THIS IS A 1 TIME POST. PLEASE REFER TO WWW.CEREBRATIONS.BIZ 4 THIS BLOG!!!!!!!

THIS IS A ONE TIME POST. PLEASE REFER TO MY NORMAL BLOG AT CEREBRATIONS.BIZ
Janine Ripper has way too much time on her hands now.  So, she decided that the 6 degrees of separation could lead to a discussion of 7 links.   A retrospective of my blog to discuss 7 posts, 7 links you may find useful.  My issue is that I not only write this blog, but I prepare reports for clients, and send notes to my clients almost every day.  So, between those reports, notes, and blogs, there are more than 2000 pieces for the last calendar year alone!  But, I will limit this to my blog-  but you are welcome to disagree with my choices.  Let me know what you think I should have chosen…

My Most Beautiful Blog:  Beautiful to me are the feelings invoked as I write the post.  And, I described a business principle that was made obvious (to me, at least) when I was sharing a baseball game with my son, daughter, son-in-law, and grandson (about ½ my immediate family).  The topic was vision, mission, and goals- and time management.   We need to remember- each and every day- that our family is a vital part of the equation.

My Most Popular Post: The problem with this choice is that the newer posts don’t get equal weight.  The question is not the most popular post the day or week you posted it- but the most popular post by number of clicks.  And, I am assuming the word “My” belongs to my blog, not to me.  So, the winner is:  Do You Know This Key to Building Team Trust.  A guest post from Mohammed Fahtelbab.   He had sent it around to clients and friends and I asked him to republish it on my blog- a request to which he acceded.  Thanks, Mo!  If you want a post I personally wrote (this comes in second by 3 views), then it’s  Well Deserved Kudos- and a lesson for us all!, when I thanked people who made a difference in my life.  (I thank them every day- this was just a public acknowledgement.)

My Most Controversial Post:   Most of my controversial discussions are NOT to be found on this blog. I try to keep my politics out of the blog.  (Actually, everything we do is politics; I am talking about Partisan Politics; and my party does not exist within the Commonwealth of Virginia…)  The winner of this category was a technical/medical series, where I disagreed vehemently with the facile conclusions presented by ProPublica in the Atlantic:  Reactions to The Atlantic (ProPublica) Dialysis Article.

My Most Helpful Post:    This is the hardest to discern, since I consider ALL my posts helpful :-).  And, there is no scientific way to determine this fact, so it’s all my personal bias… I discussed resolutions and changes we need to institute in our (business, personal, professional)  lives last September (my new year), which I do discuss from time to time.  But, this list was the most complete.

A Post Whose Success Surprises Me:  This is going to be a bust.  I expect (demand?) that everything I do be a success.  As such, how could a post’s success surprise me?  I could say that Mo’s guest post could be construed as surprising, since I didn’t write it.  But, I knew it was a winner from the second I first saw it.

A Post I Feel Did Not Get The Attention It Deserves:  All of them?  Ok, I’ll pick one.  A topic that is a real problem when traveling on the Internet.  The fact that any Tom, Dick, Harry, or Sally can print something and the rest of the world assumes it is factual.  The post was “Truth or Internet?  Why Are They Often Mutually Exclusive?”  How often do you get eMail or see something on the web and pass it along.  Do you ever check to make sure it’s true?  That’s how the Big Lie works.  One person invents a fact, someone else believes it (because it resonates with their beliefs) and sends it, and a geometric progression of publicity begins.

The Post I Am Most Proud Of (sic):  This is easy.  I am proud of every post I have ever published.  But, my first post, Opening Gambit, was the hardest one to publish.  It meant I made a promise to you- the reader- to post the very best information I can, each business day of the year.  I’m keeping my promise—and I thank you for reading them.

So, what are your choices for these categories?  Write me and let me know…

Oh, wait… I’m supposed to pass the buck… This is a hard choice (so I wrote down everyone and pulled lots for the four “lucky” choices…

• Tor Constantino- The Daily ReTort
• Janet Callaway- The Natural Networker
• Leanne Chesser- WAHM Solution
• Veronica Campos-Hallstrom- Club Creative Art….

Come on down, the pot’s boiling, so the coffee will be ready shortly….

THIS IS A ONE TIME POST SO THAT FOLKS CAN USE THE LINKS AND NOT CHANGE SITES.

THIS BLOG IS NORMALLY FOUND ON WWW.CEREBRATIONS.BIZ

The new site is ready…

Cerebrations can now be found at:

http://cerebrations.biz

OR

http://www.aduvancy.com/wordpress

Not a real post- but an announcement

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No, I have not run out of things to say or discuss. I really have tons that I would like to post at once.  But, over the past few days, I have been working to move my site- to our own domain.

Too many people found it hard to find my blog.  So, I think we’ve solved the problem.

You can find my blog here:

http:www.adjuvancy.com/wordpress

From now on, all my posts will be on that site.  We are awaiting the ICANN to approve (propogate) new subdomains- cerebrations.biz, cerebrations.us, and cerebrations.net.  We will post updates as soon as these are available.

Thanks for reading my blog.  I hope you will drop in on the new site- soon and often.

ESRD Needs Different Blood Pressure Management (from normal patients)

We love to come up with health care prescriptions that work for everyone.  But, that rarely happens.  It’s how drugs get abused- we know the drug solves this problem in one cohort, so we apply it to another cohort.  The problem is the second cohort has other associated maladies that interact negatively with the drug.

It seems the same principle applies when we try to proscribe blood pressure management for dialysis patients.  We have long known that mortality for ESRD (end stage renal disease) patients is high;  cardiovascular disease the primary cause of death (many patients have what could be termed uncontrolled hypertension).   Yet, we have set the targets for blood pressure based upon our knowledge of the general population, and not directly for or from ESRD issues.  This is true because ESRD patients have never been included in studies concerned with blood pressure management.

It seems that the relationship between blood pressure and mortality among ESRD patients may be U-shaped:  one group has higher mortality at low blood pressure, while another has problems at high blood pressure (but moderate pressures [140/90 mm Hg] are probably good for everyone).   These results were discussed in a study funded by DCI (Dialysis Clinics, Inc.) led by Dr. Philip Zager (joint appointment with DCI and University of New Mexico Health Sciences), to be published shortly in the Journal of the American Society of Nephrology (advance copy posted).  This six-year study examined 16,283 patients (6250 died during the course of the research), all of whom survived at least 150 days from first outpatient dialysis treatment (to ensure that the dialysis treatment was successful). One key fact resulted from this study: Systolic blood pressure correlated better with mortality than did diastolic pressures.  The other significant finding was that ESRD patients with diabetes had higher mortality risks with lower systolic pressures.

Low systolic pressure was linked with elevated mortality, but this correlation was even more pronounced with the elderly or those patients also suffering from diabetes.  For patients 50 y of age or older, systolic pressures below 140 mm Hg were detrimental; pressures exceeding 160 were not associated with elevated mortality.  On the other hand,  for the younger patients, systolic BP of 160 mm Hg or higher were a problem, while the 140 mm Hg or lower were not a problem (diabetes and race did not affect these results).

ESRD patients manifest different relationships from the normal population.  ESRD patients in their 30’s had similar relationships with “normal” between systolic blood pressure and mortality.  For each decade increase in age, mortality related to low systole increased and that for high systole decreased for ESRD patients (but not for the general population).   This may be related to the fact that organ perfusion is affected (higher systole would tend to augment blood flow to the various organs of the body) when the patients have non-compliant blood vessels and other arterial diseases.  [It should be noted that cardiac disease was not monitored as part of the study (and one would expect it to manifest increased incidence with age).]

In an accompanying editorial by Drs. Crews and Powe, it was suggested that,  with the purported desire of Congress (American Recovery and Reinvestment Act of 2009) to have the Institute of Medicine define national priorities for effectiveness research,  “determining which treatment works best, for whom, and under what circumstances”, a new study be funded.  The aim should be to determine the desired approaches for the treatment of cardiovascular disease and ESRD; one that would more clearly define the desired intervention in the case of blood pressure management.

Still not walking? Your brain wants you to cover 6 miles every week!

We already discussed the need to exercise to preclude disease (Parkinson’s, cancer, autoimmune).  Now, there’s more reasons to get walking.  Dr. Kirk Erickson (University of Pittsburgh) and associates just published results in Neurology from  a follow-up from the Cardiovascular Health Cognition Study.  They reported that walking six miles weekly not only protects the grey matter of the brain- but it also helped retain memories.

The study involved 299 dementia free patients (mean age 78), who tracked how many weeks they walked over the nine-year period.  At the end of the nine-year period, these participants had undergone MRI scans.  These participants were then re-examined and studied four years later (the subject of this publication). The study participants walked from 0 to 300 blocks weekly (mean distance: 56.3).  The researchers found that walking 72 blocks (6 miles) was a critical threshold.  While some 40% of the participants did develop dementia, walking the 6 miles did preserve the grey matter and reduced the risk for cognitive impairment by at least 2 orders of magnitude. (73 of the 299

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(24%) walked the threshold distance or beyond.)  Interestingly, the researchers broke the participants into smaller subsets to see if longer walks improved the results; however, they found no significant cognitive improvement among those walking longer distances.  Moreover, the grey matter volume in the hippocampus, frontal gyrus, or parahippocampal gyrus did not correlate with any change in cognitive impairment. (Please note that ONLY cognitive impairment and brain matter were studied here; there could- and should- be cardiovascular improvements from the longer duration walks, since a 6 mile walk does not equate to the recommended weekly 150 minutes of physical activity to achieve good health.)

 

Hypobaric Treatments Proposed for Cardiac Patients (patent pending)

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You heard that the Tour de France athletes have tried sleeping in sealed tents that simulate high altitudes (where the oxygen levels are lower); the goal was to improve their performance at normal elevations.  As the body acclimatized to the hypoxic conditions, their mass of red blood cell increased. This was further augmented by ventilator changes, as manifested by increased tidal volume.   Now, some cardiac specialists at the Montefiore Hospital (Bronx, NY)  are trying that same technique to improve the performance of their patients.

With heart failure, the cardiac muscle is weakened; it can no longer pump blood effectively, which leads to shortness of breath in the patient.  So, why would we try to have them in hypobaric environments?  Dr. Simon Maybaum (who is patenting just such a chamber for cardiac patients, United States Patent Application 20090025726) believes it is just the poor blood flow, not the lack of oxygen, that affects the patient’s well being.

Dr. Maybaum is now leading a small study (15 patients) to determine if this approach works as well as he hopes.  The study has chosen medicated patients with pacemakers who have limited activity (these are termed stable heart failure patients); they will be subjected to simulated altitudes of 1500 to 2700 meters.  The treatment duration will start at about 1 hour and extend to three (3) hours over the course of the study.

It is hoped that the red blood cell levels will be increased (this is what happens with the athletes on this program), so the patients’ ability to transport oxygen will be augmented. Peak oxygen consumption levels will also be monitored; the normal patient level is under 15 ml/kg/min versus that of a bicyclist of some 45+ ml/kg/min. If the test works, the patients will use the tents at home (instead of the controlled hospital environment).

Augmented Peripheral Vision in the Deaf Uses the Auditory Complex

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We have discussed several aspects of the brain- and its ability to compensate for injury and disease.  This is the mechanism by which stroke victims can relearn things that were lost- by using different parts of the brain.

The auditory complex in deaf people has not been receiving inputs for significant time periods. It has long been thought (some data) that those who are deaf from birth develop larger visual fields than hearing folks.  The question was whether this region has been developed to amplify vision for the deaf.

Now a study published in Nature Neuroscience has shown that peripheral vision amplification does employ that portion of the brain (in deaf cats) that normally deals with peripheral hearing. Dr. Stephen Lomber of the University of Western Ontario along with Dr. Meredith of MCV (Virginia Commonwealth University) and Dr. Kraj of the Medical University of Hannover determined the peripheral vision of deaf cats by flashing lights at the periphery of their vision.  If the researchers cooled the auditory cortex (which rendered its capabilities moot), the extra-ordinary peripheral vision capability  was lost.  It made little significant difference if they cooled the left side, the right side, or both sides.

The same process is being studied to determine what happens when the deaf receive cochlear implants. .  The question to be answered: Once the cochlear implant is inserted, does the brain rewire itself or just continue using pathways long gone?

Cash is King- Make sure you monitor it!

 

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Whether you run a  private company or an investor in the stock market- you should know that operating cash flow (OCF) is the lifeblood of the company.  While investors and business owners often consider net income as their key indicator, OCF is a much better choice to monitor the enterprise’s financial health.  Why?  Because OCF is a little harder to manipulate (but, of course, it can be done).  Secondly, without cash, the company dies.

Here’s where the definition is key…OCF is the cash flow provided from operations, it is different from EBITDA (earnings before interest, taxes, depreciation, and amortization).  It is defined as EBIT (obviously, earnings before interest and taxes) + Depreciation – Taxes.  (OCF= EBIT + Depreciation – Taxes.) EBITDA can be affected by financing and capital investment decisions;  OCF will not. OCF is strictly a function of net income and changes to working capital (i.e., current assets-current liabilities).

[There are two other cash flows which are not discussed today:  Investment cash flow (net cash resulting from capital expenditures, investments, and acquisitions) and financing cash flow (net cash due to raising cash to fund other flows or repay debt). ]

This is where the differences between accrual and cash accounting become obvious.  Assuming you were on accrual accounting, you use cash to produce (manufacture or acquire) inventory.  When that inventory is sold, you create an account receivable (unless you customers pay you immediately upon delivery; usually not true). When your customer pays your account receivable (decreasing it), you develop cash.  So, if you are building up inventory, you have less cash.  If you customers pay you slowly, you have augmented receivables and less cash.

If a company is public (or about to become so), there are many opportunities to seemingly increase net income.  (This is done to increase the stock price or for executives to earn bigger bonuses, which are typically tied to net income and/or stock prices.)  One of the more common “cheats” is when the company provides the retailer with extended payment terms and/or a promise to take back the inventory if it doesn’t sell. This process books sales and increases accrued earnings (with NO changes to the company’s cash).  This actually steals sales from one or two quarters hence- which is how companies tend to look good for short-term periods (and then fall apart).

The key point is when operating cash flow is much smaller than net income, there is something wrong. One should examine the inventory levels and receivables to determine if this is a short- or long- term issue.

You will recall I said you can manipulate OCF, too.  One of the ways to do so has been rampant during this Great Recession- payments get delayed to suppliers.  This means there is an increase to the accounts payable, as well as to cash (since it has not been spent).  Another approach (this is often used in the health care industry) is to restructure the reserves for the firm (cash held for self-insured portions of malpractice or other purposes).

Handwriting Counts- Our Brain Knows It!!!

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I learned how to “script” at a very early age.  My great-grandfather was a calligrapher; and I was lucky enough to have wonderful training.  Of course, when I went to elementary school, my teachers were not all that thrilled, since there was this rule about “printing first”, but, rest assured, this was not the only problem I had with teachers and their rules of learning. To this day, I love writing with a fountain pen- which is one of the best ways (at least to me) to express yourself.  But, it turns out, that handwriting skills are critical for our development. (There is some discussion that handwriting is a useful cognitive skill to keep one mind’s sharp and other physicians believe that handwriting can provide a diagnostic for neurological disorders.)

Karin Harman James at Indiana University has been studying what effects teaching toddlers handwriting have on the brain.  Results were presented in Developmental Science (March 2010) that demonstrated enhanced neural activity.  James presented letters to the children before and after providing handwriting training, while monitoring their brain activity with fMRI. These images, which depict enhanced brain activity, indicate that learning occurred.

Dr. James (and Atwood) published results that demonstrated similar effects when adults are trained in graphically different languages (Chinese, mathematic symbols, music).  In that study, the adults were asked to examine characters and their mirror images via handwriting and computers.  When handwriting was involved, recognition was quicker than via computer input.

Virginia Berninger of  the University of Washington found that handwriting is different from typing, when it comes to the brain.  Handwriting requires sequential events to form a letter; typing involves key selection only. Imaging indicates that more of the brain is involved when the sequential finger movements are required.

The fMRI imaging prove that handwriting (or calligraphy) is more than communication; it improves idea development and expression, as well as augments fine motor-skill development.

So, stay sharp.   Bring out those fountain pens and practice!

You can see an example of my great-grandfather’s copyrighted material (he etched the faces of Washington, Lincoln, and Jefferson into the Declaration of Independence and the Constitution, among other items) here.

If this has inspired you, check out some of these sites: http://www.bfhhandwriting.com/manual.php, http://www.handwritingsuccess.com/resources.php, http://www.zaner-bloser.com/educator/products/handwriting/index.aspx?id=4290

Aging and Depression

 

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Are you outgoing?  Friendly?  Should you become depressed as you age, the odds are no-one will notice. This fact is more critical, because as found by Drs. Lyness and Duberstein, if one has neurotic tendencies when faced with increased medical burdens, one is more likely to experience greater depression.   We already know that our mental attitude affects our ability to withstand disease, so diagnosis and treatment of depression becomes important.

Depression among seniors has different manifestations, than when one is younger.  Younger dejected patients manifest expressions of sadness routinely; these tendencies are depressed among seniors.  When friends and family can identify depression, treatment can be provided sooner- and more effectively. This becomes more of an issue with older people, where we have developed our expectations of their fun-loving ways over the years.   Older patients tend to discuss their health concerns with friends and family, and the troupe normally accompanies them during physician appointments.  Physicians rely on those accompanyists to help identify the at-risk patients. These results were published by Dr. Duberstein et. al.  of the University of Rochester Medical Center.

Originally, the research was focused upon patients that were introverted (the study involved 191 subjects, aged 60 or over); those were the ones they expected to have had missed diagnoses.  However, they found the opposite: patients that were characterized as agreeable, trusting, altruistic, or conformist were the ones where the diagnosis was usually missed.