This week, longtime New York Times reporter and popular “Dot Earth” blogger Andrew Revkin vividly describes his 2011 stroke in the first-person piece “My Lucky Stroke.” He includes these “prime take-home points”: “Take your body seriously. Time (wasted) is brain (lost). Question authority, but not too much. Old habits die hard.”

Dr. Lee Schwamm, chief of Massachusetts General Hospital’s stroke service and medical director of Mass General TeleHealth, would suggest that readers take away some rather different stroke lessons from Andy Revkin’s story. He shares them here.

By Dr. Lee H. Schwamm
Guest contributor

I congratulate the journalist and blogger Andy Revkin for courageously sharing the story of his stroke and his subsequent recovery. I also thank him for taking the time to share his personal experience for the benefit of his readers, and for the opportunity it presents to highlight some key learning points for patients, as we dissect his journey through the health-care system.

Mr. Revkin was relatively young and healthy, out for a run with his son, when he experienced stroke symptoms. All too often, when we think of stroke, we envision an older patient clutching their chest and being unable to move or speak. This stereotype is dangerous, both for patients and health-care providers, because it lowers our sensitivity to stroke-like symptoms in patients of any age.

Mr. Revkin and his son were concerned enough about his symptoms that he went home, but they didn’t appreciate the immediate seriousness of his condition and he took a shower, hoping his symptoms would resolve. Watch the video clip above showing a young news reporter having stroke-like symptoms, and ask yourself, would you have called 911 if you’d been present? You should have.

Then Mr. Revkin did what generations of doctors have advised us to do for a heart attack; namely, take some aspirin and call your doctor’s office. Unfortunately, when it comes to stroke, there are two types: those caused by blocked arteries (ischemic) and those caused by rupture of blood vessels (hemorrhagic). It’s not possible to tell just from symptoms if a stroke is ischemic or hemorrhagic; only a CAT scan or MRI can distinguish them.

Obviously, you don’t want to take an aspirin if you’re having bleeding in your brain, as it will make the bleeding worse. But it’s also not a great idea to take aspirin if it’s an ischemic stroke, especially not six aspirin, as Mr. Revkin did, because there are powerful clot-busting drugs that can be given to reverse the disability caused by ischemic stroke. These drugs — the main one is known as tPA — are only effective if they are given within the first 4.5 hours after the start of symptoms, and aspirin might increase the risk that the drugs could convert an ischemic stroke into a giant hemorrhage that could be fatal.

It’s also really important to realize, as Mr. Revkin mentions, that “time is brain.” This expression reflects the fact that without treatment to restore the blocked blood flow to the brain, 2 million nerve cells are dying every minute of continued stroke.

So what’s the best way to act fast and to get help fast? First you need to know the warning signs so you can recognize stroke. A simple memory tool is the acronym FAST, which stands for Face, Arm, Speech, Time: Is the Face drooping or uneven? Does one Arm drift down when held outstretched? Is there trouble with Speech or understanding?

If any of these are present, then it’s Time to call 911. The terrific animated public service message below helps reinforce this critical message and has been shown in studies to improve detection and recall of stroke symptoms.

The next issue is how to get help, and many studies have shown that if you arrive by ambulance, your odds of being seen rapidly and getting the right treatment are dramatically increased, because arriving by ambulance already signals this may be an emergency.

When EMS responds to your call for help, they need to decide where to take you, and there are many different methods they might choose to make that decision.

If you can’t breathe, they will take you to the nearest hospital; if your vital signs are stable, in many states they will take you to the nearest stroke center. Different organizations certify these stroke centers and not all stroke centers are alike. In many cities, there may be more than one nearby stroke center. So if you’ve done your homework as detailed below, you may want to weigh in on where you or your loved one is taken.

To see a map of stroke centers near you, click here and enter your zip code. There, you can select centers certified by the Joint Commission, which accredits and certifies American health care facilities, as having the processes in place that lead to quality, or by the American Heart Association Get With the Guidelines Stroke program that have demonstrated high rates of actually providing evidence-based treatments for stroke, including rates of tPA use greater than 85% of all eligible patients.

A recent editorial highlights the differences in these certification programs and explores how the different factors motivating certification might determine the quality of care that can be provided. It’s hard to tell why a center near you has chosen to become a stroke center, but as always, look for the other signs of excellence such as local reputation, service to the community, the presence of their doctors and educators serving as leaders in their fields.

As Mr. Revkin notes, telemedicine-enabled stroke care is revolutionizing the field of stroke, and programs and centers from across the country now provide this service to increase access to care and mitigate disparities in acute stroke care.

A recent survey documents programs across the United States, based at leading academic medical centers like Partners Healthcare and the Mayo Clinic as well as for-profit companies, all working to bring stroke care to the bedside wherever it is needed.

This is critical, since not every hospital has the skills and the staffing to treat acute stroke properly and safely. So look on the map cited above, ask around, and find out why the hospital near you isn’t certified, or if it is certified, why it hasnt won any awards for its care. Be an advocate for having the highest quality of stroke care in your community, since you never know when you or someone you love might need it.

Sadly, Mr. Revkin’s story is all too common, that a patient has to be the one to raise the question of whether stroke might be the diagnosis, and all too often, the chance for treatment has evaporated before the diagnosis is made.

Fortunately, it sounds like he made a substantial recovery. The good news is that most stroke patients experience some recovery, and many have a complete recovery and return to their lives, their homes and their work.

I will end by sharing with you the take-home points I give all my patients: Be prepared. Know the warning signs. Know how to activate EMS and say the word “stroke” when you call. Act FAST if you suspect a stroke. Know where the nearest stroke center is located. And know that getting to the hospital quickly is your best shot at a full recovery.

[Posted by Carey Goldberg]

Then, author and former Globe staffer Alison Bass reported a week ago on her blog here that a researcher has found that serious flaws tended to skew the biggest study ever of antidepressants toward making the drugs appear more effective than they really are.

And now, Dr. Adam C. Urato, assistant professor of medicine at Tufts, has just sent over the latest: a paper in the current American Journal of Psychiatry that suggests that antidepressants increase the risk of stroke. He emailed:

This is an important study with real public health implications. We have so many patients on these drugs and use seems to be ever-increasing. If they are associated with stroke, as they seem to be, that’s information that patients and the public need to know.
When you combine this type of study showing a risk of stroke like this with the other studies that now show that antidepressants don’t appear to have a clinically significant benefit for most patients with mild to moderate depression (i.e. most users) then you really have to question why so many patients are on these drugs.

I leave it to others to defend antidepressants, but here are the basics on the latest study: It appears in the May edition of the American Journal of Psychiatry. It uses a “case-crossover” design, which aims to identify triggers for events. In this case, the event is a stroke. It included more than 24,000 patients who’d had strokes in Taiwan. The findings:

We found that antidepressant use was associated with a 48% greater risk of stroke, after taking confounding factors into account, and that the magnitude of associations was greater in high-potency inhibitors of the serotonin transporter than in low- and intermediate-potency inhibitors. Our findings are in agreement with those of previous studies showing that antidepressant use was associated with an increased risk of stroke, both ischemic (21) and hemorrhagic (22) types.

The authors note that depression itself is considered an independent risk factor for stroke. But their conclusions suggest that fending off stroke is not a good reason for prescribing antidepressants…

Forbes Magazine has just posted here a deeply personal, multi-faceted feature on Clayton Christensen, the renowned Harvard Business School professor and co-author of “The Innovator’s Prescription,” a 2009 book on what is wrong with the health care system and how to fix it.

The Forbes piece includes his own struggles with diabetes, cancer and a recent stroke, as well as the deep religious beliefs that permeate his life. Accordiing to Forbes writer David Whelan:

Christensen’s work took on new urgency the past few years as he suffered a heart attack followed by cancer followed by a stroke. For Christensen it was not a reason to get too upset. It was another opportunity, in a lifetime full of them, to gain insight into how to make the world work better. Because of his July stroke it took a long time for Christensen to be ready to sit down with FORBES. He was in intensive speech therapy, eight hours a day at the beginning. But he graciously agreed to tell his inspiring story in January, the same month he went back to teaching.

He and my mother split up before I was born, and he went on to a second stormy divorce. He had finally found happiness in his third marriage, to a woman seventeen years his junior. But his youthful wife broke under the pressure of caring for him in his diminished, post-stroke form. She slit her own throat with a razor. He found her in the bedroom in a welter of blood and saved her life, pinching her artery closed to stop the spurting until the paramedics arrived. After she recovered, she divorced him, despite all his entreaties. Living on her own, she tried again to bleed to death, and there was no one there to save her.

My father had loved being a doctor. The stroke knocked out just enough of his memory and reasoning faculties to make him clearly unfit to practice. He had loved writing medical novels. The stroke left him unable to spell even the simplest words, and plotting that had once been complex and suspenseful now came out embarrassingly sophomoric, unpublishable. He had enjoyed public speaking and television appearances. Now he slurred his words. He was left, he said often, with nothing that he enjoyed in life except smoking — the very cigarettes that probably led to the stroke in the first place. Death had always been his nemesis, but when it finally came, four years after his stroke, I believe he welcomed it.

Stroke is the second-biggest killer worldwide, and the biggest disabler of American adults. It costs the American economy an estimated $74 billion each year. Among its surviving victims, 70% cannot work as they did before, and about one-third need help with basic self-care. Having seen its damage first-hand, I find myself always watching for word of progress on stroke as I scan the research news, and usually struck by how little there seems to be.

Why is there so very little good news, so few breakthroughs? What is so hard about stroke?

In answer, Dr. Randie M. Black-Schaffer, medical director of the stroke program at Spaulding Rehabilitation Hospital, offered this vivid analogy:

Say it’s wartime, and a bomb is dropped in a field. It’s relatively easy to fix, you just regrade the dirt and sprinkle some grass seed. That’s what happens when you get a skin wound. It’s not hard to get the cut to heal up almost as good as new.

Now say the bomb is dropped not on a field but on a town. A great many things have to happen for that town to start functioning again as a town. You start by clearing out the debris — which is like the inflammatory processes in the brain that clear out the cells killed by the stroke. Then you rebuild the buildings, but buildings alone do not make a town. You have to bring the people back, which is like bringing back the blood cells and the neurons. And then the town has to be connected to other towns, by road and by phone lines. And even then, the pattern of movements of goods and services to and from the town may never quite be the same.

In short, Dr. Black-Schaffer said, “It’s just so complex when you have damage in the brain. There are so many different components and systems involved in each functional area of the brain. They all have to be working right in order for the patient to be able to carry on the function.”

Given that image of a bombed town, it is amazing that researchers have made any progress at all. But they have. Lately there have been a couple of exciting findings, and they come against a longer-term background of growing, hard-won understanding of stroke’s effects in the brain. All in all, enough progress for a round-up of promising steps forward.

Herewith, ten relatively bright spots:

1. Overview: Treatment of stroke has advanced — though not as dramatically as hoped — and lab research has come a long way in recent years.

Experimenting in animal models and test tubes, scientists have come to understand far more about the biological cascade of events that kill or cripple people who have strokes. Dr. Michael A. Moskowitz of Massachusetts General Hospital, a leading stroke researcher, recently published an overarching look at the state of the science in the journal Neuron. Titled “The Science of Stroke: Mechanisms in Search of Treatments,” it covers an impressive array of recent research on how and why brain cells die in stroke, from inflammation to oxidative stress.

“Tremendous progress has been made in the understanding of fundamental mechanisms of neuronal cell death,” he writes.

“However,” he had to add, “the translation of these powerful molecular and cellular principles into clinically effective neuroprotective therapies in stroke has been challenging.”

Not that there have been no treatment advances. Dr. Black-Schaffer says: “We now have drugs that can be targeted, via sophisticated delivery devices and using our extraordinary imaging capability with MRI and CT scans, to dissolve, ensnare and retrieve blood clots in small cerebral arteries, enabling many patients to recover far more completely from a clot in the brain than was possible even 15 years ago.”

2. Prevent, prevent, prevent

The best stroke is still the one that never happens, and the research on preventing stroke is no less important than research on possible treatments.

Among the findings: About two-thirds of our risk for stroke can be affected by our own behavior. The American Stroke Association lists all the stroke risk factors here. They include: uncontrolled blood pressure, high cholesterol, (this was disputed for a while but is now backed by clear evidence) and smoking.

“You can’t emphasize enough the importance of that ounce of prevention,” Dr. Moskowitz said.

Dr. Lee Schwamm, director of telestroke and acute stroke services at Mass. General, says that systematic efforts to improve stroke care in hospitalized patients have been boosting the rates of stroke-prevention treatments, recent studies show. Many more patients are getting started early on prevention.

3. That first brief window — ‘clot-busters’ for the lucky few

It was an exciting advance when “clot-busters” such as Tissue Plasminogen Activator entered medical use over a decade ago. They can lessen or reverse the damage from a stroke, but must be given within about four-and-a-half hours of onset.

The nation has been developing a network of hospitals best equipped to treat stroke, in part so that specialists can administer clot-busters quickly enough. Mass. General, for example, reports that last year, 80% of its stroke patients received clot-busters within an hour of arrival at the emergency department.

The trouble is, the drugs cannot be used for all strokes; and researchers report that nationwide, only about 5 percent of stroke patients get treatment in time for clot-busting to be safely given by vein, though specialized centers can reach 20%.

Dr. Schwamm: “Many patients who aren’t eligible for intravenous clot-busting can be treated with special catheters that are advanced directly into brain arteries to remove blood clots and restore blood flow.” Also, newer clot-busting drugs are being tested to see whether they might do a better job or allow a longer window for treatment.

Bottom line: Time is of the essence, which mean we all need to know how to recognize a stroke and when to call for help. The American Stroke Association lists the warning signs here.
NPR offers a 2009 list of certified stroke-care hospitals here.

4. The longer, bigger window

Dr. Moskowitz says that the single greatest advance in the scientific understanding of stroke in recent years is the recognition that beyond that brief clot-busting window of several hours, “there are some very important events that shape the evolution of the stroke injury, and at the same time prepare the brain to repair itself.”

In the course of a stroke, he said, cells become “committed to die” — whether because of chemical signals they’ve received or their own injuries. “It’s very difficult to rescue cells in the process of cell death,” he said, “but we know more and more about what the mechanisms are that bring us to that point.” Now, that knowledge must be translated into treatment, he said.

(“Committed to die.” I can’t help thinking of my young stepmother. It remains a deep family mystery why she couldn’t just walk away. Guilt? Depression-induced psychosis? It was my father’s cells that were committed to die by the stroke. But it was as if, in her, an “I must die” switch were triggered, and that impulse, once unleashed, could not be turned off.)

“We used to think the stroke story was over in minutes or hours,” Dr. Moskowitz said, “so we would give some kind of clot-busting drug and that was it. But now we know that we can introduce certain types of drugs that target signaling mechanisms that work 24 hours later than that, even 48 hours, because there’s an evolution of tissue injury that gives us a handle for future therapy.”

Such treatments could target inflammation, for example, or “excitotoxicity,” in which an overabundance of the brain messenger glutamate kills cells.

5. Brain freeze

Studies clearly show that when a patient has a cardiac arrest and the brain is deprived of oxygen, cooling the brain to about 35 degrees somehow saves a lot of brain tissue, Dr. Moskowitz said.

Can this be used for the most common type of stroke, the ischemic form in which a clot cuts off blood from a part of the brain?

That’s tricky, because the rest of the brain is functioning and thus hard to cool. But techniques are developing. What’s clear is that lowering the brain’s temperature hinders all the signaling mechanisms that have been linked to cell damage, Dr. Moskowitz said. Hypothermia is not “ready for prime time” with ischemic strokes, but “it’s a potentially exciting therapeutic advance,” and clinical trials over the next several years should tell whether it will work out.

6. Not just neurons

Sometimes, it’s an important advance just to start thinking in a new way.

Stroke researchers used to think about blood vessels and brain cells rather separately.

“Now we’ve realized that there’s a tremendous amount of interdependence and integration, that the blood vessel is part and parcel of the brain, that there is a ‘neurovascular unit,’” Dr. Moskowitz said.

That new thinking may translate into a better understanding of how the brain fixes itself, how stem cells migrate from the blood into the stroke area to do repair work, Dr. Moskowitz said. “We don’t quite know how they’re doing that job, but the experimental data suggest they’re capable,” he said.

The new neurovascular thinking is also important for the growing understanding that stroke is powerfully connected to neurodegenerative diseases like Alzheimer’s and Parkinson’s. It has become ever clearer that stroke damage accelerates their deterioration.

7. Brain self-defense

The opposite of that deterioration is brain resilience. In “ischemic tolerance,” the brain “marshalls a whole series of defensive strategies to protect itself under conditions of lack of blood supply,” Dr. Moskowitz said.

Here’s an odd discovery: In some cases, after the brain is subjected to a stressful event — trauma, lack of oxygen — it becomes super-resilient over the next day or two or three. Hit it again with the same sort of stress, and the injury will be much less. Researchers are trying to understand how to reproduce that natural response.

“It would be nice to have that on all the time,” Dr. Moskowitz said, “and to identify a population who’s at very high risk and initiate these mechanisms. That’s very exciting.”

8. The Promise Of Prozac

Last month, researchers published some dramatic findings about the effects of the antidepressant Prozac on stroke patients. The study, funded by the French government and published by the journal Lancet Neurology, found that in a group of 118 patients, those given Prozac for three months improved 34 points on a 100-point scale, while those given a placebo improved only 24 points. That ten-point gap could make the difference between a patient being able to live independently or not.

Dr. Black-Schaffer:

“Fluoxetine (Prozac) has several effects that may benefit stroke patients.  It improves mood, and therefore motivation and energy level, which is very helpful in the recovery and rehabilitation phase after a stroke. Approximately half of stroke patients become depressed at some point after their stroke, so this is an important effect for this population. Second, there is some  data in animals and anecdotal data in humans that it can enhance muscle activation, which may improve the  speed and extent  of active movements. Third, there is animal data that if given at the time of the stroke it has neuroprotective effects and can limit the size of the stroke though this has not been tested in humans yet.

The current study is the largest to date to look at fluoxetine’s effects on stroke recovery, and their results are very positive.

My conclusion at present is that there is limited but promising evidence that it may be a useful drug for stroke patients fall of the reasons above.  I’m not ready to prescribe it for all of my patients, but am inclined to start it early in those who are becoming depressed.”

9. Better clinical trials

This one depresses me, so I’m going to make it short. Dr. Moskowitz says that one of the advances in stroke research of the last ten years is to learn how not to do clinical trials. The experiments to assess drugs have often been less than optimal, he said. When you target one aspect of the stroke cascade, other pathways may compensate, muddying the waters. Some drugs may thus have been wrongly judged ineffective.

But methods of assessing drugs are getting more sophisticated, including brain imaging techniques.

10. The biggest window of all — rewiring in the years after

Of course, the most burning question of all is whether anything more, anything at all, can be done to help the millions of people who have been living with the effects of stroke for years.

Dr. Moskowitz says that there is growing understanding that stroke involves not just cell death but the brain rewiring that comes later.

Researchers “realized that we knew an enormous amount of what was going on at the early stages, but we knew almost nothing about the later stages, and we’re recognizing that there may well be a therapeutic opportunity here,“ she said.

As the head of Spaulding’s stroke rehab program, Dr. Black-Schaffer faces the question of rewiring every day. She sums up: “Where we are now is that we have a number of interventions” — including various forms of physical therapy and some medications — “that seem to have modest effect sizes in improving people’s outcomes after a stroke, but we haven’t really figured out how best to combine them.”

The take-home message of the last 15 years, she said, is just that intensive physical activity, intensive practice at meaningful tasks by a motivated patient, “will result in significant improvement for years after a stroke.” It’s “the piano lessons model of stroke recovery: practice and practice and practice.”

So no magic bullet?

“I don’t see one,” she said. “I wish I could. The various lines of research that have been pursued in the last 20 years have not revealed the possibility of one to me. Once you have brain damage, reestablishing connections is a very daunting task. Preventing it might be a lot easier.”

A happier ending

I didn’t want to end on such a down-note, so I asked Drs. Schwamm and Black-Schaffer for a more upbeat finish.

Dr. Black-Schaffer: “Twenty years ago, our only goal was to help people adapt to the disability caused by the stroke. Now we know enough about the cellular and molecular mechanisms that we aim higher — to improve the neurological recovery after stroke, not just ease adaptation to permanent deficits. Our growing impatience as a clinical and research community derives from this higher goal that we have now set for ourselves and our patients. I am hopeful that the creative tension thus generated among “neuro-recovery” investigators will lead to significant advances in stroke recovery research in the next decade.”

Dr. Schwamm: “Exciting new research suggests that major advances may be on the way. Animal studies conclusively show that a stimulus-rich environment promotes the growth of new brain connections critical to repair. The use of telemedicine or novel computer interfaces to engage stroke patients in rehabilitation activities promises to provide this stimulus-rich environment. Preliminary data shows that something as simple as playing computer video games like the Nintendo Wii can improve cardiovascular fitness and stroke recovery.”

“While the future often looks bleak when viewed from the bedside of a newly diagnosed stroke patient, the natural history for many is one of recovery and return to independent living. For those who don’t recover spontaneously, some day — hopefully soon — a wider array of restorative treatments will be readily available.”

(A 2011 Favorite)

It’s easy to understand why this video of CBS reporter Serene Branson speaking gibberish during a live Grammys report has gone viral on the Web. It’s the quintessential nightmare. You’re speaking on live TV and suddenly your tongue — or your brain — is unable to produce a coherent sentence. I feel a cold sweat coming on just thinking about it.

But the video may also offer a good “teachable moment” about the warning signs of stroke, the brain clots or bleeds that kill more Americans every year than anything except cancer and heart disease. The American Stroke Association’s warning signs are here, and they are:

I asked Dr. Randie M. Black-Schaffer, medical director of the stroke program at Spaulding Rehabilitation Hospital, whether the video looked like a stroke in the making.

“Yes,” she replied, “she is exhibiting a fluent aphasia, suggesting dysfunction in the posterior left side of her brain. This can be due to various problems, including but not limited to stroke or TIA.” (TIA, or a Transient Ischemic Attack, is also known as a “mini-stroke” or “warning stroke,” and can signal danger of a real stroke.)

“Seeking medical evaluation is definitely in order,” Dr. Black-Schaffer said.

Dr. Lee Schwamm of Massachusetts General Hospital agreed: “This is a great teachable moment, and anyone no matter what their age who starts speaking like that is potentially having a stroke. 911 should have been called immediately, and i assume it was, and she should have been transported to the nearest stroke center in the area.”

I’ve just posted a special report on stroke here. Here’s its bottom line: Stroke treatment has advanced in recent years, but not as much as hoped, and the greatest advances by far are for stroke patients who seek treatment fast. If I had Serene Branson’s symptom, I’d be calling 911 before the cameras stopped rolling.

By the way the Los Angeles Times reports here:

Medical experts appearing on TV news shows pointed to her slurred speech as evidence that she might indeed have suffered a mild brain attack. The CBS Los Angeles station for which Branson works, however, said that she now feels fine and has had a follow-up visit with her doctor for tests. It also has removed the video from its website.

According to the Harvard Crimson, a colleague says that Rev. Gomes, 68, has been able to communicate with visitors since his stroke on Friday but “will not be preaching in the near future.”
And The Boston Globe says here that “’There are signs of improvement, both in his ability to speak and in his physical response,’’’ said Wendel Meyer, a longtime friend and an administrator and preacher at the church.”

Rev. Gomes, a Baptist minister, is considered one of the country’s most prominent preachers, and has written several popular books. He’s long been a central figure in religion at Harvard; and though he’d been planning to retire in 2012, that date may have to be moved up, colleagues say.

I’ve asked Spaulding Rehabilitation Hospital for a specialist to speak broadly about speech recovery from stroke, and am hoping for inspiring examples from history of orators who returned to the podium. But for now, I’d like to share a flashback of Rev. Gomes’s mellifluous powers. This is from a story I wrote for The New York Times way back in 1998, about a special sermon he delivered to graduating seniors:

‘You are going to be sent out of here for good, and most of you aren’t ready to go,” Mr. Gomes, gowned in cherry red, told more than 1,000 seniors in genteelly ringing tones that called to mind a cross between a Shakespearean actor and the sitcom character Frasier.

”The president is about to bid you into the fellowship of educated men and women, and you know,” he paused and slowed, ”just — how — dumb — you — really — are.”

He paused again for the cheers of agreement.

”And worse than that, the world — and your parents in particular — are going to expect that you will now be among the brightest and best,” Mr. Gomes continued. ”But you know that you can no longer fool all the people even some of the time. By noontime today, you will be out of here. By tomorrow, you will be history. By Saturday, you will be toast. That’s a fact — no exceptions, no extensions.”

Having stated the problem, the minister moved quickly to alleviate it, promising students that their best years were yet to come, and that God would be with them.

”The future is God’s gift to you,” Mr. Gomes said. ”God will not let you stumble or fall. God has not brought you this far to this place to abandon you or leave you here alone and afraid. The God of Israel never stumbles, never sleeps, never goes on sabbatical.”

He added, ”Thus, my beloved and bewildered young friends, do not be afraid.”

Mr. Gomes concluded with a benediction: ”God grant you life until your work is done, and work until your life is over.”

Twenty-five years ago, my father could not exercise. All the years of neglecting his body and soul caught up to him as he lay in the hospital bed with tubes protruding from his nose, mouth, and arms. My father’s wake-up call was a heart attack and a stroke that caused paralysis on the right side of his body. Determined to get better, he worked hard at physical therapy and at home for one year. This life-changing event sparked a revamping of my father’s lifestyle. He started a low-fat, low-salt diet and swore off cookies, cakes, as well as candies. Since that fateful event 25 years ago, my father has been exercising five days a week for at least a half an hour. These days, he chases after his grandchildren and their pets.

My father’s strong will and determination are an inspiration to me. Many days, the memory of his struggle and the commitment he made to regular exercise are just enough to get me going. On other days, the fear of a stroke pushes me out the door. On most days, the love of jogging is my sole motivator. Regardless of the spark that ignites the fire under my feet, I am grateful for the opportunity to experience the endorphins that come with a half-an-hour work out!