Author: DENT Neurologic Institute

Cannabis: A Medical Update | Facebook Live Recap

During the Facebook Live we went over what is new in the Cannabis world. The Dent Cannabis Clinic sees about 115 Cannabis patients on a daily basis.  We have over 30 individuals seeing patients for various reasons for using Cannabis. When we talk about Cannabis, there are three types of Cannabis: recreational, Medical, and Hemp-based products. 

 

Type 1: Recreational Cannabis

 

Recreational Cannabis is what you hear about smoking and is legal in 10 states. 

“I don’t deal with that [recreational Cannabis],” Dr. Mechtler says. “It is hard for me to support recreational Cannabis when individuals have to smoke it. At the end of the day, I’m a Physician. For me to promote smoking, when I have been anti-smoking my whole career, would be very difficult.”

When Recreational and Medical Cannabis are compared, there is a huge difference. Recreational Cannabis is mostly high THC and low CBD. Naturally, the plant does not produce a lot of CBD. There are some exceptions to the rule, but the higher the CBD content, the higher the price of the product. 

 

Type 2: Medical Cannabis

 

Legal in 33 states, including New York State, Medical Cannabis allows the physician to change the THC to CBD ratio to help with specific medical disorders, many of which are neurological. This includes, but is not limited to: MS, ALS, Neuropathy, Spinal Cord Injury, Epilepsy and HIV. In New York State, they added Chronic Pain, Substance Abuse and Opioid Abuse.

“With these indications, we can now look at a patient at our Cannabis Clinic,” Dr. Mechtler explains. “Most of our patients come here because of Chronic Pain, but other disorders also happen. We see close to 10% of all patients in New York State.

 

Type 3: Hemp-Based CBD Products

 

 The Hemp Farm Act of 2018 that was signed in December 2018 has lead to hemp-based CBD products being sold nationally. It comes from the same plant. The difference between hemp and recreational cannabis is that in hemp, you have less than 0.3% THC. 

“That number is very important. Once it is above 0.3% THC, it is not legal to sell in stores,” says Dr. Mechtler. “It is very low THC and high CBD. People who are looking for CBD are looking for its health benefits. The are four main health benefits of CBD. The first is that It’s an anti-inflammatory, like ibuprofen but without the stomach problems. Second, it is a pain killer, but without the problems of Opioids, such as addiction. Third, it is an anxiety medication without the side effects. Lastly, it helps you sleep without the side effects of Ambien.”

CBD is natural with minimum side effects. This is something that can help anybody, and is a product you can find almost everywhere.

 

Be cautious of where you buy CBD

 

The problem with CBD right now is that it is not regulated. Arno Hazekamp did a study where  he bought 46 different CBD products online. These products were checked to see what exactly the CBD content was. The CBD content was 0 in 39% of these products. This tells us that there is a 39% chance that the product you have does not have any CBD. The other problem is that the THC level in the products were high. Some of them were 57% THC. Those products should not be legal, but it is not regulated. 

Products with CBD need to be regulated and third-party tested. What does that mean? This means that when you buy a CBD product, look for a QR code. The QR code, when scanned, will give you all the information about the product from a third party. It will tell you what is in the product you just bought. 

“There are two things you have to look for,” says Dr. Mechtler. “First, what is the actual CBD content and what is the THC content? That is very important. Second, you are looking for what we call contaminants. These products can have contaminants such as: heavy metals, insecticides, pesticides, and fungus.” 

Not all products have third party testing, as it could make the product more expensive. In addition, not all third party testing tests for contaminants. As a consumer you need to understand that what you are buying is not regulated by the government. 

At Dent, a full spectrum physician formulated CBD stored located on the first floor, called Mend. Mendis a retail hemp-based CBD store owned by Jushi, Inc as is a tenant within the Dent Tower building in Amherst. Dent is not affiliated with the store, however, our providers believe in the high quality products that it produces and feel strongly that our patients can benefit from utilizing their products.

The Mend products are third-party tested for CBD and THC amounts, as well as for contaminants. They offer soft gels, lotion, and tincture (eye drop in the mouth).  The formula is based on the research from Dent. 

 

The MORE Act 

 

New legislation waiting to be passed in New York, called the MORE Act,  states the change in federal law to take Cannabis off of the Controlled Substance Act, which is category one. This will allow researchers in Cannabis to see more patients and do research without the any issues with the federal government. The MORE Act is hoped to be passed by the end of this year.

 

Retrospective Cannabis Research in the Elderly Population

 

One of the unique things about Dent is the amount of patients we see. However, current legislation makes it difficult to do prospective research. A prospective study watches for outcomes, such as the development of a disease, during the study period and relates this to other factors such as suspected risk or protection factor(s). The study usually involves taking a cohort of subjects and watching them over a long period. 

What we are able to do is retrospective research. A retrospective study looks backwards and examines exposures to suspected risk or protection factors in relation to an outcome that is established at the start of the study. It has been difficult to tell providers what to give patients because we do not have that data. The things that you typically have with a pharmaceutical medication, like dosage and safety, we don’t have yet with Cannabis.

“What we have been doing is creating a database and looking at different patient populations to see what works, what doesn’t work, what is safe and what is not safe,” explains Paul Hart, Research Assistant at Dent. 

This last year, the researchers at Dent looked closely at how the Elderly population reacted to Cannabis. What dosage can they receive while having the least amount of side effects? This research was presented at the  American Academy of Neurology (AAN), and it was selected for press release. That means that the AAN saw our research, thought that it was beneficial enough and helpful enough to be presented at their annual meeting. 

“Our research had the average population age of about 81 years. This population is probably on several different medications, and has different side effects from those medications,” explains Hart. “If they switch to Cannabis as an alternative, they should have fewer side effects. We found that only 30% of patients had side effects, and of that, half were resolved from changing.”

One of the focuses is to get patients off of Opioids to help ensure our patients do not form an addiction or have serious side effects. Although we have a long way to go, a solid foundation has been put into place from our funding.

 

Chronic Migraine and Cannabis

 

Chronic Migraine is a debilitating disease that affects millions of Americans. The Dent research team looked at 316 patients at Dent who incorporated Cannabis into their Chronic Migraine plan. 

“We looked at Quantitative data, numbers that we can find out from patients, but also Qualitative,” explained Vincent Bargnes, Research Assistant at Dent. “We took a look at what numbers we can pull from how Cannabis has been affecting these patients, but also the non-number things, see how it makes them feel.”

The research team at Dent saw an improvement in 88% of our patients. There was also a decrease in monthly headache days – from about 24 days to about 17. Additionally, we found that 56% of patients who were on Opioids reduce the amount of Opioids. Improvements in anxiety, mood and sleep were also found.  “It was very, very well tolerated with minimal side effects,” explains Bargnes. 

With excellent results, the Dent team has been trying to get these findings published. Unfortunately, the finding have been rejected by both organizations that Dent has submitted to. 

“This is the problem in cannabis research,” Dr. Mechtler explains. “Not only does the Federal Government give us a difficulty using cannabis in research on human beings even though it’s been used as 12,000 years. But also, the establishment of medicine is resistant to the science that we are producing here, which is very unfortunate. Now trust me, we are not giving up, we are moving forward and will find a journal that will publish our findings.”

 

The Cost of Cannabis

 

We see that the average cost of treatment is about $200 a month. The Dent Research team looked at underserved populations to get a better understanding of cost as a factor of their treatment plan.

The Dent Research team ran a study that looked at 1,200 people that are in the Cannabis Clinic and looked to see how they are doing with Medical Cannabis. “What we found is that 80% of all people that use Medical Cannabis had some positive outcome from using the treatment,” explains Chris Ralyea, Research Assistant at Dent. “We also saw that in the underserved populations, the ability to afford medical cannabis went down significantly. The retention rates in what we call normal populations at about 70%. In the underserved population, the retention rate was about 50%.” This means we are losing half the underserved population, visit after visit. 

What is the Opioid use? Are we able to reduce the amount of Opioids our patients are using? “We found that about 36% of all patients included in this study were able to reduce their use of Opioids by using Medical Cannabis, even if it was a lower dosage than what we recommend here in our clinic,” explains Ralyea. 

 

Geriatric Research

 

The geriatric research had patients from 75 to 102 years old. Age is not an issue. “Our publications showed that in that population, we don’t see significant side effects. So, it’s safe,” reports Dr. Mechtler. “We don’t see people getting high. Nobody comes to us because they want to abuse Medical Cannabis.”

 

Dr. Laszlo Mechter is also working with an insurance company in Western New York to do some research with Albany to see what happens when you pay for Medical Cannabis. “I can tell you right now, some initial research has shown that people who take Medical Cannabis save payers a significant amount of money on the use of other drugs,” explains Dr. Mechtler. “I have so many patients that throw away 4-5 medications since they have been on Medical Cannabis.”

 

 

The Dent Cannabis Clinic
 

One of the biggest complaints we have received is the wait time for an appointment at the Cannabis Clinic. “We have added more providers on, and are excited to say that our wait time is cut down,” says Amanda McFayden, DENT Cannabis Clinic Program Director. “Right now we are accepting referrals.”

To be seen at the Dent Cannabis Clinic, have your primary doctor fill out the Cannabis Clinic referral form. Once we receive that form, it will be reviewed and you will be put with the appropriate provider. We do not accept workers comp older than 2 years. We do not accept self-pay, we go through insurance. Feel free to call 716-250-2000 for any further questions. For more information, click here.

 

 

 

22 Facts About the Brain | World Brain Day

The brain is a very complex part of your body. It has the ability to send and receive a large amount of information. Because of this, there are still many mysteries about the human brain. Here are some quick facts to help you understand the most complicated organ in your body.

 

1. Multitasking is impossible

When we think we’re multitasking, we’re actually context-switching. That is, we’re quickly switching back-and-forth between different tasks, rather than doing them at the same time. The book Brain Rules explains how detrimental “multitasking” can be: Research shows your error rate goes up 50 percent and it takes you twice as long to do things.

 

2. An adult brain weighs about 3 pounds

The cerebrum makes up 85% of the brain’s weight, and the brain makes up about 2% of a human’s body weight. The texture of the brain is like a firm jelly. The heaviest normal human brain weighed 4.43 pounds. It belonged to the Russian Writer Ivan Turgenev. And the smallest brain, just 2.41 pounds, belonged to a woman.

 

3. About 75% of the brain is made up of water

This means that dehydration, even as small as 2%, can have a negative effect on brain functions. Dehydration and a loss of sodium and electrolytes can cause acute changes in memory and attention. To prevent any loss of body or brain function, take steps to keep your body properly hydrated.

 

4. The human brain will triple its size the first year of life

 A two year old baby will have an 80% fully grown brain. It will continue to grow until you’re about 18 years old. It isn’t until about the age of 25 that the human brain reaches full maturity. The human brain is the largest brain of all vertebrates relative to body size.

 

5. Headaches are caused by a chemical reaction

Chemical activity in your brain, the nerves or blood vessels surrounding your skull, or the muscles of your head and neck (or some combination of these factors) can play a role in primary headaches. Serotonin is a chemical necessary for communication between nerve cells. When serotonin or estrogen levels change, the result for some is a headache or migraine. Serotonin levels may affect both sexes, while fluctuating estrogen levels affect women only.

 

6. The human brain contains approximately one hundred billion neurons 

This is about the same as the number of stars in the Milky Way galaxy. These neurons are connected by trillions of connections, or synapses. Experts call this a “neuron forest”. Information runs between these neurons in your brain for everything we see, think, or do. These neurons move information at different speeds. The fastest speed for information to pass between neurons is about 250 mph. That being said, neurons only make up 10% of the brain.

 

7. It is a myth that humans only use 10% of our brain

We actually use all of it. We’re even using more than 10 percent when we sleep. Although it’s true that at any given moment all of the brain’s regions are not concurrently firing, brain researchers using imaging technology have shown that, like the body’s muscles, most are continually active over a 24-hour period.

 

8. Cholesterol is key to learning and memory

The brain has a higher cholesterol content than any other organ.  In fact, about 25% of the body’s cholesterol resides within the brain. The brain is highly dependent on cholesterol, but its cholesterol metabolism is unique. Because the blood-brain barrier prevents brain cells from taking up cholesterol from the blood, the brain must produce its own cholesterol. The brain’s cholesterol is much more stable than the cholesterol in other organs, but when it breaks down, it is recycled into new cholesterol right in the brain.

 

9. Dreams are believed to be a combination of imagination, physiological factors, and neurological factors

The limbic system in the mid-brain deals with emotions in both waking and dreaming and includes the amygdala, which is mostly associated with fear and is especially active during dreams. Dreams are proof that your brain is working even when you are sleeping. The average human has about 4-7 dreams per night.

 

10. Short term memory lasts about 20-30 seconds

This has to do with your brain’s capacity for holding small amounts of information in the active mind. The brain keeps this information in an available state for easy access, but only does so for about a minute and a half. Most people hold memory for numbers around 7 seconds, and memory for letters around 9 seconds. In addition, the brain can store up to 7 digits in its working memory. That is why the telephone numbers in the United States are 7 digits long.

 

11. A brain freeze is really a warning signal

Officially called a sphenopalatine ganglioneuralgia, a brain freeze happens when you eat or drink something that’s too cold. It chills the blood vessels and arteries in the very back of the throat, including the ones that take blood to your brain. These constrict when they’re cold and open back up when they’re warm again, causing the pain in your forehead. This is your brain telling you to stop what you are doing to prevent unwanted changes due to temperature. 

 

12. The brain can’t feel pain

There are no pain receptors in the brain itself. But the meninges (coverings around the brain), periosteum (coverings on the bones), and the scalp all have pain receptors. Surgery can be done on the brain and technically the brain does not feel that pain.

 

13. The human brain gets smaller as we get older

Human brain keeps developing until you are in your late 40s. It is the only organ in the human body to undergo development for such a long time. It also sees more changes than any other organ. Around mid-life, the brain will begin to shrink. However, size doesn’t matter in the brain. There is no evidence that a larger brain is smarter than a smaller one.

 

14. Alcohol effects your brain in ways that include blurred vision, slurred speaking, an unsteady walk, and more

These usually disappear once you become sober again. However, if you drink often for long periods of time, there is evidence that alcohol can affect your brain permanently and not reverse once you become sober again. Long term effects include memory issues and some reduced cognitive function.

 

15. Your brain is a random thought generator

In 2005, the National Science Foundation published an article regarding research about human thoughts per day. The average person has about 12,000 to 60,000 thoughts per day. Of those, 95% are exactly the same repetitive thoughts as the day before and about 80% are negative.

 

16. Your brain uses 20% of the oxygen and blood in your body

Your brain needs a constant supply of oxygen. As little as five minutes without oxygen can cause some brain cells to die, leading to severe brain damage. Also, the harder you think, the more oxygen and fuel your brain will use from your blood – up to 50%. 

 Every minute, 750-1,000 milliliters of blood flows through the brain. This is enough to fill a bottle of wine or liter bottle of soda.

 

17. Exercise is just as good for your brain as it is for your body

Aerobic exercise raises your heart rate and increases blood flow to your brain. As your increased breathing pumps more oxygen into your bloodstream, more oxygen is delivered to your brain. This leads to neurogenesis—or the production of neurons—in certain parts of your brain that control memory and thinking.  Neurogenesis increases brain volume, and this cognitive reserve is believed to help buffer against the effects of dementia. 

It has been noted that exercise promotes the production of neurotrophins, leading to greater brain plasticity, and therefore, better memory and learning. In addition to neurotrophins, exercise also results in an increase in neurotransmitters in the brain, specifically serotonin and norepinephrine, which boost information processing and mood.

 

18. The visual areas of the brain are in the back

The part of your brain responsible for vision, the occipital lobe, is located in the back. This is why if you get banged in the back of your head, you will see stars. The left side of your brain controls the vision on your right side, and vise versa. Your brain also processes sound on the opposite sides of the head.

 

19. Brain activity can power a small light bulb

When you are awake, your brain generates about 12-25 watts of electricity – which is enough to power a small light bulb. The brain also works fast. The information going from your arms/legs to your brain travels at a speed of 150-260 miles per hour. The brain consumes glucose from the body to produce this amount of the energy.

 

20. Reading out loud uses different brain circuits than reading silently

 Reading aloud promotes brain development. Children first learn to read by speaking words out loud. Once that knowledge is established, then they learn to read to themselves. It’s indeed one of the strange facts about the brain because we usually teach our children to read and talk politely. But to promote brain development in your child, you should read and talk aloud in front of them.

 

21. Your brain is mostly fat

Consisting of minimum 60% fat, your brain is the fattiest organ in your body. This is why healthy fats, such as omega-3s and omega-6s, are vital for brain and overall body health. Healthy fat helps stabilize the cell walls in the brain. It can also reduce inflammation and helps the immune system function properly. 

 

22. Sleep is imperative 

Your body and brain require rest in order to function properly. Judgement, memory, and reaction time can all be impaired when someone does not have enough sleep. This is due to the fact that sleep deprivation kills brain cells. Proper sleep is also essential for memory retention. During sleep, the brain accumulates all the memories from the day.

Feeling tired? Go ahead and yawn. Yawning cools down the brain, research suggests. Sleep deprivation raises brain temperature.

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The complexity of the brain is hard to understand – even for doctors and scientists. DENT provides the highest quality and compassionate patient care to the Western New York region, the direct result of a tireless commitment to staying on the forefront of medical advances and breakthrough technology.

By maintaining valuable partnerships with other specialized clinicians, and a dedication to employing the brightest minds in the medical and clinical research fields, you can rest assured knowing when you come to DENT you are receiving the best care possible. 

If you or someone you know is interested in being seen at DENT, click here.

 

 

 

 

 

Resources:

72 Amazing Human Brain Facts (Based on the Latest Science)

How a Migraine Happens

A tour inside the brain

PTSD: The Evolutionary Truth | PTSD Awareness Day

In the 1950’s, Post Traumatic Stress Disorder was often stigmatized in popular culture after the Vietnam conflict, and this stigma was portrayed in many popular films and shows. The misunderstanding of PTSD slowly began to change in 1980, when it was recognized as a specific condition with identifiable symptoms. Since then, PTSD is listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.

In 2010, the US Senate officially designated June 27th as National PTSD (Post Traumatic Stress Disorder) Awareness Day.  Staff Sergeant Joe Biel died in 2007 after suffering from PTSD; Biel committed suicide after his return from duty to his home state. SSgt. Biel’s birthday, June 27, was selected as the official PTSD Awareness Day, which is now observed every year.

Organizations that work with anyone at risk for this condition use this day to get information about symptoms and treatments out to the public. Our hope is that the more people that know about this disorder, the more people will recognize the symptoms and get treatment. PTSD is not exclusive to veterans or currently serving members of the United States military, but a portion of those who serve are definitely at risk for PTSD.

 

PTSD can affect anyone

 

Dr. Capote, Medical Director of the Division of Neuropsychiatry at DENT, speaks about who statistically is most likely to have PTSD. “When people typically hear PTSD, they think of violence or sexual assault. They are surprised to hear that automobile accidents are statistically the most likely event to cause PTSD.”

According to the American Psychological Association, car accidents are the leading cause of PTSD among the civilian (non-military) population.  Not everyone experiences the same PTSD symptoms. 

“There are varying degrees of PTSD,” says Dr. Capote, “People [who were in car accidents] may experience resistance getting into a car, might feel very uneasy, or might experience flashbacks when crossing the area of the accident. For others, the traumatic event can unleash an ongoing process of symptoms.”

For those who were in a car accident, avoidance symptoms can display themselves in three ways: driving phobias, limitations on driving, and anxious behaviors as passengers. 

 

 

Can we predict PTSD?

 

“Genetically, we can predict PTSD,” explains Dr. Capote. “People with serotonin transport problems are more likely to be affected.”

There is increasing evidence that those with PTSD show abnormalities in serotonin function. It is documented that different types of acute stress result in an increase in 5-HT (serotonin receptors) turnover in the medial prefrontal cortex, nucleus accumbens, amygdala and lateral hypothalamus in experimental animals. This can lead to a higher chance of PTSD symptoms, such as anxiety.  Furthermore, patients with PTSD had decreased platelet paroxetine binding, which suggests alterations in the serotonin receptors. 

Recently, several studies suggest close interactions between serotonergic and γ-aminobutyric acid (GABA)-ergic systems. Mice lacking the 5-HT1A receptor display marked anxiety, and animals exposed to stress exhibit down-regulation of 5-HT1A receptors. Moreover, this suggests a pathological pathway originating from 5-HT1A receptor deficit leading towards dysfunctions within GABAergic systems, resulting in increased levels of anxiety.

Research has found that 90% of US citizens are exposed to at least one traumatic event in their life, while others are exposed to more than one. “What is interesting is that if your serotonin is in tact, you can have massive amounts of trauma and not get PTSD,” says Dr. Capote.

 

The criteria

 

Any person can get PTSD at any age. Not everyone with PTSD has been through an extreme event. Someone can start showing symptoms of PTSD after a family member or friend experiences danger or harm, or when a loved one unexpectedly dies. 

“Really, the criteria is trauma in which the individual has a loss of life or limb, or an expectation of loss of life or limb. There is no objective measure of the trauma it takes to cause PTSD. It is in the context of each individuals experience and expectations,” says Dr. Capote.

 

Symptoms to look out for

 

Being exposed to a traumatic event is scary. It is very common to experience any number of symptoms associated with PTSD, including:

  • Feelings of anxiety and increased heart rate when you are faced with reminders of the event
  • Nightmares
  • Frightened thoughts
  • Staying away from places, objects or events that are reminders of that experience
  • Feeling emotionally numb
  • Feeling strong guilt, depression or worry
  • Losing interest in activities that were once enjoyable
  • Having trouble remembering the event
  • Being easily startled
  • Feeling tense or “on edge”
  • Having difficulty sleeping
  • Angry outbursts

It’s natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a few weeks and become an ongoing problem, it might be PTSD. Some people with PTSD don’t show any symptoms for weeks or months. 

 

Why does it happen?

 

These symptoms may occur as your body’s natural response to a traumatic event. Above all, these symptoms are designed to keep you aware of potential dangers and prevent you from experiencing that event again. 

“Essentially, we are talking about the triggering of the evolutionary mechanisms and developments in the brain,” explains Dr. Capote. “Not wanting the repetition of [a traumatic] event could be useful for preservation in the future. There is the belief that evolution has favored anxiety problems because it does help the species to continue to propagate.”  

 

How is PTSD diagnosed and treated?

 

A doctor who has experience helping people with mental illnesses, such as a psychiatrist or psychologist, can diagnose PTSD. The diagnosis is made after the doctor talks with the person who has symptoms of PTSD.

“While there are some medications for PTSD and new ones being studied, there is very strong evidence for cognitive behavior therapy as EMDR,” Dr. Capote explains. 

EMDR is a unique, nontraditional form of psychotherapy designed to diminish negative feelings associated with memories of traumatic events. Unlike most forms of talk therapy, EMDR focuses less on the traumatic event itself and more on the disturbing emotions and symptoms that result from the event. 

However, you don’t want to have tunnel vision when it comes to treatment. “That would be like having diabetes and only focusing on insulin. For PTSD, there is medication, therapy, good sleep, the Mediterranean diet and exercise. Not even drastic exercise, just small things you can incorporate in to make it a lifestyle,” says Dr. Capote. Additionally, he emphasizes that treatment is not one size fits all. “It’s about coming together with a plan that incorporate all domains of being a human being, and discussing solutions.” 

Seeking an experienced doctor in this field? Learn more here.

 

What to expect from your first visit

 

It can be scary and overwhelming when visiting a doctor for the first time. Here is what you can expect:

  • A frank discuss of what is bothering you, with a thorough review of all the different contributors or potential contributors from the situation
  • An assessment for a fuller understanding of the problem

  • From there, we go on to discuss potential solutions

  • It is important that everyone understands that PTSD treatment is not a one size fits all kind of thing

Our goal at the DENT Neurologic Institute is to expand psychiatric services and to improve psychiatric care in Western New York. We treat adult patients for a wide range of mental illnesses and addiction disorders including depression, anxiety, schizophrenia, bipolar disorder, and more. Over the years, our psychiatric team has continued to grow which has allowed for increased access to care as well as an expansion treatment modalities such as ECT, TMS, and psychotherapy.

If you or someone you know is looking to see one of our medical professionals, call 716-250-2000 or learn more by clicking here.

 

 

 

 

The content of this post is intended for general educational and informational purposes only; it does not constitute medical advice.  Readers should always consult with a licensed healthcare professional for diagnosis and treatment.

We are what we eat: a link between diet and PTSD symptoms

With 4 out of 5 people experiencing a traumatic event, there is a good chance you or someone you know has Post Traumatic Stress Disorder (PTSD). The symptoms of flashbacks, intense fear and nightmares are quick to appear, but slow to disappear.  Research tells us how to effectively treat PTSD. 

 

Diet and PTSD

 

Traditional treatments, like medication or therapy, are life changing treatments for some who experience PTSD symptoms. Many people are looking to incorporate other methods to improve mental health. Improving your diet is something that everyone can, and should, do. Not only is our diet something we relatively can control, eating is something we do several times a day.

Additionally, nutrition plays a key role in the function and structure of our brain and body.  A link between mental and and food was recently found. A study was conducted to see if a dietary intervention would impact those with moderate to severe depression. In this trial, 67 adults meeting the DSM-IV criteria for a major depressive episode and reporting poor dietary quality were evaluated.  They were randomly assigned to either seven sessions with a Dietitian for Dietary Support, or to an intensity matched social support control condition. This study also did an economic evaluation, taking into consideration the costs. After the study was complete, they found that a dietary support intervention was found to be a cost-effective treatment for depression from both health sector and social perspectives. 

 

We are what we eat

 

In Australia, a study aimed to investigate the association between fruit and vegetable consumption and psychological distress in those who are 45 years or older. They concluded that increasing fruit and vegetable consumption could help reduce psychological distress of middle age and older adults. Furthermore, an additional study was conducted that linked depression and anxiety with unhealthy dietary patterns. These studies are a big reminder that mental health and physical health are fundamentally connected and aggravate each other.  PTSD involves oxidative stress, brain chemical irregularities and mitochondrial dysfunction. A change in your eating lifestyle can have a positive influence on this. 

 

Eating tips for good mental health

 

  • Incorporate coping strategies that do not involve food
  • Include foods that promote gut health: garlic, yogurt, leeks Jerusalem artichoke, kefir, foods rich in dietary fiber (whole grain and plant foods), and colorful fruits and vegetables
  • Moderate red meat consumption may be beneficial for depression and anxiety
  • Implement sustainable changes, as evidence supports the importance of long-term diet for mental health
    • Swapping out an unhealthy snack with a healthy one
    • Eating vegetables at each meal
  • Limit intake of processed food
  • Follow traditional dietary patterns 

 

Other PTSD treatments

 

Psychotherapy Services
DENT Neurologic Institute offers psychotherapy services to assist patients with managing psychiatric symptoms, behavioral issues and interpersonal difficulties. These symptoms and struggles often have a significant impact on the patient’s ability to function as well as on their quality of life. Our providers work with patients and their support systems to create a treatment plan that is tailored to the patient’s specific short and long-term goals.

TMS Therapy 
Transcranial Magnetic Stimulation (TMS) Therapy is a state-of-the-art treatment utilized by our doctors to help treat adult patients with major depressive disorder. The treatment utilizes short pulses of a focused magnetic field to stimulate nerve cells in the area of the brain thought to control mood. This brief painless treatment is performed in a quiet, comfortable setting under the supervision of a psychiatrist and is done while the patient is awake and alert.

Electroconvulsive Therapy (ECT)
Finally, Dent Neurologic Institute offers ECT for relief of major depression, bipolar disorder and other serious mental illness. We are proud to be the first and only in Western New York to provide this highly effective treatment in an office-based setting as opposed to the traditional hospital setting. Our welcoming atmosphere helps ease the anxiety and tension that often accompanies patients who undergo ECT.  

If you or someone you know is looking to see one of our medical professionals, call 716-250-2000 or learn more by clicking here.

 

 

 

 

The content of this post is intended for general educational and informational purposes only; it does not constitute medical advice.  Readers should always consult with a licensed healthcare professional for diagnosis and treatment.

Facebook Live Recap: Managing Difficult Caregiver Emotions

On June 12th at noon, we went live with Sarah Harlock, Program Director for the Dent Integrative Center for Memory. We discussed Managing Difficult Caregiver Emotions, a topic that comes up regularly in support groups, classes, and general discussion.

Caring for someone with Alzheimer’s Disease or Dementia poses some special and unique challenges. As a result, caregivers very frequently experience higher levels of anxiety and stress.  Reports have shown that 30% – 40% of family caregivers who are caring for someone with Alzheimer’s or Dementia are experiencing depression. Caregivers can also experience: frustration, fear, guilt and resentment.

 

The diagnosis aftermath

 

When someone receives that diagnosis, there is no question that is is very difficult.  It is hard on the caregivers as well. Everyone’s life changes after that diagnosis. “I want people to recognize that it is not all doom and gloom,” Sarah says, “It can feel very heavy and negative. But, there are moments of joy and really important moments that are going to happen on this care-giving journey.”

 

New relationships, skills, and strengths

 

Through support groups or classes, there are new people you will meet during your journey. You also may form a new form of an existing relationship, such as sibling who are taking care of a loved one together, or partners who were independent, but start to depend on each other after the diagnosis.  New skills will be developed throughout this process. You might be in control of banking for the first time, or have to take over cooking. Strengths will be developed from this.

“When you have the opportunity, if you can step back and just reflect on all the things you have done and learned and all the effort you have put in into care-giving, I hope you are as amazed by yourself as we, as professionals, are when we talk to you. The love and compassion that people put into care-giving is really amazing”, Sarah adds in.

 

The different emotions

 

Since these diseases are things that change over time, it is realistic to think that your emotions will also change over time. Be prepared that down the road, you may have more struggles or you could develop supports to help aid you in care-giving. Emotions are signals, and some of these signals mean that you need to make a change to alleviate difficulties. Two emotions come up frequently for care-giving: guilt and depression. 

 

Guilt

 

Guilt is complex, but there is a purpose for guilt. It brings our behavior in alignment with our moral compass.

Sarah explains this feeling: “Think of an example where you you’ve done something wrong. You’ve wronged somebody or hurt their feelings. Whether you meant to or not, if it caused pain to another person, you feel it. I don’t know about you, but I feel it in the pit of my stomach. I know I have done something that doesn’t fit with who I really am or the person that I should be. So, that feeling in the pit of my stomach is a signal that my behavior was not in alignment with my moral compass, and I need to pull my behavior back in line.” 

What caregivers are often experiencing is “unjust guilt”. You are feeling guilty, but you didn’t cause this pain to this person and you did not wrong them. Sometimes we bring it on ourselves and sometimes, other people expect us to do more. Very often, it is our own expectations of ourselves that fuels that guilt. 

Caregivers can also feel guilt after losing their cool and maybe yell back or snap at the person they are care-giving for. There is never any harm in asking for forgiveness. Again, this is a signal that you need to be taking some steps or making some changes. It is important to be comfortable with the fact that being is “perfect” caregiver may not be attainable.  Your intentions are good but your time, resources and skills are limited. Try to get comfortable with that gap between perfection and reality, and stop beating yourself up for it. 

 

Depression

 

Statistics say that 30% – 40% of care-givers of people with dementia will experience and suffer from depression. It is important that care-givers, or someone who supports a care-giver, monitors the emotional health of a care-giver. 

“I do remember a phone call from a couple. She had just received the diagnosis and she she was devastated by this diagnosis. Her husband was saying ‘I’m literally calling you from our bed. We’re lying in bed, we can’t even get up and start our day.’ And that’s how pervasive this very heavy, heavy depressive feeling was for them”, says Sarah.

There is a significant portion of care-givers that actually qualify as clinically depressed and are suffering from the diagnostic criteria of major depression. This is not just the feeling of being blue, and it passes in a day. We are talking people experiencing pervasive and a consistently low mood.

Depression can come out in a lot of different ways besides sadness. It can come out in a short-temper, lack of focus, or inability to complete tasks. “The first thing that I recommend it that you talk to your primary care doctor. I think that is really important. If you don’t want to take medication, there are other things you can do.”

 

The importance of exercise and diet

 

There is all kinds of evidence out there that talks about the impact of exercise on mood. Start with something enjoyable. It could be a walk up and down your driveway. If you can’t leave your loved one and your loved one can’t join you,  some movement chair exercises are very appropriate and effective. 

Additionally, your diet can play a very large role in how you are feeling.

“If your diet is heavily processed if it is loaded with sugars you know it’s it’s definitely going to have an impact on your mood and your energy levels so where you can you want to make sure that you’re introducing fresh fruits and vegetables and that you are trying to make your diet as healthy as you can, because that also will impact energy levels and mood”, Sarah explains.

 

Finding joy in small moments

 

Finding moments of joy throughout your day can be really tough. It is a thing caregivers struggle with. There are many different things you can do, but a gratitude journal is a great way to start. Find one thing in your day that made you smile and feel good.  It could be a nice sunset, something someone said that made you laugh, a great article you read, a funny video, or drinking a nice cup of coffee while it is still hot.

Once you start looking for those moments, you find them more often. These are not things that will improve your mood overnight, but gradually. 

 

Caregiver counseling

 

Sarah also mentions counseling: ” I would also encourage you to consider counseling. We have people that actually specialize in counseling very specific challenges of caregiving. Those kinds of opportunities exist as well.” Sometimes, it takes that objective person to get our thoughts out of our head and help us organize them. That objective person can help you recognize how you are feeling, what your goals are, and how you want to get there.

Not all techniques work for everyone. It is worth giving them a try. Ignoring any emotions you experience while caregiving will not help, so finding ways to manage them is incredibly important. “There has never been a need for you to be a perfect caregiver – only a caregiver that cares”, Sarah Harlock says.

 View the entire presentation by clicking here.

 

 

 

 

The content of this post is intended for general educational and informational purposes only; it does not constitute medical advice.  Readers should always consult with a licensed healthcare professional for diagnosis and treatment.

 

PTSD affects everyone differently

 

The brain responds differently for every person after being exposed to trauma. After a traumatic event, it is normal to feel anxious, afraid or upset. These events include, but are not limited to: violent crimes, car accidents, loved ones in danger, war, and natural disasters. For some people, these feelings fade within a few weeks. Others continue to have these feelings for months or years afterwards.  They might experience reliving the event, flashbacks, negative thoughts, and a sense of nervousness.  This is Post Traumatic Stress Disorder (PTSD).

 

How do the symptoms differ?
 

Females may have PTSD symptoms longer than males. Before diagnosis and treatment, females have symptoms for 4 years, and males for 1 year. Females are more likely to:

  • Feel depressed and anxious
  • Be easily startled
  • Have more trouble feeling emotions
  • Avoid any triggers of the trauma

Males are more likely to have problems with alcohol and drugs after the traumatic event.

“It’s very common that people will try to self-medicate. They’ll try to use alcohol and drug substances to change that experience that they are having” says Dr. Horacio A. Capote, Medical Director of the Division of Neuropsychiatry at DENT.

Males and females both develop physical health problems in tandem with their PTSD symptoms.

 

Different brain responses
 

In experimental studies, the right amygdala, right rostral anterior cingulate cortex (ACC) and dorsal ACC showed more activation in females than males, when exposed to fearful stimuli.  This side of the brain is particularly associated with negative emotions.  These same brain areas are involved in stress response, mind-body awareness and emotional reactivity.  A different study used physiological measures to show that females experience fear more easily than males when exposed to fearful stimuli.

In terms of stress, females show more of an emotional and ruminative response. Ruminating about your triggers can make impact worse if it stops you from taking action. Males are more likely to engage in problem-solving.

 

Who is at risk?
 

An intensely scary or dangerous event can cause anyone to have PTSD. At least 4 out of 5 people experience a traumatic event in their lifetime.  The more serious the trauma is the higher PTSD risk.

Females are twice as more likely to develop PTSD than males.  About 1 in 10 females will develop PTSD in their lifetime. However, medical data from several VA centers have noted that male veterans were more likely to have healthcare visits or diagnosis of PTSD than females (22% vs 17%).

 

How is PTSD diagnosed?
 

PTSD is diagnosed by a medical professional.  Our goal at the DENT Neurologic Institute is to expand psychiatric services and to improve psychiatric care in Western New York. “Many of these problems are brain diseases, and we are very well situated to understand the brain. We work with it in an appropriate and helpful way, without being confrontational and stigmatizing” adds Dr. Capote.

We treat adult patients for a wide range of mental illnesses and addiction disorders including PTSD, depression, anxiety, schizophrenia, bipolar disorder, and more. Over the years, our psychiatric team has continued to grow which has allowed for increased access to care as well as expansion treatment modalities such as ECT, TMS, and psychotherapy. If you or someone you know is looking to see one of our medical professionals, call 716-250-2000 or learn more by clicking here.

 

 

 

Can exercise help with PTSD Symptoms? 

Recent research has revealed that exercise can help patients with anxiety disorders reduce their symptoms.  Post-Traumatic Stress Disorder (PTSD) is a severe anxiety disorder resulting from exposure to trauma. Flashbacks, personality changes, disturbed sleep, mood swings, startle responses, nightmares, anxiety, low self-esteem or depression are often experienced in those with PTSD. Understanding the way that PTSD impacts someone’s mental and physical health can be crucial for a successful treatment plan.

“Part of what we do is to educate the patient. To tell them, ‘Hey, this is an expected problem with this condition. It is part of your condition’… We can study it to understand what is going on and treat it.” – Dr. Capote, Medical Director of the Division of Neuropsychiatry at DENT.

 

Previous Research
 

It is thought that those who exercise regularly are less likely to suffer from anxiety and depression, which are severe symptoms of PTSD.

A study conducted in 2005 asked PTSD sufferers to participate in a 12 week long aerobic exercise program. Researchers reported positive results in participants’ moods and reduced levels of anxiety. This study was published in the International Journal of Emergency Mental Health. They saw results as early as one month into the study.

 

Evolved Studies
 

More recently, a study was done through the University of West Florida. This study was part of a master’s thesis in Exercise Science, and was designed to provide the control group empirically validated treatment for comparison that had been missed in the previous studies.

This study followed 14 women who had been survivors of rape through an eight-week treatment period. All women attended cognitive-behavioral therapy sessions, held bi-weekly. Seven of the women (50%) also participated in physical training classes two times per week. At the eight week mark, those who have engaged in physical exercise revealed more progress. Their progress was measured by the Checklist for Post Traumatic Symptoms. This is a questionnaire used to assess trauma.

 

Results in veterans
 

Researchers at Loughborough University have looked over many studies that reviewed the impact of sport and physical activity on combat veterans diagnosed with PTSD. They found that physical activity enhances the well-being of the veterans.

Aerobic exercise reduces depression symptoms and helps prevent the abuse of drugs. However, some veterans might have complications that prevent them from completing vigorous exercise.  Less physically demanding exercise, like yoga, is another option. Recent research shows that yoga may help individuals with PTSD focus on the present, reduce rumination, and combat negative thinking patterns.

 

Why does exercise help?
 

Exercise stimulates the brain’s release of endorphins. These chemicals are responsible for producing feelings of well-being. Exercise can suppress and reduce chemicals within the body related to anxiety and depression.

Exercise tires the body, which results in sleep coming a little more easily.  Physical activity can also lead to a boost in self-esteem and positive feelings of control over one’s body.

 

The importance of hope
 

The reduction of symptoms seems to appear due to the sense of determination and hope, increased quality of life and the cultivation of positive self-identity. Participating in physical activity helps one gain or regain a sense of achievement.

 

Here at Dent, our goal is to expand psychiatric services and to improve psychiatric care in Western New York. We treat adult patients for a wide range of mental illnesses and addiction disorders including depression, anxiety, schizophrenia, bipolar disorder, and more. Over the years, our psychiatric team has continued to grow which has allowed for increased access to care as well as expansion treatment modalities such as ECT, TMS, and psychotherapy.

“Because of all our different focuses at Dent, we actually have a more complete, holistic approach.” – Dr. Capote. If you or someone you know is looking for our Psychiatry Center, click here for more information.

 

 

 

What is MEND? FAQ’s about the new physician formulated CBD store located in Dent Tower.

On Monday, June 3rd, Mend will be opening up in Dent Tower at 9am. With CBD stores and products appearing everywhere, why choose Mend? Mend has one clear focus: a pure formula at an affordable price.

“Our research is based on clinical data from over 8,000 patients in our Dent Research Institute” – Dr. Mechtler, Dent Institute’s medical director and director of the cannabis clinic. Below are some FAQ’s related to this store opening.

 

What is CBD? Is there any THC?
 

Cannabidiol (CBD) is a non-psychoactive product that is from cannabis or hemp. It is different from marijuana, which has more THC (the psychoactive ingredient). Patients who have chronic pain and chronic inflammation as well as sleep trouble have had excellent results from CBD.

The cannabis plant contains hundreds of different phytochemicals including cannabinoids, terpenes, and other compounds. Full spectrum CBD or hemp oil generally refers to products that not only contain CBD but contain the other plant molecules as well. This version of CBD oil is minimally refined, leaving most of the cannabinoids and terpenes intact and in the oil.

Full spectrum, also called “whole plant,” means the full plant extract is included. Full spectrum provides more of the plant’s molecules in ratios and amounts that nature intended.

There are indications that show cannabinoids and terpenes work together to influence each other. This synergistic effect is called the entourage effect and has seen CBD work with THC to reduce the effects of a high and CBD to influence one’s own cannabinoid receptors.

Mend is a full spectrum CBD product store. There is less than 0.3% THC in CBD products. There is no risk for psychoactive effect with these products.

 

Who can buy products from Mend?
 

Mend is open to the public. You do not need to be a patient at Dent to buy the products; however, we encourage anyone who wants to establish a relationship with an experienced provider to discuss their medical condition and learn more about proper dosing and what would work best for them to call our office at 716-250-2000 to schedule a consultation. All Dent patients will get $5 off all products. 

CBD does not require a prescription. You do not need a medical marijuana card to buy products at this location, as these products are not part of the NYS Medical Marijuana Program.

If you are interested in becoming a patient in the NYS Medical Marijuana Program, please visit our website at www.dentinstitute.com and click on the cannabis clinic logo to print off a referral form for your provider to complete and submit to us.

 

What products will be sold?
 

The initial product line will consist of: Soft Gel Capsules, Lotions and Tinctures. Soon, a hemp derived CBD lozenge will be added to the product line. The prices for these products are:

Tincture: $50

Soft Gels: $60

Lotion: $65

Keep a look out for new additions as they come along, the Mend line will continue to develop new and exciting products!

What are the ingredients in each product?

 

Mend Tincture: CBD, Medium Chain Triglyceride (MCT) oil

Mend Soft Gels: CBD, Medium Chain Triglyceride (MCT) oil, glycerin

Mend Lotion: CBD, Water (Aqua), Butylene Glycol, Glyceryl Stearate, Propylene Glycol Dicaprylate/Dicaprate, Glycerin, C12-15 Alkyl Benzoate, Cetyl Alcohol, Stearic Acid, Sodium Lauryl Sulfate, Phenoxyethanol, Triethanolamine, Polyacrylamide, C13-14 Isoparaffin, Laureth-7, Carbomer, Methylparaben, BHT, Propylparaben, Menthol, Camphor, Disodium Edta, Aloe Barbadensis Leaf Juice, Tocopheryl Acetate

*All products contain less than 0.3% THC. Store at room temperature, away from sunlight. 

 

Is there an option to purchase online?
 

The store will be opening June 3rd and online purchases will be soon to follow. The store will be cash only for the first couple weeks. *UPDATE: the store is now accepting credit cards!

 

Is Mend affiliated with Dent?

 

MEND is a retail hemp-based CBD store owned by Jushi, Inc as is a tenant within the DENT Tower building in Amherst. DENT is not affiliated with the store, however, our providers believe in the high quality products that it produces and feel strongly that our patients can benefit from utilizing their products.

 

Why buy from Mend?
 

  • Third party lab testing
  • Physician formulated
  • High quality product
  • Products come with recommendation on dosing and titration based upon years of research, specialized for each condition.

 

As of now, CBD is not regulated. We believe in top-quality, highly compliant products. We track everything and third-party test everything.

“Most products on the shelves might just be vegetable oil with a sprinkle of hemp extract. You want a product that’s standardized for CBD content. We look at the lab tests for heavy metals and toxins” – Steven Przybyla, Sounds Wellness LLC company president.

Dosage is not the only thing that is important….it’s the purity of the CBD. “Physician formulated means that it’s under our supervision, and going forward, we’ll continue to modify these products,” said Dr. Laszlo Mechtler.

 

The Mend Store is opening June 3rd at 9am. Business hours will initially be from 9am – 5pm. It will be located at Dent Tower: 3980 Sheridan Drive, Amherst, NY 14226. You can contact the store by calling 716-466-MEND or emailing info@soundwellnessllc.com

Types of Headaches

37 million people worldwide are affected by migraine or another severe headache disorder. Although migraine may be the most well-known type of headache disorder, clinicians have identified more than 150 diagnostic categories for headaches resulting from a wide range causes. Initially, headaches are classified as either primary headache disorders or secondary headache disorders, depending on the cause of the headache. 

We sat down with Attending Neurologist and Headache Specialist at DENT, Dr. Shivang Joshi, who explained a few of the many types of headache disorders.  

Types of Headaches

Primary headaches occur independently and are not caused by an underlying medical condition.

Types of primary headaches include:

  • Migraine
  • Cluster
  • Tension-Type

Secondary headaches result from another medical condition such as hormone imbalances, injury or tumor.

Secondary headaches can be caused by underlying conditions including, but not limited to:

  • Fever
  • Infection
  • Medication overuse
  • Stress or emotional conflict
  • High blood pressure
  • Psychiatric disorders
  • Head injury or trauma
  • Stroke
  • Tumors
  • Nerve disorders

Migraine vs. Headache

Migraine is a type of headache disorder with specific symptoms, like throbbing pain, which can be moderate to severe in intensity and is typically located on one side of the head. According to the American Migraine Foundation, clinically, migraine is defined as “if within an individual’s lifetime there have occurred 5 or more attacks of unprovoked headache lasting 4-72 hours, severe enough to markedly restrict or even prohibit routine daily activity and accompanied by nausea or light/ sound sensitivity.”

“Most persons with migraines prefer to lie down and not move. Sometimes, migraine can also be associated with visual symptoms such as squiggly lines, flashes of lights with different colors this phenomenon is commonly referred to as migraine aura,” said Joshi.

Although migraine is the most common headache disorder, you can still be treated for headaches even you do not have migraine!

“You may have tension type headaches or another type of headaches. Treatment of headaches usually involves, identifying triggers, dietary or lifestyle medications, medications for prevention of headache as well as medications that are taken at the onset of headache,” said Joshi.

When Should I Consult a Doctor about My Headaches?

According to the Mayo Clinic, you should see a doctor if you experience headaches that:

  • Occur more often than usual
  • Are more severe than usual
  • Worsen or don’t improve with appropriate use of over-the-counter drugs
  • Keep you from working, sleeping or participating in normal activities
  • Cause you distress, and you would like to find treatment options that enable you to control them better

“Generally, when there is a change in quality, character or frequency of your headache you may want to seek medical evaluation,” said Dr. Joshi.

“Other factors include new onset headaches after the age 40, or headaches associated with neurological symptoms or other systemic illness.”

The content of this post is intended for general educational and informational purposes only; it does not constitute medical advice.  Readers should always consult with a licensed healthcare professional for diagnosis and treatment.

What is Parkinson’s Disease?

What is Parkinson’s Disease?

Parkinson’s Disease (PD) is a chronic, neurodegenerative disorder that affects 10 million people worldwide, with 60,000 Americans diagnosed each year. The average age of onset is 60, with incidences of the disease increasing with age. 

Although the cause of PD is unknown, symptoms result from a loss of cells in the brain, particularly in a region called the substantia nigra, where cells produce dopamine. Dopamine is a neurotransmitter that regulates movement and emotion. According to the Parkinson’s Foundation, most people begin experiencing symptoms later in the disease’s progression because at that point a significant amount of the substantia nigra neurons have been lost, resulting in the low levels of dopamine that affect a person’s movement. 

Symptoms

“Early signs of Parkinson’s disease include tremor, slowed movement and stiffness, as well as balance problems. Some people may notice that their handwriting has become smaller or that they have a “masked face,” making them look more serious or depressed,” said Dr. Anupama Kale, Attending Neurologist and Parkinson’s Disease Specialist in DENT Neurologic Institute’s Movement Disorders Clinic.

As the disease progresses, symptoms can include:

  • Tremor
  • Limb Rigidity
  • Gait and Balance Problems 

According to the Parkinson’s Foundation, in addition to movement-related or “motor” symptoms, Parkinson’s symptoms may be unrelated to movement or “non-motor”.

Non-motor symptoms can include: apathy, depression, constipation, sleep behavior disorders, loss of sense of smell and cognitive impairment.

Prognosis

“PD is a chronic disease that is managed over time, with treatment tailored to each individual based on his or her symptoms. Most people with Parkinson’s disease can lead productive and fulfilling lives,” said Dr. Kale. “And while there is currently no cure for Parkinson’s disease, there are several treatments available, with more and more new and promising treatments in the pipeline. 

The content of this post is intended for general educational and informational purposes only; it does not constitute medical advice.  Readers should always consult with a licensed healthcare professional for diagnosis and treatment.