Thursday, November 23, 2017

In the woods and the shadows, street medicine treats the nation’s homeless - The Washington Post

Nurse Laura LaCroix was meeting with one of her many homeless patients in a downtown Dunkin' Donuts when he mentioned that a buddy was lying in agony in the nearby woods.

"You should check on him," said Pappy, as the older man is known. "But don't worry, I put him on a tarp, so if he dies, you can just roll him into a hole."

LaCroix called her boss, Brett Feldman, a physician assistant who heads the "street medicine" program at Lehigh Valley Health Network. He rushed out of a meeting, and together the two hiked into the woods. They found Jeff Gibson in a fetal position, vomiting green bile and crying out in pain from being punched in the stomach by another man days earlier.

Feldman told him he had to go to the hospital.

"Maybe tomorrow," Gibson replied.

"Tomorrow you'll be dead," Feldman responded.

Months later, the 43-year-old Gibson is still in the woods, but this time showing off the six-inch scar — for a perforated intestine and peritonitis — that is evidence of surgical intervention. He greets Feldman warmly. "You're the only person who could have gotten me to the hospital," he says. "You're the only person I trust."

Pappy and Gibson are "rough sleepers," part of a small army of homeless people across the country who cannot or will not stay in shelters and instead live outside. And LaCroix and Feldman are part of a burgeoning effort to locate and take care of them no matter where they are — whether under bridges, in alleyways or on door stoops.

"We believe that everybody matters," Feldman says, "and that it's our duty to go out and find them."

More ...

https://www.washingtonpost.com/national/health-science/in-the-woods-and-the-shadows-street-medicine-treats-the-nations-homeless/2017/11/21/6ef037e8-ca54-11e7-b0cf-7689a9f2d84e_story.html?

Wednesday, November 22, 2017

Skin Cancers Rise, Along With Questionable Treatments - The New York Times

John Dalman had been in the waiting room at a Loxahatchee, Fla., dermatology clinic for less than 15 minutes when he turned to his wife and told her they needed to leave. Now.

"It was like a fight or flight impulse," he said.

His face numbed for skin-cancer surgery, Mr. Dalman, 69, sat surrounded by a half-dozen other patients with bandages on their faces, scalps, necks, arms and legs. At a previous visit, a young physician assistant had taken 10 skin biopsies, which showed slow growing, nonlethal cancerous lesions. Expecting to have the lesions simply scraped off at the next visit, he had instead been told he needed surgery on many of them, as well as a full course of radiation lasting many weeks.

The once sleepy field of dermatology is bustling these days, as baby boomers, who spent their youth largely unaware of the sun's risk, hit old age. The number of skin cancer diagnoses in people over 65, along with corresponding biopsies and treatment, is soaring. But some in the specialty, as well as other medical experts, are beginning to question the necessity of aggressive screening and treatment, especially in frail, elderly patients, given that the majority of skin cancers are unlikely to be fatal.

"You can always do things," said Dr. Charles A. Crecelius, a St. Louis geriatrician who has studied care of medically complex seniors. "But just because you can do it, does that mean you should do it?"

More ...

https://www.nytimes.com/2017/11/20/health/dermatology-skin-cancer.html?

Tuesday, November 21, 2017

The Power of the Placebo - Slate

Every so often, a new study comes along that challenges conventional wisdom in medicine or science. When the conditions are right, these studies can generate a lot of attention in both the popular press and the medical community. In early November, one of these such studies, called the ORBITA study, was published in the Lancet by a group of cardiologists.

The authors had set out to ask and answer a simple question: Does placement of a small wire mesh (called a stent) inside the artery that feeds blood to the heart (the coronary artery) relieve chest pain? One might ask what was novel about this question. The truth is that there was and is nothing novel about the question. The novelty was in the methods the authors used to answer the question: They conducted a prospective randomized controlled clinical trial, or RCT, the gold standard of research. The best RCTs compare the effect of the active intervention to a placebo and the best of the best keep both the subjects and the investigators blind to the intervention. The authors managed to do this for stents and chest pain, something that had never been done before, and in doing so, they had the best chance of preventing the placebo effect from skewing the results.

More ...

http://www.slate.com/articles/health_and_science/medical_examiner/2017/11/what_to_do_if_you_have_a_stent.html

Sunday, November 19, 2017

What if You Knew Alzheimer’s Was Coming for You? - The New York Times

Six years ago, at age 49, Julie Gregory paid an online service to sequence her genes, hoping to turn up clues about her poor circulation, blood-sugar swings and general ill health. Instead she learned she had a time bomb hidden in her DNA: two copies of a gene variant, ApoE4, that is strongly linked to Alzheimer's. Most Americans with this genotype go on to develop late-onset dementia.

"Alzheimer's was the furthest thing from my mind," Ms. Gregory told me. "I never thought I was at risk. When I saw my results, I was terrified."

When Ms. Gregory consulted with a neurologist about how to delay the onset of illness, he had four words for her: "Good luck with that." After all, no drug had proven effective in reversing Alzheimer's disease. And preventive measures like diet and exercise, the neurologist told her, would do no good.

Ms. Gregory is not the sort of person who pops into your mind when you think of Alzheimer's — youngish, healthy and sharp-minded. But she represents a type of sufferer we are likely to encounter more and more: those grappling with the looming threat of the disease rather than the disease itself.

More ...

https://www.nytimes.com/interactive/2017/11/17/opinion/sunday/What-if-You-Knew-Alzheimers-Was-Coming-for-You.html?

Tuesday, November 14, 2017

First Digital Pill Approved to Worries About Biomedical ‘Big Brother’ - The New York Times

For the first time, the Food and Drug Administration has approved a digital pill — a medication embedded with a sensor that can tell doctors whether, and when, patients take their medicine.

The approval, announced late on Monday, marks a significant advance in the growing field of digital devices designed to monitor medicine-taking and to address the expensive, longstanding problem that millions of patients do not take drugs as prescribed.

Experts estimate that so-called nonadherence or noncompliance to medication costs about $100 billion a year, much of it because patients get sicker and need additional treatment or hospitalization.

"When patients don't adhere to lifestyle or medications that are prescribed for them, there are really substantive consequences that are bad for the patient and very costly," said Dr. William Shrank, chief medical officer of the health plan division at the University of Pittsburgh Medical Center.

Ameet Sarpatwari, an instructor in medicine at Harvard Medical School, said the digital pill "has the potential to improve public health," especially for patients who want to take their medication but forget.

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https://www.nytimes.com/2017/11/13/health/digital-pill-fda.html?

Under New Guidelines, Millions More Americans Will Need to Lower Blood Pressure - The New York Times

The nation's leading heart experts on Monday issued new guidelines for high blood pressure that mean tens of millions more Americans will meet the criteria for the condition, and will need to change their lifestyles or take medicines to treat it.

Under the guidelines, formulated by the American Heart Association and the American College of Cardiology, the number of men under age 45 with a diagnosis of high blood pressure will triple, and the prevalence among women under age 45 will double.

"Those numbers are scary," said Dr. Robert M. Carey, professor of medicine at the University of Virginia and co-chair of the committee that wrote the new guidelines.

The number of adults with high blood pressure, or hypertension, will rise to 103 million from 72 million under the previous standard. But the number of people who are new candidates for drug treatment will rise only by an estimated 4.2 million people, he said. To reach the goals others may have to take more drugs or increase the dosages.

Few risk factors are as important to health. High blood pressure is second only to smoking as a preventable cause of heart attacks and strokes, and heart disease remains the leading killer of Americans.

If Americans act on the guidelines and lower their blood pressure by exercising more and eating a healthier diet, or with drug therapy, they could drive an already falling death rate from heart attacks and stroke even lower, experts said.

More ...

https://www.nytimes.com/2017/11/13/health/blood-pressure-treatment-guidelines.html?

Tuesday, November 7, 2017

“No Fatties”: When Health Care Hurts - Longreads

Kasey Smith began gaining weight as a teenager. The numbers on the scale started increasing overnight, and no matter how few calories she consumed, they continued to go up. "It will even out," she thought, crediting the change to puberty and hormones. But it didn't, and her hair and skin began changing as well. "Something was definitely wrong."

Each medical appointment, and there were many, concluded with doctors telling her to go on a diet. Smith (not her real name) remembers telling the endocrinologist about her frustrations with burning off the 900 calories she consumed each day and still gaining weight. "He looked at me and said, 'Maybe you can cut back your McDonald's to twice a week.' I was stunned silent, and I went into the bathroom and broke down. 'He doesn't believe me. He thinks I'm just fucking with him.'"

As Smith's weight went up, her food intake went down. Her mother signed her up for Nutrisystem, and her diet hung on the fridge for everyone in her family to see. Shame and humiliation narrowed her life down to three questions: what to eat, what not to eat, and how to burn more calories. She began to form dangerous habits, sometimes eating little more than lettuce.

Smith ultimately received a diagnosis of polycystic ovary syndrome, a hormonal disorder that can lead to excess male hormones, irregular menstrual cycles, and weight gain. She was prescribed Metformin and quickly began to lose weight, but the damage had been done. The 18-year-old developed anorexia, leaving for college at 130 pounds and coming back four months later and 30 pounds lighter, her hair falling out in clumps.

No one thought anything was wrong.

"I would go to the doctor, and there were no red flags. It was 'You look fantastic!' Not 'This is alarming.'" Smith continued starving herself for another year until she ended up in the hospital, undergoing a colectomy to remove a foot and a half of her intestines, which had twisted as a result of her severe calorie restriction.

One year after the surgery, her worst nightmare returned: She was gaining weight. Celiac disease was the cause this time, but it wasn't diagnosed until after Smith was in the habit of purging the little food she ate every day. She would regularly run in the park and pass out afterward. "I would starve all day, then I'd eat something at night, then I would purge it. In my head, I'm thinking, 'I'm literally not consuming anything. The weight has to fall off.'"

She realized she needed professional help, and Smith found a therapist who specialized in eating disorders and began treatment at The Renfrew Center, a residential facility in Pennsylvania. She continues to struggle with discussing her weight at medical appointments. After she told her endocrinologist about her treatment at Renfrew, his reply was "I see you need to lose some weight."

More …

https://longreads.com/2017/10/26/no-fatties-when-healthcare-hurts/

Sunday, November 5, 2017

How to Feign an Illness - The New York Times

"Research your symptoms," says Eve Muller, a Los Angeles-based actress who has been working in medical schools as a simulated patient since 1990. Bodies manifest ailments in recognizable patterns that medical professionals are trained to observe and diagnose. It is not enough to say your belly hurts; exactly where and how does it hurt? Stomach pain could be food poisoning, an ectopic pregnancy, pelvic inflammatory disease, appendicitis, twisted ovarian tubes or something else entirely. Know your malady's pathology and describe it with specificity. "You need to know anatomy," Muller says.

Before she interacts with students, a medical school gives Muller a detailed case study outlining the pretend patient's medical history, biography, symptoms and sometimes even scripted lines. Be similarly thorough in your preparation. If the condition requires a repeated physical action, like a limp or the trembling associated with Parkinson's disease, watch videos of real patients online and mimic their behavior in front of a mirror or on video. Use makeup, hair and clothing to help tell your story. "Look the part," says Muller, who paints bruises and rashes onto her body. She drinks yogurt smoothies to sound phlegmy if she's portraying someone with congestion. Sometimes she wears business attire; for other characters she jams dirt under her fingernails and rubs oil in her hair.

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https://www.nytimes.com/2017/11/03/magazine/how-to-feign-an-illness.html?

Sunday, October 29, 2017

The Symptoms of Protracted Dying - NYTimes.com

Geraldine was warmly opinionated and, along with her husband, she'd raised her four daughters to be the same.

When work settled and time allowed, she melted into the couch next to any of her children who were home and turned on the Hallmark channel. If a movie showed people who couldn't care for themselves, she would remark, "I don't want to live like that," or "if that's me, don't bother doing all that."

On May 25, a clot blocked a blood vessel in Geraldine's heart. Her husband performed CPR. She was whisked to the hospital, where her heart survived, but lack of oxygen launched her brain into uncontrollable seizures. At age 56, her melodic Irish accent was silenced.

Her lips sagged around a breathing tube when I met her three weeks later. Her limbs lay wherever we put them. Kinked gray hair stood in all directions from her scalp, pushed aside by electrodes that recorded brain activity.

In the small conference room in our neuro intensive care unit, we discussed Geraldine's prognosis with her family.

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https://www.nytimes.com/2017/10/24/well/live/the-symptoms-of-protracted-dying.html

Why opioids are such an American problem - BBC News

For every one million Americans, almost 50,000 doses of opioids are taken every day. That's four times the rate in the UK.

There are often good reasons for taking opioids. Cancer patients use them for pain relief, as do patients recovering from surgery (codeine and morphine are opioids, for example).

But take too many and you have a problem. And America certainly has a problem.

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http://www.bbc.com/news/world-us-canada-41701718