Category Archives: Courage

Parkinson’s Disease Research: A Commentary from the Stands and the Playing Field

“You can have a very bad end with Parkinson’s, but on the other hand, you can be like me, because I’m lucky. I’m not having a bad end.” Margo MacDonald

“My age makes me think how valuable life is. How bad is something like Parkinson’s in relation to not having life at all?” Michael J. Fox

Introduction: Last month, together with Dr. Simon Stott and his team of scientists (The Science of Parkinson’s Disease), we co-published a historical timeline of Parkinson’s disease beginning with the description of the ‘shaking palsy’ from James Parkinson in 1817. My post entitled “Milestones in Parkinson’s Disease Research and Discovery” can be read here (click this link). The Science of Parkinson’s Disease post entitled “Milestones in Parkinson’s Disease Research and Discovery” can be read here (click this link).

We spent a lot of time compiling and describing what we felt were some of the most substantial findings during the past 200 years regarding Parkinson’s disease.  I learned a lot; truly amazing what has been accomplished in our understanding of  such a complex and unique disorder.  Simon posted a follow-up note entitled “Editorial: Putting 200 years into context” (click this link). I have decided to also post a commentary from the standpoint of (i) being someone with Parkinson’s and (ii) being a research scientist.

“Every strike brings me closer to the next home run.” Babe Ruth

Baseball: I want to use the analogy of a baseball game to help organize my commentary. Baseball fans sit in the stands and have fun watching the game, thinking about the strategy behind the game, eating/drinking, and sharing the experience with family/friends/colleagues.   Most baseball players begin playing early in life and the ultimate achievement would be to reach the major leagues. And this would usually have taken many years of advancing through different levels of experience on the part of the ballplayer. How does how this analogy work for me in this blog? Stands: I am a person-with-Parkinson’s watching the progress to treat and/or cure this disorder. Playing field: I am a research scientist in a medical school (click here to view my training/credentials).

“Never allow the fear of striking out keep you from playing the game!”  Babe Ruth

Observation from the stands:
I am a spectator like everyone else with Parkinson’s. I read much of the literature available online.  Like you, I think about my disorder; I think about how it’s affecting me every day of my life. Yes, I want a cure for this disease.  Yes, I’m rather impatient too.  I understand the angst and anxiety out there with many of the people with Parkinson’s. In reality, I would not be writing this blog if I didn’t have Parkinson’s. Therefore, I truly sense your frustration that you feel in the presence of Parkinson’s, I do understand.  Given below are examples of various organizations and ads and billboards in support of finding a cure for Parkinson’s.  Some even suggest that a cure must come soon.   However, the rest of my post is going to be dedicated to trying to explain why it’s taking so long; why I am optimistic and positive a cure and better treatment options are going to happen.  And it is partly based on the fact that there really are some amazing people working to cure Parkinson’s and to advance our understanding of this disorder.

“When you come to a fork in the road take it.” Yogi Berra

Observations from the playing field (NIH, war on cancer, research lab, and advancing to a cure for Parkinson’s):

National Institutes of Health (NIH) and biomedical research in the USA: Part of what you have to understand, in the United States at least, is that a large portion of biomedical research is funded by the NIH (and other federally-dependent organizations), which receives a budget from Congress (and the taxpayers). What does it mean for someone with Parkinson’s compared to someone with cancer or diabetes? The amount of federal funds committed to the many diseases studied by NIH-funded-researchers are partly divvied up by the number of people affected. I have prepared a table from the NIH giving the amount of money over the past few years for the top four neurodegenerative disorders, Alzheimer’s, Parkinson’s, amyotrophic lateral sclerosis (ALS), and Huntington’s Disease, respectively [taken from “Estimates of Funding for Various Research, Condition, and Disease Categories” (click here)]. And this is compared to cancer and coronary arterial disease and a few other major diseases. Without going into the private organizations that fund research, a large amount of money comes from the NIH. Unfortunately, from 2003-2015, the NIH lost >20% of its budget for funding research (due to budget cuts, sequestration, and inflationary losses; click here to read further).   Therefore,  it is not an overstatement to say getting  funded today by the NIH is fiercely competitive.  From 1986 to 2015, my lab group was supported by several NIH grants and fellowships  (and we also received funding from the American Heart Association and Komen for the Cure).

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“In theory, there is no difference between theory and practice. But in practice, there is.” Yogi Berra

War against cancer: In 1971, Pres. Richard Nixon declared war against cancer and Congress passed the National Cancer Act.  This created a new national mandate “to support research and application of the results of research to reduce the incident, morbidity, and mortality from cancer.” Today, cancer is still the second leading cause of death in the USA; however, we’ve come such a long way to improving this statistic from when the Cancer Act was initiated.

Scientifically, in the 1970’s, we were just learning about oncogenes and the whole field of molecular biology was really in its infancy. We had not even started sequencing the human genome, or even of any organism.  We discovered genes that could either promote or suppress cellular growth.   We began to delineate the whole system of cell signaling and communications with both normal and malignant cells. We now know there are certain risk factors that allow us to identify people that may have increased risk for certain cancers. Importantly,  we came to realize that not all cancers were alike,  and it offered the notion to design treatment strategies for each individual cancer.  For example,  we now have very high cure rates for childhood acute leukemia and Hodgkin’s lymphoma and we have significantly improved survival statistics for women with breast cancer. Many might say this was a boondoggle and that we wasted billions of dollars  funding basic biomedical research on cancer; however, basic  biomedical research is expensive and translating that into clinical applications is even more expensive.  [ For a  very nice short review on cancer research please see the following article, it may be freely accessible by now: DeVita Jr, Vincent T., and Steven A. Rosenberg. “Two hundred years of cancer research.” New England Journal of Medicine 366.23 (2012): 2207-2214.]

“One of the beautiful things about baseball is that every once in a while you come into a situation where you want to, and where you have to, reach down and prove something.” Nolan Ryan

The biomedical research laboratory environment:  A typical laboratory group setting is depicted in the drawing below. The research lab usually consists of the lead scientist who has the idea to study a research topic, getting grants funded and in recruiting a lab group to fulfill the goals of the project.  Depending on the philosophy of the project leader the lab may resemble very much like the schematic below or may be altered to have primarily technicians or senior postdoctoral fellows working in the lab  (as two alternative formats). A big part of academic research laboratories is education and training the students and postdocs to go on to advance their own careers; then you replace the people that have left and you continue your own research.  Since forming my own lab group in 1986, I have helped train over 100 scientists in the research laboratory: 17 graduate students, 12 postdoctoral fellows, 17 medical students, and 64 undergraduates. The lab has been as large as 10 people and a small as it is currently is now with two people. People come to your lab group because they like what you’re doing scientifically and this is where they want to belong for their own further training and advancement.  This description is for an academic research  laboratory; and  I should also emphasize that many people get trained in federal government-supported organizations, private Pharma and other types of research environments that may differ in their laboratory structure and organizational format.

15.05.11.Lab_Organization

“Hitting is 50% above the shoulders.” Ted Williams

 In search of the cure for Parkinson’s:    First, I understand the situation you’re in with Parkinson’s because I’m living through the same situation.   But when people find out I’m a research scientist they always wonder why aren’t we doing more to find a cure, and I  hear the sighs of frustration and I see the anxiety in their faces. Second, the previous three sections are not meant to be an excuse for why there is still no cure for Parkinson’s. It is presented in the reality of what biomedical research scientists must undergo to study a topic.  Third, the experiments that take place in basic biomedical research laboratory may happen over weeks to months if successful. Taking that laboratory data to the clinic and further takes months and years to succeed if at all.   The section on cancer reminds me a lot of where we are going with Parkinson’s and trying to advance new paradigms in the treatment and curative strategies.  Professionally, I have even decided  to pursue research funding in the area of Parkinson’s disease.   Why not spend the rest of my academic career studying my own disease; in the least I can help educate others about this disorder. Furthermore, I can assure you from my reading and meeting people over the last couple of years, there are many hundreds of scientists and clinicians throughout this world studying Parkinson’s and trying to advance our understanding and derive a cure.  I see their devotion, I see their commitment to helping cure our disorder.

The science behind Parkinson’s is quite complicated. These complications suggest that Parkinson’s may be more of a syndrome rather than a disease. Instead of a one-size-fits-all like a disease would be classified; Parkinson’s as a syndrome would be a group of symptoms which consistently occur together.  What this might imply is that some treatment strategy might work remarkably well on some patients but have no effect on others. However, without a detailed understanding and advancement of what Parkinson’s really is we will never reach the stage where we can cure this disorder.

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In a recent blog from the Science of Parkinson’s disease, Simon nicely summarized all the current research in 2017 in Parkinson’s disease (click here to read this post). To briefly summarize what he said is that there are multiple big Pharma collaborations occurring to study Parkinson’s.  There are more than 20 clinical trials currently being done in various stages of completion to prevent disease progression but also to try to cure the disorder.  From a search of the literature, there are literally hundreds of research projects going on that promise to advance our understanding of this disorder. With the last point, it still will take time to happen. Finally, I am a realist but I’m also optimistic and positive that we’re making incredible movement toward much better therapies, which will eventually lead to curative options for Parkinson’s.

And a final analogy to baseball and Parkinson’s, as Tommy Lasorda said “There are three types of baseball players: those who make it happen, those who watch it happen, and those who wonder what happens.”  I really want to be one of those scientists that help make it happen (or at least to help advance our understanding of the disorder).

“You can’t expect life to play fair with your heart or your brain or your health. That’s not the nature of the game we call life. You have to recognize the nature of the game and know that you can do your best to make the right choices, but life if going to do whatever the hell it pleases to you anyway. All you can control is how you react to whatever life throws at you. You can shut down or you can soar.” Holly Nicole Hoxter

Cover photo credit: PNC Park photo: i.imgur.com/32RWncK

Sign post scienceofparkinsons.com/

Building Empathy for Parkinson’s

“When people talk, listen completely. Most people never listen.”  Ernest Hemingway

“To perceive is to suffer.”  Aristotle

Introduction: The loss of dopamine-producing neurons in the mid-brain leads to Parkinson’s disease, which usually presents with motor dysfunction of different degrees of progression from person-to-person.  This post explores the differences between empathy and sympathy, and describes a new device that allows one to actually experience a person-with-Parkinson’s tremor; surely providing much empathy from the experience.

“No one cares how much you know, until they know how much you care”  Theodore Roosevelt

A lesson learned from the classic rock opera “Tommy” by The Who: The plot of the 1969 rock opera “Tommy” begins with Tommy’s parents.  His father, Captain Walker, fought in World War II but it is assumed he died. However, Captain Walker is alive and returns home to his wife and Tommy. Believing her husband to be dead, Mrs. Walker has a new lover.  Captain Walker accidentally kills the lover, in the presence of Tommy. Tommy is traumatized by what he witnessed; he becomes catatonic.  Three musical examples: Go to the Mirror (listen here) Tommy sings “See me, me, feel me, touch me, heal me / See me, feel me, touch me, heal me.” Tommy’s father sings “I often wonder what he is feeling / Has he ever heard a word I’ve said? / Look at him in the mirror dreaming / What is happening in his head?” In Tommy Can You See Me? (listen here)  his mother sings “Tommy can you hear me? / Can you feel me near you? /  Tommy can you feel me / Can I help to cheer you.” In See Me, Feel Me (listen here) Tommy sings “See me, feel me, touch me, heal me / See me, feel me, touch me, heal me / See me, feel me, touch me, heal me / See me, feel me, touch me, heal me / Listening to you, I get the music / Gazing at you, I get the heat / Following you, I climb the mountain / I get excitement at your feet.” Hopefully, you can empathize, not sympathize, with Tommy and the life-struggles he encounters and overcomes in this rock opera.

“for there is nothing heavier than compassion. Not even one’s own pain weighs so heavy as the pain one feels with someone, for someone, a pain intensified by the imagination and prolonged by a hundred echoes.” Milan Kundera

*Empathy vs. sympathy: Empathy means you have the ability to understand and share the feelings of another.  By contrast, sympathy means feelings of pity and sorrow for someone else’s misfortune (https://en.oxforddictionaries.com/definition/empathy). Yes, it sucks to have a chronically-progressing neurodegenerative disorder like Parkinson’s. But it could be worse, really.

Empathy.  What a great word.  Try to be empathetic to me; you don’t have to become one with me, just strive to understand how I’m feeling.  Our bond will surely strengthen.  You may not be able to exactly feel what I’m feeling, but just trying says much to you, your inner processing, the soul of your humanity.

Please don’t pity me, that reduces the feelings between us.  Please don’t have sorrow or sadness for me, it weakens our ties. If you give me sympathy, you’ll never truly be able to grasp the extent and meaning of my Parkinson’s.  Parkinson’s is not my friend; however, having your friendship and understanding (empathy) instead of your pity (sympathy) will give me strength and help me deal on a more positive-front with this unrelenting disorder.

*This post is dedicated to the first-year medical students at the UNC School of Medicine. On Friday, May 5, I had the privilege and honor of being presented as a person-with-Parkinson’s in our Neurologic Block. They asked very specific questions in their attempt to understand Parkinson’s and to learn how I am living with this disorder. It was clear that they were trying to follow the advice of Dr. William Osler who said “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”

“Some people think only intellect counts: knowing how to solve problems, knowing how to get by, knowing how to identify an advantage and seize it. But the functions of intellect are insufficient without courage, love, friendship, compassion, and empathy.”  Dean Koontz

What is the life expectancy of someone diagnosed with Alzheimer’s, Parkinson’s, Amyotrophic Lateral Sclerosis (ALS), and Huntington’s disease? These neurodegenerative disorders are listed in ranked order of how many people are affected from most to least, respectively. Alzheimer’s typically progress over 2 to 20 years, and individuals live for 8 to 10 years after the diagnosis.  People who have Parkinson’s usually have the same average life expectancy as people without the disease.  Life expectancy from ALS is usually at least 3-4 years. The time from diagnosis  of Huntington’s to death is about 10 to 30 years.  Each of these disorders is uniquely different and unsettling to me; but your empathy, not your sympathy, will truly help me sail my boat along the shoreline for many more years.  Accept me with ‘my unique medical issues’, try to understand it. Your empathy will add stability to my battle; just watch.

“Resolve to be tender with the young, compassionate with the aged, sympathetic with the striving, and tolerant of the weak and the wrong. Sometime in life you will have been all of these.” Lloyd Shearer

A novel engineering device is empathy-producing to someone with Parkinson’s: The whole story is revealed from watching this video (click here). Klick Labs in Toronto, Canada, has created the SymPulse Tele-Empathy Device. This device is capable of mimicking and producing the tremors and involuntary movements of someone with Parkinson’s in people without Parkinson’s. The video is quite powerful, you immediately sense the empathy.

The SymPulse Tele-Empathy Device is based on digitized muscle activity from electromyograms of Parkinson’s patients. The signal is unique for each person with Parkinson’s. When the person without Parkinson’s receives this novel voltage pattern, their muscles will contract exactly as found in the person with Parkinson’s. Developing such a device shows the deviant nature of Parkinson’s to disrupt/distort normal neuro-muscular circuitry.

This device could be used to increase empathy in doctors and other caregivers. And it could enable family members and loved-ones the unique opportunity to experience the actual tremor/involuntary movements of their special person with Parkinson’s. Company officials note that most people wear the device for at most a couple of minutes; turn off the device and they return to normal. Remember, there is no off-on switch for the person with Parkinson’s.  I can only imagine empathy evolving from this device when used on someone without Parkinson’s.

“When we honestly ask ourselves which person in our lives mean the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand. The friend who can be silent with us in a moment of despair or confusion, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not curing, not healing and face with us the reality of our powerlessness, that is a friend who cares.” Henri J.M. Nouwen

Cover photo credit: gsmnp.com/wp-content/uploads/View-of-Smoky-Mountains-from-Oconaluftee.jpg

Parkinson’s Awareness Month: Veterans Health Administration PD Video Series

“My motto was always to keep swinging. Whether I was in a slump or feeling badly or having trouble off the field, the only thing to do was keep swinging.” Hank Aaron

“Nothing worth having comes easy.” Theodore Roosevelt

Introduction: Several years ago, the Veterans Health Administration produced videos to educate/inform our veterans about Parkinson’s disease.   For more information, read about the VA Core Values and Mission Statement (click here); it is an admirable sentiment.

As we are living longer, so too are our veterans. Some service-related-experiences may have predisposed some of them to develop Parkinson’s.  All of these videos are available on YouTube.  However, since this is Parkinson’s awareness month, putting them all together might benefit others to better understand Parkinson’s.   I definitely learned something from watching these videos, they were all outstanding.

Each individual video features a veteran (frequently their care-partner too) who agreed to be videotaped (having done this type of interview myself, it is not an easy experience); I admire their courage to participate and to help educate all of us. Furthermore, the VA clinical and support staff were passionate and compassionate about their roles in dealing with our veterans with Parkinson’s.

“Losing the possibility of something is the exact same thing as losing hope and without hope nothing can survive.” Mark Z. Danielewski

Veterans Health Administration – My Parkinson’s Story:
My Parkinson’s Story:
Early Parkinson’s Disease [click here for video]

My Parkinson’s Story: Thinking and Memory Problems with Parkinson Disease [click here for video]

My Parkinson’s Story: Medications [click here for video] 

My Parkinson’s Story: Dyskinesias [click here for video] 

My Parkinson’s Story: Atypical [click here for video] 

My Parkinson’s Story: Driving [click here for video]

My Parkinson’s Story: Sleep Problems and Parkinson’s Disease [click here for video] 

My Parkinson’s Story: Genetics [click here for video] 

My Parkinson’s Story: Exercise [click here for video] 

My Parkinson’s Story: Environmental Exposure [click here for video]

My Parkinson’s Story: The Impact of Depression in Parkinson’s Disease [click here for video] 

My Parkinson’s Story: Impact of Falls and Parkinson’s Disease [click here for video]

My Parkinson’s Story: The Caregiver [click here for video] 

My Parkinson’s Story: Deep Brain Stimulation and Parkinson Disease [click here for video]

My Parkinson’s Story: Hospitalization [click here for video] 

My Parkinson’s Story: Speech and Swallowing [click here for video] 

My Parkinson’s Story: Advanced Parkinsons [click here for video]

“Not I, nor anyone else can travel that road for you. You must travel it by yourself. It is not far. It is within reach. Perhaps you have been on it since you were born, and did not know. Perhaps it is everywhere – on water and land.” Walt Whitman

“We can’t equate spending on veterans with spending on defense. Our strength is not just in the size of our defense budget, but in the size of our hearts, in the size of our gratitude for their sacrifice. And that’s not just measured in words or gestures.” Jennifer Granholm

Cover Photo Credit: http://wallpapersafari.com/w/Fy0h6Q/

Part 2: Journey to Parkinson’s and Magnetic Resonance Imaging

“The best thing about the future is that it comes one day at a time.” Abraham Lincoln

“To be yourself in a world that is constantly trying to make you something else is the greatest accomplishment.” Ralph Waldo Emerson

Introduction: Along the way to the diagnosis of Parkinson’s, you may have to undergo several different kinds of tests to help your physician(s) learn what actually is going on with your physiology and neurological network.  Remember there is neither a reliable blood test nor a comprehensive genetic marker evaluation to provide a diagnosis of Parkinson’s. Therefore, the exams I’m getting ready to describe are sometimes done to exclude other disorders and to further implicate Parkinson’s.  My Neurologist says the most helpful thing is the actual patient interview (History and Physical) since most people with Parkinson’s have a characteristic set of signs and symptoms.

These posts (a series of 5 procedures) are purely descriptive/informational but they are important to describe because they can be kind of intimidating and nerve-racking to undergo (just in case any of these tests are suggested by your physician team).  Let me be clear, I am not recommending any of these procedures for you (I’m a basic scientist not a physician). Interestingly, my Neurologist was involved only in the MRI and sleep study, which were done after my diagnosis of Parkinson’s. The other procedures were done before my diagnosis as we (another group of very talented physicians) were trying to sort out what was wrong. These are the procedures:

Part 1 described the Barium Swallow test (click here to read this post);
Part 2 gives an overview of Magnetic Resonance Imaging (MRI) [Current post];
Part 3 highlights Polysomnography, which is a sleep study;
Part 4 presents Electromyography (EMG), which measures nerve/muscle interactions;
Part 5 characterizes Transradial Cardiac Catheterization and Angiography.

“Life is simple. Everything happens for you, not to you. Everything happens at exactly the right moment, neither too soon nor too late. You don’t have to like it… it’s just easier if you do.” Byron Katie

ABC’s of MRI:  Magnetic resonance imaging (MRI) uses powerful magnetic fields and radio waves to produce images of organs and structures inside your body. MRI scans are useful to help physicians diagnose a variety of disease processes, from torn ligaments to visualizing tumors. In Parkinson’s and related disorders, MRI scans are valuable for examining the brain and spinal cord.  During the scan, you lie on a table that slides inside a tunnel-shaped machine (pictured below). Good news is the scan is painless; bad news is the MRI machine is very loud. They will likely offer you earplugs.  Use the earplugs because it is that loud (magnets are being re-positioned).  If you are claustrophobic, request a damp wash cloth to place over your eyes.   They may offer you pillows for support, and they will instruct you and make sure you understand you need to be still.  There will be an emergency call button, laid close to your hand; just in case for whatever reason you need to terminate the scan.  Finally, the average duration of the scan is ~45 minutes; you need to come prepared for this time to be as relaxed and still as possible. The staff helping me get ready for my MRI were very kind, patient and friendly; they were also very knowledgeable.

“Life is not a problem to be solved, but an experience to be had.” Alan Watts

Are there any special precautions beforehand? No, there is little to no preparation required before getting an MRI scan. You will be asked to change into a gown; your clothes are stored in a locked closet. The only unusual preparation is that all removable metallic objects must be left outside the shielded MRI room itself, including removable hearing aids, dentures and other prosthetic devices.  Furthermore, magnetic strips on credit cards can be damaged by the MRI magnet.

“Our greatest glory is not in never falling, but in rising every time we fall.” Confucius

How MRI works ? (Taken from http://www.livescience.com/39074-what-is-an-mri.html): “The human body is mostly water. Water molecules (H20) contain hydrogen nuclei (protons), which become aligned in a magnetic field. An MRI scanner applies a very strong magnetic field (about 0.2 to 3 teslas, or roughly a thousand times the strength of a typical fridge magnet), which aligns the proton ‘spins’.

The scanner also produces a radio frequency current that creates a varying magnetic field. The protons absorb the energy from the variable field and flip their spins. When the field is turned off, the protons gradually return to their normal spin, a process called precession. The return process produces a radio signal that can be measured by receivers in the scanner and made into an image.

Protons in different body tissues return to their normal spins at different rates, so the scanner can distinguish among tissues. The scanner settings can be adjusted to produce contrasts between different body tissues. Additional magnetic fields are used to localize body structures in 3D.”

“Success is not final, failure is not fatal: it is the courage to continue that counts.” Winston Churchill

Why did your neurologist order the MRI? Mostly to eliminate other reasons for our symptoms of Parkinson’s; such as a stroke (ischemic or hemorrhagic), trauma resulting in bleeding (hemorrhage), or brain tumor. If there are no signs of a stroke, other forms of bleeding,  or brain tumor, most MRI brain scans of people with Parkinson’s will appear normal.

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Example of what the mid-brain looks like from the MRI scan (*SN = Substantia nigra, the dopamine-producing region).

Good news/Bad news: The difficult issue is that you’ve just been told that you have Parkinson’s; however, let’s do the MRI scan to rule out stroke, bleeding/trauma, tumor just in case.  I understand what you are feeling, I do.  Knowing you have Parkinson’s takes your breath away; verifying it by eliminating these other processes mentioned above, still sucks.  My Neurologist told me that my brain was ‘unremarkable’; in other words, you’ve got Parkinson’s.  Stay focused, keep an even keel, your life has changed; however, your life is still relevant, keep going forward.

“Never let your head hang down. Never give up and sit down and grieve. Find another way.” Satchel Paige

“Never give up, for that is just the place and time that the tide will turn.” Harriet Beecher Stowe

References about MRI:
http://www.webmd.com/a-to-z-guides/magnetic-resonance-imaging-mri#1
http://www.mayoclinic.org/tests-procedures/mri/home/ovc-20235698
http://www.medicalnewstoday.com/articles/146309.php
http://www.livescience.com/39074-what-is-an-mri.html
https://en.wikipedia.org/wiki/Magnetic_resonance_imaging

Cover photo credit: http://www-tc.pbs.org/wgbh/nova/next/wp-content/uploads/2013/11/malbec-grapes.jpg

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The Mask of Parkinson’s

“I wear the mask. It does not wear me.” Man in the Iron Mask

“See to it, then, that the light within you is not darkness.” Luke 11:35

Précis: The simplest way to describe Parkinson’s is that it’s a movement disorder due to the reduction of dopamine production.  Sometimes one of the more obvious places this absence of dopamine is noticed is the reduction of facial expressions (also referred to as masked facies or hypomimia).  The “mask of Parkinson’s” is further described below.

Loss of facial expression: There are 43 muscles in the face, which are all mostly controlled by the seventh cranial nerve.  Johann Kaspar Lavater said “…The human face is nature’s tablet, the truth is certainly written thereon.” We view the smile as a sign of friendship, happiness, and acceptance; while we view the frown as a sign of sadness or unacceptable.  The Parkinson’s face is somewhat less expressive than before; somewhat more rigid than before.  Many people-with-Parkinson’s also have chronic stiff necks; however, that doesn’t make us Frankenstein.

Scenario #1: You’ve played 17 holes of golf, and you approach the 18th hole to finish the round. This is a long par three with a lake between you on the tee box and the putting surface.  Your three golf buddies have already safely hit their balls over the lake;  you  launch the ball over the water and safely onto the green (this is a big deal).  Without Parkinson’s, your facial expression and your exuberance are so obvious.  With Parkinson’s, your joy and exuberance are still over-flowing inwardly yet it is displayed in a more muted  manner.

‘Life is a mask through which the universe expresses itself.” Frank Herbert

“You wear a mask for so long, you forget who you were beneath it.” Alan Moore

Changes in your voice: The loss of dopamine in your brain leads to reduced volume in your voice along with your voice becoming flatter/softer in tone.  The same process affecting your face is happening in your voice. If you think of dopamine as a “messenger service”, the brain uses it to send orders/messages to nerves.  When dopamine-producing cells die, all muscles are affected and diminish, including muscles involved in speaking, swallowing, facial motion, legs and  walking, and hand/arm movements.

Scenario #2:  You and your partner are attending a college basketball game;  your home team is 3-points ahead of your biggest rival, and it’s near the end of the second half.  Game over, your team wins, let the fun begin.  Like everyone else in the arena, you are standing, jumping around, high-five’s all near you, and you are shouting (and singing) your lungs out.  Such happens during great college basketball rivalry games.  Without Parkinson’s, all of this is a reality, a dream come true.  There is a feeling of satisfaction and there is a huge positive feeling from the game.  With Parkinson’s, there is the same positive feeling of happiness but with a diminished ability to clap  continuously and you’re less able to shout and sing along loudly with everybody.

Two famous masks:

“Without wearing any mask we are conscious of, we have a special face for each friend.’ Oliver Wendell Holmes

“A mask tells us more than a face.” Oscar Wilde

Consequences of the ‘Parkinson’s Mask’: The change is subtle over time. Mostly,  there is a softness to your voice, your smile is not as big, and you don’t blink your eyes as much.

Subtle differences in the before/after pictures (I’m also younger in the without PD pictures):

16-12-17photoscomp-pd

Because I do a lot of teaching, I get a lot of teaching evaluations and critiques. Here are two comments from two medical students regarding my lecturing in Immunology (one of the medical school courses I co-direct and teach in):

“Dr. Church is a wonderful lecturer! Not only is he easy to follow during lectures as far as explaining concepts is concerned, but his dedication to his students, their questions, and their general well-being never ceases to amaze me.

“Dr. Church should take it as a huge compliment that he was able to convey enthusiasm about the topic and inspire passion in students despite his expression often being limited by Parkinson’s.”

LSVT LOUD® can certainly help boost the volume and tone of your voice. If you use it and practice, it will make a difference.  My Speech Pathologists told me that we think we’re speaking at a normal volume but we’re really not.  Your goal is to train your brain to really speak loud (almost shouting). You can also practice making accentuated facial motions, trying to accentuate what’s going on with your face. You can practice smiling large, and other facial exercises (try practicing your vowels).  I have never had a loud voice and I’m not an overly expressive person; having Parkinson’s has softened everything. When you listen to someone speaking, you also listen with your eyes; thus,  the reduction in visual cues makes it harder to understand you.  To continue to get these positive comments shown above, I need to be constantly practicing on speaking louder and working on my facial exercises.

“Take the emotional temperature of those listening to you. Facial expressions, voice inflection and posture give clues to a person’s mood and attitude.” John C. Maxwell

“People are like stained – glass windows. They sparkle and shine when the sun is out, but when the darkness sets in, their true beauty is revealed only if there is a light from within.” Elisabeth Kubler-Ross

Resist the evolving Parkinson’s mask:  The worst-case scenario to what I’ve been describing is the total outward masking/blocking of your inner self and its expression. We must resist that change, we must really work hard to speak louder and to over-accentuate our facial motion to show the emotion that’s within us. Change may be subtle but change is inevitable for most of us regarding this mask. Stay vigilant. Let’s keep working on talking louder and being more expressive. The inner you is still there, it’s functioning and still wanting to get out. Keep working.

“When we can let go of what other people think and own our story, we gain access to our worthiness—the feeling that we are enough just as we are and that we are worthy of love and belonging. When we spend a lifetime trying to distance ourselves from the parts of our lives that don’t fit with who we think we’re supposed to be, we stand outside of our story and hustle for our worthiness by constantly performing, perfecting, pleasing, and proving. Our sense of worthiness—that critically important piece that gives us access to love and belonging—lives inside of our story.” Brené Brown

Cover photo credit: http://7-themes.com/6793576-free-pacific-ocean-wallpaper.html

7 Healthy Habits For Your Brain

   “Your brain – every brain – is a work in progress. It is ‘plastic.’ From the day we’re born to the day we die, it continuously revises and remodels, improving or slowly declining, as a function of how we use it.” Michael Merzenich

“The root of all health is in the brain. The trunk of it is in emotion. The branches and leaves are the body. The flower of health blooms when all parts work together.” Kurdish Saying

7 Basic Brain Facts [click here for more facts]: (1) The typical brain is ~2% of your total weight but it uses 20% of your total energy and oxygen intake. (2) >100,000 chemicals reactions/sec occur in your brain. (3) The latest estimate is that our brains contain ~86 billion brain cells. (4) In contrast to the popular belief that we use ~10% of our brains; brain scans show we use most of our brain most of the time. (5) There are as many as 10,000 specific types of neurons in the brain.  (6) Cholesterol is an integral part of every brain cell. Twenty-five percent of the body’s cholesterol resides within the brain. (7) Your brain generates between 12-25 watts of electricity, which is enough to power a low wattage LED light.

7 Healthy Habits for Your Brain: With or without Parkinson’s disease, taking care of your brain is all-important to your overall well-being, life-attitude, and health. These are  straightforward suggestions of healthy habits for your brain; hopefully, this list will serve as a reminder about their importance.  Here is a 1-page summary of the “7 Healthy Habits for Your Brain” (Click here to download file).

7-healthy-habits-for-your-brain


[1] Exercise and neuroplasticity:
  Exercise is almost like a soothing salve for your brain.  Some benefits of exercise include helping your memory and increased flow of oxygen to brain, which energizes the brain.  Exercise is good for both your heart and your brain. Exercise can reduce inflammation in the brain and increase hormones circulating to your brain.  For a brief overview on the benefits of exercise to your brain, click here.

Neuroplasticity is the ability to re-draw, re-wire the connections in your brain. What this means is that neuroplasticity is a concerted attempt of neurons to compensate for brain injury/disease. Neuroplasticity ultimately modifies your brain’s activities in response to changes in these neuronal-environments.

There is much positive evidence in animal models of Parkinson’s regarding exercise-induced neuroplasticity.  The same benefits are now being tested in humans with Parkinson’s and the results are most encouraging. One of the numerous backlogged blog drafts that will be completed in the near-future is a “Review of Exercise and Neuroplasticity in Parkinson’s”.

“Exercise is really for the brain, not the body. It affects mood, vitality, alertness, and feelings of well-being.” John Ratey

“Neuroplasticity research showed that the brain changes its very structure with each different activity it performs, perfecting its circuits so it is better suited to the task at hand.” Naveen Jain

[2] Diet and brain food: Your memory is aided by ‘what’ you eat.  Harvard’s Women Health Watch makes the following suggestion to boost your memory through diet (click here to read entire article): “The Mediterranean diet includes several components that might promote brain health: Fruits, vegetables, whole grains, fish, and olive oil help improve the health of blood vessels, reducing the risk for a memory-damaging stroke; Fish are high in omega-3 fatty acids, which have been linked to lower levels of beta-amyloid proteins in the blood and better vascular health; Moderate alcohol consumption raises levels of healthy high-density lipoprotein (HDL) cholesterol. Alcohol also lowers our cells’ resistance to insulin, allowing it to lower blood sugar more effectively. Insulin resistance has been linked to dementia.”  WebMD summarized the role of diet and brain health in “Eat Smart for a Healthier Brain” (click here to read article).

A large group of women (>13,000 participants) over the age of 70 were studied and the results showed that the women who ate the most vegetables had the greater mental agility (click here to read the article). These results suggest for a healthy brain we should eat colorful fruits and vegetables high in antioxidants; and foods rich in natural vitamin E, vitamin C, B (B6, B12) folic acid and omega-3 fatty acids. Furthermore, we should avoid refined carbohydrates and saturated fats. In small amounts, vitamin D3 is almost like candy for your brain.

“Hunger, prolonged, is temporary madness! The brain is at work without its required food, and the most fantastic notions fill the mind.” Jules Verne

“Everything one reads is nourishment of some sort – good food or junk food – and one assumes it all goes in and has its way with your brain cells.” Lorrie Moore

[3] Mindfulness/meditation: Greater Good (The Science of a Meaningful Life) describes mindfulness as “…maintaining a moment-by-moment awareness of our thoughts, feelings, bodily sensations, and surrounding environment. Mindfulness also involves acceptance, meaning that we pay attention to our thoughts and feelings without judging them—without believing, for instance, that there’s a ‘right’ or ‘wrong’ way to think or feel in a given moment.”  I recently described mindfulness as “Mindfulness means you stay within your breath, and focus within yourself, with no remembrance of the past minute and no planning for the future moment.”  Here’s a simple mindfulness experience/moment: simply be aware of the steam leaving your morning cup of coffee/tea, clear your immediate thoughts, then sip, focus and savor this moment.

“The picture we have is that mindfulness practice increases one’s ability to recruit higher order, pre-frontal cortex regions in order to down-regulate lower-order brain activity,” a comment from Dr. Adrienne Taren, a researcher studying mindfulness at the University of Pittsburgh. She also said  “it’s the disconnection of our mind from its ‘stress center’ that seems to give rise to a range of physical as well as mental health benefits.”  (Click here to read this article).  “What Does Mindfulness Meditation Do to Your Brain?” (click here to read more)

“Mindfulness practices enhance the connection between our body, our mind and everything else that is around us.” Nhat Hanh

“Mindfulness is a pause — the space between stimulus and response: that’s where choice lies.” Tara Brach

 [4] Stress reduction: When you are under constant or chronic stress your body makes more of the steroid hormone cortisol (a glucocorticoid), which is produced by the adrenal glands above your kidneys.  Over time, chronic stress can trigger changes in brain structure and function. Excess cortisol production reduces neuronal cells, over-produces myelin protective covering to our nerves, and we make more oligodendrocytes.  How do you reduce chronic stress?  Exercise and mindfulness/meditation are both able to lower cortisol levels.  Easier said then done to making life-style changes to reduce chronic stress; however, doing it will allow the neuroplastic process to begin re-wiring your brain. For an overview of stress and trying to manage/reduce chronic stress, click here.

“Stress is an ignorant state. It believes that everything is an emergency.” Natalie Goldberg

“There is more to life than increasing its speed.” Mahatma Gandhi

[5] Work, keep active mentally:  There are 2 sides to this topic.  First, stay engaged at work and you won’t age as fast as someone disengaged.  What I’m trying to say is simply staying active mentally at work will assist your brain during the ageing process.  Keep your brain stimulated with work, thought, challenges; the effort provides your brain with significant growth.  Your reward will be an active-focused and rejuvenated mind.  Second, by contrast, we’re all working long hours balancing too many tasks, all-the-time; ultimately, we’re trying to multi-task when we really can’t multi-task very well.  In a nice article entitled “The Magic of Doing One Thing at a Time“, Tony Schwartz summarized a key problem: “It’s not just the number of hours we’re working, but also the fact that we spend too many continuous hours juggling too many things at the same time. What we’ve lost, above all, are stopping points, finish lines and boundaries.”  As you balance the 2-sides-of-the-topic, focus your energy on the first-side by performing each individual task/topic; clear your mind, keep your brain engaged, focus hard and then let your brain renew.

“To let the brain work without sufficient material is like racing an engine. It racks itself to pieces.” Arthur Conan Doyle

“A fresh mind keeps the body fresh. Take in the ideas of the day, drain off those of yesterday.” Edward Bulwer-Lytton

 [6] Positive and happy is better for your brain:  I truly believe you need to be positive in dealing with Parkinson’s; trying to focus on staying happy will benefit all-around you and bolster your brain’s health. Using positivity will allow you to creatively handle many obstacles ahead, whether in the absence or presence of Parkinson’s.  Susan Reynolds summarized in “Happy Brain, Happy Life” that being happy: “stimulates the growth of nerve connections; improves cognition by increasing mental productivity; improves your ability to analyze and think; affects your view of surroundings; increases attentiveness; and leads to more happy thoughts.”  On the notion of staying positive, she said: “…thinking positive, happy, hopeful, optimistic, joyful thoughts decreases cortisol and produces serotonin, which creates a sense of well-being. This helps your brain function at peak capacity.”


Positive

“Do the best you can until you know better. Then when you know better, do better.” Maya Angelou

“You have to train your brain to be positive just like you work out your body.” Shawn Achor

[7] Sleep: It’s simple; our brains, our bodies need sleep.  Many of us battle with less than adequate daily sleep habits.  However, it’s really simple; our brains, our bodies need sleep.  Much of our day’s success resides in the quality of sleep the night before.  The science of sleep is complex but much of it revolves around our brain.  We use sleep to renew and de-fragment our brain; and sleep helps strengthen our memory.  For more details on sleep science, please look over “What Happens in the Brain During Sleep?” (click here).  Alice G. Walton very nicely summarized several aspects of the sleep-brain interactions focusing on the following 7 headings: “Sleep helps solidify memory; Toxins, including those associated with Alzheimer’s disease, are cleared during sleep; Sleep is necessary for cognition; Creativity needs sleep; Sleep loss and depression are  intertwined; Physical health and longevity; and Kids need their sleep” [click here for “7 Ways Sleep Affects The Brain (And What Happens If It Doesn’t Get Enough)”].  Finally, the Rand Corp. just released a comprehensive study on sleep and the economic burden being caused by the lack of sleep (click here to read the 100-page report).

Sleep is the golden chain that ties health and our bodies together.Thomas Dekker

A good laugh and a long sleep are the best cures in the doctor’s book.   Irish Proverb

A Personal Reflection on the “7 Healthy Habits for Your Brain”:  My fall semester is physically, mentally, and emotionally draining; and I cherish doing all of these tasks, I really do.  The writing of this blog is a deliberate attempt to remind me what I need to be doing, to re-initiate tomorrow in my daily life.  I could explain each point in detail in what poor-brain-health-habits I’ve developed this semester (but I won’t).  However, I am printing out the 1-page handout of 7-healthy-brain-habits to keep it with me as I spend the rest of December re-establishing effective habits for my brain; and doing a better job of balancing work with life-love-fun.

“Your body, which is bonding millions of molecules every second, depends on transformation. Breathing and digestion harness transformation. Food and air aren’t just shuffled about but, rather, undergo the exact chemical bonding needed to keep you alive. The sugar extracted from an orange travels to the brain and fuels a thought. The emergent property in this case is the newness of the thought; no molecules in the history of the universe ever combined to produce that exact thought.” Deepak Chopra

Cover image: https://img1.etsystatic.com/000/0/6392236/il_fullxfull.267319437.jpg

Mindfulness list: http://www.mindful.org/7-things-mindful-people-do-differently-and-how-to-get-started/

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2016 Whitehead Lecture: Advice, Life Stories and the Journey with Parkinson’s

“In giving advice I advise you, be short.” Horace

“The journey is what brings us happiness not the destination.” Dan Millman

Introduction: Last month, I presented the Whitehead Lecture to the UNC School of Medicine (SOM).  Here is what that means: “The annual Whitehead Lecture serves as an unofficial convocation for the School of Medicine. It is named in honor of Dr. Richard Whitehead, dean of the School of Medicine from 1890 to 1905. The Whitehead Lecturer is chosen by the SOM medical student governing body (Whitehead Medical Society). The selection is based on qualities of leadership, dedication, and devotion to medicine and teaching. Being elected to deliver the Whitehead Lecture is among the highest honors for faculty members at the School of Medicine.” (excerpted from https://www.med.unc.edu/md/events-awards/academic-calendars-events/whitehead-lecture).

In my 30-something year academic career at UNC-CH this was the biggest honor I’ve  received from the School of Medicine.  Here is a link to the news article written about my ~15-min lecture and the other teaching awards given to faculty, residents/fellows, and medical students (click here).

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Themes of Advice:  Below is a summary of the advice I gave to UNC-CH medical students to help them through their medical school journey (realizing I’m not a physician but a medical educator/biomedical researcher).  The lecture was divided up into 4 chapters: Chapter 1: Conflict of Interest Statement (this was done to start lightheartedly and to ‘try’ to be funny); Chapter 2: Core Values Learned from Growing up an “Air Force Brat” (childhood memories of my dad, Col. Church)Chapter 3: Life Stories and Advice Using Words that Begin with “H” (I  made a word-cloud with numerous words/phrases, e.g., Hope, Happy, Hospital, and Healthy Habits Harbor Happiness); and Chapter 4: Conclusions.

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The advice/stories were accompanied by numerous pictures and my own personal-life-events to emphasize my side of my own advice.  Advice I tried to convey to the medical students regarding my Parkinson’s disease was as follows: (a) acceptance and adaptation while still living positively; (b) adversity is rarely planned but you must be proactive as it accompanies life; and (c) a wide range of illness (from good to bad) accompanies most disorders; thus, it matters how you approach and treat each individual person (patient) with every disorder.

“My definition of success: When your core values and self-concept are in harmony with your daily actions and behaviors.” John Spence

“Never let your head hang down. Never give up and sit down and grieve. Find another way.” Satchel Paige

Chapter 1: Conflict of Interest Statement:

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Chapter 2: Core Values Learned from Growing up as an “Air Force Brat:

slide1Core Value of Integrity:
A cornerstone of my dad’s influence on me was integrity, to always be honest.
Everything I did growing up needed teamwork and integrity added strength to each team.
•Your integrity leads you forward.
“Be as you wish to seem.” Socrates

Core Value of Service:
The USAF interpretation of service is a commitment to serve your country before self.
My commitment to service and to helping others is through education and biomedical research.
•Your own service enriches your life.
“To work for the common good is the greatest creed.” Albert Schweitzer

Core Value of Excellence:
The core value of excellence revolves around doing the task proudly and right.
My dad instilled in me the notion to work hard, centered on excellence because the task mattered no matter the importance of the task.
Through this same excellence, your life matters.
“Excellence is doing ordinary things extraordinarily well.” John W. Gardner

Chapter 3: Life Stories and Advice Using Words that Begin with “H”:

slide08Help/Helpful/Helped:
There will be times when classmates, team members, and patients ask you for help/advice; always try to be helpful.
You may need to be helped on some topic-issue; that is totally okay, you are not expected to do it all by yourself.
“If
you light a lamp for somebody, it will also brighten your path.” Gautama Buddha

Colleagues Who Have Helped Me To Become A Better Educator:
A very important part of my career is centered around medical education.  I am fortunate to have colleagues who are gifted teachers, who serve as wonderful role models, and who have given me sound advice/feedback on new teaching strategies and educational ideas.
This group includes Dr. Alice Ma, Dr. Tom Belhorn, SOM Teaching Champions (Dr. Kurt Gilliland, Dr. Ed Kernick, Dr. Gwen Sancar, Dr. Arrel Toews, Dr. Marianne Meeker, Dr. Sarah Street and this group included me), Dr. Joe Costello, Johanna Foster and Katie Smith.
Since joining the Department of Pathology and Laboratory Medicine as an Assistant Professor (1987), I have had the privilege of teaching ~6,000 students (26 years of medical students x ~170 students/year = 4,420; 23 years of graduate students x ~20 students/year = 460; and 20 years of ~75 undergraduates/year = 1,500).

Find Your Holy Grail in Higher Education:
Challenge yourself, be goal-directed and discover where your passion resides (it could be patient care, research, education, service, policy, outreach, etc.).
Stay engaged in pursuit of your hallmark in higher education, which becomes your very own Holy Grail.
If you’re not happy, keep searching.
“What is known as success assumes nearly as many aliases as there are those who seek it. Like the Holy Grail, it seldom appears to those who don’t pursue it.” Stephen Birmingham

My Holy Grail in Higher Education (Hemostasis-Thrombosis Research):
34 years ago, 1982, I began my postdoctoral fellowship in the laboratory of Dr. Roger Lundblad. Since 1986, as a basic biomedical researcher in the Department of Pathology and Laboratory Medicine [Research Assistant Professor (1985-1986), Assistant Professor (1987-1994), Associate Professor (with tenure, 1994-1999), and Professor (with tenure, 1999-present)] , I have had a wonderful and enriching academic research career that has helped train over 100 scientists: 17 graduate students; 12 postdoctoral fellows; 17 medical students; and 65 undergraduates.
My research (Holy Grail) is centered on:
Biological Chemistry of Coagulation Proteases and their Serine Protease Inhibitors (Serpins);
-Aging
and Senescence-linked to the Pathophysiology of Venous
Thrombosis;
-Funding through NIH (NHLBI, NIA, and NINDS), American Heart Association, and Susan G. Komen for the Cure.

Shown below left is the antithrombin/thrombin/heparin complex and below right, a 30-year history of some of the former/current lab personnel (1987, 2003, and 2016).

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Handle Adversity in Your Journey:
We have expectations of what life should be like and what it should offer us; instead, accept what life gives you at the moment.
When life presents an obstacle, do your best to
handle adversity in your journey.
Life’s challenges are not supposed to paralyze you, they’re supposed to help you discover who you are.” Bernice Johnson Reagon

slide17Handling Adversity in My Journey:
Parkinson’s is a slowly progressing neurodegenerative disorder from the loss of dopamine-producing cells.
Dealing with an incurable disease like Parkinson’s is different than living with a terminal illness; you must accept that it’s part of your life for years to come.
Strive to live-forward, and always remember that we’re still in the driver’s seat of our world. Live decisively even as we accept the problems from Parkinson’s.” Frank C. Church

slide19Home Is Where The Heart Is:
1.Home is where the heart is. You love the place best which you call your home. That is where your heart lives.
2.Home is where the heart is. Wherever you feel most at home is where you feel you belong. That is where your heart is.
3.Your home may change many times over the coming years. Let your heart tell you where your home is.

Home Is Where My Heart Is (or Has Been for the Past 50 Years):
On a tennis court and on a golf course;
In a research laboratory and in a classroom teaching;
With family/loved ones.
“Let your heart tell you where your home is.”  Frank C. Church

home

Health (Heal, Healed, Healer):
Your foundation of knowledge is expanding to allow you to make decisions related to someone’s health.
You’ll likely encounter a spectrum of illness in your patients; health is like a rheostat that ranges from good to bad, mild to severe. Remember, you are treating a person with a disorder/illness.
“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” William Osler

Health (Heal, Healed, Healer) From My Perspective With Parkinson’s:
A Google search for “Parkinson’s disease: Images” shows these drawings from the 1880’s are still very prevalent (below left panel).
Yes, they accurately show the Cardinal signs of Parkinson’s: tremor, rigidity from muscle stiffness, bradykinesia (slowness of movement), postural instability, and facial masking.
However, these images suggest to many that all people-with-Parkinson’s must look and act like this.
An emerging picture of Parkinson’s today is (hopefully, below right panel) a person embracing an appropriate lifestyle with a treatment plan to manage and live with their symptoms.
My daily mantra: “Never give up; I refuse to surrender to Parkinson’s.” Frank C. Church

health

Chapter 4: Conclusions:
I am most pleased to welcome all of the new medical students (MS-1’s) to medical school and to everyone else, we’re glad you’re here.
The “USAF core values” could be of some use in your professional career and in your personal life.
Remember the “words that begin with the letter H”; they could be both supportive and comforting in your years of training.
We have one final “H word” to get through but I need YOUR voices…

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“I believe that curiosity, wonder and passion are defining qualities of imaginative minds and great teachers; that restlessness and discontent are vital things; and that intense experience and suffering instruct us in ways that less intense emotions can never do.” Kay Redfield Jamison

Cover photo credit: Frank Church

Home Is Where The Heart Is: (1) and (2) partly adapted from Anila Syed, Wordophile.

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