Thursday, November 13, 2008

How Old Is Too Old for Lifesaving Surgery? - The New Old Age Blog -

I recently spent a stimulating day at The Hastings Center in Garrison, N.Y. Since 1969, this pre-eminent bioethics research center has focused on such issues as care and decision making at the end of life, public health priorities and emerging technologies. I hope that many of the scholars I met there will contribute to this blog, beginning with co-founder Daniel Callahan.

Dr. Callahan wrote the essay below at my request, following a provocative conversation about his long-standing — and controversial — support for rationing health care for the elderly. He views rationing as a way of keeping Medicare solvent in an era of more and more old people, more and more advancements in high-tech medical care, and more and more confidence that age is no barrier to successful heart surgery, cancer treatment and the like.

"The biggest change in the last 40 years," Mr. Callahan said to me, "is that there are no limits. There's nothing we can't do for an old person, and there's a lot of pressure to do it. This is considered progress, and it's considered ageism to be skeptical. But we can't go on this way. It's unaffordable. And it's the hardest dilemma in our society because there's no good way to deal with it other than saying 'no."'

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The Good Cancer? - Well Blog -

Unless you or a loved one has been diagnosed with Type 1 diabetes, it's hard to imagine the daily vigilance that is required to manage the disease.

In the first installment of a new New York Times video series, you can get a glimpse of a day with Type 1 through the experiences of teenager Dominique Corozzo. The 16-year-old has been adjusting to living with Type 1 diabetes and discusses the challenges of her diagnosis and how she copes every day with the disease.

A Day in the Life of Type 1 Diabetes - Well Blog -

Unless you or a loved one has been diagnosed with Type 1 diabetes, it's hard to imagine the daily vigilance that is required to manage the disease.

In the first installment of a new New York Times video series, you can get a glimpse of a day with Type 1 through the experiences of teenager Dominique Corozzo. The 16-year-old has been adjusting to living with Type 1 diabetes and discusses the challenges of her diagnosis and how she copes every day with the disease.

In a Novel Theory of Mental Disorders, Parents’ Genes Are in Competition -

Their idea is, in broad outline, straightforward. Dr. Crespi and Dr. Badcock propose that an evolutionary tug of war between genes from the father's sperm and the mother's egg can, in effect, tip brain development in one of two ways. A strong bias toward the father pushes a developing brain along the autistic spectrum, toward a fascination with objects, patterns, mechanical systems, at the expense of social development. A bias toward the mother moves the growing brain along what the researchers call the psychotic spectrum, toward hypersensitivity to mood, their own and others'. This, according to the theory, increases a child's risk of developing schizophrenia later on, as well as mood problems like bipolar disorder and depression.

In short: autism and schizophrenia represent opposite ends of a spectrum that includes most, if not all, psychiatric and developmental brain disorders. The theory has no use for psychiatry's many separate categories for disorders, and it would give genetic findings an entirely new dimension.

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Wednesday, November 12, 2008

Sniffly Surfing: Google Unveils Flu-Bug Tracker -

You can Google to get a hotel, find a flight and buy a book. Now you may be able to use Google to avoid the flu.

One month into flu season, Google Inc. on Tuesday opened a free Web service that the Internet company says can show if the number of influenza cases is increasing in areas around the U.S., earlier than many existing methods.

The service, called Flu Trends (, uses computers to crunch millions of Internet searches people make for keywords that might be related to the flu -- for instance "cough," or "fever." It displays the results on a map of the U.S. and shows a chart of changes in flu activity around the country. The data is meaningful because the Google arm that created Flu Trends found a strong correlation between the number of Internet searches related to the flu and the number of people reporting flu symptoms.

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Monday, November 10, 2008

FDA's MedWatch

FDA has the responsibility for assuring the safety and efficacy of all regulated marketed medical products.

MedWatch, The FDA Safety Information and Adverse Event Reporting Program, serves both healthcare professionals and the medical product-using public. We provide important and timely clinical information about safety issues involving medical products, including prescription and over-the-counter drugs, biologics, medical and radiation-emitting devices, and special nutritional products (e.g., medical foods, dietary supplements and infant formulas).

Medical product safety alerts, recalls, withdrawals, and important labeling changes that may affect the health of all Americans are quickly disseminated to the medical community and the general public via this web site and the MedWatch E-list. Select Safety Information to see reports, safety notifications, and labeling changes posted to the website since 1996.

MedWatch allows healthcare professionals and consumers to report serious problems that they suspect are associated with the drugs and medical devices they prescribe, dispense, or use. Reporting can be done on line, by phone, or by submitting the MedWatch 3500 form by mail or fax.

Dancing with skeletons and mocking dermatologists in medical-student comedy shows - Slate Magazine

For decades, medical students have written and acted in satirical comedy shows spoofing their experiences. Such shows were almost always closed events, presented by the students to one another and the faculty. Audience members, the students' senior colleagues, have long tolerated fairly outrageous behavior onstage. Now, though, the videos of such shows have begun to appear on YouTube and other Internet sites. The public can watch students criticizing one another's behavior, mocking their professors, and identifying apparent flaws in the educational process.

Medical school comedy shows date back at least as far as 1897, according to a 2006 article written in the Journal of Medical Humanities by Dr. Charles R. Hayter of the University of Toronto. He traces the roots of medical school shows to the tradition of vaudeville, in which satirical skits and musical selections poke fun at others. Such humor, anthropologist Anne Burson-Tolpin has written in Literature and Medicine, "challenges the existing social structure." But there's a difference between a closed-door performance and a publicly accessible YouTube video. Should the medical profession reveal its dirty laundry publicly? More importantly, perhaps, do these skits identify genuine flaws in how doctors learn and practice medicine?

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Michigan Malpractice -

One reason we know about the great silicosis legal scam is that a Texas judge was brave enough to expose doctors who'd been paid by tort lawyers to gin up phony diagnoses. So it is encouraging to see a Michigan judge now helping to expose evidence of similar medical fraud in asbestos claims.

This action is taking place in the courthouse of Wayne County Circuit Court Judge Robert Colombo, Jr. Asbestos defendants have been attempting to disqualify Michael Kelly, a physician who appears to have falsely diagnosed thousands of people with asbestos-related disease. Judge Colombo recently gave them an opening, which is already having a dramatic effect on state asbestos claims.

Michigan is one of the last state holdouts against asbestos tort reform. Texas, Ohio and Mississippi have passed laws or created court procedures to clean up their dockets, and new asbestos filings are declining nationally. But they're still climbing in Michigan, the venue for nearly 14% of U.S. asbestos suits and No. 1 in 2007 for new filings (996).

Enter Dr. Kelly, who is behind many of these cases. The Lansing physician is neither a radiologist nor a pulmonologist. In 1989 he failed the federal test that certifies doctors to read X-rays for lung disease. Yet according to Michigan state records, over 15 years Dr. Kelly has reported 7,323 cases of asbestos-related disease. Lawyers paid him $500 per person screened.

Unlike the silicosis doctors who did their own phony work, Dr. Kelly made the mistake of sending his clients to a hospital for X-rays. Under hospital procedures, staff radiologists read the X-rays first. When asbestos defendants obtained the plaintiff medical records, the hospital findings were included. In 88% of the 1,875 cases in which plaintiff X-rays were reviewed both by Dr. Kelly and hospital radiologists, the hospital readers found no evidence of disease. The medical records also showed that the vast majority of the lung-function tests Dr. Kelly performed failed to meet accepted standards.

Of the 91 asbestos cases Judge Colombo was set to oversee this month, Dr. Kelly provided a diagnosis in 80. In addition to giving the judge a broad picture of Dr. Kelly's work, defense attorneys also retained two respected pulmonologists to review specific cases. Jack Parker, who spent years at the Centers for Disease Control, provided the court with a blind study in which independent X-ray readers found an abnormality in only one of 68 (1.5%) X-rays that Dr. Kelly read. Dr. Kelly had found abnormalities in 88% of those X-rays.

Judge Colombo, who has been the state's asbestos judge since the early 1990s, initially balked at diving into this medical evidence -- suggesting he preferred a quick and easy settlement. But in the face of evidence that up to 90% of the cases in front of him were fraudulent, he ultimately relented and last week agreed to a hearing on Dr. Kelly. At which point something astonishing happened. Within 24-hours of the judge's decision, the plaintiffs attorneys voluntarily pulled all but one of the suits. They clearly have no interest in subjecting their "doctor," and his methods, to judicial scrutiny.

Judge Colombo should do it anyway, and get to the bottom of Dr. Kelly. It's always easier for judges to orchestrate quiet settlements than to preside over trials, which take time and effort. But the reason so many asbestos defendants have pre-emptively settled over the past 20 years is because court rules have been stacked against them. Now that they've finally cracked the lid on this diagnosing for dollars fraud, courts have a responsibility to investigate.

Fitness - Workout Regimens You Can Live With -

SWIM, bike, run, rake leaves. Climb monkey bars if you’re a child, do water aerobics if you’re older. Do whatever you like. Just keep moving.

That, in essence, is the message of the physical activity guidelines announced this month by the federal Department of Health and Human Services. The basic recommendations — including the core guideline that Americans should get about 150 minutes of moderately intense activity per week — have not really changed from the ones announced in 1996 by the surgeon general’s office.

What is different is the emphasis on the variety of activities — including daily chores — that can reap the profound health benefits of exercise.

There is no “one size fits all.” Instead, the guidelines are broken into specific recommendations for adults, children, people over 65 and others. And while sustained aerobic activities are the foundation, there are other types of activities — muscle-building and flexibility-enhancing — that are also important.

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Sunday, November 9, 2008

Doctor and Patient - A Positive Approach to Doctors-in-Training -

At the core of every doctor's training is the internship, that first year of residency that begins just a few weeks after all the pomp and circumstance and lighthearted celebration of medical school graduation. Sometimes referred to as simply the first year of residency, internship is the first step in a professional journey that could include several more years of residency training, a year or two of subspecialty fellowship, and another year or two of research before one ever reaches the goal of becoming a fully trained doctor, an attending physician.

I began my internship as part of a class of five, two women and three men who had all done reasonably well in medical school. By the end of our second year, however, three had left. None of us had ever expected such an attrition rate; our teachers, the attending surgeons, had not intended, as some residency programs did at the time, to fire two of my peers. None guessed that a third would simply up and quit.

The two of us left standing knew that the official reasons were poor judgment and "unprofessional behavior" — we had heard that one of our classmates had repeatedly violated patient confidentiality, and the other had made a decision that put a young child's life in danger. But after their departure, the two of us remaining became fast friends.

We had to be, given the stark facts: we were working well over 100 hours a week with the possibility — the sheer fear, really — that we could be next in line to be fired and would lose all we had worked for until that point. Our dismissed classmates had struggled to find work after leaving; one had begun training all over again in a different specialty, and the other eventually left medicine altogether. Without the support of the other remaining intern, my best friend, I could not have survived.

We did make it through residency, and we learned during our internship and our second year to stay as far away from trouble as we could. "Remember," the two of us often warned one another, "you're only one slip-up away from one of those guys."

Negative reinforcement during those early years taught me to be a cautious and conscientious doctor. Our teachers rarely praised us for good work and never allowed us to forget our errors. But sometimes the lessons had little to do with learning how to care for patients.

One night during my internship, for example, a powerful senior attending called to chew me out for putting his V.I.P. patient in a double room. His voice was so loud I can still remember holding the phone away from my ear. "Do you know I can get you fired for this?" he roared.

"Yes, sir," I responded meekly. I was too scared to tell him the truth, which was that the head nurse, not the intern, assigned patient rooms.

Those early lessons were so effective that even today whenever I hear anyone say the words, "I need to talk to you," my first response is: Did I do something wrong?

I believe strongly that we need to train young doctors to be competent, caring and conscientious. And I would also say that most individuals in my profession feel the same way, judging by the degree of interest in journals and professional societies in cultivating "professionalism," the buzzword used to encompass all those desired qualities. "Placing the interests of patients above those of the physician, setting and maintaining expert standards of competence and integrity, and providing expert advice to society on matters of health" is how one international gathering of medical groups summed up the goals of "professionalism."

I just wonder, though, if emphasizing the negatives — what not to do and the terrible personal repercussions — is necessarily the best way to go about teaching professionalism.

Recently while reading The Journal of the American Medical Association, I came across a study on professionalism that addresses positive reinforcement. Using observation-based evaluations, Dr. Darcy A. Reed and her colleagues at the Mayo Clinic in Rochester, Minn., assessed aspects of professionalism like compassion, competence and integrity among 148 residents and then examined the specific behaviors of the most outstanding among them.

I read through Dr. Reed's paper once and had difficulty understanding her premise; there was little mention of the negative behaviors young doctors needed to avoid. I read through the paper again and this time noticed that even the so-called "average" residents in her study behaved in a very "professional" way. The differences in professionalism between the outstanding residents and those who were average were not that disparate.

In other words, most residents were trying their best to be good doctors.

I called Dr. Reed.

"People have a natural desire to do good, physicians especially," she said. "But the problem," she continued, "may be a training system that encourages not how I can improve but how I can survive."

Doctors-in-training, Dr. Reed maintained, want to know how to improve. But many of their teachers, individuals like myself who were exposed early on in their training to negative reinforcement, might not necessarily understand how encouraging rather than ignoring or discouraging might work in residency. Moreover, even for those educators who are comfortable with positive reinforcement, it is still not entirely clear which behaviors correlate best with professionalism and are thus most important to encourage.

Which is the reason why Dr. Reed and her colleagues chose to focus on only the most highly-rated residents in their study. "What is it about outstanding residents? And how can we all emulate and encourage that behavior?" she asked me on the phone. "We want to encourage residents and the behaviors that we know are associated with outstanding professionalism."

Dr. Reed paused and then added, "Negative reinforcement is so defeating. There are far fewer people who need negative reinforcement than those who need the positive."

I got off the phone that morning feeling a little unbalanced, as if I had been handed a new pair of glasses to wear. Maybe I did not need all that early negative reinforcement to have become a conscientious doctor. Maybe all those fears my best friend and I shouldered during our internship and second year of training were unnecessary.

I read Dr. Reed's paper yet again and suddenly remembered her answer to a question I include in all my interviews: What was it personally that got you interested in this topic?

Dr. Reed had, I noticed, answered without a moment's hesitation. "I became interested in educational research through interest in teaching. I was impressed by excellent teachers and wanted to emulate them."

She had learned, I now understood, through positive reinforcement.

Diagnosis - Brain Drain -

Dr. Rachel Clark could see the patient through the glass walls of the Massachusetts General Hospital intensive-care unit. A young woman lay on the bed, unconscious. The girl's mother sat next to her, stroking her head. Just minutes earlier Clark's pager called her to this ward filled with the sickest patients. The text read: "Unresponsive patient in the I.C.U. Possible Gyn etiology. Please respond asap." As she made her way through the hospital, Clark, a first-year resident in obstetrics and gynecology, tried to imagine what kind of problem would lead critical-care specialists to call on her to help with a patient in a coma.

The 26-year-old woman fell ill two months earlier, her mother told Clark. It started with a headache — the worst of her daughter's life. Her mother took her to the emergency room near their hometown in rural Maine. The doctors there thought it was a migraine and gave her something for the pain. It didn't help.

Over the next 10 days her daughter saw six different doctors, had many blood tests and scans and tried a dozen medicines. No one had a diagnosis or a cure. "There's something wrong in my head," the young woman kept repeating. "It's just not right."

On their last trip to the emergency room, her daughter went crazy. She was talking to people who weren't there. She was afraid, paranoid. Then suddenly she became violent, lashing out at everyone around her. "They told me she was having a psychotic break, that she probably had schizophrenia," her mother reported, the horror of that night still audible in her voice. The patient was taken to a psychiatric hospital. A few days later she developed a fever and was sent to yet another hospital. There she had a seizure. After that, she never woke up. She was finally transferred to Massachusetts General in Boston. But even here the doctors had found no answers.

The young woman had a history of migraines but was otherwise healthy. She took no medications. She worked in an office and lived with her parents. On exam she no longer had a fever. Her eyes were sometimes open, but she was completely unresponsive, even to pain.

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Once Just an Aging Sign, Falls Merit Complex Care -

Katherine Aliminosa, 93, shattered her lower leg while getting snacks for her nieces.

Susan Arnold, 87, broke her hip hanging a photograph.

In mid-July, in a nursing unit of a retirement community here, the two women were at the start of a recovery process that both hoped would return them to their previous lives.

Their progress over the next few months, and their divergent outcomes, illustrate the unpredictable impact that common falls can have on the bodies of older people.

By early autumn, Ms. Aliminosa had graduated to an independent living apartment and was able to get around with a walker. She looked like a different person: more robust, content.

Though six years younger, Ms. Arnold never recovered her strength after hip surgery. Her muscles atrophied from inactivity, and she developed pneumonia. She died on Sept. 6.

Once considered an inevitable part of aging, falls are now recognized as complex, often preventable events with multiple causes and consequences, calling for a wide range of interventions, both psychological and physiological, that many patients never receive.

Even falls that cause only minor injury "need to be taken as seriously as diabetes," said Dr. R. Sean Morrison, a professor of geriatrics and adult development at Mount Sinai School of Medicine in New York, because "they can be a real warning sign that something serious is wrong."

Dr. Mary E. Tinetti, a falls expert at Yale University medical school, compared falls to strokes in their harmfulness, adding that people do not always report them or seek help, for fear their families will try to put them in nursing homes. For some people, Dr. Tinetti said, admitting that they fall is tantamount to admitting that they are no longer competent to take care of themselves.

Each year, 1.8 million Americans over age 65 are injured in falls, according to the Centers for Disease Control and Prevention. Some rebound as if the injury never happened. But for some, the fall sets off a downward spiral of physical and emotional problems — including pneumonia, depression, social isolation, infection and muscle loss — that become too much for their bodies to withstand.

In 2005, the last year for which statistics are available, 433,000 people over 65 were admitted to hospitals after falling, and 15,800 died as a direct result of the fall. Less visible are the many who survive the fall but not the indirect consequences.

When first interviewed in mid-July, Ms. Aliminosa and Ms. Arnold felt vulnerable and constrained, their world diminished. Both had led accomplished professional lives — Ms. Arnold as a school psychologist, Ms. Aliminosa as a medical researcher — and had been active in the community's independent living apartments. But neither could be confident about what the future held.

Ms. Aliminosa said she was depressed, and able to walk only in very small stretches. A small woman with a soft voice and grainy New York accent, she barely filled her chair. She seemed defeated. "Emotionally I have not been well," she said. "It's made me very aware of my age, and that's hard to accept."

Ms. Arnold, by contrast, was full of emotional energy, so angry about her broken hip that she kicked out for emphasis as she talked, turning conversation into a full-contact sport. Before her fall, she had been preparing for a vacation with her daughter at a family beach house on Long Island — the same house where she had spread her husband's ashes. Now that plan was gone.

"It kills me, it just kills me," she said. "This was going to be the frosting on the cake, and somebody ate it."

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Research into medicinal marijuana grows up - Slate Magazine

This summer, British and Italian researchers found that in a laboratory plate, molecules in marijuana can slay the superbug methicillin-resistant staphylococcus aureus, which recently infected seven babies and four employees in a Yonkers, N.Y., maternity ward, heightening fears of outbreaks in schools and locker rooms, as well as in its more familiar breeding grounds, hospitals and nursing homes. In theory, compounds derived from the cannabis plant could someday serve in topical creams for patients with MRSA or other antibiotic-resistant infections.

This isn't the first time marijuana has tantalized the world as a possible wonder drug. In recent years, compounds in cannabis or related molecules have been shown to slow the growth of lung tumors in mice, decrease hardening of the arteries in rats, and boost the egg-binding capability of tobacco smokers' sperm. Research on the receptors that THC and other cannabis compounds attach to—and the nitty-gritty mechanisms by which they exert their effects—has been booming. So has work on native molecules, called endocannabinoids, that bind to the same sites. These molecular interactions affect a wide range of functions, from appetite to inflammation to the perception of pain.

The onslaught of basic science has helped to separate cannabis from an association with hippies and recreational pot smokers. It has also spurred hopes that these molecules (or similar ones) might prove therapeutic for traumatic brain injury, inflammatory bowel disease, allergic contact dermatitis, atherosclerosis, osteoporosis, and Alzheimer's disease, among others. For all the razzle-dazzle, though, potential treatments frequently seem stuck in perpetual adolescence. Research on traumatic brain injury seemed promising but got mixed results in human clinical trials, while most of the others simply haven't gotten very far in the experimental process.

Still, a few prospects show signs of inching toward adulthood. The most enticing are aimed at lessening pain associated with nerve damage and improving some symptoms of multiple sclerosis. Between 2007 and this summer, several randomized clinical trials have found that smoking marijuana can relieve pain in patients with nerve degeneration caused by HIV or other disorders. Compounds in cannabis also seem to reduce nerve pain and possibly decrease spastic movements in people with MS. A drug called Sativex—which delivers two cannabis compounds in a spray under the tongue—is now in late-stage clinical trials in Europe for MS patients. Much as we've heard the hype before, these findings deserve some notice even from the jaded.

Studying the upside of marijuana can be a bureaucratic nightmare. In 1970, Congress deemed it a Schedule 1 drug, meaning that it has a high potential for abuse and "no currently accepted medical use"—making research on possible benefits a tough sell. In the 1980s, the Food and Drug Administration approved Marinol, an oral formulation of THC, the most psychoactive ingredient in cannabis, to treat nausea and vomiting associated with chemotherapy. Later, it also approved Marinol to boost the appetites of people with AIDS. But Marinol was never fully accepted by patients, says Donald Abrams, a professor of clinical medicine at the University of California-San Francisco. It took effect more slowly than smoked marijuana and was also more psychoactive. (When THC enters the bloodstream from the digestive tract, it is broken down by the liver into even more psychoactive molecules.) Nor has Marinol been approved in the United States to treat pain. Those who wished to push research further—whether by studying smoked marijuana, developing better formulations, or testing cannabis for other conditions—got no love from the federal government.

Some did get a boost, however, from the state of California, which paid for the recent work on cannabis smoking and pain. In 2000, the state funded the University of California's Center for Medicinal Cannabis Research, which vets research proposals with an NIH-style review process, pays for projects, and helps scientists navigate state and federal regulations. The center helps researchers obtain cannabis cigarettes, for instance, and deal with federal rules for record-keeping and security—like making sure the safe in which the drug is stored is properly bolted to the floor, says director Igor Grant.

The work has moved slowly, but it's finally paying off with a handful of publications. The first clinical-trial-based paper, which appeared in Neurology in 2007, was a randomized study of 50 patients with HIV-related nerve damage, which can cause discomfort often described as aching, painful numbness, or burning. Those who smoked cannabis each day reported a 34 percent decrease in chronic pain—an effect that's on par with medications often used for this condition, like anti-convulsants and antidepressants, says Abrams. Two other randomized clinical trials, published in June and August, found similarly clear benefits. The June study focused on patients with pain related to a range of neurological conditions, including spinal cord injury. The August paper focused again on HIV-related symptoms. Both found that patients who smoked cannabis reported significantly less pain than those who used dummy cigarettes. These studies were relatively small, but cumulatively they are persuasive.

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