AGING AND POWERFUL MINDS IN HISTORY: ART AND DEMENTIAThe Basque country, straddling the Spanish-French border, has long been regarded a land of mystery. The Basque language is itself unique, unlike any Indo-European language, its origins uncertain. The Basque people are presumed to represent the earliest population of Europe, related to the Celts or possibly even pre-Celtic peoples, a vestige of the tribes inhabiting the continent before the multiple waves of migration and conquest changed its ethnic and linguistic complexion. The Basque country is also more recently known for its volatile, sporadically violent independence movement, although for a tourist this is an abstract notion, and there is no palpable feeling of menace in the air. Quite the contrary, the Basque provincial capital San Sebastian is among the most famous European beach resorts, synonymous with boats, sun, excellent restaurants, and the sybaritic pursuit of the good life. The area is also the home of a unique tradition of monumental sculpture associated in particular with the names of the great Basque sculptor Eduardo Chillida (1924-2002) and his lifelong rival Jorge Oteiza (1908-2003).During my visit to San Sebastian, the conversation over dinner turned toward Chillida, who had died earlier that year at the age of seventy-eight. My hosts, neurologists from the local medical center, were recounting how the famous sculptor had ended his life in their care, in a state of advanced Alzheimer’s dementia. It turns out that Chillida was completely incapacitated during the last year of his life, his mental powers sapped by the disease.The next morning we drove to the famous Museo Chillida-Leku, a sculpture garden in the nearby village of Zabalaga, which houses the largest collection of works by Chillida. The vast estate is centered on a sixteenth-century barn, converted by Chillida into a residence and surrounded by lush gardens and lawns studded with sculptures. Chillida’s work is monumental and mostly abstract. He used metal, marble, stone, and wood to create nonrepresentational yet highly evocative shapes, a magical fusion of a Cyclopean scale and introverted private moods. As I was strolling among the gigantic forms, I felt that an elusive similarity existed between these contemporary sculptures and Stonehenge. They seemed ageless, inspired by the same muse, or at least by the same lineage of muses. The Basques and the Celts are both direct heirs of the ancient peoples of Europe, pushed to the westernmost fringes of the continent by the invading waves of newcomers. Could it be that their shared history translated into shared artistic sensibilities, transcending the four millennia separating the druids of Stonehenge from the Basques of today, that an ancient tradition found its modern-day expression in the works by Chillida and Oteiza? The thought amused me and created a pleasant buzz in my head as I continued my stroll through the sculpture garden.And then I began to notice that some of the plaques next to the sculptures, in fact quite a few, bore the dates in the mid-nineties, late nineties, and even the year 2000. As we already know, Alzheimer’s disease does not assault one all of a sudden. Quite the contrary, it is a gradual decline, a slippage into mental oblivion that unfolds over years, not months. Someone who was in a state of advanced dementia in 2001, as reportedly Chillida was, certainly had to be already affected by the disease process in the late nineties, and probably as early as in the mid-nineties. Yet here I was surrounded with the masterpieces, which every curator of every major museum in the world would give an arm and a leg to have . . . created by an artist most likely suffering from Alzheimer’s disease. When I shared my chronological observations with my hosts, they seemed as perplexed as I was. We left it at that, but the image of an aging master, losing his memory but not the secrets of his craft and triumphing over his illness through his art, at least for a while, kept haunting me for months after the visit.Eduardo Chillida and his poignant story find a counterpart in a North American contemporary and fellow artist, Willem de Kooning (1904-1997). A Dutchman who came to the United States in 1926 at the age of twenty-two and made it his home, de Kooning epitomized twentieth-century American art like no one else. His career as a painter and occasional sculptor spanned three quarters of a century. De Kooning was a true original who helped forge a new direction in painting. Being an original was the essence of his identity. “Nothing grows under big trees,” he once told a student who was quizzing him as to why he had never studied with a famous artist. He himself became that “big tree,” which in defiance of his own admonition spurred the growth of a whole new school. From an early infatuation with cubism, through the transitional stages of painting, by his own account, increasingly abstract “quiet men” and then “wild women,” de Kooning moved on to become a founder of what has since become known as “abstract expressionism.”Sometime in the late 1970s, de Kooning’s memory loss became evident to those around him. As is usually the case, his amnesia affected his memory for relatively recent events and spared the memories of the distant past, a phenomenon well-known to neuropsychologists and neurologists under the cumbersome name “the temporal gradient of retrograde amnesia.” But even more distant memories may have faded as the disease progressed. His biographer Hayden Herrera recounts an episode in which de Kooning was unable to recognize an old and close friend of many years. The diagnosis of Alzheimer’s disease eventually followed.But the old master continued to paint, spending all his days in the studio, sometimes finishing several paintings a week. “A finished painting is a reminder of what not to do tomorrow,” he was quoted to quip at the age of eighty-one. (His memory may have eroded, but his wit was undiminished.)De Kooning’s art continued to evolve even toward the end of his career. In the 1980s his brushstrokes broadened and then -toward the late 1980s his paintings began to acquire what his biographer and friend Edvard Lieber called “hyperactive forms”—spare, brightly colored, wavy curves. De Kooning, well into his eighties, was aware of the change: “I’m back to a full palette with off-toned colors. Before it was about knowing what I didn’t know. Now, it’s about not knowing what I know.” This change was more than a change in style. For de Kooning, his work had always been a means of comprehending a deeper meaning of things and of his own experience, and not merely forging a set of formalisms. “Style is a fraud. … To desire to make a style is an apology for one’s anxiety,” de Kooning wrote many years earlier.So what evolution of de Kooning’s own human experience did the changes in his work reflect? What role did the change in his cognition play in the evolution of his art? Was the effect one of decline or one of ascendancy? Or some complex interplay of both?The change in de Kooning’s work did not elude the art critics. It was regarded as evolution and not as regression, as the ascendancy to a new level of insight and understanding. “The rhythms are more deliberate, meditated even, and the space more open … a new order prevails, a new calm. . . . de Kooning has purified his stroke, and what had been quintessentially sensuous is rendered immaterial, ethereal, a veiled tracing of its physical origins,” wrote David Rosand. “de Kooning, who has never strayed far from nature for long, is closer to it now than ever,” wrote Vivien Raynor in the New York Times.So here are the stories of two great twentieth-century masters, Eduardo Chillida and Willem de Kooning, who were able to create first-rate art despite the progression of Alzheimer s disease, with its crippling effects on many other aspects of their lives. Before we proceed further with the discussion of what made this possible, let us step back and appreciate the sheer power of the facts themselves, whatever their explanations may be.*11\302\2*
BDD – SUGGESTED GUIDELINES FOR FAMILY MEMBERS AND FRIENDS: GIVE PRAISE FOR EVEN SMALL GAINSResisting the urge to comb your hair in the mirror for an hour, not asking for reassurance for a day, or going to the supermarket may not seem like big feats, but they can be major accomplishments for someone with BDD. Recognize this, and praise your loved one for even small gains. Praise works better then criticism.Recognize and support each step the BDD sufferer takes toward resisting BDD rituals, participating in activities, leaving the house, socializing more, and appear overnight. Support any improvement, no matter how limited it may seem. Just as you can’t master learning to drive a car in a day, a person with BDD won’t be able to return to normal functioning in a day. It takes practice and time. Encourage the BDD sufferer to keep going and not give up, even if they’re having a bad day or a bad week.Don’t compare the BDD sufferer to other people who are functioning well. Most people with BDD would like to function as well as other people—if only they could. This kind of comparing only makes them feel worse. It’s important to judge progress according to their current level of functioning. If a person is housebound, they probably won’t be able to go to a baseball game the first time they leave the house. Going to the mailbox to get the mail may be the most they can initially do.*411\204\8*
SHIATSU – NATURAL THERAPYUnlike Western massage the receiver remains fully clothed throughout. As a natural therapy shiatsu is most effective when you wear comfortable clothing of natural fibres, such as a cotton track suit.Many physical complaints are accompanied by some psychological conditions, so in addition to physical relief, shiatsu will also affect these. For instance with disorders of the colon we often feel depressed and lacking initiative and openness; we withhold our emotions; or we may feel stress in our shoulders, caused by short shallow breathing.Since it is our day-to-day activities which determine the quality of our health, the experienced shiatsu practitioner will give you suggestions on aspects of your lifestyle such as diet, physical activity, breathing patterns and relaxation techniques. Some are able to give you specific macrobiotic dietary advice. Such suggestions will enable you to make positive changes and take greater responsibility for your own health.*173\326\8*
THE BOWEL AS A DUMPING GROUND: THE EXPERIENCE OF OTHERSSuzi had suffered with a swollen face, mental dullness, headaches and visual disturbances periodically since she was a child. When she was 24 she saw a nutrition counsellor who explained about the Toxic Colon Syndrome. She gave up tea, coffee and alcohol and lived on vegetables, fruit, beans, lentils, whole grains, nuts, seeds, goat’s milk and soya products for a month. She felt sick and had headaches for the first two days then she felt progressively better; she lost weight, her face did not swell, she was mentally clearer and her eyesight improved. She has kept to the basic diet but has included fish, chicken and eggs. While cleaning up her diet has changed her life she has not become obsessive about it and lapses at holiday times. Her symptoms return if she does this for too long.Pete’s digestion had been upset for three years, ever since he suffered an attack of diarrhoea while on holiday abroad. He complained of bloating, constipation, discomfort after certain foods and insomnia. After full gastroenterological tests he was diagnosed as having the Irritable Bowel Syndrome. He was given a high-fibre diet and antispasmodic drugs, but did not improve. He was not convinced when the value of the raw food diet was explained to him; he argued that since he could not digest cooked vegetables he was unlikely to digestthem raw. He gave up dairy produce, cut down on coffee and alcohol and started a 70 per cent raw food diet. He took time over his meals and chewed them well. His digestion did not improve in the first week and he was beginning to get discouraged when he noticed a rash he had had on his legs for months had completely cleared up. He continued with the diet and within a month was feeling much better. He keeps well if he combines foods carefully and includes lots of salads and fruit. How the enzymes in raw food aid digestion is fully explained in Raw Energy, by Leslie and Susannah Kenton.*57\326\8*
EPILEPSY AS A PSYCHO-SOCIAL DISEASE: “HOW DO YOU HELP TEENAGERS COPE?”"HOW DO YOU RESPOND THEN?”"I just say, ‘Hey, you’ve got to pay the piper. You know the rules and what you can do. It’s your choice.’ Teenagers want to be in control. Like all other children and adolescents, there is a need to test limits, to explore. That is a time-tested way of growing. It’s no different for kids with epilepsy; but they have additional boundaries to test. They don’t like parents or anyone else telling them what to do. They don’t like having to take medication, because it doesn’t seem to be under their control. As Karen has become more mature, she really understands. She knows it is her choice whether she takes medicine and how she treats her body. That gives her control.”Another thing which has been a big help for Karen’s self-image is that she has become a counselor to other teenagers. We have asked her to participate in conferences for parents and others. On occasion, we have asked her to talk with younger teens, either individually or in groups. She is a role model, and that works out well for everyone.”*224\208\8*
WHITAKER WELLNESS DIET FOR HIGH BLOOD PRESSURE: PROTEIN POWERProtein is one of the most important nutrients required by the human body. People often equate protein with muscle, but your muscles aren’t the only part of your body made of protein. Approximately half of the solid substances of your body are composed of protein – it is required for the construction of hair, nerves, skin, blood, sperm, and eggs. Protein also provides the basic building blocks for enzymes, hormones, blood plasma, and even saliva. However, most Americans eat more protein than they need. Excess protein is hard on the kidneys and can also contribute to osteoporosis, or thinning of the bones, as we age. Furthermore, high-protein foods such as meat and whole dairy also contain a lot of fat, much of it unhealthy saturated fat.It’s recommended to get about 20 percent of your daily total calories from protein, concentrating on lean protein sources such as fish and seafood, skinless poultry, egg whites (an occasional yolk is fine), low-fat or fat-free dairy products, tofu, legumes, and whole grains. Fish is especially recommended, particularly salmon, herring, mackerel, and other fish rich in omega-3 oils. Increased consumption of such fish is associated with decreases in blood pressure in hypertensive men and women. A plant-based diet, as long as it includes soy and other legumes, will provide adequate protein. Aim for three to four small servings of protein-rich foods per day and make sure you eat some protein at each meal.*91/313/5*
LESS OBVIOUS CAUSES OF HYPERTENSIONA 17-year-old boy was admitted to the hospital with overpowering headaches, irritability, and heavy sweating, and he was found to have severe, life-threatening hypertension (200/130 mm Hg). After a full panel of tests was taken, including urine screening and blood analysis, it was discovered that the boy was harboring dangerously high levels of mercury. Luckily, it was possible to remove this heavy metal from the boy’s body, especially since it had not yet settled into his bones. Physicians immediately gave him several courses of intravenous chelation treatments, which effectively cleared out most of the mercury. His symptoms gradually subsided, and his blood pressure normalized after two months of treatment.Obesity, dietary indiscretions, inactivity, smoking, excess alcohol, stress – these are the causes most commonly associated with hypertension. However, there are other, less evident determinants that may also increase blood pressure, even in people with none of the primary risk factors for hypertension. Many of these more subtle risk factors, including certain drugs and environmental toxins, are avoidable; it’s just that few people know they are implicated in hypertension. Others, such as age, race, and sex, are beyond your control. However, it is important that you be aware of these “uncontrollable” risk factors, for if any of them apply to you, it simply means that you need to be more vigilant in following the prevention and treatment program for reversing hypertension.*37/313/5*
HIV: ON LIVING-TAKING CONTROL: FIND COMFORTS AND INTERESTS IN THINGS OUTSIDE YOURSELF”Don’t lock yourself in,” says Steven, “get yourself out.” The world is full of pleasures, beauties, people to get to know, wrongs that need to be righted, jobs that need to be done, places to visit, adventures to be had. People find, in things outside themselves, anything from a trivial and momentary distraction to a profound interest in living. The possibilities are limitless. Some people make their surroundings beautiful and comforting. Helen says she tries to make the place where she spends her time a space she enjoys: “I like brass and glass. I like plants—they’re another life. I like a little elegance. Things should be as fine as they can be.” Alan repainted his house: “I’ve made it warm, restful, and interesting with colors. These colors reflect a color of light that looks good on people. People look wonderful in my house. My own house is a comfort to me.” Some people find things they like to do, or things they have always wanted to do but have never done. Helen gardens: “I crave being out there. I put all these bulbs in, and now I have next year to look forward to. Plus I also have a room I want to redecorate.” Steven’s cousin, whom he says is like a sister to him, moved in with him. They enjoy doing the same things, Steven says: “While I’m feeling reasonably well, we’ll do what we like doing—we go to museums, we play music together. We’ll just enjoy the things that give us pleasure.” Dean had always loved both music and teaching: “I’ve always been a closet teacher, and now I direct music full time. Being sick also gives me time to do what I want.” Some people teach themselves new things because learning, they say, takes them out of themselves. Dean became interested in archaeology and astronomy: “Maybe, in the light of ancient history and the immense universe,” he says, “my disability insurance isn’t all that important. I wonder why people worry about things that don’t matter all that much.” Some people spend more time with people they love and enjoy: “Before my husband died,” said Lisa, “we concentrated on putting lots of importance on kids and grandkids. You can get so busy with run-of-the-mill stuff, you don’t get around to it. My husband went on a fishing trip with his son. He went to visit our granddaughter at kindergarten. He listened to his grandson’s first piano piece.” Some people become activists. June runs an AIDS-advocacy agency; she says she throws herself into work. “I feel that it helps to help,” she says, “to do something.” Lisa was going to run for city council, but decided instead that she could do more putting out a newsletter, so she raised money and started one: “I think you should speak up, be visible, be yourself.” Steven began doing public speaking and recommends it to others: “Get interested in legislation,” he said, “in outreach; contact speakers’ bureaus, call people up. I’ve gone from being a passive type to being a real civil disobedient type.” Dean is writing a book about his experiences with AIDS, and says the book gives him a positive attitude: “It’s leaving my mark. It’s doing what will help other people.” Some people help others in different ways. Many become buddies or carepartners through AIDS-advocacy programs. Dean volunteered in a hospital on a floor for children with cancer. “It was hard on me to see those kids so sick,” he said, “but it put things in perspective for me. I thought, ‘Who am I to complain? They’re so good and so happy. I’ve had forty good years. How can I complain?’ ” Helen is less ambitious but no less helpful: “I visit the woman who used to be my roommate in the hospital. She won’t eat anything. I make her get out of bed, sit in a chair, go for a walk; I give her my jellybeans. I talk to her. It makes me feel good.”*246\191\2*
ALLPOX: PATHOGENESIS AND CLINICAL MANIFESTATIONSThe causative agent of smallpox is the variola virus, an orthopoxvirus within the Poxviridae family. Smallpox is a contagious disease characterized by fever and a vesicular and pustular rash.
PathogenesisSmallpox is readily transmitted from person to person via droplet nuclei, aerosols, or direct contact with contaminated fomites. Transmission generally occurs after the onset of the rash. Infection begins once the virus implants onto the oropharyngeal or respiratory mucosa. It passes rapidly into local lymph nodes and multiplies. An asymptomatic viremia ensues, followed by multiplication of the virus in the reticuloendothelial system. The virus then localizes in the oropharyngeal mucosa and dermal blood vessels.
Clinical ManifestationsAfter the usual 12- to 14-day incubation period (range, 7-17 days), the patient typically presents with high fever, malaise, headache, and backache. Severe abdominal pain may also be present. The characteristic rash usually begins 2 to 3 days after symptom onset. The rash is maculopapular and appears on the oropharyngeal mucosa, face, and forearms. It then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular then pustular. Scabs usually appear on the eighth or ninth day of the rash, and pitted scarring develops. There may be a second, less pronounced temperature spike 5 to 8 days after the onset of the rash, particularly if there is secondary bacterial infection.The World Health Organization has described five types of smallpox:- Variola major – The mortality rate in this most common form of smallpox is 30%.- Variola minor – The disease is milder, and the mortality rate is less than 1%.- Hemorrhagic smallpox – Frank bleeding can be seen in the skin and mucous membranes. This form of smallpox, which occurs in less than 3% of cases, is fatal within 6 days of appearance of the rash. Pregnant women are unusually susceptible.- Malignant smallpox – Confluent, flat, velvety lesions (no pustules) are seen in this variant of smallpox, and the case fatality rate exceeds 95%.- Variola sine eruptione – This form of smallpox, which occurs in previously vaccinated contacts, results in mild symptoms such as low-grade fever, headache, or malaise.*210/348/5*
TREATMENT OF ACUTE PYELONEPHRITIS: OUTPATIENT AND INPATIENT THERAPIESOutpatient TherapyMost pyelonephritis patients can be treated as outpatients. Compliant women with pyelonephritis who have only slight elevations in temperature and white blood cell count and who have no nausea or vomiting can be treated as outpatients with 7 to 14 days of oral antibiotics. Antibiotic treatment should be aimed at the same pathogens that cause acute cystitis (e.g., E. coli, S. saprophyticus). Fluoroquinolones are the drugs of choice for empirical therapy. Co-trimoxazole should be used only if the causative organism is known to be susceptible. If a gram-positive organism is causative, amoxicillin or amoxicillin-clavulanate can be used.16 Patients who do not improve with 48 to 72 hours of appropriate therapy should be investigated for obstruction or renal abscess with either renal ultrasonography or abdominal computed tomography (CT).To avoid hospitalizations, some clinicians will observe patients for up to 24 hours on intravenous therapy to assess response to treatment. If the response is rapid, admission can be avoided. Another option in reliable patients is to give once-daily intravenous or intramuscular dosing (e.g., ceftriaxone, levofloxacin) in the outpatient setting. Other clinicians simply administer a single dose of parenteral antibiotics before starting oral antibiotics. All of these options are reasonable.
Inpatient TherapyHospital admission for intravenous antibiotics and fluids is required in patients who appear toxic or cannot ingest medications or adequate fluids. Several antibiotic regimens can be used in the inpatient setting. These include fluoroquinolones, an aminoglycoside (with, or without ampicillin), or a broad-spectrum cephalosporin (with or without an aminoglycoside). Once antibiotics and hydration are started, most patients improve within 72 hours. Once a patient’s condition has improved, treatment can be switched to oral antibiotics tailored to the pathogen’s antibiotic susceptibility.As with outpatient therapy, renal ultrasonography or abdominal CT should be performed if a patient does not improve within 72 hours. Rarely, patients with renal parenchymal involvement will continue to mount low-grade fevers after several days of appropriate therapy. If these patients are otherwise improving (e.g., decreased pain, advancement of diet), it is reasonable to discharge them on oral antibiotics and follow them closely as outpatients.*145/348/5*