Friday, June 23, 2017

To Treat Depression, Try a Digital Therapist - WSJ

The World Health Organization estimates that more than 300 million people suffer from clinical depression world-wide. But cost, time, stigma, distance to travel, language barriers and other factors prevent many from seeking help.

Now, a growing group of health-care providers are betting that technology—from web-based courses to mobile apps that send prompts via text—can help bridge that gap.

It might seem surprising, since therapy, more than many other kinds of medicine, is so focused on the relationship between patient and therapist. But research, including a meta-analysis of studiesinvolving internet-based cognitive behavioral therapy, or CBT, suggests that digital therapies augmented by coaches who are available by text or phone can be as effective as evidence-based traditional therapy in treating some people with depression.

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https://www.wsj.com/articles/to-treat-depression-try-a-digital-therapist-1498227092?

Thursday, June 22, 2017

How to fall to your death and live to tell the tale | Mosaic

Slipping in the shower, tripping down the stairs, taking a tumble in the supermarket – falls kill over 420,000 people per year and hospitalise millions more. We can't eliminate all falls, says Neil Steinberg. So we must to learn to fall better.

Alcides Moreno and his brother Edgar were window washers in New York City. The two Ecuadorian immigrants worked for City Wide Window Cleaning, suspended high above the congested streets, dragging wet squeegees across the acres of glass that make up the skyline of Manhattan.

On 7 December 2007, the brothers took an elevator to the roof of Solow Tower, a 47-storey apartment building on the Upper East Side. They stepped onto the 16-foot-long, three-foot-wide aluminium scaffolding designed to slowly lower them down the black glass of the building.

But the anchors holding the 1,250-pound platform instead gave way, plunging it and them 472 feet to the alley below. The fall lasted six seconds.

Edgar, at 30 the younger brother, tumbled off the scaffolding, hit the top of a wooden fence and was killed instantly. Part of his body was later discovered under the tangle of crushed aluminium in the alley next to the building.

But rescuers found Alcides alive, sitting up amid the wreckage, breathing and conscious when paramedics performed a "scoop and run" – a tactic used when a hospital is near and injuries so severe that any field treatment isn't worth the time required to do it. Alcides was rushed to NewYork-Presbyterian Hospital/Weill Cornell Medical Center, four blocks away.

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Falls are one of life's great overlooked perils. We fear terror attacks, shark bites, Ebola outbreaks and other minutely remote dangers, yet over 420,000 people die worldwide each year after falling. Falls are the second leading cause of death by injury, after car accidents. In the United States, falls cause 32,000 fatalities a year (more than four times the number caused by drowning or fires combined). Nearly three times as many people die in the US after falling as are murdered by firearms.

Falls are even more significant as a cause of injury. More patients go to emergency rooms in the US after falling than from any other form of mishap, according to the Centers for Disease Control and Prevention (CDC), nearly triple the number injured by car accidents. The cost is enormous. As well as taking up more than a third of ER budgets, fall-related injuries often lead to expensive personal injury claims. In one case in an Irish supermarket, a woman was awarded 1.4 million euros compensation when she slipped on grapes inside the store.

It makes sense that falls dwarf most other hazards. To be shot or get in a car accident, you first need to be in the vicinity of a gun or a car. But falls can happen anywhere at any time to anyone.

Spectacular falls from great heights outdoors like the plunge of the Moreno brothers are extremely rare. The most dangerous spots for falls are not rooftops or cliffs, but the low-level, interior settings of everyday life: shower stalls, supermarket aisles and stairways. Despite illusions otherwise, we have become an overwhelmingly indoor species: Americans spend less than 7 per cent of the day outside but 87 per cent inside buildings (the other 6 per cent is spent sitting in cars and other vehicles). Any fall, even a tumble out of bed, can change life profoundly, taking someone from robust health to grave disability in less than one second.

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https://mosaicscience.com/story/falling-science-injury-death-falls?

The opioid crisis changed how doctors think about pain - Vox

WILLIAMSON, West Virginia — This town on the eastern border of Kentucky has 3,150 residents, one hotel, one gas station, one fire station — and about 50 opiate overdoses each month.

On the first weekend of each month, when public benefits like disability get paid out, the local fire chief estimates the city sees about half a million dollars in drug sales. The area is poor — 29 percent of county residents live in poverty, and, amid the retreat of the coal industry, the unemployment rate was 12.2 percent when I visited last August— and those selling pills are not always who you'd expect.

"Elderly folks who depend on blood pressure medications, who can't afford them, they're selling their [painkillers] to get money to buy their blood pressure drug," Williamson fire chief Joey Carey told me when I visited Williamson. "The opioids are still $5 or $10 copays. They can turn around and sell those pills for $5 or $10 each."

Opioids are everywhere in Williamson, because chronic pain is everywhere in Williamson.

Dino Beckett opened a primary care clinic there in March 2014, on the same street with the hotel and the gas station. A native of the area with a close-cropped beard and a slight Southern drawl, Beckett sees the pain of Williamson day in and day out.

He sees older women who suffer from compression fractures up and down their spines, the result of osteoporosis. He sees men who mined coal for decades, who now experience persistent, piercing low back pain. "We have a population that works in coal mines or mine-supporting industries doing lots of manual labor, lifting equipment," he says. "Doing that for 10 to 12 hours a day for 15 to 20 years, or more, is a bad deal."

Beckett sees more pain than doctors who practice elsewhere. Nationally, 10.1 percent of Americans rate their health as "fair" or "poor." In Mingo County, where Williamson is, that figure stands at 38.9 percent.

Williamson has some of West Virginia's highest rates of obesity, disability, and arthritis — and that is in a state that already ranks among the worst in those categories compared with the rest of the nation. An adult in Williamson has twice the chance of dying from an injury as the average American.

This is why the opioid crisis is so hard to handle, here and in so many communities: The underlying drugs are often being prescribed for real reasons.

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https://www.vox.com/2017/6/5/15111936/opioid-crisis-pain-west-virginia

Saturday, June 17, 2017

A dog bite sent him to the ER. A cascade of missteps nearly killed him. - The Washington Post

Becky Krall hurried through the sliding-glass doors of the hospital emergency room around 8 a.m. on Sept. 25, 2015, expecting to see her feverish husband, David, sitting among the patients waiting to see a doctor. Instead Krall, who had left him for about 15 minutes while parking their car, was met by a nurse with an urgent message: Her 50-year-old husband had suddenly become unresponsive.

Krall recalls with frightening clarity the words of a critical care specialist. "She put her hand on my knee and said, 'Your husband is very, very sick. You need to be prepared for him not to make it through the day.' "

How, Krall remembers wondering, did her fit and healthy husband of 10 years get so sick so fast? The night before, Krall had driven him to the same ER, sent by an urgent care center for a closer assessment of his fever and malaise. The couple had spent about five hours there but left before seeing a doctor because the ER was so swamped and David's condition seemed unchanged. They figured they'd have better luck in the morning.

That decision, Becky Krall says, was among a cascade of serious missteps that left David, an industrial engineer, battling a catastrophic illness that kills between 60 and 80 percent of its victims. Doctors at the University of Kentucky Albert B. Chandler Hospital in Lexington managed to save David's life, but he was left with profound, permanent hearing loss. Several of his toes had to be partially amputated.

"I felt extremely guilty for a long time," said Becky, an associate professor of STEM education at the university who continues to struggle with the emotional aftermath of the ordeal. "I have lots of information now. But I didn't know any of it then." She hopes her husband's case, which helped spur changes in the emergency department, will serve as a cautionary tale.

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https://www.washingtonpost.com/national/health-science/a-dog-bite-sent-him-to-the-er-a-cascade-of-missteps-nearly-killed-him/2017/06/16/5ea17d96-1aed-11e7-bcc2-7d1a0973e7b2_story.html?

Wednesday, June 7, 2017

Anaesthesia: what we still don't know about the 'gift of oblivion' - The Age (Australia)

I am in a smallish, whitish room in a hospital in Brisbane. It is night. On the wall opposite my bed I can dimly make out a crucifix with its limp passenger. Beneath it float wide blank windows through which I watch the synapses of city light: a web of tiny illuminations and extinctions that seem, when I loosen my gaze, almost to form patterns, as if they are about to make sense. I am surprised at how calm I feel.

In the weeks leading up to this moment I have set my affairs in order. Made a will, written letters for the children, waxed my legs. Said my farewells at the airport and boarded the flight from Melbourne with my mother. It is July 2010.

Today's specialist anaesthetists train for 12 to 13 years. The death rate from general anaesthesia has dropped from about one in 20,000 in the 1970s to one or two in 200,000 this century. Photo: Fuse
Some months before this, after decades of resistance, I gave in at last to the inevitability of major surgery. My capitulation was sudden and took place in a different wing of this same hospital, where I had come to consult a respected spinal surgeon. The surgeon had a quiet, almost diffident, manner and a moustache that put me in mind of a doleful Groucho. I am not sure what made my mind up, the moustache or the way his finger traced my wayward spine quite gently on the X-ray before him. But just as he began to tell me that I would not be a candidate for the non-invasive surgery we had been talking about, I realised with a small thud of certainty that, not only was I going to have this surgery – invasive though it might be – I was going to come back to Brisbane and he was going to do it.

In the aftermath of my decision, I was buoyed in a backwash of something like relief; a giving up of hope and its attendant efforts, a yielding to forces beyond my will. But when I lay awake at night, disquiet rose around me. It was not just the surgery that was worrying me – the cutting and drilling, the inevitable risk – it was that in some blank corner of myself I felt that I would not wake up afterwards. I knew logically, and during the day could convince myself, that for an otherwise healthy 48-year-old, the likelihood of calamity was low. But at night, in my bed in Melbourne, the conviction multiplied that even if everything went according to plan, the me who woke after surgery would not be the same in some essential way as the me who had been wheeled into the operating theatre beforehand.

I developed a dread of the moment when the anaesthetic drugs would take effect and I would cease to be. I pictured myself in a stark, poorly lit room with two doors, one in, one out, neither of which I could open from within. Otherwise the room was empty. No windows, no furniture. In this darkness – which I now realise had the same sinuous quality as the shadows beneath my childhood bed – I would be trapped alone. Perhaps forever. At least until such time as someone else chose to release, not me but some other version of me who would slip soundlessly into the life that had once been mine.

Shortly after making my decision, I rang a separate Brisbane medical practice. I asked to speak to the doctor whose job it would be to render me unconscious and keep me that way during the long operation. Halting, almost apologetic, I explained to the receptionist that I had spent some years researching the process known as anaesthesia, and that I was now rather nervous about what was going to happen to me. "I think I know too much," I said.

"Oh dear," they said. "That's not good."

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http://www.theage.com.au/good-weekend/anaesthesia-what-we-still-dont-know-about-the-gift-of-oblivion-20170511-gw2uhh.html?

Tuesday, June 6, 2017

Drug Deaths in America Are Rising Faster Than Ever - The New York Times

Drug overdose deaths in 2016 most likely exceeded 59,000, the largest annual jump ever recorded in the United States, according to preliminary data compiled by The New York Times.

The death count is the latest consequence of an escalating public health crisis: opioid addiction, now made more deadly by an influx of illicitly manufactured fentanyl and similar drugs. Drug overdoses are now the leading cause of death among Americans under 50.

Although the data is preliminary, the Times's best estimate is that deaths rose 19 percent over the 52,404 recorded in 2015. And all evidence suggests the problem has continued to worsen in 2017.

Because drug deaths take a long time to certify, the Centers for DiseaseControl and Prevention will not be able to calculate final numbers until December. The Times compiled estimates for 2016 from hundreds of state health departments and county coroners and medical examiners. Together they represent data from states and counties that accounted for 76 percent of overdose deaths in 2015. They are a first look at the extent of the drug overdose epidemic last year, a detailed accounting of a modern plague.

The initial data points to large increases in drug overdose deaths in states along the East Coast, particularly Maryland, Florida, Pennsylvania and Maine. In Ohio, which filed a lawsuit last week accusing five drug companies of abetting the opioid epidemic, we estimate overdose deaths increased by more than 25 percent in 2016.

"Heroin is the devil's drug, man. It is," Cliff Parker said, sitting on a bench in Grace Park in Akron. Mr. Parker, 24, graduated from high school not too far from here, in nearby Copley, where he was a multisport athlete. In his senior year, he was a varsity wrestler and earned a scholarship to the University of Akron. Like his friends and teammates, he started using prescription painkillers at parties. It was fun, he said. By the time it stopped being fun, it was too late. Pills soon turned to heroin, and his life began slipping away from him.

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https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html?

Monday, June 5, 2017

The Doctor Is In. Co-Pay? $40,000. - The New York Times

SAN FRANCISCO — When John Battelle's teenage son broke his leg at a suburban soccer game, naturally the first call his parents made was to 911. The second was to Dr. Jordan Shlain, the concierge doctor here who treats Mr. Battelle and his family.

"They're taking him to a local hospital," Mr. Battelle's wife, Michelle, told Dr. Shlain as the boy rode in an ambulance to a nearby emergency room in Marin County. "No, they're not," Dr. Shlain instructed them. "You don't want that leg set by an E.R. doc at a local medical center. You want it set by the head of orthopedics at a hospital in the city."

Within minutes, the ambulance was on the Golden Gate Bridge, bound for California Pacific Medical Center, one of San Francisco's top hospitals. Dr. Shlain was there to meet them when they arrived, and the boy was seen almost immediately by an orthopedist with decades of experience.

For Mr. Battelle, a veteran media entrepreneur, the experience convinced him that the annual fee he pays to have Dr. Shlain on call is worth it, despite his guilt over what he admits is very special treatment.

"I feel badly that I have the means to jump the line," he said. "But when you have kids, you jump the line. You just do. If you have the money, would you not spend it for that?"

Increasingly, it is a question being asked in hospitals and doctor's offices, especially in wealthier enclaves in places like Los Angeles, Seattle, San Francisco and New York. And just as a virtual velvet rope has risen between the wealthiest Americans and everyone else on airplanes, cruise ships and amusement parks, widening inequality is also transforming how health care is delivered.

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https://www.nytimes.com/2017/06/03/business/economy/high-end-medical-care.html?

Monday, May 29, 2017

China’s Ill, and Wealthy, Look Abroad for Medical Treatment - The New York Times

China's medical system could not stop the cancer eating at Guo Shushi's stomach. It roared back even after Mr. Guo, a 63-year-old real estate developer, endured surgery, chemotherapy and radiation at two hospitals.

Then his son-in-law discovered online that — for a price — companies were willing to help critically ill Chinese people seek treatment abroad. Soon Mr. Guo was at the Dana-Farber Cancer Institute in Boston, receiving a new immunotherapy drug, Keytruda, which is not available in China. In April, nearly four months later, his tumor has shrunk and his weight has gone up.

"When I arrived, I could feel how large the gap was," said Mr. Guo of the difference in care.

The cost: about $220,000 — all paid out of pocket.

China's nearly 1.4 billion people depend on a strained and struggling health care system that belies the country's rise as an increasingly wealthy global power. But more and more, the rich are finding a way out.

Western hospitals and a new group of well-connected companies are reaching for well-heeled Chinese patients who need lifesaving treatments unavailable at home. The trend is a twist on the perception of medical tourism as a way to save money, often on noncritical procedures like dental work and face-lifts. For these customers, getting out of China is a matter of life or death.

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https://www.nytimes.com/2017/05/29/business/china-medical-tourism-hospital.html

Wednesday, May 24, 2017

FDA Clears First Cancer Drug Based on Genetics of Disease, Not Tumor Location - Scientific American

Merck & Co's immunotherapy Keytruda chalked up another approval on Tuesday as the U.S. Food and Drug Administration said the cancer medicine can be used to treat children and adults who carry a specific genetic feature regardless of where the disease originated.
It is the first time the agency has approved a cancer treatment based solely on a genetic biomarker.
"Until now, the FDA has approved cancer treatments based on where in the body the cancer started - for example, lung or breast cancers," said Richard Pazdur, head of oncology products for the FDA's Center for Drug Evaluation and Research. "We have now approved a drug based on a tumor's biomarker without regard to the tumor's original location."
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https://www.scientificamerican.com/article/fda-clears-first-cancer-drug-based-on-genetics-of-disease-not-tumor-location/?

Friday, May 19, 2017

It'll Take an Army to Kill the Emperor - Popular Mechanics

The men and women who are trying to bring down cancer are starting to join forces rather than work alone. Together, they are winning a few of the battles against the world's fiercest disease. For this unprecedented special report, we visited elite cancer research centers around the country to find out where we are in the war.

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http://www.popularmechanics.com/science/health/a26290/we-will-beat-cancer/?