The Basics of Hemorrhagic Strokes

Hemorrhagic strokes are the second most common type of stroke. They account for almost 13% of all strokes, according to the American Stroke Association (ASA).

Typical Causes

Hemorrhagic strokes are the result of a blood vessel that bursts and bleeds in the brain. This puts increasing pressure on the brain, and cell death can happen within minutes. Let’s look more in-depth at some common causes.

Uncontrolled High Blood Pressure

Blood pressure that is not well controlled can have serious consequences. High blood pressure can cause damage and weaken arteries. Weakened arteries in the brain can rupture and lead to a hemorrhagic stroke. This is why blood pressure management is so important.


An aneurysm is a weakened blood vessel that ends up bulging and sometimes ruptures. The ASA notes that aneurysms develop over time and are more common in people over 40. They often develop due to constant pressure from blood flow.

Aneurysms grow slowly and weaken as they enlarge. It’s unknown how to predict when or if they will rupture. High blood pressure can weaken arteries, and straining can increase blood pressure.

Arteriovenous Malformations (AVMs)

An AVM is something that people are usually born with. They occur in less than 1% of the population, according to Harvard Health. An AVM consists of an abnormal tangle of arteries and veins.

  • Arteries bring blood that is rich in oxygen from the heart to the rest of the body.
  • Veins transport the blood that has delivered the oxygen (and now needs to be oxygenated) back to the heart.
  • Capillaries are tiny vessels that connect arteries and veins. They also exchange nutrients from the blood to surrounding tissues.

An AVM changes and disrupts this natural process. It connects arteries directly to veins and completely bypasses capillaries. These fragile, tangled vessels can become damaged over time. This leads to a rupture and resulting hemorrhage.

Types of Hemorrhagic Strokes

Intracerebral Hemorrhage

This type of hemorrhagic stroke is two times more common than those caused by a subarachnoid hemorrhage.

An intracerebral hemorrhage can happen deep in the brain or towards the surface. It occurs when thin-walled arteries in the brain burst and cause blood to flow into the brain tissue. This forms a hematoma: a clotted or partially-clotted pool of blood.

The part of the brain that the ruptured artery served now becomes starved of oxygen. This is when brain cell death occurs.

Pressure can also build-up and cause the brain to press against the skull. Surgeons may have to remove the hematoma to reduce pressure within the skull.

Subarachnoid Hemorrhage

This type of hemorrhagic stroke occurs in the subarachnoid space between the brain and the skull. This space is filled with cerebrospinal fluid (CSF) which cushions the brain.

Subarachnoid hemorrhages are often caused by a ruptured aneurysm. This causes blood to enter the subarachnoid space, putting pressure on the brain. The area of the brain served by the ruptured artery begins to die due to a lack of oxygen and nutrients.

This bleeding can also interrupt the normal flow of CSF. It can cause the ventricles to enlarge due to the extra fluid in the brain, aka hydrocephalus. The ventricles are cavities deep in the brain and are responsible for producing and transporting CSF.

And that’s a wrap! We’ve covered the 4 main types of strokes, and the basics of ischemic and hemorrhagic strokes. Stay tuned for upcoming posts on how the effects of a stroke change based on brain location and a series on neuroplasticity!

Anger Encompasses This Person

Dear Joyce:


I am 32 had my stroke only a year ago, but I still have an angry mood. I argue with my wife, mother, and friends when I know they mean the best for me. Does this anger go away or will I have it forever!


Angry is LA


Dear Angry in LA,


The answer is complicated, and some people get rid of the anger quickly, while some take longer. But no, you won’t have it forever.


I have a theory: the better your life was before the stroke, the longer I will take you to get rid of the anger. There’s a reason for this theory: Let’s say you enjoy your job. You just got a promotion. You go shopping on the weekends and buy another new purse or an article of clothing. All is right with the world, and in a split second, no longer. You have a stroke, and everything goes in the reverse immediately. You no longer have the job, your promotion bit the dust, and you are not able to browse in stores as you once have.


Only by looking back, you realize the anger is going away. But by asking your question, and realizing that an anger mood is not where you want to be, you have an awareness and are cognizant of the fact you don’t want to be angry any longer. Good luck as your anger is slowly losing its grip on you!



Simple Pleasures for This Simple Stroke Survivor

Looking back over my life, I had very complicated pleasures. For example, when I wanted to convince people in the office to maintain their opposition to a particular practice, it all depended on what other people would do. Crowd mentality indeed. Or when I celebrated holidays, the host would make what she liked rather than what the compan liked. Mom mentality.

But as a stroke survivor, I found that my preferences transformed into simple. Here are the top ten, all of which I didn’t do before my stroke:

Waking up to greet the day

Waking up every day is my top simple pleasure. What do I do to achieve that goal? Well, there are no guarantees in life, but switching over to the plant diet almost a year ago gave me so many chances to stay healthy. In pretending about the pandemic, I maintain that eating high Vitamin C oranges somehow kept me immune from the coronavirus. That theory is not on the proven list, but eating Vitamin C is great for preventing or lessen the severity of so many other diseases anyway.

Adding the perfect amount of water to my oatmeal

I actually celebrate with an audible “Yes!” multiple times when my oatmeal comes out of the microwave perfectly. Of course, nobody is there to hear it, and I find that reassuring. It’s a game I play with myself, guessing which amount of water is suitable to add to the instant variety. Somebody who lives with one or more people doesn’t get it, but I get it. I am the only one I have to please.

Watching the washer wash

I like the sound of the washer wash clothes. I like the “Spin” cycle the best. Oftentimes, I find myself watching the washer wash the clothes–my clothes, mesmerized–which I could have worn over again but didn’t because the washer sound is relaxing, which I wouldn’t hear on re-wearing.

Balancing my checkbook

I used to balance my checkbook as drudgery, something I had to do to keep my sanity in check, often getting frustrated when I reversed numbers or got the period in the wrong place. Now, I welcome it every month because I remembered my math functions. And I like the way my handwriting improved in 11 years, keeping the figures inside the lines.

Monitoring the vegan cooking

I was always a participant, from jumping rope as a youngster, to playing my songs as a teen in the talent show, to throwing events as an adult. Now, cooking-wise, I’m still a participant. Clare, my nurse friend, who prepares all my meals, brings the pot over to me to check on the consistency or taste or color. I’d rather cook myself, but having got the handle on do’s and dont’s. this method is the next best thing.

Observing the houses surrounded by nature

Normally, in those normal times before the stroke, I went around the block and that was it, not noticing the fine points. Now, my friend and I find something new every time we go like a new fence, plants and trees in bloom, or a missing shingle or the roof. That’s the game we play, because remembering what we found a few days ago keeps my memory sharp.

Making a schedule

Every time my friend comes which are on weekdays, I present her with a to-do list of things that should be done. I can move the entries if she doesn’t have time to finish, and she likes to check off completed tasks. Most importantly, this system, too, helps me remember the current and future tasks.

Pronouncing words until I say them perfectly

I have trouble pronouncing some words. Sometimes, if I say it over and over in a day, that will be enough for future times. Sometimes, like with the “scr” words, as in prescription and subscription, having practiced for 8 years, I still get tripped up. I used to be a public speaker so it’s difficult I can’t do that anymore, but just saying words correctly is the next best thing in order to communicate effectively. When somebody says, “I can’t understand you,” my heart just breaks.

Getting a coffee package from Amazon

Not that trillionaire Jeff Bezos need free advertising, but I look forward to this Amazon coffee coming because it wakes me up with a jolt in the morning. A jolt equals instant awareness of my surroundings so that I have an uninterrupted and clutter-free path when I’m going to walk around. At $4.95 for a 12-ounce bag, you can sample all the flavors while staying alert. In a sense, priceless.

Counting the birds that fly by in 10 minutes

Birds, predominantly crows, fly by in groups. I never see one crow without another one to follow. Especially now that it’s mating season, the birds are frequent. And no, I don’t watch the birds “fornicating.” Sheesh! Birds, too, need a little privacy. And don’t think I’m a nerd. People need something to do in this pandemic.

New Facts on COVID-19: “Don’t Come In Unless You’re Short of Breath” Doesn’t Apply Anymore

I had an annoying, dry cough in the beginning of February. Then the cough roared like a hungry beast. No fever. Just the cough, with shortness of breath and fatigue that escalated quickly over a two-week period. Was it COVID-19, I asked myself repeatedly? I don’t know now, and maybe I wouldn’t ever know, unless the testing starts very shortly to all people, rich or poor, healthy (for the asymptomatics amongst us) or sick, despite what Jared Kushner, as a spokesman for President Trump, says about enough tests now. I haven’t had one at the peak of coughing/shortness of breath/fatigue. Have you? Just to make sure?

But with Trump in charge, forget that option. “Coming up shortly,” or “Within the next two weeks,” or, my favorite, “Soon” is Trump-speak, when most people, after the passage of time, forget he made those promises in the first place. But I remember. You can count on that.

WIRED had an article written by Megan Molteni who says that scientists are running like crazy to comprehend why some patients also develop neurological ailments like confusion, stroke, seizure, or loss of smell. Stories of other, stranger symptoms like headaches, confusion, seizures, tingling and numbness, the loss of smell or taste have been going on for weeks.

“The medicines we use to treat any infection have very different penetrations into the central nervous system,” says S. Andrew Josephson, chair of the neurology department at the University of California, San Francisco. He is saying that most drugs can’t pass through the blood-brain barrier, a living wall around the brain. He also says if the coronavirus is penetrating the barrier and infecting neurons, that could make it more difficult to find appropriate treatments.

When the virus first started in Wuhan, China, health records indicate that 214 patients admitted to the Union Hospital of Huazhong University of Science and Technology, 36.4 percent of the patients showed signs of nervous-system-related issues, including headaches, dizziness, confusion, strokes, prolonged seizure, and a slowly disappearing sense of smell, some before the fever and cough were apparent.

“We’ve been telling people that the major complications of this new disease are pulmonary, but it appears there are a fair number of neurologic complications that patients and their physicians should be aware of,” says Josephson.

Without that information, datasets in particular, there’s no way to know how to interpret reports on patients, and “single cases are tantalizing, but they can be fraught with coincidence,” says Josephson.

COVID-19’s horrendous death toll, 61, 656 as of this writing, is other-worldly, science fiction-like worthy, and not many autopsies are being done. Only some pictures of the lungs, but a good chance that there’s some viral invasion of the brain.

A paper in the New England Journal of Medicine examining 58 patients in Strasbourg, France, found that more than half were confused or agitated, with brain imaging suggesting inflammation.

“You’ve been hearing that this is a breathing problem, but it also affects what we most care about, the brain,” says Josephson. “If you become confused, if you’re having problems thinking, those are reasons to seek medical attention,” he added.

Viruses affect the brain, explained Michel Toledano, a neurologist at Mayo Clinic in Minnesota. The brain is protected by something called the blood-brain-barrier, something that Josephson says, too, which blocks foreign substances but could be penetrated if compromised.

Since loss of smell is one of the symptoms of COVID-19, some have hypothesized the nose might be the pathway to the brain. But in the case of the novel coronavirus, doctors hold on to current evidence that the neurological impacts are more likely the result of overactive immune response rather than brain invasion.

Jennifer Frontera, who is also a professor at NYU School of Medicine, explains documenting notable cases including seizures in COVID-19 patients with no prior history of the episodes, and new patterns of small brain hemorrhages.

“We’re seeing a lot of consults of patients presenting in confusional states,” said Rohan Arora, a neurologist at the Long Island Jewish Forest Hills hospital, adding that more than 40 percent of recovered virus patients. “Returning to normal,” added Arora, “appears to be taking longer than for people who suffer heart failure or stroke.” [Apparently, Dr. Arora hasn’t worked extensively with stroke patients. After 11 years, I’m still recovering. Just sayin’.]

Anyway, good advice if you have any of those symptoms–headaches, dizziness, confusion,  prolonged seizure, and a disappearing sense of smell–go to the doctor. Many doctors are seeing patients through tele-conference now. If you had a stroke as a result of COVID-19, you probably have already gone to the hospital where there are tests but not too many of them.

One more thing. How about Trump supporters try injecting or swallowing disinfectants to see if they work or this headline: Online demand for hydroxychloroquine surged 1,000% after Trump backed it, study finds. I say that statement with sarcasm, but unlike Trump, he said it confidently when he recommended Lysol, Clorox, and hydroxychloroquine, despite his walkback when people were alarmed and others broke into peals of laughter. It’s on tape, Mr. President.

Eyedrops After Cataract Surgery

People who do not have someone to put drops in their eyes four times a day need help.  Task modification helped me succeed after my recent cataract surgery.  It is easy to drop and difficult to squeeze the stiff sides of a tiny 5 ml bottle.  I am glad I found the Autosqueeze Eye Drop Bottle.  The big wings are easy to hold and require only a gentle squeeze.

Before I lie down on my bed I gather two bottles of eye drops and a Kleenex tissue.  I put a pillow on my chest (not stomach) and put my sound elbow on the pillow.  This support makes my hand remain steady instead of bobbing around as I hold the bottle in the air.  To stop myself from blinking I distract myself by looking through the opening formed by my thumb and index finger instead of the bottle.  I try to get the drop in the inner corner of my eye.

When I put the cap back on I need to stop my hand from bobbing up and down and accidentally touching the tip of the bottle.  I keep my hand still by pressing my elbow firmly against the pillow.

Smartphone Use During Quarantine: Ways in which to keep it in Check

As you read this article, potentially on your smartphone, you may wonder if you may be overusing your smartphone during the radical shift in schedule that is this quarantine.  Keep in mind that, in the US, 41 states, 3 counties, 8 cities, the District of Columbia and Puerto Rico have enacted abrupt and extreme social distancing measures.  This amounts to approximately 310 million people being asked to stay and work at home, except for emergency needs.  Know that while the USA is waiting this out in their homes, so too are countries worldwide restricting the movement of people.  This may mean a lot of people with more free time, or at least some time to kill, now that the commute times have been reduced to getting up from the bed and walking to your home office.

What is likely to happen while we are sheltering in place?  While many of us have the best intentions to use this time to bond with our families at home, we still need to keep in touch with our work groups and our extended families who may live in other states or countries.  Additionally, more options are available for online learning, reading and video content options, including those with socializing elements, and they are getting more trendy as we hunker down.  While a smartphone can be a tremendous tool to allow us to venture virtually out of our houses and connect with distant family, it can also be emotionally isolating, physically harmful for us, and a disconnect to the family in house.

What most people don’t realize is the negative impact of excessive use of smartphones. When one has difficulty regulating the amount of time they spend on the phone or have negative consequences from use such as relationship strain, financial issues, accidents and loss of productivity, smart phone use becomes problematic or addictive.  One study suggested that the prevalence of problematic smartphone use is common (about 38%). During this shelter-in-place period, you might be tempted to spend the better part of the day on your smartphone, or quickly realize that what started as a “quick check” just ate up more time than you planned.

One common behavior seen with any dependence, including substances and devices, is that it becomes the first and last thing done each day.  When a smoker wakes up, there is a stimulus to use, as serotonin and dopamine deficiencies increase cravings and the brain triggers an action or a person goes through withdrawal.  Prior to going to bed, a smoker may take a cigarette to reduce withdrawal at night.  These behaviors are usually reflexive and outside of the realm of  conscious awareness.  Though they describe a pattern that is seen in dependence.

Does this apply to you?  Do you find yourself looking at your phone the moment you get up and just prior to calling it the night?  You are not alone.  One survey of 536 online respondents in 2017 found that nearly half of those surveyed checked their phones just after waking up and half checked their phones just before going to bed.


The World on Smartphones, the Brain’s Wiring and Where did all the time go?

Over the last twenty years, there has been an expansion of internet use around the world.  Some of this has been fueled by smartphones and increased availability of Wi-Fi and satellite coverage.  It is estimated that approximately half of the world’s population has access to a smartphone.  With increased access comes increased use.  With increased use comes increased dependence.

global internet usage

In his thought-provoking book, “The Shallows: What the internet is doing to our brains,”  Nicholas Carr outlines the neuroscience of technologies like the internet and smartphones and how they affect the neurotransmitters and neural maps in our brains.  Essentially, our brains incorporate smartphones as if they were an appendage of our bodies.  That harkens back to that sudden visceral feeling we get when we think we lost our phones.  Interesting research discussed in the book is how our attention spans and memory are altered with smartphone use.  Essentially, the internet, and smartphone use, is dumbing us down.

The problem with smartphone use is that it is insidious and can be hard to know when it has become too much – and even harder to limit.  According to research conducted by a senior living community provider Provision Living,  the average person spends approximately 5.4 hours on their smartphones each day, with millennials spending 5.7 hours a day.  Facebook and Instagram each took up about one hour daily.  While this is a substantial amount, people tend to underestimate their use.  When you put that time together, it makes up about 81 days a year, or about one and a half days a week on the phones.  Sure, some of the time may be work-related, but probably a lot less than you think.


Side Effects of Smart Phone Overuse

Here is a list of some of the known side effects of smart phone overuse:

Neck pain or “Text Neck”

Excessive use of smartphone can result in neck strain.  This occurs when the neck is flexed forward and there is rounding of the shoulders.  With normal posture, the neck supports the 10-12 pound weight of the head well.  Looking down at your smartphone flexes the neck and exerts a force on it that may be up to 60 pounds.  Since our smartphone use can be almost subconscious, we often don’t realize that we are forward flexed until we start noticing the neck tension and headaches.  The ongoing strain can eventually lead to degenerative disk disease and cause you increased pain issues and severe disability.

Other than generally spending less time on the phone, taking care to look at the phone for shorter durations, doing neck stretches, and keeping the phone at a higher viewing angle may reduce the strain.

Photo by Oladimeji Ajegbile on

Eye strain or “Computer vision syndrome”

Also referred to as “digital eye strain“, eye strain is associated with the excessive use of mobile phones and tablets. It generally causes the following problems:

• Blurred vision and eye fatigue
• Pain and discomfort due to looking at a digital screen for more than two hours
• Eye burning and itching from dry eye
• Frontal headaches

Eye strain and dry eye are worsened by a greater duration of smartphone use and a brighter intensity of light.


Driving a car requires one’s full attention, and greater velocities require shorter reaction times for emergency stops.  The use of a phone while driving increases the chance of an accident 6 times more than driving while drunk.  Given the average person checks their phones once every 12 minutes, it isn’t unreasonable to predict that the brain would want to look at it anytime — even while driving.  But it’s a completely unreasonable behavior and anyone would agree.

Yet, it happens and it can be lethal.  The National Safety council reports that phone use, whether talking, texting or checking, leads to 1.6 million crashes each year.  That’s nearly one in every four car crashes, and one in ten that are fatal.  An estimated 3,500 people (and probably more) die from distracted driving in the United States each year.

And it isn’t just deaths from cars.  There is a growing list of sometimes bizarre, all of the times tragic, deaths caused by distraction from smartphone use.  Whether it is a person who falls to their death while taking a selfie or dies trying to rescue their phone, it begs the question:  was it worth it?


Sleep issues

Interrupted or Self-induced sleep deprivation.  Smartphone use can impact sleep in a number of ways.  The use of smartphone can reduce the duration of sleep and increase pre-sleep arousal, either from spending time binge-watching movies or checking social media in bed.  If the phone is not turned off or to silent mode, it can interrupt sleep with a chime, ring or buzz alert.    Even after you check the message and see that it wasn’t important – just an email about a coming discount at a store you only went to once – getting back to sleep is not always successful.  In one study, the majority (76.5%) of sleep disruptions that were caused by smartphones were outgoing message, while calls (21.7%) and Facebook checks (1.8%) occurred less commonly.  The interruptions were seen in 41% of subjects in the study period of month, amounting to at least one weekday in a four week period.  Those with frequent interruptions were also found to have less sleep duration and a higher  body mass index.

Insomnia.  Computer screens, TV screens and phone screens emit a greater degree of blue light.  Our brains take in environmental cues to sleep, including a decrease in ambient light.  These signals trigger the release of melatonin from our pineal gland, which prepares the body for the sleep state.  When we see the blue lights of a screen, the body is receiving the light which causes mixed signals and impairs the ability to sleep.  Just a simple behavioral change of turning the phones off thirty minutes before bedtime made a significant improvement of sleep quality and duration.


Mood alterations with increased risk of depression and loneliness

Multiple studies have shown a correlation between smartphone dependence and depressive symptoms and reports of loneliness.  This is particularly prevalent in cell phone dependence in adolescents.  It is likely that the overuse of smartphones leads to destabilization and development of poor coping skills and reduced resilience that provokes depression, anxiety, loneliness. As with other dependent states, an imbalance of neurotransmitters, gamma aminobutyric acid (GABA) and glutamate, is likely involved.


Exposure to radiofrequency (RF) radiation

The CDC does not report any definite evidence of cancer from smartphone.  However, smartphones give off radiofrequency radiation.  The International Agency for Research on Cancer (IARC) does classify RF radiation as a “possible human carcinogen!” (cancer-causing agent).  It is possible to mitigate the risk of this possible carcinogen by using a hand-free headset, airpods, or headphones, using the speaker of the phone, and turning the phone in airplane mode or placing the phone in another room while charging.



Strategies to Protect Yourself From Problematic Smartphone Use During the Quarantine

Photo by Skitterphoto on

Anyone in their forties like me recalls the day that they bought their first smartphone.  I was in my early twenties and in my medical training.  Beside handy books for the white coat, many of us residents, interns and students used personal desktop assistants (PDA), which were aptly termed “peripheral brains.”  With the PDA, cellphone and a pager, we carried the devices to keep us informed and stay within-reach.  There was an immediate appeal to have an all-in-one device with a resource available at hand to review literature and link our curiosity to answers.

Now children are getting phones at an increasingly younger age.  In one European study in 2015, 46% of children between the ages of 9 and 16 had a smartphone.  As parents we are unwittingly enrolling our children in a research study on how the smartphones affect the developing brain.  It is becoming increasingly harder to unplug, in part because of increased convenience, but more so because of dependence.

The only time we can experience smartphone-free time (aside from powering down our devices!) is in locations where Wi-Fi service is unavailable, such as hiking or traveling – though I am amazed at many people I see toying with their phones even in remote areas.  In the year 2020, a child operating a device without Wi-Fi loses interest rapidly.   We are fast approaching a day when satellite internet access will be available in all reaches of the world – and people are working on this now.

During the current situation, there are even less options to distract yourself from using your smartphone.  Other than breaking it, locking it away, or going off the grid, here are some of the ways everyone can still enjoy the benefits of smartphone technology while limiting excessive, problematic use:


1. Set a daily time limit on the phone.

Time use can add up throughout the day.  A check every 12 minutes could be a set-up for checking sites, responding to other’s texts.  Most smartphones have a program that does a daily assessment of your use and calculates an average usage during a week.

Another way around counting your time is simply to change a behavior that you normally do.  For example, if you check your phone immediately when you wake up, use the bathroom, or fall asleep you could avoid that behavior.  This will likely cut down on the total time.  While it is hard to say an exact time of healthy smartphone use, it likely a “less is more” thing.


2.  Set aside the smartphone and other electronics for one days each week and set that as an example for all family members.

One important point is that children’s screen-time used is influenced by their parent’s use.  Techniques such as selecting one day a week without electronic devices, including smart phones, may be a welcome strategy for keeping overuse in check.  I have encouraged our family to do this once a week – I am calling it, somewhat ironically, “Sunday Funday.”  It is interesting to see how often topics of electronics and smartphones come up during the day.


3. Set up some daily time-out routines with phone use.

During this quarantine for COVID-19, there is much more time to fall into the use of a smartphone.  Setting up a routine, such as all the phones are switched off or to airplane mode by 8:00pm may prevent the time creep of evening use and sleep issues.


4. Practice Mindfulness. Know when you might need to limit.

One thing about human behavior is that it occurs below the level of conscious detection.  Yes your brain makes you do things that you don’t realize that you are doing. Although smartphone doesn’t seem to overlap with mindfulness, the use of this practice may help you by slowing down reflex decision-making to use or staying aware of the passing of time.


5.  Get outside and power down.

Aside from the (peculiar) behavior of using an outdoor smartphone app (e.g. Pokémon go), getting outside may provide a chance to power off your phone and connect to the present moment.  Smell the flowers, hear the birds chirp, and hear the wind.  Nature doesn’t know that there is a pandemic.


5. Refer to a number of applications that are designed to curb phone addiction.

There are a number of Apps available on Android and IPhone that can help regulate time and curb smartphone overuse.  Some of these include AppDetox  (free/android), Flipd (free/android/ios), Offtime (ios/android), ClearLock (paid/android), and QualityTime (free/android).

It’s always a slippery slope when using an app on your smartphone to modify your smartphone overuse.  It is always possible to turn off the alarm and just continue to use it.  Nevertheless, they may be beneficial in creating mindfulness of the behavior.

6.  Consider getting help if the above efforts don’t work.

Cognitive behavioral therapy (CBT) has a role in the treatment of forms of dependence, including smartphone addiction.  The idea of CBT is to increase one’s awareness of how emotions and thoughts shape an action that leads to the dependence and how to break that arc.  There are several online conferencing CBT sites available as well.



At least for the next three or four weeks, the United States and other countries will continue these strict social distancing measures, which result in a change in the usual schedule.  If it hadn’t been a problem already, it is likely that this adjustment might come with it increased smartphone use.  Besides increasing the risk of physical problems, problematic smartphone use can lead to disrupted sleep, increases in anxiety and depression and relationship problems, and increase distraction.  An awareness and attention to this problem can ensure that this time is one of growth and productivity.



Proposed Diagnostic Criteria for Smartphone Addiction

Take the Nomophobia Test   Nomophobia  “No mobile phone phobia”

Screen Time and Children:  Advice regarding setting limits on screen time for children

Bank my cell website:  Informational Website regarding tools to manage overuse of smartphones

Nurturing the Resilient Spirit: Ways to Support Mental Wellness during the COVID-19 Quarantine

My Stroke Strategies for the Corona Virus

These strategies are related to my daily routine.  They are examples of what stroke survivors can do to protect themselves.  Your risk of catching the corona virus is probably different from mine but I think we can agree that a stroke creates enough drama for a lifetime.

Washing hands with the backwards rule:   With the soap dispenser facing away from me, I push down on the nozzle with my palm and catch soap with my fingers.  After I scrub my hands, I run my soapy thumb over the top of the handle before I rinse.  I started washing my hands this way years ago when I handled raw chicken.  I did not want to leave chicken fluids on the bar of soap and soap dish.

Paying:  Many infected people do not cough so the rapid spread of the corona virus cannot be explained by lots of people spraying germs in the air.  We do not know how long the corona virus lives on environmental surfaces.  For now I pay with a credit card instead of handling coins that hundreds of people have touched.  It is cold enough to wear a coat so I put this credit card in my coat pocket rather than dig through my purse to find it.

Shopping cart:  It is easier to push and steer a shopping cart with both hands.  However, physical exertion makes my hemiplegic thumb bend fully so I don a piece of foam to stop my thumb nail from cutting into my skin.  I use a Kleenex tissue to take the foam off when I get in the car and then I isolate it in a special location.

Handles and keys:  Some people wipe the handle of a cart before they start shopping.  This does not protect them when they touch cans and boxes touched by employees who stock the shelves.
We do not know how long the corona virus lives on environmental surfaces.  I currently have 2 cuts on my sound fingers so before I get out of the car I don a thin vinyl glove used by beauticians.  It is one size too large so it is easier to don.  I remove the glove after I get the cart to my car.  My sound hand is clean when I open the car door, pull my car key out of my purse (green wrist band), and put my hand on the gear shift handle and steering wheel.  I throw the glove in a bag in my car.  My sound hand is clean when I pull out my house key (purple band) and open my front door.  I wash both hands when I get inside.

Touch screens:  Before the corona virus I refused to use a filthy touch screen to order a meal and then pick up food with my sound hand.  Ordering in person is slower but safer as long as I use a napkin to handle the menu which is never washed.  If a transaction forces me to use a touch screen, I use the back of a knuckle which I never stick in my ear, nose, or mouth.

Touching my face:  On the news a reporter touched her face 13 times in one hour while using a computer even though she was trying not to.  Transferring germs from our hand to our eyes, nose, or mouth is a common way to get sick.  The news story concluded that it is really hard to stop this unconscious behavior.  Any suggestions would be welcome.  

Pandemic COVID-19: Applying Early Lessons Learned

The novelty of the novel COVID-19 outbreak has passed. Sure our imagination that drums up images of viral apocalypse and global chaotic destabilization are simmering. Although the fears are transforming into measured preparedness, there still remains an allure of uncertainty with how this outbreak will affect the rest of the world.    In the wake of this recent outbreak, the global public health community and the world in general is left with many important questions.  In real-time, the community has had to develop a blueprint to testing, containment and risk mitigation.  While the United States and countries in Europe are reporting higher case loads, some important lessons can be gleaned from the early part of the epidemic:

Emerging Lessons:

  1.  Containing the Transmission of a Respiratory Virus is like trying to hold water in your hands.

When the nCoV-19 (COVID-19) outbreak was declared in Wuhan, China in late December 2019, about three weeks of potential transmission for the index cases had occurred.  The first wave of cases were close contacts and healthcare workers.  The virus was transmitted to others through coughing, sneezing, talking, kissing, or from contaminated surfaces or objects.

Just one cough sends out thousands of respiratory droplets, varying from 10 to 100 microns in size, at a speed of 50 miles an hour to a distance of a meter or more.  If you sneeze when you have the cold, you are sending out 40,000 droplets of 0.5 to 12 microns at a speed of 100 m/s.  Imagine that if viruses, such as COVID-19, are 100 nanometers (0.1 micron), hundreds can surf on these droplets and easily become sprayed onto objects or surfaces at a closer distance, while droplet nuclei (<5 microns) may spread distances of a few meters or may even follow air currents still further.

These infectious secretions can easily then enter the mouth, nose of eyes of a passersby or get ingested after touching the face from surface or fomite transfer.  Studies support the concept of a “personal cloud” of infectious particles supplied by coughing and sneezing and air currents around an infected person.  With so many viral particles, transmission of an infection to multiple people becomes easy.

droplet modelThe Wells evaporation-falling curve of droplets  From Annex C. Respiratory droplets.


2.  Case Fatality Rates (CFR) are always overestimated in the beginning of outbreaks

An outbreak requires constant reassessment.  Imagine trying to isolate and contain an outbreak, while at the same time trying to identify the pathogen, confirm cases, protect those at risk, and consider treatment and vaccination options – all in real time.

Epidemiologists can draft a case definition early on, but if the outbreak is from a novel pathogen, cases are defined by syndromic presentation first until more specific tests become available.  The public health system and the general public have sensitive ears for case fatality rate, the amount of those dying from a specific infection over the amount of those infected.

Case fatality rates (CFR) depend on knowledge of all affected cases, which for respiratory virus is usually not possible.  The problem is that most patients that have mild infection may not get tested.  On the other hand, some serious cases may not go attributed to the infection.  As we are learning, even later into the outbreak, e.g. in the US, outbreak investigation and containment largely depends on the availability of tests kits.

In China, the Wuhan COVID-19 outbreak had an attributable CFR of 4%. These original rates are higher than what has mostly been seen in secondary outbreak countries, such as South Korea.  One-third of the caseload was determined by syndromic definition rather than specific testing.  Many more may have not been tested.  The more people that are tested including those mildly symptomatic or asymptomatic, the closer we get to understanding the true CFR.

Enter South Korea.  When COVID-19 was reported in South Korea, great strides were made to identify cases.  On Tuesday March 3rd, Moon Jae-in declared “war” on COVID-19.  This comes after an outbreak of MERS in South Korea where tests kits were not readily available, and 38 people died.  By March 4th, South Korea has already tested more than 140,000 people for COVID-19, even providing a “drive-through” testing option.  South Korea has detected 6,593 cases with 43 total deaths.

If you take into account a sensitivity of 95%, there may be 5% false negatives, this would equate to a CFR of  43 deaths/6,593 x 100% = 0.65%.   This represents the unadjusted CFR based on the positive tests.  However, there is a false negative rate of 5%, so taking into account all of those tested (158,456 – 6,593),  the adjustment could be as low as 0.2%.  Although there is a possibility that the numerator may not be correct, it is less likely to shift, as there isn’t another definition for “death” but it could not capture the attributable deaths from COVID-19.

The WHO declared that the case fatality rate of COVID worldwide has been 3.4%, which appears to be an gross overestimate.  However and importantly, even with the calculated CFR from  South Korea, the rate is likely to be twofold higher (or greater) than what is encountered with seasonal influenza yearly.  When determining risk, the Wuhan data closely correlated advanced age and those with chronic diseases with increased CFR.  So the adjusted case fatality rate is likely to be higher in these at-risk groups and lower in the general population.

covid-mortality-rates*This is coming from the China outbreak – Expect a similar mortality distribution though needs adjusted from other underlying risk factors


Think of a virus as a chain reaction.  Anytime a virus can spread easily and only cause some deaths, sometimes considered a “sweet spot” in disease transmission, it is likely to have a significant impact.  When a virus kills off its hosts too quickly or is transmitted by a different route (e.g. Ebola with infected blood and secretions), it is impactful in its severity, but it can’t get around to infecting too many people.  The CDC estimates that influenza causes about 10,000 to 60,000 deaths annually (CFR 0.1%) – in the Unites States alone.  Even if the CFR for COVID-19 similar to influenza, widespread disease could be impactful on our elderly and other at-risk groups and strains health care delivery.


3.  Outbreak Containment and Risk Mitigation Strategies Benefit Greatly from Accurate Case Definition 

Efforts to contain COVID-19 improve as the case definition becomes more specific.  The original CDC case definition was more rigid, since the outbreak was related to the specific outbreak city, Wuhan.  As is always the case, coming up with an accurate definition up front can be difficult in real-time.  The Chinese government imposed strict lockdown measures, which crippled the cities and was meant to interrupt further transmission.  It became apparent, that low grade transmission and milder cases continued both inside China and to other countries.

Chinese scientist defined the genome of the novel Coronavirus shortly after declaring the outbreak, allowing for the development of testing.  Once testing became available, it was as if an invisible menace could be seen.  In the South Korea outbreak, people were readily tested, so active recommendations for quarantine could be given.  Truly it is important to recognize the efforts of the South Korean government and medical community to contain and test the population.  This testing may have contributed to the lower case fatality rates, by identifying at-risk people and keeping them free of disease.

With the further spread of COVID-19, a country will be able to gain a greater control on the outbreak through greater testing.  This provides knowledge of active cases, so that voluntary quarantine can be put into affect.

4.  Protecting Healthcare workers, Care givers and High Risk Populations is a key strategy 

With the SARS outbreak in 2002, we were reminded that the ability to provide healthcare relies on its personnel.  During that epidemic, one-fifth of all cases were healthcare workers.  As the outbreak of COVID-19 continues, some people will require medical attention and report to the hospital – maybe not even knowing that they have the disease.

As the caseload increases in the United States, the at-risk definition will increase.  It may be necessary to wear personal protective equipment with anyone who exhibits a viral infection.  Healthcare workers will be a greater risk of acquiring the illness.  When healthcare workers are unable to attend to patients because they are sick, healthcare delivery is consequently impacted.

It is clear that there is a higher case fatality rate with the elderly and those with health condition.  When an infected person, whether it is a healthcare worker, patient or visitor comes into a population of those at risk, you see a perfect storm for severe disease and fatality.  Recently, the Life Care center in Kirkland, Washington had a spate of 13 deaths from COVID-19.  it is incumbent on long-term care facilities to develop strategies to prevent any further outbreaks of COVID-19 in such high-risk settings.

5.  With any viral spillover, there are always two outbreaks: Infectious Disease and the Infectious Fear. 

An outbreak is an unpredictable process.  It can sometimes burn out, even as we are still learning of the risk factors of its spread.  As for a respiratory virus outbreak, it is easily transmitted, often leading to relatively silent spread.  Containment strategies are often too late.  As information emerges from the virus, speculation can create narratives that lead to fear, panic and rapid decision-making.

Reports from the news are often related to deaths and how the viral infection is changing regular life and can be sensationalistic.  Online authors and presenters are shaping the news and narratives.  The images of the strict containment measures in China tempt us to think about self-preservation from an unknown invader.  These fears shape behaviors:  cancelling flights, stocking up on masks, cancelling conferences.  While it is not wrong that containment measures can help, defining cases can lead to more targeted containment without crippling the flow of a functioning society.

In the unknown of the COVID-19 outbreak, the stock market has seen great losses and is showing volatility.  Imposing mass quarantine and containment efforts can have real effects on the economy and productivity.  Canceling major conferences can lead to losses that can affect multiple sectors.  Even if you decide not to cancel your European trip, strict measures could be applied in the setting of an outbreak, that can limit or spoil your vacation plans.

Stories of vampires, werewolves and zombies go back hundreds, if not thousands of years.  The concept of some unknown force overpowering humans and causing them to morph into someone or something else hits the nerve of our self-preservation instinct.  In many ways, viruses are the true vampires.  They are lifeless forces other than the primitive instincts of self-preservation and self-generation.  A virus’s consciousness is generativity – producing copies to transmit to others.  It’s  result is a destructive untangling of the fiber of society. A virus is transmitted through social interactions and an interruptions in these behaviors although may be useful,  often results in a significant fallout.

A Viral Outbreak Creates a Fissure in Human Collaboration Efforts, leaving a wake of economic and sociopolitical fallout.


Future direction:

  1.  The use of already existing apps for description of symptoms to determine places for targeted testing.
  2.  The coordination of an international outbreak system either through already-arranged WHO or influenza surveillance sites.
  3.  Selecting specialized labs to launch testing as early as possible.
  4.  More rapid protocols for vaccine development in emergency situations that do not require the rigid testing phases as those that are currently imposed by the FDA and other entities.



Managing the COVID-19 outbreak will require a group effort to stay aware of our individual symptoms and use standard precautions, to identify cases through rapid testing, to mitigate risk through targeted containment and to transform fears into preparation.






A viral outbreak in many ways is like a natural force.  The transmission



At present, with multiple people testing positive, COVID-19 has hit several areas in the United States.  Do we need to be concerned about this.

High Cholesterol is a Bad Thing, and Now Low Cholesterol Is Not Much Better

Since I was a little girl and able to understand scary stuff, my mother said that her body “manufactured” too much cholesterol. Never mind the fatty foods she ate like red meat and extra buttery toast and cheesecake, her favorite dessert. She stood by her story to the end. I was scared I would inherit the same “manufactured” condition. But I was spared even though I had a hemorrhagic stroke that was from Protein S deficiency. (Don’t get me started on a lousy gene pool).

My mother probably familial hypercholesterolemia, this news  brought you by US National Library of Medicine, a disorder that is passed down through families. It causes LDL (bad or think of loathsome) cholesterol level to be very high. The condition begins at birth and can cause heart attacks at an early age. My mother didn’t have a heart attack, but she could have had one.

Familial hypercholesterolemia is a genetic disorder. It is caused by a defect on chromosome 19. The defect makes the body unable to remove low density lipoprotein (LDL, or bad) cholesterol from the blood. This results in a high level of LDL in the blood.

This condition makes you more likely to have narrowing of the arteries from atherosclerosis at an early age. The condition is typically passed down through families in an autosomal dominant manner (that is, inheriting a disease, condition, or trait depending on which type of chromosome was affected).

And that’s probably what she meant by manufacturing high cholesterol. So I thought to myself, I’m lucky that I escaped the high-cholesterol syndrome, and now that I am a pescatarian or, as I like to say, a vegan with fish. That got me thinking: Can your cholesterol be too low? The answer scared me more.

In April of 2019, a study by the American Academy of Neurology said that low cholesterol was linked to a higher risk of “bleeding [hemorrhagic] stroke” in women.

A study found out that women who have levels of LDL cholesterol 70 mg/dL or lower may be more than twice as likely to have a hemorrhagic stroke than women with LDL cholesterol levels from 100 to 130 mg/dL.

The study also discovered that women with the lowest triglyceride levels, that is, fat found in the blood, had an increased risk of hemorrhagic stroke compared to those with the highest triglyceride levels.

“Strategies to lower cholesterol and triglyceride levels, like modifying diet or taking statins, are widely used to prevent cardiovascular disease,” said Pamela Rist, ScD, study author of Brigham and Women’s Hospital in Boston and a member of the American Academy of Neurology.

“But our large study shows that in women, very low levels may also carry some risks. [I’ll say]. Women already have a higher risk of stroke than men, in part because they live longer, so clearly defining ways to reduce their risk is important. Women with very low LDL cholesterol or low triglycerides should be monitored by their doctors for other stroke risk factors that can be modified, like high blood pressure and smoking, in order to reduce their risk of hemorrhagic stroke.

“Also, additional research is needed to determine how to lower the risk of hemorrhagic stroke in women with very low LDL and low triglycerides,” Rist said.

My head was spinning. Low cholesterol and low triglyceride are considered bad now? I wanted to find out more.

The study of 27,937 women age 45 and older participated  in the Women’s Health Study (supported by the National Institutes of Health) who had total cholesterol, LDL cholesterol, high density lipoprotein (HDL or good cholesterol), and triglycerides measured at the beginning of the study. Researchers reviewed tons of medical records to determine how many women had a hemorrhagic stroke.

With an average follow up at 19 years, researchers identified 137 women who had a bleeding stroke. Nine out of 1,069 women with cholesterol 70 mg/dL or lower, or 0.8 percent, had a bleeding stroke, compared to 40 out of 10,067 women with cholesterol 100 mg/dL up to 130 mg/dL, or 0.4 percent.

Some other factors were weighed in that could affect risk of stroke, such as age, smoking status, high blood pressure and treatment with cholesterol-lowering medications, and researchers discovered that those with extremely low LDL cholesterol were 2.2 times more likely to have a bleeding stroke.

Researchers divided the women into four groups for triglyceride levels. Women in the group with the lowest levels had fasting levels 74 mg/dL or lower, or non-fasting levels of 85 mg/dL or lower. Women in the group with the highest levels had fasting levels that were higher than 156 mg/dL, or non-fasting levels that were higher than 188  mg/dl. Researchers found that 34 women of the 5,714 women with the lowest levels of triglycerides, or 0.6 percent, had a bleeding stroke, compared to 29 women of the 7,989 with the highest triglycerides, or 0.4 percent.

The study’s key limitation was that cholesterol and triglyceride levels were only measured once at the beginning of the study. In addition, menopause was evident in a large number of the women, which prevented researchers from examining whether menopause status may be the missing link between cholesterol and triglyceride levels and bleeding stroke. More study is needed.

WELCOME TO CHECK. CHANGE. CONTROL. CALCULATOR, compliments of the American Heart association (AHA).

Through blood tests, CBC and Lipid Panel, and vitals like blood pressure, you can fill in the blanks on the form to see if you’re susceptible to a heart attack or stroke. Shouldn’t you know rather than guess?

Statins are effective at lowering cholesterol and protecting against a heart attack and stroke, although they may lead to side effects for some people.

The Mayo Clinic says that doctors “often prescribe statins for people with high cholesterol to lower their total cholesterol and reduce their risk of a heart attack or stroke.” But they have been associated with the onslaught of muscle pain, digestive problems, and mental confusion in some people who take them and may cause liver damage, albeit rare.

Statins include:
  • atorvastatin (Lipitor)
  • fluvastatin (Lescol XL)
  • lovastatin (Altoprev)
  • pitavastatin (Livalo)
  • pravastatin (Pravachol)
  • rosuvastatin (Crestor, Ezallor)
  • simvastatin (Zocor, FloLipid)


The reason that doctors prescribe statins is that that block a substance your liver needs to make cholesterol, and causes your liver to remove cholesterol from your blood.
If you’re already on statins, talk to your doctor before stopping them. My doctor told me to stop reading articles on the Internet. Hoo, boy. Like that’s gonna happen.
If you have muscle pain, the statin you’re on may be producing  rhabdomyolysis which can cause severe pain, liver damage, kidney failure, and death. The risk is very low, and numbers are equal to a few cases per million people taking statins. Rhabdomyolysis can happen when you take statins in combination with certain drugs so ask your pharmacist.

Or statin use could cause an increase in liver inflammation. But if the increase is severe, you may need to try a different statin because all statins are not alike. Again, talk to your doctor, if you also have unusual and increased fatigue or weakness, loss of appetite, pain in your upper abdomen, dark-colored urine, or yellowing of your skin or eyes.

It also possible your blood sugar level may increase when you take a statin, which may lead to developing type 2 diabetes.
The risk is barely significant but important enough that the Food and Drug Administration (FDA) has issued a change on warning labels regarding blood glucose levels and diabetes with statin use prevalent.

Also, the FDA issues a warning on statin labels that some people have memory loss or confusion while using statins.

Everyone who takes a statin may not experience side effects.

Risk factors include:

  • Being female
  • Being age 80 or older
  • Having kidney or liver disease
  • Drinking too much alcohol
  • Having certain conditions such as hypothyroidism or neuromuscular disorders including amyotrophic lateral sclerosis (ALS)
  • Having a small body frame
  • Taking multiple medications to lower your cholesterol

If your doctor says it’s fine, take a small break from statin and see whether the muscle aches or other problems you’re having are statin side effects. It may be just part of the aging process.

Or switch to another statin drug if that’s ok with your doctor.
Or change your dose with the doctor’s permission. Another option is to take the medication every other day, especially if you take a statin that stays in the blood for several days. Again, talk to your doctor.
More than usual exercise may increase the risk of muscle injury. And it’s difficult to know if your muscle pain comes exercise or a statin.
One more thing. Is your diet healthy enough not to produce high cholesterol and, by the way, high triglycerides? My mother, again, probably had Familial hypercholesterolemia, the inherited gene that you could help by eating healthy, exercising, and not smoking, all of which my mother did not do.