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Sick But No Fever? It May Be Swine Flu!

Update September 23, 2009, as reported in today’s U.S. News & World Report:

According to Dr Richard Wenzel, a swine flu expert and former president of the Infectious Diseases Society of America, at the beginning of the H1N1 (swine flu) outbreak in Mexico, only 30 percent of patients hospitalized with the infection had fever initially.  Fifteen (15%) percent of patients never developed a fever at all.  What usually sent them to the hospital was shortness of breath or chest pain. In Chile, about half of those with confirmed H1N1 had no fever; many just had a headache and runny nose. 

______________________________________    Original Post  __________________________________
31 August 2009
A few days ago, I wrote a blog entry which was intended to summarize "everything you need to know about Swine Flu (H1N1)," including links to primary sources.  (For link to that blog entry, click HERE). 
There’s good news and bad news.  The good news is that most cases of the H1N1 flu are mild.  The bad news is that, in a small percentage of people, the virus directly attacks the lung tissue. People with this variant of H1N1 will become severely ill and will need hospital based life support to survive. People particularly at risk include asthmatics and others whose respiratory systems are already compromised, minorities, pregnant women, people with high blood pressure, and the morbidly obese.
What I’m most alarmed about — and the reason for this blog entry — is my fear that current criteria for diagnosing H1N1 will miss significant numbers of infected and contagious people, thus contributing to rapid spread of the illness in the population.  Namely, unlike other types of flu, a person can have flu yet be walking around with no fever.  When fever is used as a primary screening measure, therefore, significant numbers of people will not be diagnosed and will therefore continue to spread germs in the general population. 
Public health authorities have known since April that a significant number of people infected with H1N1 have NO FEVER.  Yet, the USA Center for Disease Control has not revised its criteria for clinical evaluation.  My understanding is that it is being left to individual school districts to create their own policies.  At the present time, in my school district, screening for flu still includes fever as a criterion, even though the evidence shows this will result in a false negative assessment somewhere between 12% and 50% of the time!!   If this is correct, it means that significant numbers of H1N1 cases will not be diagnosed quickly.  
School children are one of the groups most at risk for this flu, since older members of the population seem to have some residual resistance due to swine flu epidemics in the 1950’s and 1960’s.  If children are not screened, diagnosed, and contagious students excluded, the virus could spread like wildfire.
Because of the potentially deadly side of H1N1, the consequences of leaving a contagious student in the the general school population can be very serious.
 

I URGE THAT SCHOOLS REVISE CRITERIA FOR SCHOOL EXCLUSION SO THAT

CRITERIA FOR EXCLUSION FIT THE SYMPTOMS OF THIS FLU!

 

references:

 

Many Swine Flu Cases Have No Fever

By LAWRENCE K. ALTMAN

Published: May 13, 2009 NY Times

TO READ ARTICLE, CLICK HERE

__________

Pandemic Flu Fever Failure Fuels

School Cluster Explosions
Recombinomics Commentary 17:06
August 21, 2009

TO READ ARTICLE, CLICK HERE
____________

Swine Flu: The Next Wave
Wall Street Journal, August 18, 2009

TO READ ARTICLE, CLICK HERE
_______________


Should Fever Be the Main Screening
Tool in School H1N1 Decision Making?


Discussion thread on Flutrackers internet forum

TO READ CLICK HERE

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Swine Flu (H1N1): What You Need to Know

I track flu and other public health threats.  I write this blog entry to help anyone who asks the question, "What do I need to know about swine flu?" or "What can I do to protect myself from pandemic flu?" I rely heavily on the Australian public health information system because it seems to be more proactive about prevention — educating and putting responsibility for preventive measures on the public.  I have mainly cut and pasted information from sources that I deem reliable, with links to each source so that you can read the information for yourself.  I hope you this useful — if you do, please let me know by leaving a comment.   

____________________________________________

H1N1 IS A PANDEMIC FLU

As school returns to fall session in the USA, a new, pandemic flu is sweeping through campuses across the nation. In the first week of classes, Georgia Tech had 150 suspected cases; the University of Kansas had 200 stricken with it. Source: Associated Press via WDSU News   In Aiken County, South Carolina, 52 students were sent home with flu symptoms during the first week of school. (Eleven of those students were confirmed to have been infected with pandemic flu, though at this time further testing for H1N1 has ceased due to its widespread incidence in the population.) Source:  Aiken Standard Newspaper

ORIGIN AND SPREAD OF THE VIRUS WORLDWIDE

It is speculated that the virus now known colloquially as “Swine Flu” originated about ten years ago in Mexico. It became more widespread in December 2008 and was declared pandemic in the summer of 2009. Source: International SOS Clinics It has now become the dominant influenza strain throughout most of the world. Source: WHO

The term “swine flu” does not mean that humans can catch the flu from eating pork. Rather, this is a virus that has mutations that originated from swine. Source: SC DHEC  Technically speaking, the name of the disease is "Influenza A (H1N1)". With declaration of pandemic status, the proper term for the illness is "Pandemic (H1N1) 2009". (The term "pandemic (H1N1) 2009" refers to the disease, and the term “pandemic H1N1/09 virus" refers to the agent.)

At this time, Pandemic H1N1 flu virus is widespread worldwide, but especially so in the Americas. Indeed, there are so many cases that attempts to keep count of numbers have been discontinued in the USA.  Source: USA CDC

Confounding matters, it is widely reported that somewhere between 30% and 50% of swine flu infections may not induce fever.  Because fever has for so long been a main indicator of flu, many infected students may remain in school, thinking they do not have swine flu.  Further, health departments may refuse to test students for H1N1 because they have no fever. Source: NY TimesRecombinomics, Inc.

For a flu tracker map, click HERE

SEVERITY OF ILLNESS

Most cases of H1N1 are mild. An odd feature of the new virus is the lack of fever in a significant proportion of documented cases, even after some patients become seriously ill. Wall St. Journal  In Chile about half of those affected had no fever. In Mexico City, about a third had no fever, and similar patterns have been reported in other places. Source: NY Times 1 NY Times 2.  In the US, fever is used in the case definition, so patients presenting without fever are not even tested.  Coincidentally, the official USA numbers show that 93% of lab confirmed cases have a fever.  However, this is almost certainly linked to the case definition, because in the USA the standard definition of influenza includes a fever.   Recombinomics, Inc.

The absence of fever in H1N1 can be significant in several respects. Absence of fever among substantial proportions of patients, when fever is specified in the definition, can cause serious underestimation of case totals. For example, the CDC by definition only characterizes symptoms formally as "influenza-like illness" (ILI) if there is a fever of 100 degrees or more, body aches, fatigue and a cough or sore throat for which there is no other known cause. Source: USA CDC Secondly, absence of fever limits the usefulness of thermal scans to identify people who have the virus and thus control the pandemic.  This eliminates a handy means of selecting individuals for segregation or quarantine.  Thirdly, absence of fever removes a traditional identifying symptom for flu and therefore keeps infectious individuals in the public environment (e.g. school or workplace).  Lack of identification and separation from the general population thus leads to increased exposure, school clusters, and faster spread throughout the population. Source:  Recombinomics, Inc.

In contrast to the mild cases, there is also a severe form of H1N1 which directly attack lung tissue.  Clinicians from around the world are also reporting that there is a very severe form of H1N1, also found in young and otherwise healthy people. In these patients, the virus directly infects the lung, causing severe respiratory failure. Saving these lives depends on highly specialized and demanding care in intensive care units, usually with long and costly stays. 

To date, most severe cases and deaths have occurred in adults under the age of 50 years, with deaths in the elderly comparatively rare. This age distribution is in contrast with seasonal influenza, where around 90% of severe and fatal cases occur in people 65 years of age or older.

RISK FACTORS FOR SEVERE FORM

Risk factors for the more severe form of the H1N1 infection include obesity, asthma, cardiovascular disease, and diabetes. Pregnant women are also at higher risk.  Source: WHO, NY Times

Minorities and indigenous populations have a particular, increased risk for the severe form. Black and Hispanics are four times more likely than Caucasians to need to be hospitalized for pandemic flu. Source: Associated Press The causes of this difference are not known, though it is suspected there may be a relation to overall health and increased risk factors associated with poverty.  Source: WHO

School Children:  To date, highest attack rates are seen in school children. This is expected for a novel influenza virus, especially considering children’s relatively poor hygiene and lack of social distancing. The virus will likely move upwards into the older siblings and parents and, in later successive waves, to the grandparents. Source: International SOS Clinics

H1N1 and HIV: Early data suggests that people co-infected with H1N1 and HIV are not at increased risk of severe or fatal illness, provided these patients are receiving antiretroviral therapy. In most of these patients, illness caused by H1N1 has been mild, with full recovery. http://www.who.int/csr/disease/swineflu/notes/h1n1_second_wave_20090828/en/index.html

The Aged:  Unlike seasonal flu, older people appear to have less risk. It is theorized that people over the age of 65 may have some natural immunity, perhaps due to circulation of a swine flu virus in the 1950’s. However, due to genetic drift (mutation) of the current virus, the benefit of this immunity is expected to last only one to two years as the virus mutates into new forms. Source: WHO

HOW SWINE FLU IS SPREAD

H1N1 flu is an airborne virus.  It is most likely spreading from person to person in the same way seasonal flu viruses spread: through infectious respiratory droplets. These droplets are expelled when an infected person coughs, sneezes or talks. These droplets can spread about 1 to 2 meters (3-6 feet) before they fall. If they get into a healthy person’s nose or mouth, the person can get infected. (This is called "direct contact".)

Hand hygiene:  Hand hygiene is essential in the reduction of transmission of infectious agents. Hand hygiene includes washing hands with soap and water or cleaning hands with alcohol based products (gels, rinses, foams) that can be used without water.

• If your hands are visibly dirty with respiratory secretions (phlegm, spit), you need to wash them with soap and warm water, scrubbing your wrists, palms, fingers and nails for 15-20 seconds, and then dry with a clean dry towel or paper towel.

• If there is no visible dirt, you could use an alcohol-based hand rub.

• In general, try to keep your hands away from your face.

( source: Australian Dept of Health )

People can also get infected through "indirect contact". The droplets expelled by a sick person can contaminate objects. Flu virus can live on hard surfaces for hours, as long as 2 days. It can get onto people’s hands when they touch something contaminated, such as doorknobs, keyboards, counters, etc. If the person then touches his or her eyes/nose/mouth with their hand, the virus can enter their body.

Influenza may also spread via "aerosol" transmission, where the where the virus floats in the air and infects people. This is particularly possible in crowded places. This is not thought to be a frequent mode of flu transmission, and may only happen in unusual circumstances where ventilation is poor.

Cough and sneeze etiquette:  If you cough or sneeze, you should

• Wear a Facemask if you are coughing and sneezing

• Cover your nose and mouth with a disposable tissue rather than your hands.

If there are no tissues available, cover your nose and mouth with your upper arm rather than your hands. Wash your upper arm (or sleeve) as soon as practical if you have sneezed or coughed into it.

• Dispose of used tissues in the nearest bin.

• Wash your hands afterwards or after touching used tissues.

(source:  Australian Dept of Health)

Any secretions and bodily fluids of someone with H1N1 are considered potentially infectious. This includes vomit, diarrhea and mucus.  (source:  International SOS Medical Clinics)

SYMPTOMS OF SWINE FLU

Initial symptoms of H1N1 are similar to the symptoms of "regular" (seasonal) flu. These are:  fever, body aches, tiredness, headache, runny nose, sore throat and cough. With this virus, people also often have vomiting and diarrhea. Some infected people develop a severe illness, which can include pneumonia and difficulty breathing. Australian CDC

As noted above, however, somewhere between 30% and 50% of cases do not have a fever.  The atypical symptoms with the H1N1 flu, with lack of fever being common, as well as the presence of diarrhea, both of which are unusual in seasonal influenza, are likely to confuse practitioners and lead to delays in diagnosis. Source: Wiki-medpedia (Dr. Richard Wenzel) If you have all the symptoms of flu but no fever, assume that you are contagious and use appropriate precautions to avoid infecting others! 

The incubation period appears to be between one and seven days. People can spread the germs for flu before they begin to feel symptoms and until after symptoms completely disappear.

WHAT TO DO IF YOU GET FLU

Stay at home and keep away from work, school and crowded areas or public gatherings until symptoms have resolved. If medical attention is required, people should consult a medical practitioner by telephone;

Avoid contact with other people where possible;

Cover nose and mouth when coughing and sneezing and, if using tissues, make sure you dispose of them carefully;

Clean hands regularly, and immediately after coughing or sneezing with soap and water or cleanse them with an alcohol-based hand rub;

Alleviate the symptoms: rest, drink plenty of fluids and use a pain reliever for aches. This is adequate for recovery in most cases. A non-aspirin pain reliever should be used by children and young adults because of the risk of Reye’s syndrome

At the present time, the antiviral drugs oseltamivir and zanamivir are effective against the H1N1 virus and reduce the incidence of severe respiratory complications. Source:  WHO. Because these drugs must be administered within 24 to 48 hours of onset of symptoms to be effective, treatment should not be delayed. At present, only a handful of pandemic viruses resistant to oseltamivir have been detected worldwide, despite the administration of many millions of treatment courses of antiviral drugs. Source:  WHO The pandemic flu is resistant to a second class of antivirals, the M2 inhibitors. Source:  Ibid, Australian Dept of Health

Worldwide, most patients infected with the pandemic virus continue to experience typical influenza symptoms and fully recover within a week, even without any form of medical treatment. Healthy patients with uncomplicated illness need not be treated with antivirals.  Source: WHO   Severe cases, however, should be treated immediately with antiviral medications.

DANGER SIGNS

Clinicians, patients, and those providing home-based care need to be alert to danger signs that can signal progression to more severe disease. As progression can be very rapid, medical attention should be sought when any of the following danger signs appear in a person with confirmed or suspected H1N1 infection:

  • shortness of breath, either during physical activity or while resting
  • difficulty in breathing
  • turning blue
  • bloody or coloured sputum
  • chest pain
  • altered mental status
  • high fever that persists beyond 3 days
  • low blood pressure.

In children, danger signs include

  • fast breathing or trouble breathing,
  • bluish or grey skin color,
  • not drinking enough fluids,
  • severe or persistent vomiting,
  • lack of alertness,
  • difficulty in waking up,
  • being so irritable the child does not want to be held,
  • little or no desire to play, and
  • flu symptoms seem to improve but then return. 

Sources: WHOUSA CDC

USE OF FACE MASKS

If you are not sick you do not have to wear a facemask. If you are sick, you should wear a facemask when seeking medical attention or when in close company of vulnerable people.

A household member should wear a facemask if they need to come within one meter (three feet) of an ill person who is not able to wear a mask, particularly if they are in a vulnerable group. 

If you choose to wear a mask you should follow the Facemask procedures below. Wearing a facemask incorrectly or removing or disposing of it improperly can contaminate the wearer’s hands, mouth or eyes with virus, possibly resulting in exposure of the wearer or others to the virus. Sources:  Australian Dept of Health and Aging (Note: The USA CDC seems not to condone use of Facemasks, for reasons unknown to me.   See USA CDC facemask page.  I notice from living in Asia that use of Facemasks as a matter of courtesy to prevent sharing of germs is much more prevalent in Asia.  I speculate this is due to having significantly higher population density, as well as Asian culture in general seems more focused on prevention of illness while American culture seems more focused on intervention after illness.)

A PERSON WITH SWINE FLU SHOULD ISOLATE THEMSELVES AS MUCH AS POSSIBLE

A person ill with flu should be isolated in a different area of the house from the rest of the family. One member of the household should be designated to care for the affected individual. The person caring for the affected individual should use fastidious hygiene, including hand washing and proper use of a face mask. If possible, ventilate the ill person’s room with outside air and disinfect surfaces and doorknobs. 

WHAT YOU CAN DO TO PROTECT YOURSELF FROM SWINE FLU

Wash your hands thoroughly and often. Cover your cough with your sleeve, not your hand. Stay home if you’re sick. Stay away from people who are sick. Eat a healthy diet and get plenty of rest

You can prevent getting infected by avoiding close contact with people who show influenza-like symptoms (trying to maintain a distance of about 1 meter (3 feet) or more, if possible) and taking the following measures:

• Avoid touching your mouth and nose;

• Clean hands thoroughly with soap and water, or clean hands with an alcohol based hand rub on a regular basis;

• Do not visit people who have the flu unless it is absolutely necessary; Eat a healthy diet; get plenty of rest;

When someone in the house has flu it is important that:

  • they clean their hands regularly;
  • the household environment is regularly cleaned; surfaces should be cleaned with disinfectant
  • the person with illness stays home and avoids contact with others; and
  • the person with illness wears a surgical mask or other appropriate face coverings, if possible, when others are in the room,
  • and stays at least 1 meter (3 feet) distant from others.

Sources: State of SC DHEC , Australian Dept Health & Aging

VACCINATION

Significant quantities of H1N1 vaccine will not be available until October. Source: Reuters News Service .  In the northern hemisphere, this is well into the expected fall/winter epidemics.  Source: International SOS Medical Clinics

When H1N1 vaccine is available, it will only protect against H1N1; it will not protect against ordinary seasonal flu. Therefore, individuals who seek to be protected against flu will need to be vaccinated separately for seasonal and pandemic flu. It is not yet known whether the pandemic flu vaccine will require one shot or two. Source: Australian Dept Health  Thus, complete flu protection will require either two or three separate shots.

WORKPLACE PRECAUTIONS

Workplaces should focus on:

• Promoting good hand, respiratory hygiene etiquette and other infection control

practices..

• Ensuring that materials needed for hand and respiratory hygiene are readily

available in the workplace (e.g. tissues and receptacles for their disposal, soap and

hand washing facilities and/or alcohol-based hand sanitizers).

• Encouraging and supporting staff members with acute respiratory illnesses to stay

at home until they are well (that is until their symptoms have completely resolved).

• Encouraging visitors/customers with acute respiratory illness to stay away from the

workplace until they are well (that is until their symptoms have completely

resolved).

SWINE FLU IN THE FUTURE

Waves of anxiety and public concern are affecting social patterns in affected countries. High levels of public concern can lead to disproportionate and discriminatory behavior. Source:  International SOS Clinics .  This in itself could be very disruptive to business and trade, travel, and daily pursuits. This type of disruption was evidenced by the reaction to SARS in 2004. It is hoped that disruption will be minimized by a combination of public education and effective control and treatment of the disease.

A serious concern is the possible mixing of genes from H1N1 (Swine Flu) with H5N1 (Bird Flu). Because H5N1 is currently much more deadly to humans than H1N1, any mixing of genes which resulted in increased human to human transmissibility of H5N1 could be hugely threatening. A much less threatening scenario is if the H1N1 outbreak caused suppression of H5N1 virus outbreaks. Source:  International SOS Clinics

In the final analysis, few of the 6 billion people who live on Earth will escape the H1N1 pandemic, but such global spread will take 3-4 years. A combination of sensible behavior, social distancing, hand and surface hygiene and the use of antivirals and vaccines to protect vulnerable groups should suppress mortality to that experienced in the last pandemic of 1968. Source:  International SOS Clinic

REFERENCES

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Mai Gei Wong Wing Chun (a type of Kung Fu)

 

28 January 2009

Before we went to China, my daughter had studied American Karate.

We promised her that she could continue these studies after we were in China.  This was a bit ignorant on our part. For reasons that don’t need to be stated, Japanese martial arts are not popular in China.  We were also hampered in our efforts to find a martial arts teacher by a couple of other factors.  For one, there is the idea of just finding out where to go.  If you don’t speak the language, how can you even find out where to study?  Secondly, there was a factor involving safety. 

Some of the places we visited were unsafe.  Some didn’t use any safety precautions when they were sparring.  Others used training methods which could damage the body.  One place seemed safe enough, but nothing seemed to be taught, either. 

Fortunately, we eventually found a man I only know as Shifu.  Shi fu is the term which means "Master".  His real name is Wong Nim Yi, and he is a master in the form of martial art called Wing Chun, or Ving Tsun (an alternate spelling).  Here is the English version of his school’s web site: 

click here for Mai Gei Wong Wing Chun

A demonstration of the form may be found at these links: 

Click HERE for Wing Chun Demonstration

and at:

       

(The pole he so deftly maneuvers in this video is about 10 feet long and weighs about 20 lbs., just guesstimating.  About double the length and bulk of a bo staff.)

On a much more personal note, here is a collection of our family photos, along with some video clips, which I’ve made into a slideshow at the following link :

CLICK HERE   (link to slideshow)


(THIS SMILEBOX SLIDE SHOW HAS SEVERAL VIDEOS EMBEDDED SO IT TAKES QUITE A WHILE TO LOAD):


Finally, here is a bit more information.  The Wing Chun school of martial arts has a long heritage that was almost wiped out during the civil war and, later, the cultural revolution.  A museum devoted to Ving Tsun martial arts has been opened at the Wong Fei Hung Temple in Foshan.  The museum has a room dedicated to photographs and history of the art, the Masters, showing as well some equipment.  One of the most interesting things to me was an interactive  video which had demonstrations of various forms such as the "crane" or the "tiger".  Each animal has a characteristic which the practioner seeks to incorporate into the form. At last report, I was told that demonstrations are held every Saturday mornings at 10:00 A.M.   The demonstration includes a Lion Dance.  There are other activities at the temple on Saturday mornings, such as demonstrations of Chinese opera as well.  Like many temples in China, the main part of the temple doesn’t seem to get much use but it has been generally rehabilitated to use as a public gathering place to demonstrate or preserve some shadow of pre-cultural revolution culture. 

To get the temple, take the bus from Guangzhou to Foshan, and exit at the main bus station.  It is just a five minute walk (East, I think) from the bus station to the temple.  The temple itself is a fascinating Daoist place, so plan to spend several hours.  One word of warning, however: do not go unless you are with someone who speaks Chinese.  No English is spoken in Foshan, and this temple is not a well known tourist spot, so a foreigner attempting the trip alone could well run into difficulty.  Taxi’s in Foshan are also not well regulated, and your taxi driver may try to cheat you (not that this doesn’t happen elsewhere, but my luck in Foshan has been particularly bad). A day trip to Foshan ought to also include a trip to the Nanfeng Kiln, the oldest continually operating pottery kiln in the world.  The travel guidebook Lonely Planet has links to these places, but even with the addresses it may be hard to find them without a strong knowledge of Chinese.  There is public bus service between the two locations.  

If this has whetted your appetite, here are two more videos from YouTube.  You can also do a web search for " mai kay wong wing chun kuen".  If you do so, it’s likely you’ll find links to Bruce Lee, because he studied Wing Chun in Foshan (and then added in additional forms of kickboxing to his technique later).   Notice the perfect balance and centering.  When Shifu does a demonstration, at times his hands move so fast that it is not possible to follow them with the eye!  This is a particularly suitable form of martial art for someone with a smaller physique. 

          

An American version with American language explanations: 

  

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Ice Water Diet

This is an update on a new way I have found to lose weight, called the ice water diet.  You diet normally.  Then, you jump in a pool of ice water.  To avoid immediate death from hypothermia, you burst into a flame of speed splashing across the pool.  You burn up all the calories at once that you’ve consumed for the last five days.  Then you go lay in bed the rest of the day to recover. 
 
Actually, to be honest, it’s not really that bad.  I’ve decided it really, truly is an issue of mental attitude!  If I sit there and shiver and think, "boy this sure is cold," well, yeah, it feels like really cold.  Water torture.  But if I tell myself, "this really isn’t so bad," and just swim, then it’s just refreshing.  I can actually make myself feel good or bad at that moment, depending on how I think.  It’s like walking on a razor wire — lean one way or the other, and the whole body goes that way. 
 
The contrast was obvious on Sunday, when David joined me after I was already in the pool and had done a couple of laps.  He thought the water was frigid.  He never got to the point of enjoying the swim.  I, on the other hand, finished the laps I had set out to do and decided to do two more for good measure.  I could have done more, but I didn’t want to overdo it in one day. 
 
This is in pretty sharp contrast to even a few months ago when I first started swimming.  The first time, when it was much warmer, I thought it felt like torture.  It really does get easier over time.  I do truly believe it’s about 95% mental, both in terms of taking the first steps as well as making the decision to stick with it and keep going back every day, even when one doesn’t feel like it.  Then, over time, one does begin to notice a difference in stamina, and it becomes rewarding. 
 
But it definitely doesn’t feel rewarding in the first 20 days.  Those days are just a matter of making the commitment and doing it!  What the cold water actually did for me was to remind me that it truly is all mental, in terms of making myself do it to start with. 

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Harder Bodies Faster Stronger

Epitomizes qualities that make America great:  light hearted, creative, active, well planned and executed, excellent teamwork . . . FUN!   
 
 
Oh, is this about fitness?  Well, maybe so.  Good humor => Good health 
 
 

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The Mental Barrier

I fell off the exercise bandwagon when I got back from Beijing.  I had promised myself that I was either going to swim or bicycle every day.  When I got back, the air was so bad, I felt I couldn’t breathe outside, let alone do aerobic exercise in it.  Then, when the air cleared up, it was because of a cold snap.  But it turned warm again this week, with highs consistently in the ’80’s.  For the last several days, I’ve had really no excuse.  Except, the water in the pool was so darned cold! 
 
I told Song Ying about this.  She’s really supportive of my efforts to exercise.  She exercises every day by riding her bicycle to work, and more, and she thinks I should, too.  When I told her it was so cold to get in the pool, she said, "Just jump in, do your laps, get out and take a hot shower!"  In truth, it’s not the cold water that’s so bad.  It’s the THOUGHT of the cold water!  Getting in the pool involves more in the way of a mental barrier than a physical one! 
 
So today, I did it.  I jumped in that cold water, face first.  It felt like a bath of ice water!  I refrained from yelling.  I thought to myself, the answer is to swim really fast.  So I did.  After half a lap the water felt tolerable.  "This is FRESH," I assured myself!  Really, it was quite refreshing.  However, I swam too fast.  I only did ten laps, then decided I had run out of steam.  It was a start, and tomorrow I’ll do more.  I promise.  So there, and now that I’ve said it, I have to, right?  It’s all a matter of overcoming the mental barrier:  I’ve decided I need to, therefore I will. 

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Exercise Science

So, here’s what I need to do . . .
 
 
Op-Ed Contributor
Exercise on the Brain
By SANDRA AAMODT and SAM WANG
Published: November 8, 2007
Instead of spending money on computer games or puzzles to improve your brain’s health, invest in a gym membership.

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Responsibility

The doctor’s statement came as such as shock that I almost gasped.  Did I hear him correctly?  I was in a neurosurgeon’s office for a third opinion on whether to have surgery to repair a ruptured disc in my neck.  His recommended plan of treatment, and the reason for it, was so completely unexpected that I almost gasped with shock. 
 
I was desperate for a cure for the pain in my neck.  To cope with the pain, I was having to take narcotic pain killers.  Even with narcotics, there were days when I was in so much pain I couldn’t sit up to work at a desk.  On days when I did work, I would be in so much pain afterwards that I couldn’t carry on a conversation with my children when I picked them up from daycare. 
 
It all started when I worked very long hours to complete an appellate brief in a highly contested death penalty case.  I had one week, or maybe ten days, to write a brief which defended the death penalty handed down by a jury to a retarded man after he shot two sisters to death in the parking lot of a Wal Mart store.  During the ten days or so that I worked on that case, I basically worked all day and long hours into the night, including on the weekends, going home basically long enough to eat and sleep.  The transcript of the trial was roughly 3,500 pages long, and there were roughly sixteen, separate issues which needed to be briefed on appeal.  The final copy of my appellate brief ended up being 88 pages long after I had parsed and whittled my arguments into as brief a form as I could possibly make them. 
 
"Ah, relief," I thought, as I submitted my final, bound copies to the state supreme court.  My neck was sore and stiff from working such long hours at my computer desk.  I could hardly turn my head from side to side.  I told my boss I was taking a few days off, and I went home for a much needed rest.  After one day, my neck was no better.  After three days, it was still no better.  I went to an orthopedic doctor.  To my utter shock, he said, "you have a ruptured disc in your neck."  Then he said, "It took a long time to get this way, and it’s going to take a long time to get better."  He sent me to physical therapy where I was given exercises to stretch and strenghten the muscles in my shoulders and neck. 
 
But after months of therapy, I was still in terrible pain.  I had recovered some range of motion in my neck, but the pain was ever present.  That’s when my daughter’s pediatric neurologist agreed to treat me, even though he normally only sees children.  He was the first doctor who felt my pain was worth treating and prescribed pain killers, explaining to me the "pain muscle spasm cycle:"  pain causes muscle spasm, muscle spasm causes pain, and it creates a vicious cycle.  This was the first real breakthrough in my treatment.  But moreoever, he sent me to a neurosurgeon to be evaluated for surgery.  The first neurosurgeon told me I needed surgery, but a second neurosurgeon disagreed.  This third neurosurgeon was, thus, to cast the deciding vote.  So, we are talking a long history, a lot of doctors, and a desperate patient.  The ramifications rippled all through my life, including my ability to work or be a contributing member of my family. 
 
"You don’t need surgery," said this new neurosurgeon.  "Further," he continued, "It’s something you’re doing that is causing this.  It’s a continuing injury.  The body’s natural tendency is to heal itself.  If this weren’t an ongoing injury, you would be better by now.  It’s probably something that you’re doing every day, and you’re the only one who can figure out what it is." 
 
Then, he said the most shocking thing of all:  "No doctor cares enough about you to sort out what is causing this problem with your neck!  You’re going to evaluate everything you’re doing in your life and figure it out on your own!" 
 
"What?!" I thought, utterly taken aback.  "My doctors didn’t care about me?!  A doctor couldn’t figure it out?  A doctor couldn’t fix it?  Did this doctor not care?"  This guy was very brusque.  He wasn’t smiling; he didn’t have a kind demeanor.  Then he elaborated. 
 
"It’s probaby something you’re doing for several hours per day.  You should examine every aspect of how you are using your body every day:  how your desk is set up at work, how your car seat is adjusted, how you are sleeping at night, what your pillow is like.  But the bottom line is, only you can make yourself better.  You’re going to have to figure it out and then do whatever it takes to change it.  It will probably involve a whole change of lifestyle." 
 
I left his office in a state of shock and disbelief.  This man had told me that my doctors didn’t care about me.  He had told me that surgery wouldn’t fix my problem.  He had told me that I was, in fact, on my own to solve the mystery of what was causing this terrible disability and pain.  I thought he was a very callous person, to make light of my obvious suffering. 
 
After the intial shock wore off, however, I realized he was right.  In the end, I’ve come to consider his advice to be the most valuable medical advice I’ve ever received.  His insight did, in fact, point me to the realization of the truth:  the habits that had caused a ruptured disc in my neck were, indeed, continuing habits, related to things I was doing every day.  I researched and learned about ergonomics, particularly proper posture and proper setup of a computer desk. 
 
Because in my job as an appellate lawyer, I was spending hours daily hunched over books in a library or crouched in front of a poorly fitting computer desk:  keyboard, monitor, and chair all at improper heights, with improper arm or back support as well.  Even the angle of my car seat in my car needed to be changed. 
 
And here’s the other fact:  No doctor cares as much about me as I care about myself!  It is only me, and my immediate family, who feel the consequences of health or poor health in a profound way.  Unless the doctor is my friend or relative (and there are some for whom I’ve very grateful), he’s not going to be personally affected if his diagnosis is wrong or if I don’t get better.  So, his investment in me is limited.  "Ten minutes, here’s a prescripton, and that will be ninety dollars, thanks."  This is okay for something simple like strep throat, but when the causes are complex and harder to tease out, it becomes more problematic. 
 
The bottom line is, in fact, that each of us must — absolutely must — take responsibility for our own health.  When we have health issues, it is only through being proactive and self assertive that we will gain insight, knowledge, and appropriate treatment.  If we are lucky enough to have caring, involved doctors who help us with this process, so much the better, but the bottom line is that it is an individual responsiblity.  Health is something we must take personal interest in and responsibility for, it is not a responsibility that can be shifted on to someone else. 
 
Over time, with research and self analysis, I learned about and addressed each of these daily issues, and gradually my symptoms did improve.  Unfortunately, I couldn’t undo the damage that had already been done, but by taking responsibility for and addressing all the things I could do on my own, I did more for myself than any doctor could have done for me. 
 
He was right.  I didn’t need surgery, I needed to change my life.  And nobody could tell me how to do that other than myself.  Thanks, doc.  I remain grateful for those shocking words of advice. 

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Avian Flu Update

Health
Scientists Hope Vigilance Stymies Avian Flu Mutations
By DONALD G. McNEIL Jr.
Published: March 27, 2007
Scientists around the world are racing to study the ways in which H5N1 might mutate to spread easily among humans.
 
 
 

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