Saturday, November 22, 2008

Obituaries - Hospice nurse who humanised the American way of dying

When Florence Wald, American granddaughter of German immigrants, filed into the Fitkin amphitheatre of Yale University for a lecture in 1963 she was a middle-aged nurse, albeit one of the most senior nurses in the US. She was dean of Yale's School of Nursing, already 46, but what she heard that day changed her life and, through her, the lives of countless Americans.

The lecturer was British nurse and physician Cicely (later Dame Cicely) Saunders, who described to a rapt audience of student nurses her plans to set up a "hospice" in London that would give terminally ill patients not only medical but also emotional and spiritual comfort in the last months of their lives. It was a revolutionary, holistic approach, treating the dying patient as an individual human being rather than a condition or a collection of symptoms. To Florence Wald, Saunders' words crystallised her own concerns: too much power had been left in the hands of doctors – their focus was on medical technology, on cure rather than care – and the needs and rights of dying patients had been neglected. Wald believed what was needed was a "coalition" of doctors, nurses, patients and their families.

For Wald, the Saunders lecture was "so powerful. To me, it was like opening a door where there had been a wall. She blew me away". Four years after that lecture, Saunders opened the world's first modern hospice – St Christopher's Hospice in Sydenham, south-east London – aimed at minimising the pain of cancer and other terminal-illness sufferers, and preparing them and their loved ones for death. Wald gave up her coveted position as nursing dean at the mighty Yale and visited London in the summer of 1968 to serve as a lowly intern at St Christopher's. "Only bring your shoes," Saunders told her in a letter. "We'll give you a uniform. We are quite hard work!"

While Saunders is considered to be the "mother of the modern hospice", Wald, widely known as "Eppie" to her colleagues, is credited with spreading the hospice message to the US and beyond. The women remained close friends and confidantes until the last days of Saunders' life in 2005, when the latter described her own suffering, and spiritual strength, in regular calls and letters. That was despite the fact that Saunders was strongly Christian, Wald a "secular humanist".

After her spell at St Christopher's, Wald returned to the US and founded the first modern American hospice, the Connecticut Hospice, in 1974. She first visited the terminally ill in hospitals or in their own homes. Then, in 1980, she opened a 44-bed in-patient facility, which became a model for the current 3,200 hospices around the US. These treat about 900,000 patients a year, covered by the Medicare national health scheme. Wald's husband Henry gave up his job as an engineering consultant to back her financially, morally and with concrete ideas as to how a hospice could work. Their son and daughter turned the project into a family affair.

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News Keeps Getting Worse for Vitamins -

This week, researchers reported the disappointing results from a large clinical trial of almost 15,000 male doctors taking vitamins E and C for a decade. The study showed no meaningful effect on cancer rates.

Another recent study found no benefit of vitamins E and C for heart disease.

In October, a major trial studying whether vitamin E and selenium could lower a man's risk for prostate cancer ended amidst worries that the treatments may do more harm than good.

And recently, doctors at Memorial Sloan-Kettering Cancer Center in New York warned that vitamin C seems to protect not just healthy cells but cancer cells, too.

Everyone needs vitamins, which are critical for the body. But for most people, the micronutrients we get from foods usually are adequate to prevent vitamin deficiency, which is rare in the United States. That said, some extra vitamins have proven benefits, such as vitamin B12 supplements for the elderly and folic acid for women of child-bearing age. And calcium and vitamin D in women over 65 appear to protect bone health.

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Friday, November 21, 2008 When it comes to statins, don't believe the hype by Andre Picard

The headlines were dramatic and unequivocal:

"Cholesterol drug causes risk of heart attack to plummet" - Fox News.

"Cholesterol-fighting drugs show wider benefit" - The New York Times.

"Cholesterol drug cuts heart risk in healthy patients" - The Wall Street Journal.

The New York Times article summarized the exciting news in a front-page story saying that "millions more people could benefit from taking the cholesterol-lowering drugs known as statins."

That's big medical/business news, because statins are already the bestselling drugs in the world, with sales in excess of $20-billion (U.S.).

Quoting some of the world's top heart researchers, media reports touted the importance of a blood test for C-reactive protein. That's because those benefiting from statins had high levels of CRP (a marker for inflammation) rather than high levels of LDL cholesterol, which is usually the criterion for statin prescription.

The news stories were based on research published last week in the prestigious New England Journal of Medicine and presented, with much fanfare, at the annual convention of the American Heart Association.

Like much reporting on medical research (and drug research in particular), however, there is more (or, more accurately, less) to these stories than meets the eye.

The principal finding in this study was that participants who took a statin pill recorded a 50-per-cent reduction in the risk of heart attack, stroke, surgery and death compared with those who took a placebo (a sugar pill).

Who wouldn't be wowed by those numbers? Who wouldn't want that miracle drug?

But the benefits are relative risk reductions.

When you look at the raw data in the study, they reveal that 0.9 per cent of statin users had cardiovascular problems. By comparison, 1.8 per cent of those taking a placebo had heart problems.

There were 17,802 participants in the study, yet there were only 83 cardiac events among statin users, compared with 157 in the placebo group. That's 50 per cent fewer.

Are those really "dramatic" findings? Do statins really make heart attack risk "plummet"?

According to a cautionary editorial in the New England Journal of Medicine (which received virtually no mention in news reports), 120 people in this study needed to be treated with a statin for two years to see a benefit in one person.

That's a lot of people taking a pricey drug ($3 Canadian a day) for no benefit - not to mention that there are risks.

While researchers (and journalists who report on studies) love to highlight benefits of drugs, they too often gloss over risks.

Like all drugs, statins have side effects. The drug used in the study, rosuvastatin (brand name Crestor), has been associated with muscle deterioration and kidney problems.

In the study, those taking statins had a higher risk of developing Type 2 diabetes - 3 per cent compared with 2.4 per cent of those taking a placebo. That's a 25 per cent higher relative risk among people with very little heart disease to begin with.

As noted earlier, researchers (and news stories) suggested that, based on the findings, the number of patients taking statins could and should expand dramatically.

But is that really what the research tells us, even in its most optimistic interpretation?

The study involved exclusively men older than 50 and women older than 60 who did not have high cholesterol or histories of heart disease or inflammatory illness. All the people in the study needed to have low cholesterol and high CRP.

Initially, researchers recruited 90,000 people in those age groups, but more than 80 per cent of them were deemed ineligible. This is a very select population.

To say, by extrapolation, that these "dramatic" (read: modest) benefits apply to the general population is erroneous.

Similarly, while it is true that about half of all heart attacks and strokes occur in people whose cholesterol is not considered high, does that mean everyone should get a blood test to measure levels of C-reactive protein? Hardly.

Yes, there is more heart disease among people with high levels of CRP, but the jury is still out on what this means.

Some scientists believe that because CRP - secreted in response to inflammation - is present in plaque, it increases the risk that the plaque will burst, leading to blood clots that cause heart attacks. But other researchers think that CRP levels are, at best, a telltale sign of heart disease, a bit like grey hairs are a sign of aging - not its cause.

The CRP test is expensive at almost $50. And it's worth noting that one of the principal authors of the new research holds the patent on the test and makes money every time it is used.

When you cut through all the hype and the self-interest, what we know is this: Statins reduce levels of HDL cholesterol. This is beneficial to people who have had a heart attack or other serious heart problems.

But for otherwise healthy people, high CRP levels or not, the potential benefits of taking statins are marginal, and the risks are not insignificant.

Hardly the stuff of dramatic newspaper headlines.

Thursday, November 20, 2008

The Cochrane Collaboration

Cochrane reviews

Based on the best available information about healthcare interventions, Cochrane reviews explore the evidence for and against the effectiveness and appropriateness of treatments (medications, surgery, education, etc) in specific circumstances. Designed to facilitate the choices that doctors, patients, policy makers and others face in health care, the complete reviews are published in The Cochrane Library four times a year. Each issue contains all existing reviews, plus an increasing range of new and updated reviews.

Cochrane Reviews investigate the effects of interventions for prevention, treatment and rehabilitation in a healthcare setting. They are designed to facilitate the choices that doctors, patients, policy makers and others face in health care. Most Cochrane Reviews are based on randomized controlled trials, but other types of evidence may also be taken into account, if appropriate.

Structure of a Cochrane Review

This is the general layout of a Cochrane Review:

1. Plain-language summary - a short statement summarising the review, specifically aimed at lay people.

2. Structured Abstract - a structured summary of the review, subdivided into sections similar to the main review. This may be published independently from the review and appears on the medical bibliographic database MEDLINE.

3. Background - this gives an introduction to the question considered, including, for example, details on causes and incidence of a given problem, the possible mechanism of action of a proposed treatment, uncertainties about management options etc.

4. Objectives - short statement of the aim of the review.

5. Selection criteria - brief description of the main elements of the question under consideration. This is subdivided into:

  • Types of studies - for example, randomized controlled trials.
  • Types of participants - the population of interest. This section may include details of diagnostic criteria, if desired or appropriate.
  • Types of interventions - the main intervention under consideration and any comparison treatments.
  • Types of outcome measures - any outcome measures/endpoints (for example, reduction in symptoms) that are considered important by the reviewer, defined in advance; not only outcome measures actually used in trials.

6. Search strategy for identification of studies - details of how an exhaustive identification of relevant information was attempted, including details of searches of electronic databases, searches for unpublished information, handsearching of journals or conference proceedings, searching of reference lists of relevant articles, etc.

7. Methods of the review - description of how studies eligible for inclusion in the review were selected, how their quality was assessed, how data were extracted from the studies, how data were analysed, whether any subgroups were studied or whether any sensitivity analyses were carried out, etc.

8. Description of studies - how many studies were found, what were their inclusion criteria, how big were they, etc.?

9. Methodological quality of included studies - were there any reasons to doubt the conclusions of any studies because of concerns about the study quality?

10. Results - what do the data show? The results section may be accompanied by a graph to show a meta-analysis, if this was carried out.

11. Discussion - interpretation and assessment of results.

12. Authors' conclusions - subdivided into Implications for practice and Implications for research.

This database offers free access to the abstracts and, where available, the plain language summaries of all Cochrane systematic reviews. Links to the full-text versions are available on each page.

Wednesday, November 19, 2008

Toxic Chemicals Blamed for Gulf War Illness - Washington Post

Toxic Chemicals Blamed for Gulf War Illness

By Steven Reinberg
HealthDay Reporter

Gulf War illness, dismissed by some as a psychosomatic disorder, is a very real illness that affects at least 25 percent of the 700,000 U.S. veterans who took part in the 1991 Gulf War.

Its likely cause was exposure to toxic chemicals that included pesticides that were often overused during the war, as well as a drug given to U.S. troops to protect them from nerve gas, a frequent weapon of choice of former Iraqi leader Saddam Hussein.

And no effective treatments have been devised for the disorder.

Those are three key conclusions of a Congressionally mandated landmark report released Monday by a federal panel of scientific experts and veterans.

"It is very clear that Gulf War illness is a real condition that was not caused by combat stress or other psychological factors," said Lea Steele, scientific director of the Research Advisory Committee on Gulf War Veterans' Illnesses, which issued the report, and an associate professor at Kansas State University.

"This is something we need to take seriously," Steele said. "These folks were injured in wartime service, much as people who were shot with bullets or hit with bombs."

The committee presented the 450-page report to Secretary of Veterans Affairs James Peake.

Gulf War illness is frequently described as a collection of symptoms that includes memory and concentration problems, chronic headaches, fatigue and widespread pain. Other symptoms can include persistent digestive problems, respiratory symptoms and skin rashes.

The panel also said Gulf War veterans have much higher rates of amyotrophic lateral sclerosis (ALS, or Lou Gehrig's Disease) than other veterans, and soldiers who were downwind from large-scale munitions demolitions in 1991 have died from brain cancer at twice the rate of other Gulf War veterans.

In reaching its conclusions, the panel reviewed evidence about a wide range of possible environmental exposures that could cause Gulf War illness. That review included hundreds of studies of Gulf War veterans, research in other groups of populations, animal studies of toxic exposures, and government investigations about events and exposures during the Gulf War, which began after Hussein invaded Kuwait.

Speculation about the causes of Gulf War illness has included exposure to depleted uranium munitions, vaccines, nerve agents and oil well fires.

The new report says the illness was caused by soldiers' exposure to certain chemicals, Steele said.

"When you put all the evidence together there are two chemicals that jump out as the main causes," she said. One is a drug called pyridostigmine bromide, which is a cholinesterase inhibitor that was given to the troops to protect them against nerve gas.

"It turns out that people who took those pills have a higher rate of Gulf War illness," Steele said. "And people who took more pills have even higher rates of Gulf War illness."

In addition, soldiers were exposed to pesticides that were also cholinesterase inhibitors, Steele said. "The strongest evidence points to pyridostigmine bromide and pesticides as causal factors," she said. "This type of illness has not been seen after other wars."

While pyridostigmine bromide is still in use, its use is more limited than it was in the first Gulf War. It's currently being used against one type of nerve agent, but is not being given out on a widespread basis, Steele said.

"The Gulf War was the only time a lot of people used this drug," she said.

Steele added that the U.S. military has also cut back on its use of pesticides since the 1991 war.

There are other factors that, while not likely causes of Gulf War illness, can't be ruled out, Steele said. These include exposure to nerve agents, exposure to smoke from oil well fires, and vaccines given to the troops. The panel ruled out depleted uranium and anthrax vaccine as causes.

The panel also found government research and funding into Gulf War illness wanting. "There has not been sufficient attention given to Gulf War illness. It's a real problem," Steele said.

"In recent years, both the Department of Defense and the Department of Veterans Affairs have reported a lot of studies that weren't Gulf War illness as Gulf War research," Steele added. "Some of the money was misused."

The panel noted that overall federal funding for Gulf War research has declined substantially in recent years; the group urged lawmakers to devote $60 million annually to such programs.

When veterans with Gulf War illness go to Veterans Administration hospitals for treatment, their problems often aren't taken seriously, Steele said. "VA docs often know nothing about it and aren't able to help them. Sometimes they treat them as if they are head cases or malingering," she said.

James Binns is chairman of the U.S. Department of Veterans Affairs' Research Advisory Committee on Gulf War Veterans' Illnesses.

"We have no treatments that work," said Binns, a Vietnam veteran and former Pentagon official. "I would like to see the new administration take this more seriously. When you look at all the studies, it's as clear as the nose on your face that this [Gulf War illness] is real."

It took 20 years to admit that Agent Orange, a defoliant used in the Vietnam war, caused illness, Binns said. "It's now coming up to 17 years on Gulf War illness," he said. "Troop exposures [to these chemicals] were a serious but honest mistake. Covering it up rather than trying to help them has been unconscionable."

One-third of asthma cases may be misdiagnosed, study says

TORONTO — One-third of Canadian adults who have been told they have asthma may have been wrongly diagnosed by their doctor, according to a new study that reveals serious problems with the way the disease is identified and treated in Canada.

The findings, being published Tuesday in the Canadian Medical Association Journal, suggest thousands may needlessly be taking medications that could have life-altering side effects and major costs.

"There's a lot of drugs being consumed and paid for that really are not likely to have any therapeutic role for these patients," said Shawn Aaron, head of the respirology division at the University of Ottawa and lead author of the study. "If this study is true, and I have no reason to believe it's not, there are 30 per cent of people walking around in Canada who believe they have asthma, whose physicians have told them they have asthma, who don't [have asthma]."

About 8.3 per cent of Canadians aged 12 and older were identified as having asthma in 2005, according to Statistics Canada. In 2007, 3.4 million prescriptions were issued for the top five asthma medications, at a cost of nearly $329-million, according to IMS Health Canada, a company that tracks the pharmaceutical industry.

The reason for the inflated rates of asthma diagnosis seems to be a lack of adequate testing, the study says.

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Tuesday, November 18, 2008

Picturing our thoughts - The Boston Globe

In May 1991, Dr. Kenneth Kwong, a radiologist at Massachusetts General Hospital, became one of the first scientists to enjoy a new vision of the human brain. The experiment was simple: Kwong would show a subject some visual stimuli - such as a sequence of flashing red lights - and then monitor the brain to see how it reacted. To Kwong's surprise, even a brief light show triggered a telltale pattern of activity in the visual cortex, as the brain processed the sensory information.)

"It took a few months before I believed what I was seeing," Kwong remembers. "I was actually watching the brain at work."

This ability to peer inside the mind was made possible by a new technology known as fMRI, or functional magnetic resonance imaging. The technology quickly became one of the most popular tools of neuroscience. Last year, an average of eight peer-reviewed papers using fMRI were published per day, and more than 19,000 fMRI papers have been published in the last 15 years. The past few months have brought articles on everything from the neural substrate of sarcasm to the patterns of brain activation triggered by pornography. The technique is invading other fields as well, as psychologists, psychiatrists, philosophers, and even economists increasingly rely on these powerful machines.

The brain scan image - a silhouette of the skull, highlighted with bright splotches of primary color - has also become a staple of popular culture, a symbol of how scientific advances are changing the way we think about ourselves. For the first time in human history, the black box of the mind has been flung wide open, allowing researchers to search for the cortical source for every flickering thought. The expensive scanners can even decode the hidden urges of the unconscious, revealing those secret feelings that we hide from ourselves. The machine, in other words, knows more about you than you do: It's like a high-tech window into the soul.

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Brain Scans as Mind Readers? Don't Believe the Hype

"So here's your brain," the doctor says, as the center of my mental life pirouettes before me, rendered in electric blues and reds. Daniel Amen, MD, manipulates the screen image with a few taps on his keyboard.

"It looks good, pretty symmetrical. Red means more activity, blue means less."

We're peering at a Spect scan taken a half hour ago. He takes a closer look. Spect scans are a type of brain-imaging technology that measures neural activity by looking at blood flow. "The only question I'd ask you is whether you've ever had a brain injury, because there is low activity in your occipital cortex and your parietal lobe, all on the left side."

I admit to the occasional fall while snowboarding, but I've always worn a helmet. Amen shakes his head. "Your brain is 80 percent water and the consistency of tofu, and your skull is hard, so your brain was not meant to snowboard, even with a helmet. I recommend tennis or Ping-Pong."

He calls up a different view, this one from below, as though looking up from the spinal cord. I see a spot on one side that is conspicuously ... empty. "What's that?" I ask.

"That's a left temporal lobe ding. It's in a fairly innocuous area, but I'd still ask your wife how your temper is."

I'm in Newport Beach, California, undergoing the $3,300 Amen Clinic evaluation. The price includes two Spect scans and a series of clinical interviews. At the end I'll get a report on my mental health, along with recommendations about lifestyle changes, supplements, and medications — a prescription for a "better brain." It's an alluring prospect, but the approach is still viewed with some suspicion by mainstream psychiatrists. Not that serious scientists aren't interested in taking pictures of the brain — in fact, journals churn out hundreds of brain-imaging articles each month. It's just that we haven't quite figured out what these pictures mean. Are we really seeing the mind in action, or are we allowing ourselves to be seduced by images that may actually tell us very little?

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Analysis Finds Marked Increase in Chronic Kidney Disease -

In February 2005, Rita Miller, a party organizer in Chesapeake, Va., felt exhausted from what she thought was the flu. She was stunned to learn that persistent high blood pressure had caused such severe kidney damage that her body could no longer filter waste products from her blood.

“The doctor walked over to my bed and said, ‘You have
kidney failure — your kidneys are like dried-up peas,’ ” recalled Ms. Miller, now 65, who had not been to a doctor or had her blood pressure checked for years.

“The doctor said, ‘Get your family here right away,’ ” she said. “They were telling me I might not make it. I was in shock. I starte
d dialysis the next day.”

Ms. Miller, who has since moved to Connecticut to be with her children, was one of the millions of Americans unaware that they are suffering from chronic kidney disease, which is caused in most cases by uncontrolled hypertension (as in her case)
or diabetes, and is often asymptomatic until its later stages. The number of people with the disease — often abbreviated C.K.D. — has been rising at a significant pace, thanks in large part to increased obesity and the aging of the population.

An analysis of federal health data published last November in The Journal of the American Medical Association found that 13 percent of American adults — about 26 million people — have chronic kidney disease, up from 10 percent, or about 20 million people, a decade earlier.

“We’ve had a marked increase in chronic kidney disease in the last 10 years, and that continues with the baby boomers coming into retirement age,” said Dr. Frederick J. Kaskel, director of pediatric nephrology at the Children’s Hospital at Montefiore in the Bronx. “The burden on the health care system is enormous, and it’s going to get worse.

“We won’t have enough units to dialyze these patients.”

Concerned about the emerging picture, federal health officials have started pilot programs to bolster public awareness, increase epidemiologic surveillance and expand efforts to screen those most at risk — people with high blood pressure, diabetes or a family history of kidney disease.

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Mind - In Psychiatry, Is It Safe to Use Humor With a Patient? -

“Has anything changed since the treatments began?” I ask the patient, as he lies down on a stretcher in the ECT suite. The anesthesiologist places an IV line in his arm and checks his vital signs. My attending psychiatrist adjusts the machine that delivers the electric stimulus. I’m a psychiatry intern, and this is my electroconvulsive therapy rotation. I’m here to watch and learn.

“My cellphone always has a great charge,” the patient deadpans.

If this were a friend or colleague, I would laugh easily. But this is a patient I barely know. He ha
s bipolar disorder, a previous suicide attempt and a history of bizarre, impulsive behavior. In that context, his joke just feels inappropriate and overly familiar.

I’m taken aback. Is it O.K. to laugh, I wonder? An intern, with years of experience being inexperienced, I quickly glance around to take stock of the room.

The nursing assistant laughs and the anesthesiologist grins broadly. The attending psychiatrist remains stone-faced, and says, “Clearly he’s improving.” As the anesthesiologist inject
s a sedative, a telephone rings. Everyone’s hands are occupied; the ringing continues. Just as the patient starts to drift off, he looks over at me and says: “Can you get that? It might be the governor calling to stay my execution.”

A moment later, he’s out. The attending hands me the leads, and I feel slightly uncomfortable as I bring them to the patient’s head. The nurses are still laughing as he begins to convulse.

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