Thursday, July 23, 2009

The Placebo Effect: My Genes Made Me Do It -

When I wrote about the placebo effect a couple of months ago, scientists didn't have any real understanding of why placebo works for some people but not others. Some patients can think themselves out of pain (the best-known placebo effect), but others cannot. Some patients with Parkinson's disease can take a sugar pill and, through the power of belief and hope, see their symptoms improve—but not all. Some patients, having experienced the respiration-depressing effects of morphine, will find their breathing becoming shallower even when they're injected with an inert solution, not morphine; others experience no such placebo effect. The difference, it turns out, may come down to the levels of particular neurotransmitters that carry messages through the brain, and those levels may reflect genetic differences.

In the August issue of the Journal of Clinical Psychopharmacology, scientists led by Andrew Leuchter of UCLA will report that in patients with major depressive disorder, variants of two genes affect whether someone will respond to a placebo. (The genes have no effect on whether someone will develop major depression in the first place.)

The genes that matter are those that make enzymes called catechol-O-methyltransferase (COMT) and monoamine oxidase A (MAO-A). That makes sense if you believe that one way the placebo effect works is by goosing the brain's natural reward pathways. Those pathways run on two neurotransmitters, dopamine and norepinephrine. "Most research on how placebos work now focuses on the brain's reward system and on dopamine signals," Leuchter told me by e-mail. "Our work suggests that norepinephrine should be examined as well. Dopamine and norepinephrine actually work hand-in-hand to manage reward information. One way to think of it is that dopamine helps an individual expect a reward, and norepinephrine helps you sustain attention on the possible reward and figure out how it can be achieved. We theorize that a person has to have the optimal level of norepinephrine in order to sustain the placebo response." COMT breaks down dopamine; MAO-A breaks down norepinephrine. The scientists therefore guessed that levels or forms of these enzymes would affect brain levels of the reward chemicals and thus whether that brain is more or less likely to respond to a placebo.

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Goodbye Grogginess? A Watch Tries to Reduce Sleep Inertia - David Pogue,

Last week in The Times, I reviewed a weird, wonderful, sleep-tracking alarm clock called the Zeo. It's a $400 bedside alarm clock that comes with a wireless headband that monitors your brain waves. In the morning, the clock's screen shows you a graph of your night's sleep cycles (light sleep, deep sleep, dream sleep, waking).

In that column, I promised to review another sleep-monitoring gadget that doesn't require strapping anything onto your forehead: the Sleeptracker watch ($180, It's a fairly homely black plastic watch and band with four buttons and a big, clear L.C.D. digital screen.

This watch makes no attempt to monitor your brainwaves. (Unless you're a spectacularly loud thinker, that'd be quite a feat, all the way down on your wrist.)

It also makes no attempt to identify which sleep phase you're in, upload the data to the Web, or give you personalized advice, as the much more expensive Zeo does.

Instead, the Sleeptracker watch contains a tiny motion sensor--an accelerometer, like the one in the iPhone. It attempts to identify, by your restless nighttime movements, the moments during the night when you nearly wake up (or wake up momentarily but don't remember). Those are either the moments *between* sleep cycles or wakeups from environmental factors like pets or city noises.

What's the point? Two, actually. First, you can connect the watch to a USB cable and upload a record of the night's near-wakeups to a companion Windows program. It shows you a timeline of each night's sleep, with tick marks that represent those near-wakeups, and a place to record factors like caffeine or naps so that you can spot correlations.

I doubt many people will stick with this past the novelty phase. The watch stores only one night's worth of data. So if you truly want to track your sleep, you have to perform the entire ritual every single day: take off the watch, set it to Data mode, connect it to your Windows computer, fire up the software, click the Upload button. It's a lot of work, and the results aren't especially enlightening.

Furthermore, the watch tracks your sleep only if you tell it what time to start and stop tracking.

Unfortunately, despite its name, the Sleeptracker doesn't actually know when you're asleep. You have to tell it ahead of time when you *expect* to fall asleep. (If you're still awake at that hour, you have to guess-program it again. And so on.)

As for the stop time, that's the alarm time (read on). In other words, the watch doesn't track your sleep on days when you don't set an alarm.

The watch's primary feature, though, is that it tries to wake you (by vibrating, beeping or both) at the best possible time, within an "alarm window" that you specify.

For example, if you have to be up by 7 a.m., you set the watch's alarm to 7:00, but you might set the alarm *window* to 30 minutes. If, in that last half hour before 7, the watch senses that you're having a near-wake moment, it goes off early.

The idea is to wake you when you're nearly awake anyway. That way, you avoid the groggy, out-of-it-for-hours feeling of "sleep inertia," which happens when you're awakened from a deep sleep.

It's a little hard to believe that somebody who got *less* sleep could feel more refreshed than someone who got *more* sleep. But that, in fact, is what the Sleeptracker promises. (The Zeo offers the same feature. So does the Axbo alarm clock, which I haven't tried.)

Does it work?

Well, during my two weeks wearing the watch, I never woke up groggy. The thing is, it's hard to say whether I would have felt fine on those days anyway.

(One absolutely great feature, though, is that the vibrating can wake you without waking your sleeping partner. Or vice-versa. Now *that's* a key to better sleep.)

Most of the customer reviewers on Amazon write that the alarm-window concept really works; many write unequivocally that they rarely wake up groggy anymore. (The watch has received a lot of poor reviews, too, but most cite a too-quiet beeper alarm. I didn't experience that problem with the current model, the Elite.)

Some, on the other hand, reported no change in their grogginess. (I especially liked this one: "This gadget does what it promises: wakes you up when you are almost awake. Having said that, I am still grumpy no matter what. And being woken up 15 min before my alarm rings just makes me even grumpier.")

Note, too, that a number of reviewers have noted how easy it is to shut off the alarm clock when you're wearing it--and go back to sleep. You don't even have to reach over to the nightstand.

So this watch's wake-me-at-the-perfect-time system won't work for everyone. The thing has some baffling design quirks, the software is crude, and it won't win any fashion awards.

But I'm a big believer in, and worrier about, the sleep-deprivation problem. You only have one life, and going through it exhausted diminishes just about everything worth enjoying: relationships, productivity, creativity, feeling good.

So if there's even a chance that it could improve your quality of life, you should try the Sleeptracker (or the Zeo). There's a 30-day guarantee, which makes that experiment even more palatable.

Should we blame overdiagnosis for rising health costs? - By Darshak Sanghavi - Slate Magazine

Healthy people, goes the popular doctors' joke, are simply those haven't gone through enough medical testing. Excessive diagnostic evaluations with fancy body scans or blood tests will always find something amiss. Call these searches what you like—defensive medicine to ward off lawsuits, useless procedures to line doctors' pockets, patient-initiated testing from the worried—but observers like Peter Orszag, director of the Office of Management and Budget, estimate they contribute a good chunk to the estimated $700 billion in wasted annual health costs.

Taken another way, however, the joke hints at the nature of illness in the modern world. In 2006, Harvard economist and Obama adviser David Cutler calculated what we get in return for our health care spending. Over the past 50 years, we've increased per-person lifetime health care costs by roughly $70,000, and the average lifespan has jumped seven years. The trends show that it's getting harder to save lives; in the 1970s, we got an extra year of life for only $7,400, but by the 1990s, each ran more than $36,000 (in inflation-adjusted 2002 dollars). That makes sense, since we've picked all the low-hanging fruit, so to speak. And though it's getting more expensive to buy life, Cutler puts the money in context. "According to virtually any commonly cited value of a year of life," the economist writes, "the increased spending has, on average, been worth it."

Policymakers tend to speak glibly about the oceans of cash depleted by wasteful spending. But there's another way to frame the explosion of medical costs: We now recognize and treat problems that were previously hidden or never diagnosed—which is a good thing. Consider these sample statistics, all from generally reliable federal agencies: One percent of the population has celiac disease, causing anemia and other problems, one in 150 children tests positive for autism spectrum disorders, 2 percent to 5 percent of adults have an eating disorder, 20 percent of children are overweight, one in 22 pregnancies is complicated by a minor or major birth defect, and 10 percent of people have asthma. The list goes on. In the past, people just lived with these problems. Today, for better or worse, we do not simply let them go—and that costs more and more money.

It's tempting to complain that Americans today are wussy hypochondriacs, overmedicated and overtreated for all kinds of imagined disorders. Some of them no doubt are. But, to take my personal experience as an example, many aren't.

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Tuesday, July 21, 2009

Our Scars Tell the Stories of Our Lives -Dana Jennings, NYTimes

Our scars tell stories. Sometimes they're stark tales of life-threatening catastrophes, but more often they're just footnotes to the ordinary but bloody detours that befall us on the roadways of life.

When I parse my body's motley parade of scars, I see them as personal runes and conversation starters. When I wear shorts, the footlong surgical scar on my right knee rarely fails to draw a comment.

And in their railroad-track-like appearance, my scars remind me of the startling journeys that my body has taken — often enough to the hospital or the emergency room.

The ones that intrigue me most are those from childhood that I can't account for. The one on my right eyebrow, for example, and a couple of ancient pockmarks and starbursts on my knees. I'm not shocked by them. To be honest, I wonder why there aren't more.

I had a full and active boyhood, one that raged with scabs and scrapes, mashed and bloody knees, bumps and lumps, gashes and slashes, cats' claws and dogs' teeth, jagged glass, ragged steel, knots, knobs and shiners. Which raises this question: How do any of us get out of childhood alive?

My stubborn chin has sustained a fair bit of damage over the years. On close examination, there's a faint delta of scars that brings back memories of my teenage war on acne. Those frustrating days of tetracycline and gritty soaps left my face not clean and glowing but red and raw. The acne also ravaged my back, scoring the skin there so that it still looks scorched and lunar.

I further cratered my chin as an adult. First, I sprinted into a cast-iron lamppost while chasing a fly ball in a park in Washington; I actually saw a chorus line of stars dance before my eyes as I crumpled to the ground. Second, I hooked one of those old acne potholes with my razor and created an instant dueling scar.

Scanning down from the jut of my chin to the tips of my toes, I've even managed to brand my feet. In high school and college I worked at Kingston Steel Drum, a factory in my New Hampshire hometown that scoured some of the 55-gallon steel drums it cleaned with acid and scalding water. The factory was eventually shut down by the federal government and became a Superfund hazardous waste site, but not before a spigot malfunctioned one day and soaked my feet in acid.

Then there are the heavy hitters, the stitched whips and serpents that make my other scars seem like dimples on a golf ball.

There's that mighty scar on my right knee from when I was 12 years old and had a benign tumor cut out. Then there are the scars on my abdomen from when my colon (devoured by ulcerative colitis) was removed in 1984, and from my radical open prostatectomy last summer to take out my cancerous prostate. (If I ever front a heavy metal band, I think I'll call it Radical Open Prostatectomy.)

But for all the potential tales of woe that they suggest, scars are also signposts of optimism. If your body is game enough to knit itself back together after a hard physical lesson, to make scar tissue, that means you're still alive, means you're on the path toward healing.

Scars, perhaps, were the primal tattoos, marks of distinction that showed you had been tried and had survived the test. And like tattoos, they also fade, though the one from my surgery last summer is still a fierce and deep purple.

There's also something talismanic about them. I rub my scars the way other people fret a rabbit's foot or burnish a lucky penny. Scars feel smooth and dry, the same way the scales of a snake feel smooth and dry.

I find my abdominal scars to be the most profound. They vividly remind me that skilled surgeons unlocked me with their scalpels, took out what had to be taken, sewed me back up and saved my life. It's almost as if they left their life-giving signatures on my flawed flesh.

The scars remind me, too, that in this vain culture our vanity sometimes needs to be punctured and deflated — and that's not such a bad thing. To paraphrase Ecclesiastes, better to be a scarred and living dog than to be a dead lion.

It's not that I'm proud of my scars — they are what they are, born of accident and necessity — but I'm not embarrassed by them, either. More than anything, I relish the stories they tell. Then again, I've always believed in the power of stories, and I certainly believe in the power of scars.

When Weight Is the Issue, Doctors Struggle Too -

The mother came out of the exam room to intercept me: she knew I would probably have to talk to her daughter about how she was gaining weight, she said, but please don't use the word "fat," or even "overweight." Don't make her feel bad about herself.

The girl was about 8, and when I plotted her growth chart, it was clear some balance had shifted over the past year, and her weight was increasing much too fast relative to her height. It was worth talking about.

But I was as conscious of my own body as I was of hers. How on earth, I was thinking, am I supposed to give sound nutritional advice when all they have to do is look at me to see that I don't follow it very well myself? How to reconcile that with her mother's reasonable request: Don't make her feel bad about herself? And taking it all together, how am I supposed to help stem the so-called epidemic of childhood obesity when not a week goes by that I don't break my own resolutions? What price the not-skinny doctor?

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Considering Longer Chemotherapy -

The newest prognosis for cancer may be longer chemotherapy.

Doctors and pharmaceutical companies are moving toward treating cancer patients with drugs continuously, even when they may not urgently need them. That would be a departure from the common practice of stopping treatment when the cancer is under control and resuming it only if the cancer worsens.

The strategy is called maintenance therapy — akin to periodic tune-ups aimed at preventing a car from breaking down. Doctors say it could prolong the time tumors are under control, helping to turn cancer into a chronic disease that is kept in check even if it is not cured.

While maintenance therapy is not entirely new, its use is growing, in part because some of the newer cancer drugs are more tolerable than the toxic ones of old and can be taken for longer periods.

At the recent annual meeting of the American Society of Clinical Oncology, for instance, doctors filled a huge auditorium for a debate on whether it is time to adopt maintenance therapy for lung cancer, the nation's leading cause of cancer death. Other cancers for which maintenance therapy is being used or tried include ovarian cancer, multiple myeloma and non-Hodgkin's lymphoma.

But some experts say that in many cases, the longer-term use of drugs has not been proved to prolong life.

Instead, it may just subject cancer patients to more side effects and tens of thousands of dollars in extra costs. There is also concern that tumors might become resistant to a drug used for a long time.

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Monday, July 20, 2009

American health care, like America, is innovative and wasteful. - By Jacob Weisberg - Slate Magazine

In his new book The Healing of America, the journalist T.R. Reid employs a clever device for surveying the world's health systems: He takes an old shoulder injury to doctors in various countries. In the United States, a top orthopedist recommends a major joint-replacement operation, costing tens of thousands of dollars. In France and Germany, general practitioners offer him the same surgical option, at little or no cost, but steer him instead toward a regimen of physical therapy. In Britain, the doctor is unimpressed with his injury and tells him to go home. In Canada, he is offered a place in line, where he will wait a year just to consult a specialist. In India, he is sent to an ayurvedic clinic, where he is treated, quite effectively, with herbs, massage, and meditation.

America's system has become wildly unfair and expensive. In fixing it, Reid says, we should follow other countries where health care is fairer, cheaper, and produces better results. He's right that we can learn much from practices elsewhere—why, for instance, can't we have those nifty smart cards the French use instead of paper records? But the lesson I took away from Reid's book was somewhat different: Health care systems are not just policy choices but expressions of national character and values. The alternatives he describes work better than ours not just because they're well-designed and competently managed but because they reflect the expectations and traditions of their societies.

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