Saturday, November 7, 2009

Painful Stories Take a Toll on Military Therapists -

Many of the patients who fill the day are bereft, angry, broken. Their experiences are gruesome, their distress lasting and the process of recovery exhausting. The repeated stories of battle and loss can leave the most professional therapist numb or angry.

And hanging over it all, for psychiatrists and psychologists in today's military, is the prospect of their own deployment — of working under fire in Iraq or Afghanistan, where the Pentagon has assigned more therapists to combat units than in previous wars.

That was the world that Maj. Nidal Malik Hasan, an Army psychiatrist, inhabited until Thursday, when he was accused of one of the worst mass shootings ever on a military base in the United States, an attack that killed 13 and left dozens wounded. Five of the dead were fellow therapists, the Army said.

Major Hasan's motives are still being investigated, though his family and acquaintances cited stress from his counseling job, his opposition to the wars, his pending deployment and his feeling that he was being harassed as a Muslim. But those who work day in and day out treating the psychological wounds of the country's warriors say Thursday's rampage has put a spotlight on the strains of their profession and of the patients they treat.

Major Hasan was one of a thin line of military therapists trying to hold off a rising tide of need. So far this year, 117 soldiers on active duty were reported to have committed suicide. The Army has only 408 psychiatrists — military, civilian and contractors — serving about 553,000 active-duty troops around the world. As a result, some soldiers home from war, suffering from nightmares and panic attacks, say they have waited almost a year to see a psychiatrist.

Many military professionals, meanwhile, describe crushing schedules with 10 or more patients a day, most struggling with devastating trauma or mutilated bodies that are the product of war and the highly advanced care that kept them alive.

Some of those hired to heal others end up needing help themselves. Some go home at night too depressed to talk to their children. Others, like Bret A. Moore, a former Army psychologist at Fort Hood, ultimately quit.

"I planned for a career in the military, but I burned out" after about five years, he said.

The biggest problem, Dr. Moore said, was "compassion fatigue."

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If Health Care Is Going to Change, Dr. Brent James's Ideas Will Change It -

During one of our first conversations, Brent James told me a story that you wouldn't necessarily expect to hear from a doctor. For most of human history, James explained, doctors have done more harm than good. Their treatments consisted of inducing vomiting or diarrhea and, most common of all, bleeding their patients. James, who is the chief quality officer at Intermountain Healthcare, a network of hospitals and clinics in Utah and Idaho that President Obama and others have described as a model for health reform, then rattled off a list of history books that told the fuller story. Sure enough, these books recount that from the time of Hippocrates into the 19th century, medicine made scant progress. "The amount of death and disease would be less," Jacob Bigelow, a prominent doctor, said in 1835, "if all disease were left to itself."

Yet patients continued to go to doctors, and many continued to put great in faith in medicine. They did so in part because they had no good alternative and in part because, as James put it, they wanted a spiritual counselor with whom they could talk about their health. But there was something else, too. There was a strong intuitive logic behind those old treatments; they seemed to be ridding the body of its ills. They made a lot more sense on their face than the abstract theories about germs and viruses that began to appear in the late 19th century.

So the victory of those theories would require a struggle. The doctors and scientists who tried to overturn centuries of intuitive wisdom were often met with scorn. Hippocrates himself wrote that a physician's judgment mattered more than any external measurement, and the practice of medicine was long organized accordingly.

In the end, of course, the theories about germs and viruses won out. They had the advantage of being correct, and doctors — haltingly and skeptically, but eventually — embraced them. "Medicine adopted the scientific method," James said as we were sitting in his Salt Lake City office, which looks out onto the Utah State Capitol Building and the Wasatch Mountains. "It transformed medicine, and it's easy to make the case." Diphtheria, mumps, measles and polio were conquered, and pneumonia and heart attacks became far less deadly. In 1910, life expectancy at birth in the United States was less than 50 years, and it had not risen much for centuries, James noted. Life expectancy today is 78 years.

But there is one important way in which medicine never quite adopted the scientific method. The explosion of medical research over the last century has produced a dizzying number of treatments for different ailments. For someone with heart disease, there is bypass surgery, stenting or simply drugs and behavior changes. For a man with early-stage prostate cancer, there is surgery, radiation, proton-beam therapy or so-called watchful waiting. To enter mainstream use, any such treatment typically needs to clear a high bar. It will be subject to randomized trials, statistical-significance tests, the peer-review process of academic journals and the scrutiny of government regulators. Yet once a treatment enters the mainstream — once we know whether it works in certain situations — science is largely left behind. The next questions — when to use it and on which patients — become matters of judgment, not measurement. The decision is, once again, left to a doctor's informed intuition.

"There are some real advantages to that," James says, "and in some ways there are some real disadvantages too." The human mind can sometimes do a better job of piecing together amorphous bits of information — diagnosing a disease, for example — than even the most powerful computer. On the other hand, human beings can also be unduly influenced by just a few experiences, like the treatment of an especially memorable patient. As a result, different doctors frequently end up coming up with different answers to the same question. Cardiologists in Davenport, Iowa, are quick to insert stents; cardiologists in Iowa City and Sioux City are not. They can't both be right. Some people with heart disease are getting the best treatment, and some are not. The same is true of debilitating back pain, various cancers and even pregnancy.

The health care debate of 2009 has had so many moving parts that it has sometimes seemed impossible to follow. The crisis behind the debate, though, is about one thing above all: the scattershot nature of American medicine. The fee-for-service payment system — combined with our own instincts as patients — encourages ever more testing and treatments. We're not sure which ones make a difference, but we keep on getting them, and costs keep rising. Millions of people cannot afford insurance as a result. Millions more have had their incomes pinched by rising insurance premiums. Medicare is on a long-term path to insolvency. The American health care system is vastly more expensive than any other country's, but our results are not vastly better.

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Ideal Medical Practices

Ideal Medical Practice Wiki!

To help physicians create or improve Ideal Medical Practices that can provide patients with "exactly the care they want and need, exactly when and how they want and need it", while at the same time providing superb care in vital and sustainable practices.

Blazing Cat Fur blog: TGH - Toronto Generally Hopeless

I suppose I should have been tipped off by the fact that the surgeon who performed my Mom's angioplasty last Friday couldn't be bothered to check up on her afterward. This same surgeon discharged her Saturday morning from TGH, Toronto General Hospital - by phone.

Tuesday afternoon my Mother suffered a "False Aneurysm", this, the paramedic explained, is a fairly common side effect that may have been caused by the anti-clotting medication she has been prescribed. However I read now that "The most common cause of pseudoaneurysm is femoral artery puncture during cardiac catheterisation." Hmmmm, thanks for that followup Doctor. An angioplasty requires that an incision be made in the groin in order to access the femoral artery via which they transport the stent that keeps a plugged heart artery "open". Her femoral artery opened up like Hoover Dam. The thigh and groin swelled with the mass of blood that collected till it looked like someone had taken a baseball bat to her, inflicting perhaps the largest bruise you ever saw.

She was scared, in a great deal of pain and very weak by the time she hit TGH's ER, though commendably the paramedics had stabilized her - this was 6:20 PM. The paramedics stayed with her, monitoring her vitals and answering my questions as best they could until well after their shift ended at 7. At 8:30 PM, in order to release the paramedics my 84 year old Mother was officially admitted to TGH. Admission consisted of moving her from the ambulance gurney to a hospital gurney and pushing her 20 yards down the corridor, next to the homeless guy with the festering sores on his legs. The attentive care of the paramedics was replaced by - nothing.

We waited nearly an hour for a resident to finally stop by and enquire what the matter was. Appallingly, she had no prior knowledge of why my Mother had been admitted. My shock increased after she asked, in all seriousness, if the angioplasty had been a success. I can only assume that the look on my face caused her to retreat and summon the physician on duty. Exhibiting Solomon like wisdom, the attending doctor suggested that a physical examination was in order. She then disappeared with the resident in tow. A nurse was dispatched who informed us that my Mother would have to be undressed for the examination. Since this Angel of Mercy made no offer to assist, I took it upon myself to undress my bedridden mother in a public corridor, in full view of the passing parade of visitors, patients and staff. (Truth be told, the homeless guy was pretty discrete, or at least preoccupied.)

Mom was eventually examined, in the public corridor, and an ultrasound ordered, all while a street person dumped a filled adult diaper on the floor and replaced her own soiled bed linens in the ward next to us. At this point we were informed that the vascular surgeon would be called in to interpret the ultrasound. The Ultrasound technician showed up earlier than anticipated and Mom had her pictures done shortly before 11 pm. This procedure afforded Mom some privacy as they chose to conduct it in the unused examination room next to her "room" in the corridor. Our Angel of Mercy, the nurse, made her second appearance, sticking her head in to enquire "Who left her like this?" - -Mom had been left in a partial state of undress, uncomfortably positioned and without the recommended bags of saline solution in place to compress the swelling. I replied that the Ultrasound technician had just left, having finished her session. Five minutes later I watched our Angel of Mercy clock out to end her shift- - but thanks for asking, Florence Nightingale.

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Medical Apps for the iPhone -

Last week, I spoke at the TED MED conference. It's like the much higher-profile TED conference (you can read about it on my blog), but under different management and, of course, dedicated to healthcare topics.

My assignment was to speak for 18 minutes (the standard talk length) about medical apps for the Apple iPhone. Sounds easy, right? Only one problem: there are about 7,000 medical apps.

After a lot of time reading "best medical apps" stories online, asking Twitter users for their suggestions and reading online reviews, I finally boiled the list down to about 50 promising apps. I tried them out and further winnowed the list to a bunch that I ultimately demo'ed in my talk. Eventually, the video of the talk will be posted at, but in the meantime, here's what I covered.

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The Forever War of the Mind -

The Forever War of the Mind

By Max Cleland

"Every day I was in Vietnam, I thought about home. And, every day I've been home, I've thought about Vietnam." So said one of the millions of soldiers who fought there as I did. Change the name of the battlefield and it could have been said by one of the American servicemen coming home from Iraq or Afghanistan today. Wars are not over when the shooting stops. They live on in the lives of those who fight them. That is the curse of the soldier. He never forgets.

While the authorities say they cannot yet tell us why an Army psychiatrist would go on a shooting rampage at Fort Hood in Texas, we do know the sorts of stories he had been dealing with as he tried to help those returning from Iraq and Afghanistan readjust to life outside the war zone. A soldier's mind can be just as dangerous to himself, and to those around him, as wars fought on traditional battlefields.

War is haunting. Death. Pain. Blood. Dismemberment. A buddy dying in your arms. Imagine trying to get over the memory of a bomb splitting a Humvee apart beneath your feet and taking your leg with it. The first time I saw the stilled bodies of American soldiers dead on the battlefield is as stark and brutal a memory as the one of the grenade that ripped off my right arm and both legs.

No, the soldier never forgets. But neither should the rest of us.

Veterans returning today represent the first real influx of combat-wounded soldiers in a generation. They are returning to a nation unprepared for what war does to the soul. Those new veterans will need all of our help. After America's wars, the used-up fighters are too often left to fend for themselves. Many of the hoboes in the Depression were veterans of World War I. When they came home, they were labeled shell-shocked and discharged from the Army too broken to make it during the economic cataclysm.

So it is again, with too many stories about veterans of Iraq and Afghanistan ending up unemployed and homeless. Figures from the Department of Veterans Affairs show that 131,000 of the nation's 24 million veterans are homeless each night, and about twice that many will spend part of this year homeless.

We know of the recent failures at Walter Reed Medical Center, where soldiers were stranded in substandard barracks infested with rats while awaiting treatment. I was in Walter Reed myself at that time seeking counseling for post-traumatic stress disorder, which, ignited by a barrage of Iraq headlines and the loss of my United States Senate seat, had simply consumed me.

I never saw it coming. Forty years after I had left the battlefield, my memories of death and wounding were suddenly as fresh and present as they had been in 1968. I thought I was past that. I learned that none of us are ever past it. Were it not for the surgeons and nurses at Walter Reed, I never would have survived those first months back from Vietnam. Were it not for the counselors there today, I do not think I would have survived what I've come to call my second Vietnam, the one that played out entirely in my mind.

When I was wounded, post-traumatic stress disorder did not officially exist. It was recognized as a legitimate illness only in 1978, during my tenure as head of the Veterans Administration under President Jimmy Carter. Today, it is not only recognized, but the Army and the V.A. know how to treat it. I can offer no better testament than my own recovery.

Weeks before the troubles at Walter Reed became public in 2007, my counselor put it to me simply. "We are drowning in war," she said. The problems at Walter Reed had nothing to do with the dedicated doctors and nurses there. The problems had to do with the White House and Congress and the Department of Defense. The problems had to do with money.

When we are at war, America spends billions on missiles, tanks, attack helicopters and such. But the wounded warriors who will never fight again tend to be put on the back burner.

This is inexcusable, and it comes with frightening moral costs. There are estimates that 35 percent of the soldiers who fought in Iraq will suffer post-traumatic stress disorder. I'm sure the numbers for Afghanistan are similar. Researchers have found that nearly half of those returning with the disorder have suicidal thoughts. Suicide among active-duty soldiers is on pace to hit a record total this year. More than 1.7 million soldiers have served in Iraq and Afghanistan. Imagine that some 600,000 of them will have crippling memories, trapped in a vivid and horrible past from which they can't seem to escape.

We have a family Army today, unlike the Army seen in any generation before. We have fought these wars with the Reserves and the National Guard. Fathers, mothers, soccer coaches and teachers are the soldiers coming home. Whether they like it or not, they will bring their war experiences home to their families and communities.

In his poem "The Dead Young Soldiers," Archibald MacLeish, whose younger brother died in World War I, has the soldiers in the poem tell us:"We leave you our deaths. Give them their meaning." Until we help our returning soldiers get their lives back when they come home, the promise of restoring that meaning will go unfulfilled.

Max Cleland, the secretary of the American Battle Monuments Commission, was a Democratic senator from Georgia from 1997 to 2003. He is the author, with Ben Raines, of "Heart of a Patriot: How I Found the Courage to Survive Vietnam, Walter Reed and Karl Rove."

Friday, November 6, 2009

Texting as a Health Tool for Teenagers -

Gina (not her real name) had been born with a defect in her liver, with ducts so damaged and narrow that the bile could not drain. In the first year of her life, she underwent two urgent operations. The first was an unsuccessful effort to convert a loop of intestine into a drainage system for her bile; the second was a lifesaving liver transplant.

Other than a single episode of rejection a few months later, Gina's new liver worked perfectly. Her visits to the hospital were limited to an annual clinic visit; as the years passed, she became a stunning example of pediatric transplantation's success.

Then Gina turned 14. Like other young patients I had cared for, she began having problems with her transplant as soon as she hit adolescence. She missed appointments, forgot to get her blood drawn and had sharp fluctuations in the blood levels of her immunosuppressive medications, a sign that she was not consistently taking her drugs. Her liver function tests began to deteriorate, and despite efforts by her doctors, nurses, social workers and family members, shortly before her 16th birthday, she would be in desperate need of a new liver.

I remember visiting Gina one afternoon, then speaking to her longtime liver doctor. "It's such a pity," the doctor said, shaking her head. "She's no different than every other teenager, except that her youthful indiscretions are a matter of life or death."

Nonadherence, or the failure to follow medical advice, is the most important cause of organ rejection in long-term transplant survivors. Indeed, it is a leading reason for poor outcomes in all chronic medical conditions. But teenagers are at particularly high risk. Studies have shown that more than half of all teenage liver transplant recipients are nonadherent, and they are four times more likely than adult patients to take their medications at the wrong time or to forget to take them.

For years, health care professionals in transplantation and other medical fields have struggled to address adolescent nonadherence, with little success. Many of the interventions proposed to help this age group have been cumbersome at best and awkward and potentially demeaning at worst. One potential solution, for example, has a clinician first identifying teenage patients who have been nonadherent, then increasing the frequency of their clinic visits and lecturing them about the importance of taking medications.

It is not hard to see why a teenager might not respond.

I recently thought about Gina and patients like her when a friend recounted a night out at the movies with his own teenage children. While he and his wife sobbed, his children sat in the theater unmoved. "They were doing this," my friend said, folding his hands in his lap and flapping his thumbs wildly while looking up and down between an imaginary movie screen and an invisible qwerty keyboard. "I started thinking I should text them the next time I want to get their attention."

My friend, it turns out, was on to something.

This past month in the journal Pediatrics, researchers at Mount Sinai Hospital in New York published the results of a study showing that text messaging could significantly improve the rate of adherence among young liver transplant patients. Using a program called CareSpeak, the researchers issued text messages to a group of 41 pediatric liver transplant patients. The text messages reminded the patients to take their medications, which ranged from one to three different pills once or twice a day.

Over the course of a year, investigators found that with text messaging, patients were more likely to take their medications than they had been before. Moreover, while 12 of the young people experienced rejection episodes in the previous year, only two did so during the study.

"Nonadherence can be a vicious circle, and it is difficult to penetrate this specific age group," said Dr. Tamir Miloh, assistant professor of pediatrics and surgery at Mount Sinai Hospital in New York and the lead author of the study. "Once the cycle starts, these children have to take many more toxic immunosuppressants, and that makes adherence even more difficult.

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Thursday, November 5, 2009

Costs Surge for Medical Devices, but Benefits Are Opaque -

When makers of heart defibrillators wanted Medicare to vastly expand the types of patients eligible to receive the devices, which can cost upward of $25,000, agency officials were skeptical. It was not clear how many of those patients would actually need a defibrillator, a device that can deliver a life-saving shock to restore a faltering heart to normal rhythm.

So government and industry struck a deal back in 2004. Medicare agreed to expand the device's use, nearly doubling the number of patients who qualified for one. The companies, in return, agreed to pay for a study to see which patients really benefited.

Five years later, Medicare underwrites more than half of the $4 billion the nation now spends annually on defibrillators, but the agency is no closer to knowing how many lives that big investment is saving. That is because the device companies did not finance the study beyond their initial $4 million commitment, and Medicare did not pick up the slack. As a result, researchers still cannot gather data that would identify the types of patients who would most benefit from a defibrillator.

And so, doctors keep implanting costly defibrillators in patients who may not benefit from them. And doctors and patients have no way of knowing whether one producer's model performs better than a competitor's.

The picture is no clearer for the many other types of medical devices that taxpayers, through government-run programs like Medicare, underwrite. Every year, for instance, doctors give patients tens of thousands of artificial hips and knees, without having the data to indicate how long they will last or which ones work best, and Medicare picks up the bills.

As Congress seeks to revamp the nation's health care system, medical devices might seem an inviting target to better control Medicare spending. Outlays on implanted devices stand at about $76 billion annually in this country and are rising at a rate faster than the cost of drugs, according to a recent study by the McKinsey Global Institute, a consulting group. With an aging population in America, Medicare is picking up more of those costs.

But legislation pending in the House and Senate may not help, some experts say, because the proposals do not require device makers to compete on the same ground as other manufacturers — product performance and price.

Medical devices pose unique challenges for lawmakers. Medicare does not set or negotiate prices for the implants. Instead, it pays a flat rate to a hospital for procedures to give a patient a defibrillator or a hip, leaving it up to the hospital to negotiate the price of the device with the maker — a negotiation in which hospitals may have little leverage.

Unlike other hospital products, implants are so-called physician preference items, meaning that doctors — not the hospitals — often choose which manufacturer's implant to use. It is a decision that can be skewed by a doctor's relationship to a company and can also undercut a hospital's ability to negotiate the best price, experts say.

Medicare's laissez-faire approach has big implications for taxpayers because every year, spending on device-related procedures soars ever higher.

"This is a dysfunctional market if you take the perspective of the consumer or public programs like Medicare," said Jeffrey C. Lerner, the president and chief executive of the ECRI Institute, a nonprofit organization in Plymouth Meeting, Pa., that evaluates medical devices for clients that include hospitals.

No one questions that implants like defibrillators and artificial hips extend and improve lives. But profit margins on medical devices are also among the highest for any medical products — over 20 percent, in the case of a defibrillator or an artificial hip, according to analysts.

In an effort to slow federal spending, the bill passed by the Senate Finance Committee would require the device industry to pay the government $4 billion a year for five years, with the portions allocated among individual companies based on their market shares. But device makers, including the ones that initially financed the defibrillator study — Medtronic, Boston Scientific and St. Jude Medical — have fiercely resisted the provision, calling it an unfair "tax" that will stifle innovation and cause job losses.

The companies have the support of some elected officials from the device makers' home states, including Al Franken, the freshman Democratic senator of Minnesota, where Medtronic, the nation's biggest device producer, and St. Jude Medical and some other device companies are based.

Although a political compromise over the issue is expected, the type of revenue claw-back contained in the Finance Committee bill would do little to address the underlying scientific and economic challenges that devices pose, several experts said.

The big problems, in such experts' view, is that there is little data available to compare the benefits of competing makers' products or to determine how much buyers, like hospitals, should be paying for them, said Eugene Schneller, a business professor at Arizona State University in Tempe.

For example, even doctors acknowledge that they typically have little reason to be concerned about a device's costs when it comes to deciding which one to use. One doctor compared it to giving a car buyer a blank check and letting him choose between a Maserati or Honda.

"You are going to walk out of a dealership with a really nice car, if you don't have to pay," said William Maisel, a cardiologist at Beth Israel Deaconess Medical Center in Boston.

However, unlike a car buyer, who can see a vast array of comparative information about competing products, a cardiologist or an orthopedic surgeon has little if any comparative data when choosing a device.

Also, many doctors are unlikely to shop around, because they tend to stick with a single producer — either because they have been trained on a particular maker's devices or because they have financial ties to the company.

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Wednesday, November 4, 2009

Quandary With Mammograms - Get a Screening, or Just Skip It? -

Here we go again. Another study raises questions about the benefits of mammograms, and another set of confusing statements issue forth from experts.

Last month, Dr. Otis Brawley, the American Cancer Society's chief medical officer, told The New York Times that the medical profession had exaggerated the benefits of cancer screening, and that if a woman refused mammography, "I would not think badly of her, but I would like her to get it."

Then, the cancer society issued a statement saying women over 40 should keep having mammograms every year, because seven studies have shown that the test decreases the risk of death from breast cancer.

But the statement also said mammography can "miss cancers that need treatment, and in some cases finds disease that does not need treatment." In other words, the test may lead to some women being treated, and being exposed to serious side effects, for cancers that would not have killed them. Some researchers estimate that as many as one-third of cancers picked up by screening would not be fatal even if left untreated. But right now, nobody knows which ones.

So what are women supposed to do?

Mammograms are no fun, to put it mildly. Like many women, I have been putting up with them in hopes that, if I get cancer, they might find it early enough to save my life and maybe help me avoid extensive surgery and chemotherapy. Have I been kidding myself?

Hoping to make sense of it all, I consulted several experts. All said mammograms were still important — after all, breast cancer kills 40,000 women a year in this country — but they differed about who really needed them and how often. All agreed that research was badly needed to figure out how to tell dangerous tumors from the so-called indolent ones.

One of the experts was Dr. Laura J. Esserman, a breast surgeon from the University of California, San Francisco, and author of the Oct. 21 report in The Journal of the American Medical Association that touched off the latest debate about mammography. Dr. Esserman described breast cancers as slow, medium or fast in growth rate and aggressiveness, and said screening seemed to be good at finding the slow ones, which probably didn't need treatment, but might not catch the aggressive and deadly types before they began to spread. But it also picks up the medium ones, and those are the women who may benefit most. Again, more research is needed to figure out which kind of tumor a patient has.

"The first thing to talk about is who's helped and who's not," Dr. Esserman said. In her view, women over 70 or 75 can stop being screened, because no studies have shown that it helps them. If they do develop breast cancer, she said, it is likely to be a slow-growing type that will not kill them.

Like many other researchers, she said that, despite the cancer society's guidelines, evidence was also lacking for a benefit in screening women from 40 to 50 — unless they have a strong family history of breast cancer or a mutation in a gene called BRCA, which greatly increases the risk.

For women 50 to 70, Dr. Esserman said, the story is different. In that age range, there is good evidence that screening can reduce the risk of death from breast cancer by 20 percent to 30 percent.

Also, she said, women should try to get a sense of their own risk, and if it is high, talk to a doctor about taking tamoxifen or raloxifene, drugs that can lower the risk.

One risk factor is having dense breast tissue, which is a double threat: cancer is more likely and harder to detect, because X-rays do not penetrate this tissue as well as they pass through fat. The only way to find out whether you have dense breasts is with a mammogram, and the radiologist's report should mention density, Dr. Esserman said. Patients may have to request the full report.

Other risk factors include taking hormones to treat menopause symptoms; having a history of biopsies, no pregnancies before 30, or a mother or sister with breast cancer; and aging.

A risk calculator for breast cancer, used by the National Cancer Institute, provides a score based on the answers to seven quick questions. But it's only an estimate, and Dr. Susan Love, a breast surgeon and researcher in Santa Monica, Calif., cautions that the calculator is not so good at predicting individual risk. As for screening, Dr. Love praised Dr. Brawley and Dr. Esserman for questioning the status quo.

"Boy, everybody was afraid to go there, like it was the third rail," she said, adding: "I really don't think we should be routinely screening women under 50. There's no data showing it works."

Younger women, she said, are less likely to have cancer, and they tend to have dense breast tissue, so mammograms are more likely to miss tumors. For them, she said, "it's radiation without much benefit."

Dr. Love noted that not all medical groups agreed with the cancer society's guidelines. Some recommend no screening for women under 50 or over 70, and some advise mammograms only every other year. In European countries that screen every other year, she said, the breast cancer death rates are no higher than in the United States.

She added that women from ages 50 to 70 should find out whether they have dense breasts, and those who do not could probably get by with less frequent mammograms.

But some researchers say that the benefits of yearly screening far outweigh the risks, and that if women skip it, gains against breast cancer — death rates have declined in recent years — could be undone.

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Monday, November 2, 2009

Suddenly, What Ails Them Is What Medical Marijuana Is Good For -

Like other states, Colorado is trying to figure out how to deal with the United States Department of Justice's announcement last week that users and providers of medical marijuana will not be prosecuted when they are in compliance with state law. Here in Colorado, local officials say that a big concern is a surge in new users of the drug, which Colorado's top health official, James B. Martin, called "an abuse of the system."

In recent months, he said, thousands of young men in their early 20's have applied to doctors and, by complaining of severe or chronic pain, received cards to put in their wallets that allow them to legally buy high-quality marijuana. Marijuana is an itemized category of treatment for those symptoms under an amendment to the Colorado Constitution passed by voters in 2000.

"It is exceedingly unlikely that there's an epidemic of chronic pain among young male adults," said Mr. Martin, the executive director the Colorado Department of Health and the Environment, which administers the state's system for medical marijuana.

Figures from the department also show that issuing medical marijuana cards has become something of a medical specialty. Based on figures through mid-August, nearly three-fourths of the 10,003 marijuana permits issued in the state had come from just 15 doctors. One doctor alone was responsible for about one-quarter of the total.

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A Virtual Voyage Through the Brain of a Mouse -

Mouse brain enthusiasts can finally relax. They have a place of their very own to hang out, swap stories and share information.

Researchers from the University of California, San Diego, have released something they're calling the Whole Brain Catalog. At its core, the catalog is meant to serve as a repository for data gathered about the mouse brain. Scientists around the globe can opt to pop their brain studies into the catalog and help create a richer, shared set of information than what's available at each individual research institution.

Mark Ellisman, a neurosciences and bioengineering professor at U.C.S.D., likens the project to Google Earth. He said scientists were trying to build a 3-D model of the mouse brain that could be explored at various levels, from the overall structure of the brain down to its most intricate features. Such an effort requires the scientists to harness an immense amount of data.

"If you talk about just looking at the wiring in the brain, that would require the equivalent resolution in Google Earth of being able to read the license plates on all of the cars in North America," Mr. Ellisman said. "Seeing things that give the wiring their life like drug receptors and channels would be like seeing the bugs on all the windshields of the cars."

Individual labs can gather data on this scale, but the U.C.S.D. researchers wanted a place to combine all the available information and make it open to scientists around the globe. The project has been financed by the Waitt Family Foundation, a philanthropic organization started by Ted Waitt, the co-founder of Gateway.

Scientists who want to tap into the Whole Brain Catalog can download a software application that does, in fact, behave much like Google Earth. It allows researchers to explore images of different regions of the brain and to burrow down into cellular structures. If Ammon's Horn is what you're after, just type the phrase into the search bar, and off you go.

Mr. Ellisman says he hopes that the Whole Brain Catalog will help unite researchers working in very specific areas and give them a more complete picture of the interplay between different parts of the brain.

"This gives you an immediate ability to see the domains that you are not so familiar with," Mr. Ellisman said. "Someone working on the region of the brain that controls fear can see where the structures sit on multiple scales and where they interact with the rest of the components."

The researchers at U.S.C.D. settled on the mouse brain for this project for a handful of reasons. First, scientists generally run a wide range of experiments on mice brains in a bid to replicate human disorders. And second, the mouse brain was of a reasonable size to study from a data standpoint. In addition, an agreement already in place in 15 countries has set standards for how data about mice is taken and shared.

Scientists have turned more and more to computer models like the Whole Brain Catalog to complement their lab experiments.

Mr. Ellisman said that just looking at the 3-D models generated by the computers and simulations of things like neuron growth could lead to unexpected revelations about the brain.

"I think humans are very visual animals," he said. "And these visualizations open up an opportunity to do what we call discovery science. You put yourself in a new space that came from many, many experiments being mashed together."

Sunday, November 1, 2009

Chronicle of a Death We Can’t Accept -

At a funeral directors' convention recently, I wandered around an exhibition floor crowded with the usual accouterments of the trade — coffins, catafalques, cemetery tents, cremation furnaces and the like. Scattered among these traditional goods were also many new baubles and gewgaws of the funeral business — coffins emblazoned with sports logos; cremation urns in the shape of bowling pins, golf bags and motorcycle gas tanks; "virtual cemeteries" with video clips and eerie recorded messages from the dead; pendants, bracelets, lamps and table sculptures into which ashes of the deceased can be swirled and molded.

It is hard to know what to make of this wild blossoming of unconventional mortuary merchandise. Perhaps it is the creative expression of a society grown weary of the extravagant hearse-and-limousine funerals of the past and ready to experiment with less costly and more personal ways to memorialize the dead. Some funeral directors seem to think so and are responding like dazed Blockbuster managers outmaneuvered in a Netflix age, scrambling to stay afloat in the wake of new technology and cultural improvisation.

But there is another, more accurate way to understand current funeral fashions. They illustrate the sad truth that, as a society, Americans are no longer sure what to do with our dead.

Rituals of death rest on the basic need, recognized by all societies, to remove the bodies of the dead from among the living. A corpse must be taken fairly quickly from here, the place of death, to somewhere else. But no healthy society has ever treated this as a perfunctory task, a matter of mere disposal. Indeed, from the beginning, humans have used poetry, song and prayer to describe the journey of the dead from "here" to "there" in symbolic, even sacred, terms. The dead are not simply being carted to the pit, the fire or the river; they are traveling toward the next world or the Mystery or the Great Beyond or heaven or the communion of the saints.

And we are accompanying them the last mile of the way. Every generation re-imagines these images of what lies beyond this life, but what persists is the conviction that the dead are not refuse to be discarded; they are human treasures traveling somewhere and it is our holy responsibility to go with them all the way to the place of farewell.

Thus, funerals often involve processionals, sometimes simple, sometimes elaborate, a form of community theater in which we enact publicly the journey from here to there, thereby enabling both the dead and the living to process the reality and meaning of mortality. Historically, funerals have not simply been quiet times of reflection in secluded chapels but often have included noisy parades winding through the streets.

When the Rev. Dr. Martin Luther King Jr.'s body was borne on a mule-drawn sharecropper's cart through the thronged streets of Atlanta, the Rev. Ralph David Abernathy wisely and symbolically wore scuffed marching boots under his pulpit robe. "A good funeral," says Thomas Lynch, a poet and undertaker in Milford, Mich., "is one that gets the dead where they need to go and the living where they need to be."

Today, however, our death rituals have become downsized, inwardly directed, static and, as a result, spiritually and culturally impoverished. We tend now to recognize our dead only for their partial passions and whims. They were Mets fans, good for laughs at the office, pleasant companions on the links. At upbeat, open-mike "celebrations of life," former coaches, neighbors and relatives amuse us with stories and naïvely declare that the dead, who are usually nowhere to be seen and have nowhere to go, will nevertheless live always in our memories. Funerals, which once made confident public pilgrimage through town to the graveyard, now tread lightly across the tiny tableau of our psyches.

Even those mourners who, by will or habit, wish to take their dead to the place of departure often find their way blocked. Some cemeteries, fearing liability lawsuits from falls and the like, no longer allow funeral processions to go the distance to the open grave but encourage the mourners to leave the coffin in a faux sanctuary at the entrance. And many American crematories, unlike their European counterparts, are not designed to allow mourners to accompany the body all the way to the fire. Instead the dead must be dropped off, like a night deposit at the bank.

We hardly complain, though. For the first time in history, the actual presence of the dead at their own funerals has become optional, even undesirable, lest the body break the illusion of a cloudless celebration, spoil the meditative mood and reveal the truths about grief, life and death that our thinned-out ceremonies cannot bear.

A corpse is a stark reminder that human beings are inescapably embodied creatures, and that a life is the sum of what has been performed and spoken by the body — a mixture of promises made and broken, deeds done and undone, joys evoked and pain inflicted. When we lift the heavy weight of the coffin and carry the dead over the tile floor of the crematory or across the muddy cemetery to the open grave, we bear public witness that this was a person with a whole and embodied life, one that, even in its ambiguity and brokenness, mattered and had substance. To carry the dead all the way to the place of farewell also acknowledges the reality that they are leaving us now, that they eventually will depart even from our frail communal memory as they travel on to whatever lies beyond.

"Show me the manner in which a nation cares for its dead, and I will measure with mathematical exactness the tender mercies of its people," William Gladstone, the British statesman, is said to have observed. Indeed, we will be healthier as a society when we do not need to pretend that the dead have been transformed into beautiful memory pictures, Facebook pages or costume jewelry, but can instead honor them by carrying their bodies with sad but reverent hope to the place of farewell. People who have learned how to care tenderly for the bodies of the dead are almost surely people who also know how to show mercy to the bodies of the living.