require both clinician and patient reports contain plain language around the woman’s breast density, and to discuss with her provider. The FDA then created standard language that has now been implemented, requiring reporting on a woman’s individual breast density, and recommendation to discuss with her provider.
There is still much to be learned about what causes dense breasts and why women with dense breasts have an increased risk of breast cancer, and our ongoing study is one of many that are seeking to answer these questions at the molecular and genetic level. But the evidence that supplementing mammograms with other imaging modalities can increase the rate of early detection is substantial, and provides us with tools we can use right now to make a difference. [3,4]  Despite this progress, there are still significant hurdles in changing the standard of care. A recent experience with my routine breast cancer screening highlighted the ongoing challenges. When I had asked to schedule an ultrasound with my screening mammogram, I was informed that it was not done this way – I could only get a mammogram. After my mammogram, I had to wait to receive my letter in the mail approximately one week later to be able to take any additional steps. The interpretation included a description of breast density and recommended to discuss any additional care with my physician. 

When I called to schedule an ultrasound, I was told that since the radiologist did not recommend it in the report, I could not schedule it. I then had to speak with my primary care provider, educating her on dense breasts and why I needed an ultrasound. Luckily, she agreed to order one. While the radiology facility still questioned the order, eventually I was able to have this done. When the radiologist came in to discuss my results, she too was confused as to why I was having the ultrasound, and was not aware that this should be standard for women with dense breasts.

See 2022 Dense Breast Ultrasound Study
Fortunately all was fine, but had I not been a physician that was fully aware of this issue, I would very likely have had only a mammogram and walked away with a dangerously false sense of security. This experience highlighted for me how much still needed to be done more than 20 years after my first experience. Legislation is only part of the solution. Clinician education and public awareness are the keys to changing how the intention behind these laws gets translated into actual change in health care.

As I experienced, many clinicians are ill-informed about the nature of dense breasts, and options for adjunctive screening including ultrasound or MRI. This means that many of these reports end up being filed away with no further action being taken that could make a significant difference in early detection and saving lives.

EPILOGUE: CURRENT STANDARDS VS NEEDS
ACOG still officially does not recommend any further imaging for women with dense breasts on mammogram, despite the significant body of evidence suggesting that mammogram alone is insufficient and adjunctive imaging with ultrasound or MRI increases rate of early detection. [5] The U.S. Preventive Task Force [6]  does not recommend routine adjunctive imaging for screening women with dense breasts. This leaves many healthcare practitioners, from ObGyns to other primary care providers, unprepared to discuss this with their patients or provide sound recommendations. 

The American College of Radiologists, who also publishes the BIRADS standards for breast cancer screening, acknowledges awareness of breast density detection issues with mammography but stops short of recommending routine adjunctive imaging. Instead, they list ultrasound and MRI as “may be appropriate”. [7] We have enough evidence to know how to better serve women with dense breasts, and we can do better. Now we need to push for better education of all primary health care providers, including ObGyns, and continue to raise awareness for women around current knowledge and best practices. 



References
1) Gordon PB. The Impact of Dense Breasts on the Stage of Breast Cancer at Diagnosis: A Review and Options for Supplemental Screening. Curr Oncol. 2022 May 17;29(5):3595-3636.
2) Chiu, S.Y.H.; Duffy, S.; Yen, A.M.F.; Tab├ír, L.; Smith, R.A.; Chen, H.H. Effect of baseline breast density on breast cancer incidence, stage, mortality, and screening parameters: 25-Year follow-up of a Swedish mammographic screening. Cancer Epidemiol. Biomark. Prev. 2010, 19, 1219–1228
3) Harada-Shoji N, Suzuki A, Ishida T, Zheng YF, Narikawa-Shiono Y, Sato-Tadano A, Ohta R, Ohuchi N. Evaluation of Adjunctive Ultrasonography for Breast Cancer Detection Among Women Aged 40-49 Years With Varying Breast Density Undergoing Screening Mammography: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2021 Aug 2;4(8):e2121505
4) Mann, R.M., Athanasiou, A., Baltzer, P.A.T. et al. Breast cancer screening in women with extremely dense breasts recommendations of the European Society of Breast Imaging (EUSOBI). Eur Radiol 32, 4036–4045 (2022).
5) Management of Women With Dense Breasts Diagnosed by Mammography. ACOG Committee Opinion. CO Number 625 March 2015
6) https://uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening
7) American College of Radiology ACR Appropriateness Criteria® Supplemental Breast Cancer Screening Based on Breast Density. 2021

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