Monday, December 31, 2012

Top Ten Brain Posts 2012: #1 ADHD and IQ

The most highly viewed Brain Post of 2012 examined a study of brain development, IQ and ADHD.

ADHD rates are increased in lower IQ children but can be found in those with normal and above normal IQ performance.  

This study looked at a sensitive measure of brain development and compared the structural brain patterns of children with ADHD with low IQ and children with ADHD with normal IQ.

The study found two distinct patterns related to brain development in these two groups:
Low IQ children with ADHD showed delay brain gray matter development in the prefrontal cortex region compared to control children
High IQ children with ADHD had reduced gray matter volume throughout the brain but no focal developmental abnormality patterns

These results suggest more than one brain developmental abnormality in ADHD.  Future studies of brain structure, brain function and genetic risk factors will need to consider controlling for IQ performance.

Photo of blue heron and snowy egret hunting together is from the author's files. 

Top Ten Brain Posts 2012: #2 Cannabis Neurosis

The number two rated Brain Post for 2012 looked at a study of the risk factors associated with the development of cannabis dependence.

This study examined genetic and psychological factors found in a group of 50 individuals with DSM-IV cannabis dependence compared to a control group without a diagnosis of cannabis dependence.

The study found two factors appeared to increase the risk for cannabis dependence.

One factor was a genetic factor involving the proenkephalin gene.  A second factor was high score on a psychological measure of neurosis.  Neurosis is a psychological factor related to risk for a variety of anxiety conditions.

The study found a particularly elevated interaction risk for individuals who had both the high risk proenkephalin genotype as well as high scores on neuroticism.  When both factors were present, risk for cannabis dependence was estimated to be about ten times higher compared to individuals without the high risk gene and with low neuroticism scores.

Legalization of marijuana in some states in the U.S. will provide a natural experiment to look at rates of problems with cannabis use.  Although limited cannabis may be used without major complications in some individuals, others may find increased access leading to development of dependence and related social, medical and behavioral complications.

Photo of Christmas ornament angel from the author's files. 

Friday, December 28, 2012

Top Ten Brain Posts 2012: #3 Brain and Fatigue

Fatigue plays a key role in limiting athletic performance.  Athletes with superior control of the physiology of fatigue have a competitive advantage.

Fatigue with exertion has been felt to be primarily a peripheral phenomenon.  As muscles fatigue, peripheral lactic acid appears to limit continued exertion.

However, in the #3 rated Brain Post of 2012, I reviewed a summary of research showing the brain plays a key role in assessment of fatigue

This review found evidence for the brain insula playing a key role in the central assessment of fatigue.  The insula appears to be a key connection between motor and limbic brain areas of function including assess of fatigue.

The review suggests athletes with better brain control of fatigue may be able to better finish the final stages of competition.

Photo of Christmas ornament angel from the author's files. 

Top Ten Brain Posts 2012: #4 Naltrexone Polydrug Abuse

A significant clinical challenge in the treatment of drug dependence is the common abuse of multiple classes of drugs.  Targeting one specific class of drugs with a pharmacologic intervention may do little to reduce cravings and use of drugs in other classes.

The number four ranked Brain Post in 2012 suggests naltrexone implants may be effective in reducing use of both opiates and stimulants.

One hundred opiate and stimulant abusers participated in a randomized controlled trial research study.  This study used an implantable form of the drug that reduces problems with compliance.

Implantable naltrexone proved superior to placebo implants in study retention (52% vs 28%), proportion of drug free urine samples (38% vs 16%) and clinician rated proportion with good outcomes (56% vs 14%).

This study provides hope for an pharmacologic intervention to be added to standard substance abuse treatment in those with polydrug abuse.

Photo of Christmas ornament angel from the author's files. 

Thursday, December 27, 2012

Top Ten Brain Posts 2012: #5 Depression WMHI

The fifth-ranked Brain Posts blog for 2012 was a review of research related to brain white matter hyperintensities and depression.

White matter hyperintensities (WMHI) are brain changes that can be seen with sensitive imaging techniques such as magnetic resonance imaging (MRI).

These types of changes can be noted in individuals without brain or cognitive symptoms.  The clinical relevance of WMHI are not yet fully understood.  However, some outcome research suggests these changes are related to later risk for stroke, dementia and premature death.

A study of WMHI in elderly individuals from Norway added to our understanding of these brain changes.

Their study quantified the WMHI changes in a series of subjects and examined the relationship between these changes and symptoms of depression.

Individuals with WMHI changes in the frontal lobes had elevated scores on depression and these depressive symptoms tended to persist with time.  Individuals with high burdens of WMHI throughout the brain also had increased risk of depression morbidity.

This study highlights the importance of monitoring for vascular changes in the elderly and looking at potential risk for vascular-related depression.  Persistent depression symptoms in elderly individuals that do not respond to treatment should prompt consideration of medical causes of depression.

Photo of Christmas ornament angel from the author's files.

Top Ten Brain Posts 2012: #6 Opiate Deaths

The number six ranked post for 2012 on Brain Posts was "Risk Factors for Accidental Overdose". This post examined a research study from the VA that looked a series of accidental overdose deaths in Veterans between 2000 and 2006. 

Most of these deaths involved overdose with prescription or illicit drugs.  Often a combination of drugs is implicated in an accidental overdose.  

Risk factors for accidental deaths as expected included a substance abuse or alcohol abuse diagnosis.  Opiate dependence was the strongest risk factor.

However, other psychiatric disorders also increased risk for accidental overdose including: bipolar disorder, major depression, PTSD and schizophrenia.  The take home message from this study is that clinicians treating those with mental disorders should monitor patients for risk of death related to prescription and illicit use.

Another post on a related topic demonstrated that risk for accidental overdose with prescription and illicit opiates has more than doubled in the U.S. over the last decade.  Rates of opiate-related deaths vary widely between states and are highest in states with the highest rates of opiate prescription use of Lortab, Oxycontin, Vicodin and similar drugs.  Public health and law enforcement efforts are underway to reduce the number of accidental opiate overdose deaths.

Photo of Christmas tree angel ornament from the author's files. 

Wednesday, December 26, 2012

Top Ten Brain Post 2012: #7 Tinnitus and Depression

The number seven highest viewed Brain Post blog from 2012 was a review of research related to tinnitus and depression.

In this study, a survey of adults in Sweden examined a series of medical and psychological problems over a period of time.

Individuals with rating of severe tinnitus also endorsed high levels of depression.  Increased depression severity tended to be associated with increased ratings of tinnitus severity.

The authors noted depression and tinnitus appear to "share core symptomatology or stem from a common etiolog

Because depression is a treatable problem, clinicians would be wise to screen for depression in tinnitus clinical populations.  

Photo of manger scene from the author's files.

Top Ten 2012 Brain Posts: #8 Adolescent Brain

The number eight highest ranked post in 2012 was my summary of the TED talk by Dr. Sarah Blakemore.  

In this presentation, she summarizes some of what is known about brain development during adolescents.

Adolescents brains tend to lag in key brain regions and circuits associated with executive function.  The results in increased impulsive behavior and risk taking. 

Significant brain development continues into the early twenties.  Adolescence and early adulthood provides an outstanding window for brain training in cognitive as well as psychomotor tasks.

Photo of manger scene from the author's files.

Monday, December 24, 2012

Top Ten Brain Posts 2012: #9 Antisocial Brain

The number nine most viewed post at Brain Posts for 2012 was a post looking at a research study of brain imaging in antisocial personality disorder.

This study used a functional magnetic resonance imaging technique known as functional connectivity.  The study compared a group of adolescents with a history of physical or sexual assault compared to control adolescents.

The compared the connectivity between brain regions between the antisocial group and control groups along with psychometric scores on empathy and impulsivity.  Antisocial groups tend to show low scores on empathy and high scores on impulsivity.

No brain connectivity differences were found for those with low empathy scores.  However, high impulsivity scores in the antisocial group was linked to reduced connectivity between the brain regions of executive function and control (frontal cortex) and the brain regions of behavior and self-referential cognition.  The authors concluded that adolescent antisocial impulsivity appears to be linked to a delayed maturation of brain circuits linking executive function, self-cognition and behavior.

In a second post on brain imaging study, I reviewed a study showing children with markers for antisocial personality risk showed reduced amygdala response to viewing sad faces.  This brain response may contribute to the lack of social empathy development in those who later emerge with adult antisocial behavior.

Readers with more interest in this topic are invited to click on the link to the original posts were full access is available to the full research manuscripts at the PMID link located at the bottom of the post.

Photo of lorikeet from Tampa Busch Gardens aviary in Tampa, FL from the author's files.

Top Ten 2012 Brain Posts: #10 Best Diets

I would like to thank all the Brain Post readers this year for making this the most successful year for the blog.  Over the next few days, I will highlight the posts from 2012 with the most page visits during the year.

The number ten post came from a review of research study comparing three diets following weight loss.  Weight loss maintenance is as important as weight loss in successful weight loss.

This study followed a series of subjects following weight loss who were randomized to one of three weight maintenance diets:

  • Low fat diet
  • Low glycemic index diet
  • Low carbohydrate diet
In this study, the low fat weight maintenance diet had a relatively poor effect.  It tended to produce the lowest resting energy consumption level.  Although the low carbohydrate diet produced the highest resting metabolic rate, it was inferior to the low glycemic diet on stress and inflammatory markers.

This research study suggested the low glycemic index diet might be the best choice for weight maintenance.  Additional randomized weight maintenance trials will be needed to confirm this finding.

Photo of bird from Busch Garden's aviary in Tampa Bay, FL from the author's files.

Saturday, December 15, 2012


It is with great sadness that we repost this article that we have now posted two times...once as recently as August of this year.  The horrible, ghastly, unconscionable events at Sandy Hook School make us reflect on our children, great-grandchildren, family, friends and the inexcusable violence that exists in our world.  Our keyboard is wet with tears, as we "click" to "post" this once again. We hope to NEVER have to repost this again!!!!  

Recently it was Colorado, then Wisconsin and now Connecticut…where and when will it happen next???

The TV and newspapers are constantly full of images and discussions about very scary happenings: neighborhood shootings, floods, droughts, children starving, wars much more. While some of our great-grandchildren may be too young to read about it or actually watch it on TV, they certainly can hear us all talk about these terrible, frightening tragedies. No matter the age, children sense our fears, anger and concerns, and even though they may not totally understand the specific incident, they internalize our feelings, overt or not…they can read us like an Ipad or Kindle. Their concerns often are displayed in their play and/or discussions with their peers.

Every generation has real dangers to worry about: AIDS, nuclear bombs, presidential assassinations, wars, etc. But it seems that this generation has it more vividly and immediately “in their face”…making it closer to home.

We’ve written about this topic in several venues, but still feel that the person with the BEST perspective was Fred Rogers. While some of our children and grandchildren may not be aware of his great contributions to children and families, we know that after reading this, you too, will be pleased to remember him with great respect. These words of advice apply to ANYONE involved with children.

Helping Children Deal with Tragic Events in the News: Timeless wisdom from Fred Rogers
During his lifetime, Fred Rogers became known for his reassuring way of helping families of young children deal with difficult times, beginning with his response to Robert Kennedy’s assassination. Over the years since then, there have, unfortunately, been other tragic events during which parents and educators turned to him for his calming and thoughtful insight. Fred Rogers’ wisdom is timeless, and his messages continue to be valuable for children and the people who care for them, as we deal with the events of today’s world.

In times of community or world-wide crisis, it’s easy to assume that young children don’t know what’s going on. But one thing’s for sure, children are very sensitive to how their parents feel. They’re keenly aware of the expressions on their parents’ faces and the tone of their voices. Children sense when their parents are really worried, whether they’re watching the news or talking about it with others. No matter what children know about a crisis, it’s especially scary for them to realize that their parents are scared.

Who will take care of me?
In times of crisis, children want to know, “Who will take care of me?” They’re dependent on adults for their survival and security. They’re naturally self-centered. They need to hear very clearly that their parents are doing all they can to take care of them and to keep them safe. They also need to know that people in the government, in their community and in the world, and other people they don’t even know, are working hard to keep them safe, too.

Helping children feel more secure
Play is one of the important ways young children have of dealing with their concerns. But, even playing about the news can be scary and sometimes unsafe. So adults need to be nearby to redirect that kind of play into nurturing themes, such as a hospital for the wounded or a pretend meal for emergency workers. When children are scared and anxious, they might become more dependent, clingy, and afraid to go to bed at night. Whining, aggressive behavior, or toilet accidents may be their way of asking for more comfort from the important adults in their lives. Little by little, as we adults around them become more confident, hopeful and secure, our children probably will, too.

Scary, confusing images
The way that news is presented on television can be quite confusing for a young child. The same video segment may be shown over and over again through the day, as if each showing was a different event. Someone who has died turns up alive and then dies again and again. Children often become very anxious since they don’t understand much about videotaped replays, close-ups, and camera angles. Any televised danger seems close to home to them because the tragic scenes are taking place on the television set right in their own living room. Children can’t tell the difference between what’s close and what’s far away... what’s real and what’s pretend... or what’s new and what’s re-run. The younger the children are, the more likely they are to be interested in the typical news scenes of close-up faces, particularly if the people are expressing strong feelings. When there’s tragic news, the images on TV are most often much too graphic and too disturbing for young children.

Turn off the TV
When there’s something tragic in the news, many parents get concerned about what and how to tell their children. It’s even harder than usual if we’re struggling with our own powerful feelings about what has happened. Adults may be somewhat surprised that their own reactions to a televised crisis are so strong, but great loss and devastation in the news often reawaken our own earlier losses and fears... even some we thought we have “forgotten.” It’s easy to allow ourselves to get drawn into watching televised news of a crisis for hours and hours; however, exposing ourselves to so many tragedies can make us feel hopeless, insecure, and even depressed. We help our children—and ourselves—if we’re able to limit our own television viewing. Our children need us to spend time with them—away from the frightening images on the screen.

Talking and listening
Even if we wanted to, it would be impossible to give our children all the reasons for such things as war, terrorists, abuse, murders, fires, hurricanes, and earthquakes. If they ask questions, our best answer may be to ask them, ”What do you think happened?” If the answer is, “I don’t know,” then the simplest reply might be something like, ”I’m sad about the news, and I’m worried. But I love you, and I’m here to care for you.” If we don’t let children know it’s okay to feel sad and scared, they may try to hide those feelings or think something is wrong with them whenever they do feel that way. They certainly don’t need details of what’s making us sad or scared, but if we can help them accept their own feelings as natural and normal, their feelings will be much more manageable for them. Angry feelings are also part of being human, especially when we feel powerless. One of the most important messages we can give our children is,”It’s okay to be angry, but it’s not okay to hurt ourselves or others.” Besides giving children the right to their anger, we can encourage them to find constructive things to do with their feelings. This way, we’ll be giving them useful tools that will serve them all their life and help them to become the world’s future peacemakers... ...the world’s future “helpers.”

Fred Rogers often told this story about when he was a boy and would see scary things on the news: “My mother would say to me, ’Look for the helpers. You will always find people who are helping.’ To this day, especially in times of ‘disaster,’ I remember my mother’s words and I am always comforted by realizing that there are still so many helpers—so many caring people in this world.”

Helpful hints
• Do your best to keep the television off, or at least limit how much your child sees of any news event.

• Try to keep yourself calm. Your presence can help your child feel more secure.

• Give your child extra comfort and physical affection, like hugs or snuggling up together with a favorite book. Physical comfort goes a long way towards providing security. That closeness can nourish you, too.

• Try to keep regular routines as normal as possible. Children and adults count on familiar patterns of everyday life.

• Plan something that you and your child can enjoy together, like taking a walk or going on a picnic, having some quiet time together or doing something silly. It can help to know there are simple things in life that can help us feel better, both in good times and in bad.

• Even if children don’t mention what they’ve seen or heard in the news, it can help to ask what they think has happened. If parents don’t bring up the subject, children can be left with their misinterpretations. You may be surprised at how much your child has heard from others.

• Focus attention on the helpers, like the police, firemen, doctors, nurses, paramedics and volunteers. It’s reassuring to know there are many caring people who are doing all they can to help in this world.

• Let your child know if you’re making a donation or going to a meeting, writing a letter or e-mail of support, or taking some other action. It can help children know that adults take many different active roles...and that we don’t give in to helplessness in time of crisis.


We encourage you to LISTEN to your great-grandchildren for cues about their anxiety. Children need to know that EVERYONE has fears…but using some of these timeless and time-tested ideas, can help mitigate the intensity.

With deep sadness,
Laurie and June

This material is excerpted with the permission of Family Communications, Inc., from The Mister Rogers Parenting Book. Family communications is the nonprofit company founded by Fred Rogers to produce Mister Rogers’ Neighborhood and a wide variety of material for and about children. The company continues to support Mister Rogers’ Neighborhood in its national broadcast on PBS and to expand Fred Rogers’ legacy in new directions.For more information on Family Communications and Mister Rogers’ Neighborhood, visit their website at Text copyright 2004 Family Communications, Inc

Thursday, December 13, 2012

Does Your Smartphone Know How Smart You Are? IQ Pro iPhone App Review

Smartphones and tablet computers hold the potential to extend the availability of testing intelligence quotient (IQ) and other neuropsychological functions.

So if you use your smartphone to test your IQ your smartphone will know how smart you are.  I recently downloaded and tested the iPhone app IQ Pro.

When you search IQ at the Apple app store you get 1,919 hits.  I selected IQ Pro because it had a high user rating score (4.5 stars out of 5) and appeared to have information about the reliability and validity of the test.

IQ Pro uses a test designed to measure fluid IQ.  Fluid IQ is a concept of intelligence developed by the neuropsychologist Cattell (see reference link below).  Fluid IQ tests are designed to measure problem solving ability in unfamiliar and novel settings.  This is in contrast to estimates of IQ that measure verbal and mathematical skill level.

The figure illustrates this type of fluid IQ task from the IQ Pro app.  Users are provided a series of timed sections where a single correct response is available for a series of patterns or figures.  Users select their response and use the touch screen to move their response to the question box. 

In the app documentation, the Russian developers of this app note that the fluid IQ methods of Cattell are culturally independent and have been studied in various populations including the U.S., U.K., Germany and Czechoslovakia.

This app puts the user through a series of timed sections lasting a total of 35 minutes.  Before each section, users are introduced to the section and practice questions are available before the actual testing period.  

I found the app easy to use.  Some sections I easily completed before the time limit. On others, I was completing the last question as time expired.  There is no feedback on the correctness of responses during the test.  However, after the test is over, users can review their responses and the correct responses.

After completion of the test, the app provides an IQ estimate and a nice plot of your performance against the bell curve distribution of IQ scores in the population.  My score was consistent with other measures of IQ I have previously completed.

This app provides a measure of IQ between 50 and 160.  I know Brain Posts readers represent a high-IQ population, so if your IQ is over 160 this app may not be for you.

The app is free to download and to take one time by the user.  Additionally tests can be purchased at the following rates:
  • 10 additional tests $1.99
  • 100 additional tests $3.99
  • Unlimited tests across multiple devices $7.99

These costs are very reasonable as individual IQ test applications will run $1.99 or less depending on the number of administrations.  Formal IQ  and neuropsychological testing can run into hundreds of dollars.

I would like to see the app provide a measure of score variance such as the 95% confidence interval for IQ based on the test performance.

I was unable to locate an Android IQ Pro app in the Google Play Store.  A version is available for the iPad although my testing was limited to a version on the iPod Touch.

This app has some entertainment value but may be a helpful tool for clinicians, psychologists and educators.  I would like to see more research in the use of this type of app in real world testing.  Smartphone and tablet apps hold the promise of extending cognitive testing into remote third world populations where testing currently has limited availability.

Feel free to comment if you have experience with smartphone and tablet use for cognitive testing purposes.  I will review some additional neuropsychological apps in future posts.

Figure of screen shot from the IQ Pro app is from the author's files.

Cattell, R. (1963). Theory of fluid and crystallized intelligence: A critical experiment. Journal of Educational Psychology, 54 (1), 1-22 DOI: 10.1037/h0046743

Wednesday, December 12, 2012

Smartphone Apps in Medicine: Review

In a previous post, I examined a research survey of smartphone app use by medical students and junior physicians in the United Kingdom.  I would like to follow up on this topic by summarizing a recent review of  the smartphone in medicine.

Ozdalga and colleagues from Stanford University Hospital recently published results of literature review on this topic in the Journal of Medical Internet Research.

Their study examined all published research studies with the search term smartphone and similar terms, i.e. iPhone through May 2012.

I will summarize key findings from their review by the four categories outlined in their manuscript.  I will highlight some of the noteworthy apps and the author's assessment of the current status and future of smartphone apps in medicine.

Patient Care and Monitoring
  • iWander: This app is designed for patients with early Alzheimer's.  It employs GPS technology to track the patient 24/7.  When GPS indicates location outside a specific range, the patient is triggered by smartphone to respond and confirm status.  Failure to confirm status by the patient results in emergency notification of the patient's family and primary care physician.
  • Diabeo: This diabetes app collects self-measured plasma glucose levels, dietary carbohydrate levels and physical activity via accelerometer data.  The data is then analyzed with individualized insulin dose recommendations.  A controlled study in France found use of the Diabeo app by patients with type 1 diabetes resulted in better diabetes control compared to patients using only standard office visit monitoring.
  • Smartphone apps are in use and in development to provide mobile tech monitoring for ECG, ultrasonography and blood flow measurement.

Health Apps for the Layperson
  • Lose It! and Calorie Counter: These two apps and others provide a system for monitoring and recording daily calorie consumption as part of a weight loss program.  However, the authors note that many wellness apps fail to incorporate current medical research and guidelines in their programs.
  • iTriage: This app provides patients emergency medical information including location of nearest emergency rooms and current waiting times.  Additionally, patients can provide basic information through the app prior to arrival at the emergency room.

Communication, Education, and Research
  • Electronic medical record providers are beginning to incorporate smartphone apps into medical records systems.  An app by Epic Systems allows physicians access to patient medical records via their smartphones
  • Outbreak Near Me:  The authors note this app is a collaborative project between Googe and the U.S. Centers of Disease Control.  It locates users and provides information about infectious disease outbreaks geographically close to the user.

Physician and Student Reference Apps
  • Popular medical references used by physicians have smartphone apps for on-the-go access to important clinical information.  These apps include drug reference resources such as Epocrates and antibiotic selection references including Johns Hopkins Antibiotic Guide and the Sanford Guide to Antimicrobial Therapy reference.  One advantage of smartphone reference apps is the ability for the apps to be instantly updated providing more current information that found in hard copy references that may be only updated every year or more.  These types of reference apps also are easy for physicians to adopt as often have experience with the hard copy reference before using the smartphone app.
  • Diagnosaurus:  This app provides lists of diagnoses to use in differential diagnosis for a variety of symptom and sign categories.  The app may prompt physicians to consider diagnoses that may have been initially overlooked in clinical practice.
  • Doximity: Physicians with a medical license can access this app that the authors note is like a "Facebook for doctors".

The authors note a significant problem in smartphone apps is the variability in quality of health information.  This opens the door for errors by patients in self diagnosis.  

Additionally, the authors also note many physicians and patients may not adopt smartphones limiting the implementation of current and future apps.

In summary, this review documents the emerging development and use of a variety of smartphone apps in medicine.  The question of whether smartphone apps will improve population health is unknown and needs to be an important research focus in the future.   However, the authors conclude "the smartphone may one day be recognized as a diagnostic and therapeutic tool that is as irreplaceable as the stethoscope has been in the practice of medicine".

I would agree with this assessment of the potential of smartphone apps in medicine.  Having the capability of a portable computer in your smartphone should be used to contribute to the evolution of high-tech patient care.

Readers with interest in this topic can find the full access article by clicking on the DOI link in the reference below.

Diagnosaurus app screen shot from an iPod Touch is from the author's files. 

Ozdalga, E., Ozdalga, A., & Ahuja, N. (2012). The Smartphone in Medicine: A Review of Current and Potential Use Among Physicians and Students Journal of Medical Internet Research, 14 (5) DOI: 10.2196/jmir.1994

Monday, December 10, 2012

Are Physicians Using Medical Smartphone Apps?

The number and types of medical apps for physicians and other medical providers is rapidly increasing.  Smart phone apps (i.e. iPhone and Android apps) have the potential to allow physicians real time access to medical records, treatment guidelines and medical reference information. 

As these apps increase in number and type, it will be important to understand the facilitators and barriers to implementation in the medical setting.  Additionally, research will be needed to document whether physician apps actually improve the quality of care.  What seems in theory to be important, may fall short in actual clinical practice settings.

A recent survey of medical student and junior physician use of smartphone apps in the UK has recently been published in the journal BioMed Central.  Karl Frederick Braekken Payne and colleagues surveyed 257 medical students and 131 junior physicians about their ownership and use of smartphones and smartphone apps.

Seventy nine percent of the UK medical students surveyed owned a smartphone with the iPhone being the most common type (3:1 over the an Android smartphone).  Among junior physicians surveyed, 75% owned a smart phone again with the iPhone owning a significant 4:1 advantage.  The following key findings were documented in the study:
Medical students used their smartphones for both medical school education and clinical rotation functions
  • The majority of users had relatively few medical related apps (1-5 apps) on their smartphones
  • The majority of junior resident physicians used their medical related smartphone apps 20 minutes per day or less
  • Medical students were more likely to use their smartphone apps more than 20 minutes per day in clinical rotations

The attached chart shows they types of medical related smartphone apps that were used often, very often or constantly in the medical student and junior physician groups.

The medical student group tended to more frequently use drug reference, disease management and procedure/case documentation apps compared to the junior physician group.

The junior physician group tended to use medical calculator/clinical score apps more frequently.  It is unclear whether these trends represent true cohort differences between medical students and junior physicians or a tendency with increased skill level to become less reliant on smartphone app use.

One of the barriers to smartphone and smartphone app use in the study was cost.  Medical students and junior physician noted device cost and app cost were barriers to medical related smartphone app implementation.

The survey also showed that medical students and junior physicians at times did not use available apps in the presence of patients or medical supervisors.  One concern was that smartphone app use could be misinterpreted as just checking personal email or web-surfing.

There would seem to be an important opportunity to grow the use of smartphones for documentation of educational experiences.  Medical students and junior physicians are increasingly required to document the number and type of procedure experiences during training.  The smartphone (with central backup) would seem to be an important tool for this process.

The research study authors conclude that their survey showed "junior doctors and medical students are overwhelmingly enthusiastic and endorse organisational associated apps that help their learning activities".  Clearly there are also barriers that need to be overcome.

It will be important that medical related app development be paired with research studies of their implementation and value of such devices in the medical care setting.

Readers with more interest in the details of this survey can access the free article by clicking on the PMID link below.

Top figure is an iPod screen shot of the medical related drug reference app Epocrates from the author's files.

The figure is an original figure for this post produced from data provided in the manuscript.

Payne KF, Wharrad H, & Watts K (2012). Smartphone and medical related App use among medical students and junior doctors in the United Kingdom (UK): a regional survey. BMC medical informatics and decision making, 12 PMID: 23110712

Thursday, December 6, 2012

Can Exercise Reduce Stroke Damage?

This is the fourth and final post is a series focusing on exercise and the brain.  In the first post, I reviewed research documenting the brain's role in exercise fatigue.  The second post examined the hypothesis that aerobic physical activity had a key evolutionary role in the growth of brain size in humans.  The third post focused on animal study research supporting a role for exercise in reducing vulnerability to anxiety by changes in the 5-HT2C serotonin receptor.

In this post, I will review a provocative study suggesting that physical fitness and it's effect on brain vascular health, may limit the brain damage produced by stroke.

Dunn and colleagues at the University of Calgary in Canada conducted an experiment in rats that has recently been published in the journal PLOS ONE.  They noted that in the mammalian brain a chemical called hypoxia inducible factor, or HIF-1alpha, exists that improves "the capacity of tissue to survive low oxygen conditions".   They hypothesized that manipulation of environmental factors that increase HIF-1alpha may serve as a potential mechanism to reduce the brain damage associated with hypoxic events.

In their study, rather than exercise, they exposed rats to hypoxia by placing them in a 1/2 atmosphere environment for three weeks.  This results in brain changes that can also be seen with aerobic exercise including:
  • Increase in capillary density by up to 30%
  • Increase in brain oxygen partial pressure by up to 40%

The hypoxia-exposed experimental rat group was then compared to a group of control rats following stroke simulation by occlusion of the middle cerebral artery for one hour.  They then compared the stroke outcome of the case and control groups and noted the following key findings:
  • Case rats had an increase in total hemoglobin, total hematocrit, capillary density and brain tissue oxygen level prior to the stroke simulation
  • Absolute brain volume of stroke damage assessed by magnetic resonance imaging was reduced by 52% in the case group compared to controls
  • Case rats showed no motor behavioral deficits 48 hours after the stroke simulation while control rats showed continued motor deficits
  • Case rats showed a reduction in brain inflammation post stroke simulation measured by levels of lymphocyte infiltration and number of macrophages

The authors note in their discussion, that one clinical implication from their study relates to humans living in high altitudes under chronic acclimation to hypoxia.  They note there is limited study of stroke in these populations.  There is some human research showing that chronic high-altitude hypoxia with increased hemoglobin and hematocrit might actually lead to a higher incidence of stroke.  However, individuals living at high-altitude might be expected to have a better stroke outcome due to other adaptive brain mechanisms associated with acclimation to hypoxia.

The authors also note their study supports additional research in humans for ways to increase brain neuroplasticity through stimulation of HIF-1alpha.  This might be accomplished by a high baseline rate of aerobic exercise or use of pharmacological agents such as desferoxamine.

Such interventions in high-risk stroke populations (i.e. those who have had a transient ischemic attack) may lead to reduction in brain damage related to future stroke events. 

For the general population, this study suggests one benefit of aerobic exercise might include reduction in both the risk for stroke and a better outcome if one occurs.

For free access to this study, select the PMID link from the reference below. 

Photo of blue jay is from the author's files.

Dunn JF, Wu Y, Zhao Z, Srinivasan S, & Natah SS (2012). Training the brain to survive stroke. PloS one, 7 (9) PMID: 23028788

Wednesday, December 5, 2012


As with the calendar, our blogs over the years always seem to come around to the holidays and the perils and pleasures they bring (see: Ho Ho Hum The holidays are usually hard work, but they can also be fun. You may be chosen to be the caregiver(s) of the grand/great grandchildren while there is school vacation and parents are at work. As we have said many times it means you need to take care of yourself in order to handle all the extra errands, activities, and stresses of the holidays. You have a better chance of enjoying the season and your family if you are in good health (have you had your flu shot?) and plan ahead.

Eat Sensibly and Take Care of Yourself
This is not the time to skimp on sleep or turn to junk foods. They are an unhealthy and expensive solution. Plan ahead by cooking meals that can be made in double batches, such as stews, soups, and casseroles. Freeze the second batch, add a salad, and you'll have a nutritious meal ready to serve.

If you need to buy gifts try to shop by yourself. It really does go faster and there’s less stress. Protect yourself from overdoing things. It doesn't do anything for your disposition, your family, or your work to feel over-committed and under-appreciated.

Make Lists and Set Limits
If you've got a long list of adults and children to buy gifts for, make a list for adults, and another for the children. If the list of adults is too long, think about drawing names so that each adult buys only one item and gets only one item. That way the gift giving ritual can be more appropriately focused on the kids.

Keep in mind that advertisers target your great/grandchildren, who will want everything that is marketed to them. However, it’s a good idea for you to make a list and a holiday spending budget, and stick to it. Remember to check with the parents as to what is OK and what is off-limits.

If you decide to make purchases online, be aware of the expensive shipping costs, especially when you have waited to order closer to the holiday. However, many online sites offer free shipping (with a minimum purchase) and you might find it more effective than dealing with driving or using public transportation to a mall.

The Holiday Spirit
The holidays are a good time to help your great/grand children understand the importance of sharing with those in need. Think about the gifts that the children can make and give: cards, gift wrapping, baking cookies, etc. There are many charities that collect toys, food and clothes for those who are less fortunate or have survived a disaster. Check with the parents about possible gifts the children can make or give to deliver to a charity of their or your choice. Police and Fire Stations are also very thankful for homemade goodies the children can make.

Also, kids are NEVER too young to write or draw “Thank-You” notes. Have some blank card/paper ready to go, for the younger kids, and ask them to draw a “thank-you picture”. The older children can write a short “thank-you” note. The cards go a long way: children learn some basic courtesy skills, and the recipient of the card feels gratified.

Children Shopping For Others
If you become the person in charge of helping the children buy for others, we still like the $.99 Store solution that we have touted before for Mothers’ Day (see: 99 Cents for Mother’s Day Another idea would be to take your phone/camera, or have the parents take a phone/camera, to a toy store, sporting goods store, animal shelter or other favorite places to purchase gifts, and have the children take pictures of what each one “could not live without”. Be sure each photo shows the shelf price and name of the item. When finished, you’ll have a “virtual catalog”, which you can share with other family members who need to buy gifts. You may even be able to find the same things online or cheaper at other stores, if you have the time and inclination to bargain shop. Again, make sure to check out all the children’s choices with the parents, before buying anything.

Have Sensible Expectations
If the family will be spending extended time at your home during these days, have some pre-planned activities to do with the children. (see: A Few Of Our Favorite Things, Above all, remember, some of the stress at this time of year can come from trying to do too much. Make this a time to share with your family and friends, by planning, prioritizing and being kind to yourself.

  Hallelujah, Felicidades and don’t eat too many latkes!

PS. If you want to go back and look at other blog we’ve written regarding holidays and gifts, see:
GIFTS, MORE GIFTS AND EVEN MORE GIFTS…