A Quandary on Blood Drops in the Brain

By GINA KOLATA

On Dec. 18, 2005, Ariel Sharon, then Israel’s prime minister, was taken to a Jerusalem hospital with symptoms of a stroke, unable to speak or understand what others were saying.

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Dr. Steven Greenberg

An M.R.I. scan shows microbleeds, the small black dots.

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Ariel Sharon in 2002. Microbleeds were later detected in his brain.

Over the next 36 hours, his doctors found themselves in a quandary. Mr. Sharon had two conditions that might lead to a new and devastating stroke. And treating one condition could make the other one worse.

First, he was susceptible to blood clots that could be swept from his heart to his brain, causing a major stroke. Anticlotting drugs might protect him.

But his brain scans showed microbleeds, pinpoint drops of blood that leaked from blood vessels in the brain. The fear was that an anticlotting drug might turn a new microbleed into a life-threatening, incapacitating hemorrhagic stroke.

Until recently, microbleeds were all but unknown. Now, with improved scans, they are turning up constantly; one recent study found them in the brains of 1 out of 5 people age 60 and older. And they are leading to a classic conundrum of modern medicine: Just because something turns up on an M.R.I. scan, is it significant? And if it may or may not be significant, what to do about it?

With strokes, the stakes can be life or death. Or, as happened with Mr. Sharon, somewhere in between.

His doctors decided that blood clots were his biggest risk, so they gave him heparin, an anticlotting drug. Two weeks later, he had a major bleeding stroke. Mr. Sharon remains in a persistent vegetative state to this day, awake but not aware, unable to respond, unable to communicate, able to breathe but unable to think.

It can never be proved that an anticlotting drug caused a stroke in an individual case. But it is known that when patients taking such drugs have hemorrhagic strokes, the strokes are much worse, with double the normal fatality rate.

The microbleed story began when neurologists, using newer magnetic resonance imaging techniques, began seeing them in patients who had symptoms of a stroke or, in some cases, signs of an electrical disturbance in the brain. A patient might have numbness or tingling in part of the face that then migrated to a hand and went away.

On scans, neurologists would see a few drops of blood in the patient’s brain, smaller than the tip of a pen. Or they would see tiny drops in routine scans in patients with dementia, or in patients who had had a serious stroke.

Now, neurologists are seeing microbleeds even in some patients who seemed free of neurological problems — people who were given a scan because of a blow to the head, or memory problems, or headaches.

“They clearly are being picked up more often,” said Dr. Steven M. Greenberg, a neurologist at Massachusetts General Hospital who studies microbleeds. “That’s one reason why we all get nervous about getting scans on people who don’t necessarily need them. You have to be able to deal with the consequences.”

With microbleeds, that can be difficult. At a loss as to what to do, doctors call specialists like Dr. Greenberg, asking for advice.

“I get a lot of calls I didn’t used to get,” Dr. Greenberg says. “And they mostly involve questions I can’t answer.”

When the bleeds are on the outer surface of the brain, they often seem associated with a condition in which blood vessels are damaged by the protein amyloid. This is the same protein that piles up in the brains of patients with Alzheimer’s disease; microbleeds from amyloid can be associated with dementia.

Other times, the microbleeds are deep in the brain and may be linked to high blood pressure, a leading cause of strokes. But it is not clear whether microbleeds, especially those deep in the brain, are of any real consequence. Until recently, no one asked how often they turn up in healthy people, nor whether they predict strokes or other serious brain damage.

That changed when Dr. Monique M. B. Breteler, a neuroepidemiologist at Erasmus University in Rotterdam, the Netherlands, decided to look for microbleeds among residents of her city.

“If there were more than we knew of in the general population, that might — and I want to stress might — have important consequences,” Dr. Breteler said. “That is why we started to look for them.”

For more than a decade, Dr. Breteler and her colleagues have followed a group of Rotterdam residents age 45 and older. The goal is to do repeated brain scans on 8,000 people; so far they have scanned nearly 4,000 and are analyzing those data.

“What we found came as a big surprise,” Dr. Breteler said. Previous estimates were that 5 to 7 percent of healthy older people had microbleeds. The Rotterdam study found them in more than 20 percent. And the older the person, the more likely the microbleeds. They were present in 18 percent of 60-year-olds and nearly 40 percent of those over 80.

“We now know that these changes are there and that they are frequent,” Dr. Breteler said. “But we don’t know yet what their clinical impact is, what their prognosis is.”

Still, she and other experts say, there is reason for concern.

Dr. Greenberg has found that if the microbleed is near the brain’s surface, where it might be associated with amyloid, then anticlotting drugs are more likely to precipitate a brain hemorrhage. But sometimes a patient is at such grave risk of a stroke that the balance tips in favor of an anticlotting drug anyway, he says.

If the microbleed is deep in the brain, it is not clear whether anticlotting drugs are dangerous.

Even patients who come in with symptoms that might be caused by microbleeds can pose a problem.

Edward Reynolds, 74, of Beverly, Mass., was referred to Dr. Greenberg after an episode in which part of his face went numb, then his hand, and then the numbness faded and he felt fine. He had an abnormal heart rhythm, which meant that anticlotting drugs might help him avoid a stroke caused by blood clots in his heart.

But an M.R.I. scan found microbleeds on the surface of his brain, which meant they were probably associated with amyloid. And that meant powerful anticlotting drugs like warfarin could be dangerous for him.

“Here’s a guy on a knife edge of being anticoagulated or not,” Dr. Greenberg said. “There really are major risks on both sides. You can see bad things happening either way.”

Dr. Greenberg decided in the end that the risk from drug like warfarin was not justified. He advised Mr. Reynolds to take baby aspirin, with its mild anticlotting properties.

“It’s only one decision, but it’s a big one,” Dr. Greenberg said.

So far, Mr. Reynolds has done well, with no recurrence of the numbness and no signs of a stroke.

“I’m feeling pretty good,” he said.

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Can your company force you to be healthy?

By Maya Dollarhide

(LifeWire) -- Three years ago, Danilo Reyes, a test engineer for Intel, received a $50 gift card from his employer to take a health-assessment test. Reyes figured that he'd pass the test with flying colors -- he doesn't smoke or drink -- and Intel made it easy by offering the free test at his office in Hillsboro, Oregon.

Rising health care costs are prompting firms to offer wellness programs for employees.

But when Reyes received the results, the diagnosis was a complete shock: His cholesterol and blood-sugar levels were abnormally high.

"It turned out I was a borderline diabetic and at high risk for a heart attack," says Reyes, 41. "I was terrified."

Motivated by his diagnosis, Reyes consulted his family doctor, who put him on medicine to lower his cholesterol. A health coach at Intel, part of the company's wellness program, helped by advising Reyes on joining a gym and eating better. Over time, Reyes says, he's seen tangible benefits and shed some excess pounds.

"Getting healthy even inspired me to start up a hobby," he says. "I take karate now, as well as going to the gym. I'm happy and healthy."

Steps toward wellness

Almost a third of companies offering health insurance benefits to their employees also provide a wellness program of some sort. Fitness, smoking cessation and weight-loss programs are provided most frequently, according to 2006 employer health benefits survey by the Kaiser Family Foundation. The telephone survey contacted 2,122 randomly selected public and private employers.

While most companies say they have a genuine concern for their employees' well being, the rising cost of health care is obviously part of the equation. Obesity-related health issues, for example, cost American companies approximately $13 billion dollars per year, according to the Washington D.C.-based National Business Group on Health, a non-profit organization representing large employers on health policy issues.

"Health and wellness programs at work are a win/win situation for everybody," says Richard Taylor, vice president of human resources at Intel. "We keep our insurance costs down, and the employees are offered free health and wellness opportunities."

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Alfred Sanchez, the CEO of the YMCA of Greater Miami, agrees. He started a free health and fitness program in March for his staff and their families that include weigh-ins, meetings with health counselors, nutritional guidance and exercise plans. Out of a staff of 170, all but 40 employees signed up.

"Our business is all about health and fitness," says Sanchez. "Losing weight is nice, so is lowering your cost of health insurance, but the real pay-off is helping your staff lower their cholesterol and stay healthy."

Invasion of privacy?

Some people, however, bristle at what they perceive as having lifestyle choices dictated by an employer.

This May, for example, the University of Massachusetts Medical School banned all tobacco use from their campus and hospital, including parking lots. If an employee is caught smoking, they risk being fired.

"They won't even allow people to smoke in their cars," says James LeBlanc, 45, an employee at the university and himself an ex-smoker who kicked the habit prior to the ban. "We all know smoking is bad for you, but last time I checked it was still legal in this country."

Some companies forbid their employees to light up at all -- even at home. There are at least 20 states that allow for this type of work policy, including Ohio, where the state's second-largest employer, the Cleveland Clinic, stopped hiring smokers in September.

In Massachusetts, Scott Rodrigues, was fired from Scotts Miracle-Gro Company -- which bans its workers from smoking at all -- after testing positive for nicotine. Rodrigues has sued the multibillion dollar corporation for an invasion of his privacy and civil rights. The case is still being decided in the Massachusetts courts. A spokesperson for Scotts Miracle-Gro said the company does not comment on pending litigation.

"We're really seeing a provocative attitude, like Scotts, towards smokers in the workplace, but there is concern about where employers might draw the line," says Glenn Patton, a partner in Alston & Bird's Labor & Employment Group in Atlanta, Georgia, and an authority on legal issues in the workplace.

Where companies draw that line is a particular concern for Chicago resident Paul McAleer. He runs the Web site BigFatBlog.com, which focuses on weight-related issues in the media and serves as a forum for its 2,600 members to write about and discuss "fat acceptance." He says members of his site fear companies may one day treat losing weight like they do quitting smoking, as something workers should be encouraged -- or required -- to do.

"[The term] 'health and wellness' has become a euphemism for 'not fat'," says McAleer, 30, whose site grew out of research he conducted on size-discrimination issues in the media and society while enrolled at Morton College in the mid-1990s. "When employers set up these programs, they shouldn't penalize people for not losing weight. Your weight shouldn't be anyone's business but your own."

Some commitment required

Of course, just having a wellness program in place is no guarantee that employees will become healthier -- or even that the program will succeed. When the Austin, Texas-based brokerage firm, Resource Financial Group initially offered their employees a program, it was a flop.

"No one really knew about it. It was just an online program," says Shannon Scott, 42, an account manager.

As it turns out, maintaining a successful wellness program can require the same sort of commitment from a company as working to stay healthy does from an employee.

"Now we have a program that offers us incentives like a gym pass when we sign up for the company health program online. We even have a subcommittee that organizes trips to hear nutritionists or guest lecturers," Scott says. "What we learned is that it's not enough to offer a program, you have to promote it to get people involved."

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20 Ways to Attack Shyness

Photo by Jordan Fraker. See more of his work here.

Can you remember the last time you stepped into a room full of strangers and felt that self-conscious and awkward feeling rush over you? Or that heart thumping moment when you wanted to ask someone on a date, but were too shy to do so? Or wanting to approach someone for business, but was too hesitant to actually do it? That anxiety in the pit of your stomach in social situations? Does it always feel like something is holding you back?

Regardless of whether you are introverted or extraverted, we can all relate to that feeling of shyness at some point in our lives. Socially, we tend to have the misconception that only introverts experience shyness, but that is not true. Shyness has more to do with being uncomfortable with one’s self, especially around other people.

This article is the result of collaboration between Amanda Linehan, an introvert, and Tina Su, an extravert. Together, we wanted to shed some light on the topic of shyness in a collective perspective from both extremes. We will also share the ways that we used to turn shyness into personal empowerment.

The Three Components of Shyness

According to Dr. Bernardo J. Carducci of the Shyness Research Institute, shyness has three components:

• Excessive Self-Consciousness - you are overly aware of yourself, particularly in social situations.
• Excessive Negative Self-Evaluation - you tend to see yourself negatively.
• Excessive Negative Self-Preoccupation - you tend to pay too much attention to all the things you are doing wrong when you are around other people.

Can you relate? When you are experiencing shyness, can you fit your state of mind into one or more of the above categories? We sure can.

Why Do We Experience Shyness?

We all experience shyness differently and on varying degrees. However, root cause can be boiled down to one of the following reasons:

• Weak Self Image - This is especially true to our experiences in high school. We would believe in the fallacy that our unique qualities were not interesting, cool or worthy of anyone’s admiration.We would try to fit in with everyone else, resulting in us not feeling like ourselves.
  • Amanda: Looking back I’m not even sure I knew what my unique abilities were, I just knew that everybody else seemed to be a cooler, more interesting person than I was, so I tried to imitate them…poorly.:)
  • Tina: I thought of myself as cool, because I was loud, and worked very hard at keeping that image. It was of course, a false image that I worked hard to keep. It was exhausting and I was exceedingly self conscious. Even though people didn’t view me as shy, but I felt shy most of the time with a lot of built up anxiety. Turns out, the ‘cool’ kids themselves have weak self images and wanted to fit in with everyone else.
• Pre-occupation with Self - When we’re around other people, we become extremely sensitive to what we’re doing, as if we’ve been put on center stage. This creates anxiety and makes us question our every move. Our focus centers around ourselves and particularly on “what I was doing wrong”. This can cause a downward spiral.
  • Amanda: Coupled with a weak self image,I didn’t thinkIwas doing anything right! And this would start a cycle that I couldn’t get out of. What I understand now is that is that most people are not looking at me with the detail thatI was looking at myself.
  • Tina: I too was very sensitive to my every move around other people. My senses were heightened to the way I talked, walked, laughed, etc. My focus was on how to not screw up in front of other people, and this made me very nervous. What I understand now is that everyone is so caught up with their own insecurities that they hardly notice yours.
• Labeling - When we label ourselves as a shy person, we psychologically feel inclined to live up to those expectations. We may say to ourselves, “I am a shy person, than it must be true that I am shy. This is how I am, and this is the way things are.” When we label something, that thing has the perception of being fixed and therefore we must live up to the expectations of the labeling.
  • Amanda: I was known by others as a shy person, or a quiet person, and this perception held me captive at times. People expected me to be a certain way and so I was. And knowing that other people regarded me as shy, in addition to my not wanting to be shy, resulted in great anxiety when I was with people. I really wanted to show myself to others when I was around them, but it was easy to simply go along with what others expected from me.
  • Tina: Deep down, I felt the anxieties from shyness often, yet, when I’m around people, I had to live up to the expectations that I wasn’t shy. My experiences with shyness would manifest in unusual ways, like when I’m ordering food, when I call someone on the phone, or speak to strangers. I would never let that side of myself show, but I do experience it. In those moments, I can hear myself say, ‘I am shy.’

How to Overcome Shyness

We’ve both experienced different variations of shyness, and through practice and increased awareness we have both overcome this. The following are tips that have helped us overcome this uncomfortable feeling.

Photo by Lauren

1. Understand Your Shyness - Seek to understand your unique brand of shyness and how that manifests in your life. Understand what situation triggers this feeling? And what are you concerned with at that point?

2. Turning Self Consciousness into Self Awareness - Recognize that the world is not looking at you. Besides, most people are too busy looking at themselves. Instead of watching yourself as if you are other people, bring your awareness inwards. Armed with your understanding of what makes you shy, seek within yourself and become the observing presence of your thoughts. Self awareness is the first step towards any change or life improvement.

3. Find Your Strengths - We all have unique qualities and different ways of expressing ourselves. It’s important to know and fully accept the things we do well, even if they differ from the norm. If everyone was the same, the world would be a pretty boring place.

• Find something you are good at and focus on doing it. An identifiable strength will boost your natural self esteem and your ego, helping you better identify with yourself. It is a short term fix, but will give you the confidence you need to break your self-imposed barrier of fear.
• See how your unique strength gives you an advantage. For example, Amanda is a naturally quiet person who prefers to spend time alone. She learned that she listens better than others and notices things that others miss in conversations. She also discovered that her alone time has given her a better understanding of herself.

4. Learn to Like Yourself - Practice appreciating yourself and liking the unique expression that is you. Write a love letter to yourself, do things you enjoy, give gratitude for your body and its effortless functions, spend quality time getting to know yourself, go on a self-date.

5. Not Conforming - Trying to fit in like everyone else is exhausting and not very much fun. Understand that it is okay to be different. In fact, underlying popular kid’s public displays of coolness, they too are experiencing insecurities, self-consciousness, and awkwardness. Accept that you may not be perceived as the most popular social butterfly, and you may not want to be either. At the end of the day, being popular will not make you happy. Accepting your unique qualities can set you free.

6. Focus on Other People - Rather than focusing on your awkwardness in social situations, focus on other people and what they have to say. Become interested in learning about others, and probe them to talk about themselves. You can try pondering the question while interacting: What is it about this person that I like?

7. Releasing Anxiety through Breath - Anxiety and fear can feel overwhelming if you are practicing to become more assertive in order to overcome this fear.

• One simple technique to calm this anxiety into manageable bites is taking deep breaths with your eyes closed, while concentrating on just your breaths. Inhale and exhale slowly while clearing out all thoughts.
• Another technique is from yoga: counting as you inhale and then as you exhale. Slowly leveling out your inhale and exhale duration. Example, 4 count for in and 4 for out. Once your breaths are leveled, add an extra count during your exhale. This means slowing down your exhale by just a tad as compared to your inhale. Continue for a few minutes until you are comfortable, than add another count to your exhale. You can easily do this in the bathroom, or in a spare room of when you need it.

8. Releasing Anxiety through Movement - One way of viewing anxiety is that it is blocked energy that needs to be released. We can release this energy through physical movement.

• Exercises like jogging or walking will help to re-channel some of the blocked energies, but also helps by pulling you out of the situation and shifts your state of mind. This refreshed state of mind will help by adding perspectives to things.
• Another effective technique is a simple muscle meditation/exercise. Sit down or lie down. Bring awareness to every part of your body, starting from your toes and moving up your body to the top of your head. At every part of your body, tighten the muscles at the center of awareness for 3-5 seconds, and then relax. Repeat this until you get to the top of your head. Remember to breathe.

9. Visualization - Visualizing yourself in the situation as a confident and happy person helps to shape your perception of yourself when you are actually in the situation. Close your eyes, sit back somewhere relaxing, listen to some relaxing music, imagine yourself in a scene or situation and see yourself the way you would like to be. In this scene, how do you feel? What do you hear? Do you smell anything? Are you moving? What do you see? Get all your senses involved to make it real.

10. Affirmation - Words can carry incredible energy. What we repeatedly tell ourselves, gets heard by our unconscious mind, and it acts accordingly. If we repeatedly tell ourselves that we are incapable, and too shy to do anything, we will become increasingly aware of evidence to back up this ‘fact’, and our actions will always match what we tell ourselves. Similarly, if we repeatedly tell ourselves that we are capable, confident, and wonderful human beings, our unconscious mind will likely surface the awareness that gives evidence to this new ‘fact’. While, we can’t lie to ourselves, positive visualization and affirmation are helpful in placing us along the road of positive thought patterns.

11. Do Not Leave an Uncomfortable Situation - When we leave shy situations, what we are really doing is reinforcing our shyness. Instead, face the situation square in the face. Turn the fearful situation into a place of introspection and personal growth. Become the observer and dig into yourself, answer the questions: why do I feel this way? What caused me to feel this way? Can there be an alternative explanation to what is happening?

12. Accept Rejection - Accept the possibility that we can be rejected and learning to not take it personally. Remember, you are not alone and we all experience rejections. It is part of life and part of the learning process. The key lies in how you handle rejections when they come. It helps to be mentally prepared before they happen:

• Never take it personally. It was not your fault. It just wasn’t meant to be. The scenario was not the best fit for you.
• Find the lesson - what did you learn? There is a lesson ingrained in every situation. And through these life lessons lies the potential for you to become a better person, a stronger person. Nothing is lost if you can find the lesson. See these as the blessings in disguise.
• Move on. Recognize that when you fall into self-pity, you are not moving forward. Nothing will be changed from your self-pity. When you start to recognize this, it becomes clear that only energy is wasted while we feed to our problem-seeking ego. Pick yourself up, dust off the dirt and move on to the next thing. Try again, try again, try again. It will pay off!

13. Relinquish Perfectionism - When we compare ourselves, we tend to compare ourselves with the most popular person in the room or we compare ourselves with celebrities we see on TV. We set excessive expectations by comparing ourselves unreasonably to people unlike ourselves and wonder “why can’t I be that?” We carry with us a vision of another’s perfection and expect ourselves to fit that exact mold. And when we don’t fit, we beat ourselves up for it, wondering why we are such failures. You see, the problem lies in our emphasis on fitting into a vision we have created in our minds, which is not us. Let go of this perfect image, create visions of yourself out of the Being from who you are, naturally; and let that expression flow, naturally.

Photo via g2slp

14. Stop Labeling Yourself - Stop labeling yourself as a shy person. You are you, you are unique, and you are beautiful. Can’t we just leave it at that?

15. Practice Social Skills - Like any other skill, social skills can be cultivated through practice and experience. The more you put yourself out there, the easier it becomes next time. If you have a hard time knowing what to say, you can practice what to say ahead of time.

16. Practice Being in Uncomfortable Situations - Sometimes, it is not the social skills we lack, but rather the lack of self confidence that we may succeed, and a heightened fear that we will fail. Placing yourself in these uncomfortable situations will help to desensitize your fear towards the situation. The more you force yourself to face it, and to experience it completely, you will realize that it is not that bad after all. It may be hard for your ego to accept at first, but quickly you will find that you can just laugh and enjoy it.

17. The Three Questions - During social settings where you may experience nervousness, periodically ask yourself the following three questions. Doing so will distract yourself from more self-destructive thoughts. Make it your mantra:

1. Am I breathing?
2. Am I relaxed?
3. Am I moving with grace?

18. What is Comfortable for You? - Going to bars and clubs isn’t for everyone, and that’s okay. Understand what feels comfortable for you, and find people, communities and activities which bring out the best in you. You can be just as equally social in settings that you connect with on a personal level, than the popular social settings. You don’t have to be doing what “everyone” else is doing. Besides, everyone else isn’t necessarily happy, despite your perception as such.

19. Focus on the Moment - Becoming mindful of what you’re doing, regardless of what you’re doing, will take focus away from the self. When you are having a conversation, forget about how you look, focus on the words, fall into the words, become absorbed in the words. The tones. The expression. Appreciate it and give gratitude for it.

20. Seek and Record Your Successes - As you overcome this condition we’ve been labeling as shyness, you will have many wins and realizations about yourself. You will gain insights into the truth behind social scenarios. You will start to view yourself differently and come to recognize that you can become comfortable and confident. When these wins and realizations happen, make sure to keep a notebook and write them down. Keeping a journal of your successes will not only boost self confidence, but also shift your focus towards something that can benefit you.

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