Thursday, December 31, 2009

Review of ‘The Other Side of Sadness,’ by George A. Bonanno -

Poets ramble on at length about mortality, but it was an anonymous World War I lyricist who probably said it best: "The bells of hell go ting-a-ling-a-ling for you but not for me." We can visualize other people's deaths, but not so much our own ("For me the angels sing-a-ling-a-ling").

Unfortunately, this standard psychic defense routinely backfires. We may aim all our fears outward, but then they boomerang back to fill us with terror. When our loved ones die, how will we manage without them? When the worst possible news hits — and it will — how will we survive?

Orthodox psychology has long emphasized the grim slog in store for those who must live without the people they cannot live without. Freud called it "grief work," a process of painfully severing the emotional ties to the deceased. Elisabeth Kübler-Ross mapped out five morose stages of effective grieving.

But if you actually talk to the bereaved, says George A. Bonanno, you find these classic perspectives are pure — well, Dr. Bonanno doesn't actually say baloney, but so he implies in his fascinating and readable overview of what he calls "the science of bereavement."

Just as meticulous observation and experiment transformed astronomy from a compendium of mythology and wishful thinking into a coherent science, the same tools are changing the psychology of loss.

A professor of clinical psychology at Columbia University, Dr. Bonanno has now interviewed hundreds of bereaved people, following some for years before and after the fact, looking for patterns.

His conclusion: the bereaved are far more resilient than anyone — including Freud, and the bereaved themselves — would ever have imagined.

Dr. Bonanno has not written a self-help book in the ordinary sense, but his message winds up being just about as comforting as if he had. Don't worry, he says. When the worst possible news breaks, you will almost certainly get through it unscathed. Almost everyone does. And if your friends and neighbors mutter that you aren't grieving normally, don't worry; you probably are.

In other cultures, Dr. Bonanno points out, it is the ceremonies of death that are the focus of public attention; the community makes sure they are carried out with precision. In our own navel-inspecting society, it is the emotions of death that well-meaning observers focus on instead. Why isn't that widow shedding at least one little tear? How could the boyfriend be off at the ballgame like that? What is wrong with that bizarrely cheerful orphaned child? Surely they all need therapy.

Not so, Dr. Bonanno maintains. In contrast to the grim slog of Freudian grief work, the natural sadness that actually follows a death is not a thick soup of tears and depression. People can be sad at times, fine at other times. The level of fluctuation is "nothing short of spectacular"; the prevalence of joy is "striking."

Over all, we are hard-wired to move on, helped by innate mechanisms that may seem maladaptive or abnormal but are actually quite common and effective.

One of those tools may well be the ability to smile through the worst of it. Humans are inherently drawn to comfort sad people, but can seldom tolerate more than a few minutes in the presence of the seriously depressed. The fact that the bereaved can shake it off periodically means that people will willingly stay with them, protecting them from a spiral of self-involved solitude.

Other tools are less convoluted. Almost everyone idealizes the deceased and spends long solitary sessions remembering good qualities, overlooking bad ones. Some talk to the deceased regularly. Some indulge in what Dr. Bonanno calls "ugly coping" — anger at the damn doctors, the damn hospital or the stupid minister's stupid eulogy can make the bereaved feel better about the loss.

And some realize early on that their lives have actually improved. The consuming worry about incurable illness is over. Old dramas end.

Dr. Bonanno uses his own tense relationship with his father to illustrate this last point: the two were mired in a classic "go to college or get out of my house" situation for many years, long after Dr. Bonanno had grown tired of his self-imposed James Dean role. "It felt to me that I had been living my life as if in a stage play," he writes.

"When my father died, it was as if the house lights had come on. To my surprise, I found that the theater was empty. Not only was I the only one left on the stage, but I was the only person in the entire theater. I had been acting out a play by myself. I could have stopped at any point, but I hadn't known it."

His sadness for his father is continuing — the closing chapters of the book find him burning joss paper in ceremonial Chinese mourning for the old man — but "in fact, my life opened up after my father's death." In his view, it is perfectly normal for the two emotions to coexist, with no need to "process" or "resolve" further.

Medical science being what it is, there are undoubtedly rebuttals to Dr. Bonanno's appealing analysis out there somewhere. But it still makes good reading, a sensitive and sensible view of loss (applicable not only to death, one suspects, but also to lost love, lost opportunity, even lost time) to warm the waning days of the year.


How Little Exercise Can You Get Away With? -

Recently researchers trawled through a vast database of survey information about the health and habits of men and women in Scotland, hoping to determine how much exercise is needed to keep the Scots from feeling gloomy (or in technical terms, experiencing "psychological distress"). The answer, according to a study published in this month's British Journal of Sports Medicine: a mere 20 minutes a week of any physical activity, whether sports, walking, gardening or even housecleaning, the last not usually associated with bringing out the sunshine. The researchers found that more activity conferred more mental-health benefits and that "participation in vigorous sports activities" tended to be the "most beneficial for mental health." But their overall conclusion was that being active for as little as 20 minutes a week is sufficient, if your specific goal is mental health.

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Tuesday, December 29, 2009

Shock Waves: an article by Bethany Vaccaro about her brother's brain injury resulting from a blast in Baghdad | The American Scholar

Going to war brings with it the very real possibility of dying. When my brother Robert left for Iraq in September 2006, our family feared that his commitment might demand what is often called the highest price. Before he left, I imagined what it might be like as the sister of a dead soldier to tell everyone that he had laid down his life in such a contentious struggle. I pictured the flag-draped coffin, the article in our local newspaper, the murmuring friends and neighbors filing through to praise the dead hero. Always a realist, I prepared myself for his death as the worst possible outcome. I failed to conceive of any scenario that could rival the bitter finality of his dying.

I soon discovered that giving one's life can come in more than one form. For my brother, his life as he knew it was taken on January 14, 2007, in Baghdad, when an EFP—an explosively formed projectile device—detonated outside his Army Humvee, sending a shock wave through his brain, severely injuring him without leaving a mark on his body. Robert escaped death, but has paid a price almost as high. Today, he is back from war, 25 years old, brain-injured, and disabled. My brother accepted this risk when he signed his military contract in 2002 through the ROTC program at the University of Rhode Island. Although my family didn't sign an agreement or contract, we have discovered that we are as bound to his commitment as he is himself. Before my brother's injury, the phrase traumatic brain injury, or TBI, meant very little to my family. Now it defines our daily existence. The ongoing process of rehabilitation since his injury has tenaciously enmeshed each one of us, altering our plans, our family structure and interactions, our ideas about life and sacrifice, and most resolutely our belief that if he would only make it back home, everything would be okay.

My brother's injury occurred in the early hours of the morning in Baghdad, as his platoon was finishing a 10-hour shift of route clearing. He was a mechanical engineer and a second lieutenant, in charge of 25 men. Their assignment was to find and dismantle or detonate IEDs (improvised explosive devices) and other explosives that litter the roadways in Iraq. His convoy was nearing an Iraqi checkpoint when his vehicle, the third in line, was targeted by an EFP. The explosion catapulted the vehicle into the side of a building. The force of it blew a hole in the side of the armored Humvee, sending a chunk of metal into the driver's head, killing him almost instantly. My brother was in the passenger seat, and it was the force of the explosion rather than metal that penetrated his head.

After he was wounded, Robert's brain began to swell and the pressure inside his skull skyrocketed. He was taken into surgery as quickly as possible, where a large part of the skull on the right side of his head was removed to allow his brain to expand unencumbered. The pressure continued to rise, and a second surgery to remove even more of the skull was necessary before he left Iraq. It was almost a week before he was stable enough to be moved to the Landstuhl Regional Medical Center in Germany. During this time, my family did little besides sit together and pace around the house, waiting for the phone to ring with an update on his condition. We didn't fully grasp the severity of his injury. We weren't told at the time that he was awarded his Purple Heart in the middle of the night after he was wounded, because doctors feared he wouldn't live until the next day.

Once Robert was in Germany, the Army flew my father out to be with him. It was only then that we understood the gravity of the situation. As his body began to awaken, my brother was kept in an induced coma, allowing his brain to rest. When they finally tried to bring him out of it, he would not wake up.

I am one of five children spanning 14 years. Robert, the eldest, and I were lumped together for much of our childhood, being the closest in age to each other. Although he is 18 months older, I have always acted like the eldest. My mother says he didn't talk until I did. I distinctly remember explaining to him how to pronounce "Hallelujah." Because we were homeschooled, much of our schoolwork was done together. We did our English and history lessons as a pair, as well as all of our science projects—I dictated the steps of the scientific method while he scribbled ferociously into a notebook that would later prove indecipherable. We didn't stay particularly close. He moved into his own sphere when he joined ROTC in college, while I studied philosophy and kept to myself. I could tell he relished being in the traditionally masculine world of the military, where he could perform and deliver, unlike at our university, where he struggled to get through his required courses. Occasionally, he would let me go out with him and his ROTC buddies. I would sit back with my pint of beer and listen to their rapid banter, chuckling where I thought it was appropriate, as they fired movie quotes at each other. I liked watching him laugh and gesticulate. Like our father, Robert would laugh until his eyes watered—with an exuberance that seemed a long time coming after the hesitations of his childhood.

My parents have organized their lives around their children, creating a force field that continually draws us home even as we have grown up. The night we learned of Robert's injury, the rest of us were at our house in Kingston, Rhode Island, where we had spent most of our lives. We were sitting on the floor of the kitchen tie-dyeing T-shirts when the phone rang. A crackly voice told us he had been in an explosion and was going into surgery for head trauma. They would call again in two hours to let us know how it had gone. We gathered in our living room, stunned and unsure of what to do with ourselves. My father stood in the center of the room, slowly rocking back and forth on his feet. When he moved, the imprint of his shoes was chiseled into the carpet as clearly as if he had been standing on clay. He finally sat down, dragging an armchair tight into the circle of chairs and couches. It was not a time for sitting on the other side of the room. I knew my parents were praying, clinging to their lifelong faith, but I only waited for events to unfold and eventually sat at the kitchen table coloring fairies and dragons with my siblings to pass the hours. Every instant seemed like it could be the magical moment—surely now he is gone, or now all is well.

The phrase head trauma meant very little to me that night. I wondered to myself if my brother had perhaps lost an ear or an eye. The possibility of cognitive changes never crossed my mind. I was only vaguely aware of traumatic brain injury as the so-called "signature" wound of the Iraq war, something that is largely due to the increasing sophistication of the explosive devices used by the insurgency. I learned later that the Defense and Veterans Brain Injury Center, which operates out of Walter Reed Army Medical Center, had treated 1,803 cases of TBI stemming from the Afghanistan and Iraq conflicts as of November 2008, while cumulatively their sites had recorded 9,100 cases of this injury. I was completely unaware of the large advocacy and support networks, such as the Wounded Warrior Project, that exist to rally for the treatment of severely injured service men and women, the influx of whom our government has proven sadly unequipped to handle. I didn't know that it is still an uphill battle for many families to receive the kind of care that this incredibly complex injury needs in order to maximize recovery. This was the world we were about to enter that night, although we couldn't have been more ignorant of its existence.

As soon as my brother was moved to Bethesda Naval Hospital in Maryland, my parents began the arduous task of attending to him. I never saw a hint of hesitation in them, even through the long months of care, as everything else in their lives took a distant second place. They were unflinchingly proud of Robert, as they had been when he joined the Army, decided to volunteer for deployment, and ultimately left for Iraq. My parents saw his wartime role in crisp black and white. They were not angry, like I was. Any political context for his actions and what had happened to him collapsed into the overarching fact that he is their son and was in need.

The day my mother prepared to leave for Bethesda, she told us she might stay the whole week. She was sure we could mind each other (two of my brothers were still being homeschooled), the house, and our grandmother for that amount of time. It would be hardest on my nine-year-old brother, who had never been separated from both his parents at once. But we were all eager to rally and pitch in, snapping into an automatic mode that propelled us through our daily routines. My mother was gone for the better part of four months, my father for six months. They would rotate, depending on my father's university work schedule, and were often not home for more than three days at a time. But even when they were home, my parents were present in Rhode Island only in body. Their minds and all their energies were concentrated on a single hospital bed hundreds of miles away.

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Sunday, December 27, 2009

Months to Live - Hard Choice for a Comfortable Death -

In almost every room people were sleeping, but not like babies. This was not the carefree sleep that would restore them to rise and shine for another day. It was the sleep before — and sometimes until — death.

In some of the rooms in the hospice unit at Franklin Hospital, in Valley Stream on Long Island, the patients were sleeping because their organs were shutting down, the natural process of death by disease. But at least one patient had been rendered unconscious by strong drugs.

The patient, Leo Oltzik, an 88-year-old man with dementiacongestive heart failure and kidney problems, was brought from home by his wife and son, who were distressed to see him agitated, jumping out of bed and ripping off his clothes. Now he was sleeping soundly with his mouth wide open.

"Obviously, he's much different than he was when he came in," Dr. Edward Halbridge, the hospice medical director, told Mr. Oltzik's wife. "He's calm, he's quiet."

Mr. Oltzik's life would end not with a bang, but with the drip, drip, drip of an IV drug that put him into a slumber from which he would never awaken. That drug, lorazepam, is a strong sedative. Mr. Oltzik was also receiving morphine, to kill pain. This combination can slow breathing and heart rate, and may make it impossible for the patient to eat or drink. In so doing, it can hasten death.

Mr. Oltzik received what some doctors call palliative sedation and others less euphemistically call terminal sedation. While the national health coverage debate has been roiled by questions of whether the government should be paying for end-of-life counseling, physicians like Dr. Halbridge, in consultations with patients or their families, are routinely making tough decisions about the best way to die.

Among those choices is terminal sedation, a treatment that is already widely used, even as it vexes families and a profession whose paramount rule is to do no harm.

Doctors who perform it say it is based on carefully thought-out ethical principles in which the goal is never to end someone's life, but only to make the patient more comfortable.

But the possibility that the process might speed death has some experts contending that the practice is, in the words of one much-debated paper, a form of "slow euthanasia," and that doctors who say otherwise are fooling themselves and their patients.

There is little information about how many patients are terminally sedated, and under what circumstances — estimates have ranged from 2 percent of terminal patients to more than 50 percent. (Doctors are often reluctant to discuss particular cases out of fear that their intentions will be misunderstood.)

While there are universally accepted protocols for treating conditions like flu and diabetes, this is not as true for the management of people's last weeks, days and hours. Indeed, a review of a decade of medical literature on terminal sedation and interviews with palliative care doctors suggest that there is less than unanimity on which drugs are appropriate to use or even on the precise definition of terminal sedation.

Discussions between doctors and dying patients' families can be spare, even cryptic. In half a dozen end-of-life consultations attended by a reporter over the last year, even the most forthright doctors and nurses did little more than hint at what the drugs could do. Afterward, some families said they were surprised their loved ones died so quickly, and wondered if the drugs had played a role.

Whether the patients would have lived a few days longer is one of the more prickly unknowns in palliative medicine. Still, most families felt they and the doctors had done the right thing.

Mr. Oltzik died after eight days at the hospice. Asked whether the sedation that rendered Mr. Oltzik unconscious could have accelerated his death, Dr. Halbridge said, "I don't know."

"He could have just been ready at that moment," he said.

With their families' permission, Dr. Halbridge agreed to talk about patients, including Mr. Oltzik and Frank Foster, a 60-year-old security guard dying of cancer. He said he had come to terms with the moral issues surrounding sedation.

"Do I consider myself a Dr. Death who is bumping people off on a regular basis?" he asked. "I don't think so. In my own head I've sort of come to the realization that these people deserve to pass comfortably."

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Friday, December 25, 2009

Can Touching Your Toes Test Your Arteries? - Well Blog -

For years, cardiologists were aware that heart attacks are more common during the winter months than in any other season. Most assumed that the cause was cold weather. But then researchers in California examined death certificates in Los Angeles County, an area not known for its inclement winters, and found that, even there, fatal heart attacks spiked during the winter months. More specifically, they started rising around Thanksgiving, climbed inexorably through Christmas and peaked on New Year's Day. A subsequent study of death certificates nationwide, published in Circulation in 2004, confirmed the association between the two holidays and heart-attack deaths. It was accompanied by a cheery editorial headlined "The 'Merry Christmas Coronary' and 'Happy New Year Heart Attack' Phenomenon."
Why the number of heart-attack deaths should surge so significantly during the holidays still is not clear, although cardiologists have some well-founded guesses. "We suspect there is often an inappropriate delay in seeking medical attention" at this time of year, says Dr. Robert A. Kloner, a professor of medicine at the University of Southern California, a cardiologist at Good Samaritan Hospital and the lead author of both the 2004 study of deaths in Los Angeles County and the accompanying editorial. "People ignore the pain in their chest," perhaps because they don't wish to disrupt the festivities or they misinterpret the ache as overindulgence, Dr. Kloner says. By the time they get to an emergency room, it's too late to save them. Stress and tension likely play a role, too. "Spending time with family members can be trying," he says. "And there are often concerns about financial issues, buying presents and so on." Even a wood-burning fireplace, a romantic symbol of wintry, holiday evenings, could be a contributing factor, because particulate matter in the air has been connected to an increase in the risk of heart attacks, Dr. Kloner says.
A provocative new study published this year in the journal Heart and Circulatory Physiology suggests, however, that there may be a novel way to test at least one element of your heart's health right in your own living room, right in the middle of the holidays. Sit on the floor with your legs stretched straight out in front of you, toes pointing up. Reach forward from the hips. Are you flexible enough to touch your toes? If so, then your cardiac arteries probably are also flexible.
In the study's experiment, scientists from the University of North Texas and several Japanese universities recruited 526 healthy adults between the ages of 20 and 83 and had them perform the basic sit-and-reach test described above, although their extensions were measured precisely with digital devices. Taking into account age and gender, researchers then sorted the subjects into either the high-flexibility group or the poor-flexibility group.
Next, using blood-pressure cuffs at each person's ankles and arms, researchers estimated how flexible their arteries were. Cardiac artery flexibility is one of the less familiar elements of heart health. Supple arterial walls allow the blood to move freely through the body. Stiff arteries require the heart to work much harder to force blood through the unyielding vessels and over time could, according to Kenta Yamamoto, a researcher at North Texas and lead author of the study, contribute to a greater risk for heart attack and stroke.
What the researchers found was a clear correlation between inflexible bodies and inflexible arteries in subjects older than 40. Adults with poor results on the sit-and-reach test also tended to have relatively high readings of arterial stiffness. In short, the study concluded that "a less flexible body indicates arterial stiffening, especially in middle-aged and older adults." No such correlation was found in those under 40, even when gender and fitness were considered as factors.
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Wednesday, December 23, 2009

A table that's clear, concise, worth reading and not boring | Michael Tomasky |

TNR's Jon Cohn and MIT's Jonathan Gruber, both oft-cited in this blog, have collaborated on a chart laying out typical costs for families up to about $85,000 per annum without reform (Senate version) and with it. The table can be found here
The numbers aren't just good, they're pretty great. Take a family of four at $48,000, double the poverty line. Currently, this family faces roughly a $12,000 premium and another $12,000 limit on out-of-pocket expenses, for a total possible annual cost of $24,000 -- half their income. Under reform, the premium is $3,629, and total out-of-pocket max is $6,300, for a total possible liability of $9,929 -- 21% of income. That's still a lot, but it's a helluva lot less than half.
The political problem -- the "backlash" problem everyone speaks of -- is that $9,929 is, well, a lot more than zero, which is what a lot of people (who choose to eschew insurance) pay now. But of course people will hit that $9,000-plus only if they have extraordinary health issues (in which case another benefit of reform kicks in -- they can't be thrown off their plans or see their rates jacked up extortionately). 
So assume instead that the typical family that does not now buy insurance won't spend the full $9,929, but something closer to the $3,600 premium level -- a few trips to the doctor, a couple of prescriptions, one consultation with a specialist. Say it brings them to right around $4,800. That's 10% of their income. 
It's a lot. But if this family didn't buy insurance and had to rush a kid to an emergency room, they'd be staring at maybe a $2,000 bill right away. And they wouldn't even bother with the trips to the doctor and the specialist, meaning that they would really only pay more later.
The backlash question, it seems to me, comes down to this. Will this family decide that $300 a month is a rape of their liberty? Or will they decide yeah, $300 a month in premiums hurts, but it sure feels nice to be able to take a kid to a doctor when she's sick instead of just avoiding the problem, and to pay a usually affordable co-payment. And get the kid antibiotics when needed for $5 or $10. 
The coverage has to be good, and the GOP will find every little example where things didn't work and will peddle them to the media and so forth. But big-picture, I dunno: I really think most people would take the above trade-off. And of course they'd really take if one of them had diabetes or MS or something worse.

Tuesday, December 22, 2009

U.C.L.A. Medical Center at Heart of End-of-Life Debate -

LOS ANGELES — The Ronald Reagan U.C.L.A. Medical Center, one of the nation's most highly regarded academic hospitals, has earned a reputation as a place where doctors will go to virtually any length and expense to try to save a patient's life.

"If you come into this hospital, we're not going to let you die," said Dr. David T. Feinberg, the hospital system's chief executive.

Yet that ethos has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.'s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

Take the case of Salah Putrus, who at age 71 had a long history of heart failure.

After repeated visits to his local hospital near Burbank, Calif., Mr. Putrus was referred to U.C.L.A. this year to be evaluated for a heart transplant.

Some other medical centers might have considered Mr. Putrus too old for the surgery. But U.C.L.A.'s attitude was "let's see what we can do for him," said his physician there, Dr. Tamara Horwich.

Indeed, Mr. Putrus recalled, Dr. Horwich and her colleagues "did every test." They changed his medicines to reduce the amount of water he was retaining. They even removed some teeth that could be a potential source of infection.

His condition improved so much that more than six months later, Mr. Putrus has remained out of the hospital and is no longer considered in active need of a transplant.

Because Dartmouth's analysis focuses solely on patients who have died, a case like Mr. Putrus's would not show up in its data. That is why critics say Dartmouth's approach takes an overly pessimistic view of medicine: if you consider only the patients who die, there is really no way to know whether it makes sense to spend more on one case than another.

According to Dartmouth, Medicare pays about $50,000 during a patient's last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

"One of them costs twice as much as the other, and I can tell you that we have no idea what we're getting in exchange for the extra $25,000 a year at U.C.L.A. Medical," Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. "We can no longer afford an overall health care system in which the thought is more is always better, because it's not."

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients' final year of life account for about a quarter of the program's total spending.

Under the House health care legislation pending in Congress, the Institute of Medicine would conduct a study of the regional variations in Medicare spending to try to determine how to reward hospitals like Mayo for providing more cost-effective care. Hospitals identified as high-cost centers might even be penalized, perhaps receiving lower payments from the government. The Senate bill calls only for studies of Medicare spending variations, so it will be up to House-Senate negotiators to resolve the matter in the final legislation.

That prospect worries Dr. Rosenthal and his U.C.L.A. colleagues, who say that unless the distinction can be clearly drawn between excellence and excess in medical care, efforts to cut wasteful spending could be little more than blunt rationing.

"There's a real risk of doing harm here — real harm," he said.

Indeed, U.C.L.A. and five other big California medical centers recently published their own research results with a striking conclusion: for heart failure patients, the hospitals that spend the most seem to save the most lives.

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Saturday, December 19, 2009

A New Disquiet About Some Generic Drugs -

Let me start by saying I'm a fan of generic drugs. They save Americans billions of dollars each year and give us access to wonderful drugs at affordable prices. I've recommended generics in this column many times and use them myself when possible.

But there is a gnawing concern among some doctors and researchers that certain prescription generic drugs may not work as well as their brand-name counterparts. The problem is not pervasive, but it's something consumers should be aware of — especially now that more insurers insist that patients take generic medications when they are available.

Let me also prepare the groundwork for what I hope will be full and frank reader comments, by acknowledging that this issue is controversial.

Joe Graedon, who has been writing about pharmaceuticals for three decades and runs a consumer advocacy Web site, the People's Pharmacy (, was 100 percent behind generics for many years.

"We were the country's leading generic enthusiasts," he told me recently. But over the last eight or nine years, Mr. Graedon began hearing about "misadventures" from people who read his syndicated newspaper column, also called The People's Pharmacy.

The stories were typically from patients who were switched from a brand name drug to a generic one and had side effects or found that their symptoms returned — or even became worse than before they were medicated. Most recently Mr. Graedon has been hearing complaints on his Web site about generic forms of the antidepressant Wellbutrin XL 300 (known as Budeprion XL 300 in one generic form), the heart medicine Toprol XL (metoprolol succinate) and the antiseizure medicine Keppra (levetiracetam).

"Consumers are told generics are identical to brand name drugs, but that is clearly not always the case," Mr. Graedon said.

Some specialists, particularly cardiologists and neurologists, are concerned about generic formulations of drugs in which a slight variation could have a serious effect on a patient's health. The American Academy of Neurology has a position paper that says, in part, "The A.A.N. opposes generic substitution of anticonvulsant drugs for the treatment of epilepsy without the attending physician's approval."

But insurers tend to argue otherwise. On Thursday, ExpressScripts, which handles drug insurance for big employers, put out a news release announcing results of a study it sponsored that found no difference in hospitalizations or emergency-room visits for people on brand-name epilepsy drugs compared with those taking generics.

The Food and Drug Administration, meanwhile, says it stands behind generic medications and its methods for approving them.

"We have not seen any scientific studies that show generics do not hold up as well as brand name drugs," says Gary J. Buehler, director of the agency's office of generic drugs. "We believe the generic drugs we approve work in everyone."

The American Medical Association concurs. A spokeswoman for the group told me in an e-mail message, "the A.M.A. position is that as a whole generic drugs do work as well as name-brand drugs."

Yet, after hundreds of consumers posted messages about problems with the generic drug Budeprion XL 300 on the People's Pharmacy Web site, Mr. Graedon worked with an independent laboratory,, to test the drug, which in other generic versions is typically known as bupropion.

The lab found that Budeprion XL 300 released the active drug at a different rate than the brand name Wellbutrin XL 300. Mr. Graedon and the lab conjecture that the different dissolution rates might be to blame for the reported side effects and lower effectiveness of Budeprion.

But Mr. Buehler at the F.D.A. explained to me that over the course of 24 hours a patient ends up with the same amount of the drug in the bloodstream, so there should be no reason for a variation in effectiveness. "We remain puzzled," he said.

The maker of Budeprion XL 300, Teva Pharmaceutical Industries, recently announced that it would conduct a clinical trial comparing its product against the original, Wellbutrin XL.

A Teva spokeswoman said in an e-mail message that the company was working with the F.D.A. on a study "specifically designed to answer the questions raised following the recent anecdotal commentary on generic budeprion."

"We believe the study and the resulting data will provide further scientific support for the product's bioequivalence to the innovator drug," she said.

To parse that statement — or at least understand "bioequivalence" — it is worth taking a step back to consider what a generic drug is and how it gets approved.

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Monday, December 14, 2009

CBC News - Measuring the return from electronic health records is murky math, at best

I recently flew into Charleston, S.C., to see how the Medical University of South Carolina was handling its electronic health record systems. I went Deep South because MUSC has had the Oacis medical record system in place since 1993 ? it was the first hospital system in the world to buy one.

I went there to check out the system because all the hospitals in Montreal, along with Sunnybrook Hospital in Toronto and the Children's Hospital of Eastern Ontario in Ottawa (not to mention almost the entire state of South Australia) either have or are about to use an Oacis system supplied by Canada's Telus Health Solutions.

I especially wanted to see the effectiveness of an EHR system after it had been used for 16 years in a locale that has a million patient visits a year.

At first glance, everything seemed somewhere between coolisimo and highly efficient.

Larry Afrin, who is both a hematologist and director of information technology for MUSC's Office of Graduate Medical Education, demonstrated how he could comb through 16 years' worth of medical records and uncover a previously unforeseen negative interaction between a standard antibiotic and the suppressed immune system of patients undergoing chemotherapy.

He then showed me, with a couple of keystrokes, how you can retrieve an electronic version of a chest X-ray, or indeed any image, at will. And finally, he gleefully described how the moment Oacis was put in place he had torn up stacks and stacks of the three-by-five-inch cards on which he previously wrote all his patients' medical particulars to refer to when visiting their bedsides.

Following the money

With these successes in mind, I began asking people at MUSC a very different kind of question. Had the purchase of electronic health records saved or made money for the hospital?

I asked first because cost-saving is the lure many EHR vendors claim or imply when selling their products.

Novarad Corp. of Utah, for example, crows on its website about one of its products: "Because it takes care of all of your information and imaging needs, you'll start saving tons of money before you even plug it in." It then directs purchasers towards an online return-on-investment calculator to figure out their future savings.

Companies are not alone in seeing the EHR systems turning into operational gold for hospitals and clinics.

Canada Health Infoway, the federally funded agency partnering with provinces and territories to create a cross-country electronic health record system, commissioned a private consulting firm to monetize the values of computerized health imaging ? what is known as PACS, or picture archiving and communication systems.

Their estimate []: It could save our medical system up to $1 billion a year in existing or projected expenses.

Another study CHI quotes says EHRs could save the country as a whole $6 billion to $7 billion. In the U.S., Rand Corp. estimated in 2005 [] that a digitized American medical system could save that country $81 billion annually.

But what is happening on the ground in South Carolina is a lot less convincing.

After 16 years of experience with electronic health records, and after spending $23 million a year on its clinical computer systems, MUSC still doesn't know if it is saving or making money.

"We have some studies underway to document ROI ? that is, the return on our investment ? but at this stage we feel we can't say it has been positive," says Frank Clark, chief information officer for the MUSC.

What about all those money-saving claims from companies?

"Vapourware," Clark says in his soft southern accent.

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Sunday, December 13, 2009

Mammogram Math -

In his inaugural address, Barack Obama promised to restore science to its "rightful place." This has partly occurred, as evidenced by this month's release of 13 new human embryonic stem-cell lines. The recent brouhaha over the guidelines put forth by the government task force on breast-cancer screening, however, illustrates how tricky it can be to deliver on this promise. One big reason is that people may not like or even understand what scientists say, especially when what they say is complex, counterintuitive or ambiguous.

As we now know, the panel of scientists advised that routine screening for asymptomatic women in their 40s was not warranted and that mammograms for women 50 or over should be given biennially rather than annually. The response was furious. Fortunately, both the panel's concerns and the public's reaction to its recommendations may be better understood by delving into the murky area between mathematics and psychology.

Much of our discomfort with the panel's findings stems from a basic intuition: since earlier and more frequent screening increases the likelihood of detecting a possibly fatal cancer, it is always desirable. But is this really so? Consider the technique mathematicians call a reductio ad absurdum, taking a statement to an extreme in order to refute it. Applying it to the contention that more screening is always better leads us to note that if screening catches the breast cancers of some asymptomatic women in their 40s, then it would also catch those of some asymptomatic women in their 30s. But why stop there? Why not monthly mammograms beginning at age 15?

The answer, of course, is that they would cause more harm than good. Alas, it's not easy to weigh the dangers of breast cancer against the cumulative effects of radiation from dozens of mammograms, the invasiveness of biopsies (some of them minor operations) and the aggressive and debilitating treatment of slow-growing tumors that would never prove fatal.

The exact weight the panel gave to these considerations is unclear, but one factor that was clearly relevant was the problem of frequent false positives when testing for a relatively rare condition. A little vignette with made-up numbers may shed some light. Assume there is a screening test for a certain cancer that is 95 percent accurate; that is, if someone has the cancer, the test will be positive 95 percent of the time. Let's also assume that if someone doesn't have the cancer, the test will be positive just 1 percent of the time. Assume further that 0.5 percent — one out of 200 people — actually have this type of cancer. Now imagine that you've taken the test and that your doctor somberly intones that you've tested positive. Does this mean you're likely to have the cancer? Surprisingly, the answer is no.

To see why, let's suppose 100,000 screenings for this cancer are conducted. Of these, how many are positive? On average, 500 of these 100,000 people (0.5 percent of 100,000) will have cancer, and so, since 95 percent of these 500 people will test positive, we will have, on average, 475 positive tests (.95 x 500). Of the 99,500 people without cancer, 1 percent will test positive for a total of 995 false-positive tests (.01 x 99,500 = 995). Thus of the total of 1,470 positive tests (995 + 475 = 1,470), most of them (995) will be false positives, and so the probability of having this cancer given that you tested positive for it is only 475/1,470, or about 32 percent! This is to be contrasted with the probability that you will test positive given that you have the cancer, which by assumption is 95 percent.

The arithmetic may be trivial, but the answer is decidedly counterintuitive and hence easy to reject or ignore. Most people don't naturally think probabilistically, nor do they respond appropriately to very large or very small numbers. For many, the only probability values they know are "50-50" and "one in a million." Whatever the probabilities associated with a medical test, the fact remains that there will commonly be a high percentage of false positives when screening for rare conditions. Moreover, these false positives will receive further treatments, a good percentage of which will have harmful consequences. This is especially likely with repeated testing over decades.

Another concern is measurement. Since we calculate the length of survival from the time of diagnosis, ever more sensitive screening starts the clock ticking sooner. As a result, survival times can appear to be longer even if the earlier diagnosis has no real effect on survival.

Cognitive biases also make it difficult to see the competing desiderata the panel was charged with balancing. One such bias is the availability heuristic, the tendency to estimate the frequency of a phenomenon by how easily it comes to mind. People can much more readily picture a friend dying of cancer than they can call up images of anonymous people suffering from the consequences of testing. Another bias is the anchoring effect, the tendency to be overly influenced by any initially proposed number. People quickly become anchored to such a number, whether it makes sense or not ("we use only 10 percent of our brains"), and they're reluctant to abandon it. If accustomed to an annual mammography, they're likely for that reason alone to resist biennial (or even semiannual) ones.

Whatever the role of these biases, the bottom line is that the new recommendations are evidence-based. This doesn't mean other right-thinking people would necessarily come to the same judgments. To oppose the recommendations, however, requires facts and argument, not invective.

John Allen Paulos, professor of mathematics at Temple University, is the author most recently of "Irreligion."

Children on Medicaid Found More Likely to Get Antipsychotics -

New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.

Those findings, by a team from Rutgers and Columbia, are almost certain to add fuel to a long-running debate. Do too many children from poor families receive powerful psychiatric drugs not because they actually need them — but because it is deemed the most efficient and cost-effective way to control problems that may be handled much differently for middle-class children?

The questions go beyond the psychological impact on Medicaid children, serious as that may be. Antipsychotic drugs can also have severe physical side effects, causing drastic weight gain and metabolic changes resulting in lifelong physical problems.

On Tuesday, a pediatric advisory committee to the Food and Drug Administration met to discuss the health risks for all children who take antipsychotics. The panel will consider recommending new label warnings for the drugs, which are now used by an estimated 300,000 people under age 18 in this country, counting both Medicaid patients and those with private insurance.

Meanwhile, a group of Medicaid medical directors from 16 states, under a project they call Too Many, Too Much, Too Young, has been experimenting with ways to reduce prescriptions of antipsychotic drugs among Medicaid children.

They plan to publish a report early next year.

The Rutgers-Columbia study will also be published early next year, in the peer-reviewed journal Health Affairs. But the findings have already been posted on the Web, setting off discussion among experts who treat and study troubled young people.

Some experts say they are stunned by the disparity in prescribing patterns. But others say it reinforces previous indications, and their own experience, that children with diagnoses of mental or emotional problems in low-income families are more likely to be given drugs than receive family counseling or psychotherapy.

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Menopause, as Brought to You by the Drug Companies -

MILLIONS of American women in the 1990s were told they could help their bodies ward off major illness by taking menopausal hormone drugs. Some medical associations said so. Many gynecologists and physicians said so. Respected medical journals said so, too.

Along the way, television commercials positioned hormone drugs as treatments for more than hot flashes and night sweats — just two of the better-known symptoms of menopause, which is technically defined as commencing one year after a woman's last menstrual cycle.

One commercial about estrogen loss by the drug maker Wyeth featured a character named Dr. Heartman in a white coat discussing research into connections between menopause and heart disease, Alzheimer's disease and blindness.

"When considering menopause, consider the entire body of evidence," Dr. Heartman said. "Speak to your doctor about what you can do to help protect your health during and after menopause."

Connie Barton, then a medical office assistant in Peoria, Ill., was one woman who responded to such messages. She says she took Prempro, a hormone drug made by Wyeth, from 1997, when she was 53, until 2002, when she received a diagnosis of breast cancer. As part of her cancer treatment, she had a mastectomy to remove her left breast.

Now Ms. Barton, who said in an interview that she used Prempro in part because her doctor told her it could help prevent heart disease and dementia, is one of more than 13,000 people who have sued Wyeth over the last seven years, claiming in courts across the country that its menopause drugs caused breast cancer and other problems.

The suits also assert, based on recently unsealed court documents, that Wyeth oversold the benefits of menopausal hormones and failed to properly warn of the risks.

In October, a jury in a Pennsylvania state court awarded Ms. Barton $75 million in punitive damages from Wyeth on top of compensatory damages of $3.75 million.

The drug giant Pfizer, which absorbed Wyeth and its hormone drugs in a merger this year, says that Prempro is a safe, federally approved drug that did not cause Ms. Barton's breast cancer. Chris Loder, a Pfizer spokesman, says Wyeth acted responsibly by including a clear warning about a breast cancer risk on Prempro labels and by updating the warning as new evidence emerged.

Mr. Loder also notes that Pfizer plans to appeal every product-liability case on menopausal drugs it loses, including Ms. Barton's.

While Wyeth has faced periodic complaints about its blockbuster menopause drugs, the latest lawsuits have turned the company's menopausal hormone franchise into the kind of case study dissected at Ivy League business schools. Lawyers have made some documents public in the suits, and The New York Times and the nonprofit Public Library of Science filed successful motions to unseal thousands of documents in July.

To be sure, even some doctors who think hormone therapy has risks say it is the most effective treatment for symptoms directly associated with menopause.

The documents that have surfaced in the Wyeth cases offer a rare glimpse inside the file cabinets and hard drives of a major drug company. And the cases demonstrate the importance of litigation in detailing exactly how drug makers operate their businesses, says Dr. Jerome L. Avorn, a professor of medicine at Harvard Medical School who has written about the subject in The Journal of the American Medical Association.

"The information coming out in litigation helps us understand how a belief in a 'protective benefit' of estrogens on the heart was able to spread like wildfire through the medical community," says Dr. Avorn, who is not involved in the Wyeth litigation.

"Thousands of doctors prescribed the drugs for millions of women on that basis," he says, adding that studies later contradicted the belief. "It will be very interesting to see whether the courts are able to connect the dots and make it clear whether this was a kind of medical ventriloquism on Wyeth's part."

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Thursday, December 10, 2009

Life Lines Conference: Poetry for Our Patients, Our Communities, Our Selves

What are the challenges and benefits of offering poetry to patients? Can the sharing of poetry expand the vision of practitioners and students in healthcare professions?  What is the role of poetry in community treatment programs? In shelters? In prisons? What can caregivers gain from writing and reading poetry?

This conference is designed for those who have an interest in examining the place of poetry in caregiving.  Three panels of poets and health practitioners will present perspectives on the ways poetry can play a part in caring for our patients, our communities and our selves. Through discussion sessions, participants will have an opportunity to share experiences, to dialogue, to develop techniques, and to gain a deeper appreciation for poetry in the art of healing.

Medicine in Translation | Psychology Today

Danielle Ofri, M.D., Ph.D. is Associate Professor of Medicine at New York University School of Medicine and an internist at Bellevue Hospital, the oldest public hospital in the country. She is co-founder and Editor-in-Chief of the Bellevue Literary Review. Her newest book, Medicine in Translation: Journeys with my Patients--is about the experience of immigrants and Americans in the U.S. health care system.
She is the author of two collections of essays about life in medicine: Incidental Findings: Lessons from my Patients in the Art of Medicine and Singular Intimacies: Becoming a Doctor at Bellevue. She also edited the anthology The Best of the Bellevue Literary Review.

Trawling The Brain - Science News

The 18-inch-long Atlantic salmon lay perfectly still for its brain scan. Emotional pictures —a triumphant young girl just out of a somersault, a distressed waiter who had just dropped a plate — flashed in front of the fish as a scientist read the standard instruction script aloud. The hulking machine clunked and whirred, capturing minute changes in the salmon's brain as it assessed the images. Millions of data points capturing the fluctuations in brain activity streamed into a powerful computer, which performed herculean number crunching, sorting out which data to pay attention to and which to ignore.

By the end of the experiment, neuroscientist Craig Bennett and his colleagues at Dartmouth College could clearly discern in the scan of the salmon's brain a beautiful, red-hot area of activity that lit up during emotional scenes.

An Atlantic salmon that responded to human emotions would have been an astounding discovery, guaranteeing publication in a top-tier journal and a life of scientific glory for the researchers. Except for one thing. The fish was dead.

The scanning technique used on the salmon — called functional magnetic resonance imaging — allows scientists to view the innards of a working brain, presumably reading the ebbs and flows of activity that underlie almost everything the brain does. Over the last two decades, fMRI has transformed neuroscience, enabling experiments that researchers once could only dream of. With fMRI, scientists claim to have found the brain regions responsible for musical ability, schadenfreude, Coca-Cola or Pepsi preference, fairness and even tennis skill, among many other highly publicized conclusions.

But many scientists say that serious issues have been neglected during fMRI's meteoric rise in popularity. Drawing conclusions from an fMRI experiment requires complex analyses relying on chains of assumptions. When subjected to critical scrutiny, inferences from such analyses and many of the assumptions don't always hold true. Consequently, some experts allege, many results claimed from fMRI studies are simply dead wrong.

"It's a dirty little secret in our field that many of the published findings are unlikely to replicate," says neuro­scientist Nancy Kanwisher of MIT.

A reanalysis of the salmon's post­mortem brain, using a statistical check to prevent random results from accidentally seeming significant, showed no red-hot regions at all, Bennett, now at the University of California, Santa Barbara, and colleagues report in a paper submitted to Human Brain Mapping. In other words, the whole brain was as cold as a dead fish.

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Craig Bennett's blog:

A personal weblog of developmental cognitive neuroscience