Friday, December 31, 2010

The Daily Nightly - 'Diagnosing dialysis': An investigative report

Why is the government withholding data on clinics that perform dialysis treatments? NBC News teamed with the investigative group ProPublica. Below are links related to the report.
The Dialysis Facility Tracker (
A site is for dialysis patients and others who want to learn about the quality of care at individual dialysis clinics. Among other things, you can learn how often patients treated at a facility have been hospitalized, report certain types of infections or are placed on the transplant list.
National Kidney Foundation

The Doctor vs. the Computer -

Electronic medical records promise efficiency, safety and productivity in the switch from paper to computer. But there are glitches, as a patient of mine recently brought to light.

My patient needs prostate surgery. It is my job, as his internist, to estimate the risks this surgery poses, decide whether he can proceed with the surgery and make recommendations for his medical management before and after the operation.

He is an extremely complicated patient. His hypertension requires three concurrent medications. He's taking pills for diabetes, but he really should be giving himself insulin injections. His kidneys are wending their way toward dialysis. A few years ago he had a reaction to a diabetes medication that caused congestive heart failure. His aortic valve is narrowed — not severely, but enough to keep me on edge.

Estimating my patient's surgical risk and planning for his operative care is not a straightforward process. After our physical exam, I sit down to write a detailed evaluation, because I want the surgeons and anesthesiologists to fully understand the complexity of his situation.

As I type away, I feel like I'm doing the right thing, explicating my clinical reasoning rather than just plugging numbers into a formula. I'm midway into a sentence about kidney function when the computer abruptly halts.

I panic for a moment, fearful that the computer has frozen and that I've lost all my work — something that happens all too frequently. But I soon realize that this is not the case. Instead, I've come up against a word limit.

It turns out that in our electronic medical record system there is a 1,000-character maximum in the "assessment" field. While I've been typing, the character number has been counting backward from 1,000, and now I've hit zero. The computer will not permit me to say anything more about my patient.

I go back and remove excess articles: the, a, an. Then I try to gain a few characters by using abbreviations: DM for diabetes mellitus, CRF for chronic renal failure. Still, I am over the limit.

A new trick dawns on me. Maybe if I cut back on my descriptions of the clinical problems I've already assessed, then I can gain enough characters for his cardiac status and operative assessment.

I nip and tuck my descriptions of his diabetes, his hypertension, his aortic valve stenosis, trying to placate the demands of our nit-picky computer system. Nevertheless, I am still unable to fit a complete assessment into the box.

In desperation, I call the help desk and voice my concerns. "Well, we can't have the doctors rambling on forever," the tech replies.

I want to retort with something snarky, like I hope that his next critical illness clocks in at less than 1,000 characters, but I hold my tongue. Instead I focus on eliminating verbs and prepositions, wondering just how skeletal my text can become.

As I do this, I think about the current push for all doctors to convert to electronic medical records. I don't deny that it is much easier finding information online than running around the hospital hunting for a chart stuck in the dermatology clinic.

But there are huge trade-offs. Nobody, for example, leafs through a chart anymore, strolling back in time to see what has happened to the patient over many years. In the computer, all visits look the same from the outside, so it is impossible to tell which were thorough visits with extensive evaluation and which were only brief visits for medication refills. In practice, most doctors end up opening only the last two or three visits; everything before that is effectively consigned to the electronic dust heap.

Most importantly, the electronic medical record affects how we think. The system encourages fragmented documentation, with different aspects of a patient's condition secreted in unconnected fields, so it's much harder to keep a global synthesis of the patient in mind.

Now I've learned that file-size restrictions will limit the extent and depth of analysis. What will happen to the tradition of thorough clinical reasoning?

I've finally condensed my patient's complicated medical conditions to exactly 1,000 characters. I quickly hit "save" before I lose everything. I wish him good luck on his operation, wondering if his surgeons will have to condense the entire operative report to 1,000 characters as well. What happens if there are complications?

For my next medical evaluation, I think I will use haiku.

Thursday, December 30, 2010

BBC News - Nearly one in five UK citizens 'to survive beyond 100'

The Department for Work and Pensions (DWP) said its figures suggested 10 million people - 17% of the population - would become centenarians.

These are based on Office for National Statistics population projections and life expectancy estimates.

Pensions Minister Steve Webb said the "staggering" figures brought home the need for pension reforms.

"Many millions of us will be spending around a third of our lives or more in retirement in the future," he said, adding that the government was determined to reform the pensions system to make it "sustainable for the long term".

The DWP estimates there will be at least 507,000 people aged 100 or over by 2066, including 7,700 people aged 110 or over - so-called super-centenarians.

Currently 11,800 people in the UK are aged 100 or over and fewer than 100 are over 110.

'New phase'
The government figures suggest that of the more than 10m who will go on to reach 100, 3m are currently aged under 16, 5.5m are aged between 16 and 50, and 1.3m are aged between 51 and 65.

About 875,000 are already aged over 65, it says.

The fear is that longer life spans will put an intolerable pressure on the pensions system and the NHS.

Dr Ros Altman, director general of the Saga Group, said pensions were not the only aspect of older life that needed to considered.

"Saving more and having a good pension is one thing - but there are also opportunities, and should be, for us to keep working longer, but not necessarily full time," she said.

"There is, in my view, a whole new phase of life which has been out there for grabs which still is available to us where we're not working full time. You're not suddenly stopping when you're in your 60s just because you've reached a particular chronological age.

"But you're thinking 'OK, what's my next career going to be?' - which is going to be part-time, let's say three days a week, four or five days a week off. But still earning some money, because at the end of the day, the state pension is not going to give you a decent lifestyle."

Wednesday, December 29, 2010

The Radiation Boom — Stereotactic Radiosurgery Overdoses Harm Patients -

The initial accident report offered few details, except to say that an unidentified hospital had administered radiation overdoses to three patients during identical medical procedures.

It was not until many months later that the full import of what had happened in the hospital last year began to surface in urgent nationwide warnings, which advised doctors to be extra vigilant when using a particular device that delivers high-intensity, pinpoint radiation to vulnerable parts of the body.

Marci Faber was one of the three patients. She had gone to Evanston Hospital in Illinois seeking treatment for pain emanating from a nerve deep inside her head. Today, she is in a nursing home, nearly comatose, unable to speak, eat or walk, leaving her husband to care for their three young daughters.

Two other patients were overdosed before the hospital realized that the device, a linear accelerator, had inexplicably allowed radiation to spill outside a heavy metal cone attachment that was supposed to channel the beam to a specific spot in the brain. One month later, the same accident happened at another hospital.

The treatment Ms. Faber received, stereotactic radiosurgery, or SRS, is one of the fastest-growing radiation therapies, a technological innovation designed to target tiny tumors and other anomalies affecting the brain or spinal cord, while minimizing damage to surrounding tissue.

Because the radiation is so concentrated and intense, accuracy is especially important. Yet, according to records and interviews, the SRS unit at Evanston lacked certain safety features, including those that might have prevented radiation from leaking outside the cone.

The mistakes in Evanston involve linear accelerators — commonly used for standard radiation therapy — that were redesigned by the manufacturer, Varian Medical Systems, so they could also perform SRS. As the devices became more versatile and complex, problems arose when vital electronic components could not communicate with one another.

In the last five years, SRS systems made by Varian and its frequent German partner, Brainlab, have figured in scores of errors and overdoses, The New York Times has found. Some mistakes were caused by operator error. In Missouri, for example, 76 patients were overradiated because a medical physicist did not realize that the smaller radiation beam used in radiosurgery had to be calibrated differently than the larger beam used for more traditional radiation therapy.

Medical physicists say there is nothing inherently wrong with linear accelerators that deliver general radiation therapy, as well as SRS. And, they say, the overdoses might have been caught had users followed a more rigorous system of checks and double-checks.

"Tens of thousands of patients have been treated with protocols properly followed and no mistakes were made," said Dr. Frank J. Bova, a medical physicist in Gainesville, Fla., and a pioneer in developing and enhancing the accuracy of SRS. "It has changed many difficult procedures, ones with high surgical risk, into one-day outpatient procedures."

But radiation safety experts say the retrofitted devices made up of different companies' products present a special challenge.

More ...

Better health care at the click of a mouse - The Globe and Mail

For Canada's economy to remain competitive, we need a health care system that takes good care of our aging population without creating a crushing financial burden for individuals and corporations.

To help achieve this, Canada's doctors need to adopt the slogan once used by Home Depot: "You can do it, we can help." When it comes to looking after our health, we must learn to rely less on our doctors and more on our own resources, otherwise we're going to bankrupt the system. Soon.

A recent Commonwealth Fund report ranked Canada dead last in the prevention and management of chronic disease. So it is no surprise that in the past 10 years health care spending in Canada has more than doubled, to $192-billion from $95-billion. Virtually all this increase is due to the treatment of Canadians living with chronic, but often preventable illnesses such as cardiovascular disease, diabetes, depression and arthritis.

Despite the advancements of modern medicine, our basic approach to health care has remained unchanged for centuries. It assumes that physicians are smart and patients aren't. Doctors wait in their office or hospital for sick people to come to them, then tell them what to do. Traditionally, patients have been passive and ill-informed, playing little or no role in deciding their own treatment. As one physician puts it: "Today's health care institutions are like the old media: centralized, one-way, immutable and controlled by the people who created and delivered it. Patients are passive recipients."

Now, courtesy of the Internet, there are tools that allow us to take more responsibility for our own health. All of us, including newborns, should have our own online Personal Health Page. Just as Facebook keeps you updated on your friends' activities, your Health Page would keep you up to date on issues affecting your health. You could have links to organizations such as Weight Watchers or a local diabetes support group. You could create a community or join medical "causes." And low-cost or free applications could help you measure your own health, prediagnose a sick child or test for possible drug interactions.

By moving the heart of our health care system online, and making each of us more informed and involved in our health, we would get a lot more bang for our health care buck. Knowing what's happening in your body motivates you to change your behaviour. If you weigh yourself daily, for instance, you'll be more successful at shedding pounds and keeping them off than if you weigh in weekly.

When we are better informed about our health, we make fewer trips to the emergency department, we don't make unnecessary doctors' appointments and we require fewer costly home-nurse visits.

Some early examples of this kind of thinking can already be seen online. Users of, a popular online health community, are able to track more than 1,500 symptoms and treatments on a daily basis using iPhone apps that cover both general health conditions, such as weight loss and allergies, and very specific disorders, such as infertility and diabetes. If they want, patients can share this information on a continuing basis with their doctors or caregivers.

Dr. Michael Evans of Toronto's St. Michaels Hospital says doctors should do more to encourage patients to take advantage of the resources available in online health care communities. Dr. Evans cites, a vibrant health care community whose members – 60,000 and growing – suffer from debilitating chronic conditions such as ALS, Parkinson's and bipolar disorder. Members use the site to track the evolution and management of their diseases. But rather than keep all their data private, many members share it with the patient community and the medical research community.

This openness ultimately benefits everyone. Patients can learn what's working and, in consultation with their doctors, adjust their own treatment plans. Drug companies can use anonymous patient data to evaluate new treatments and thus bring them to market more quickly. "People think we are a social networking site," says PatientsLikeMe co-founder Ben Heywood. "But we're an open medical framework. This is a large-scale research project."

Of course, without the buy-in of the biggest players – namely provincial governments and doctors – we won't be able to maximize these opportunities and more people will get needlessly sick. Harness these new capabilities, on the other hand, and the medical establishment can join with patients and other stakeholders in making the health care system work for everyone.

Tuesday, December 28, 2010

Prescription Drug Use in Children and Teens -

Gage Martindale, who is 8 years old, has been taking a blood-pressure drug since he was a toddler. "I want to be healthy, and I don't want things in my heart to go wrong," he says.

And, of course, his mom is always there to check Gage's blood pressure regularly with a home monitor, and to make sure the second-grader doesn't skip a dose of his once-a-day enalapril.

These days, the medicine cabinet is truly a family affair. More than a quarter of U.S. kids and teens are taking a medication on a chronic basis, according to Medco Health Solutions Inc., the biggest U.S. pharmacy-benefit manager with around 65 million members. Nearly 7% are on two or more such drugs, based on the company's database figures for 2009.

Doctors and parents warn that prescribing medications to children can be problematic. There is limited research available about many drugs' effects in kids. And health-care providers and families need to be vigilant to assess the medicines' impact, both intended and not. Although the effects of some medications, like cholesterol-lowering statins, have been extensively researched in adults, the consequences of using such drugs for the bulk of a patient's lifespan are little understood.

Many medications kids take on a regular basis are well known, including treatments for asthma and attention-deficit hyperactivity disorder.

But children and teens are also taking a wide variety of other medications once considered only to be for adults, from statins to diabetes pills and sleep drugs, according to figures provided to The Wall Street Journal by IMS Health, a research firm. Prescriptions for antihypertensives in people age 19 and younger could hit 5.5 million this year if the trend though September continues, according to IMS. That would be up 17% from 2007, the earliest year available.

Researchers attribute the wide usage in part to doctors and parents becoming more aware of drugs as an option for kids. Unhealthy diets and lack of exercise among children, which lead to too much weight gain and obesity, also fuel the use of some treatments, such as those for hypertension. And some conditions are likely caught and treated earlier as screening and diagnosis efforts improve.

Gage, who isn't overweight, has been on hypertension drugs since he had surgery to fix a heart defect as a toddler, says his mother, Stefanie Martindale, a Conway, Ark., marketing-company manager.

Most medications that could be prescribed to children on a chronic basis haven't been tested specifically in kids, says Danny Benjamin, a Duke University pediatrics professor. And older drugs rarely get examined, since pharmaceutical firms have little incentive to test medicines once they are no longer under patent protection.

Still, a growing number of studies have been done under a Food and Drug Administration program that rewards drug companies for testing medications in children. In more than a third of these studies, there have been surprising side effects, or results that suggested a smaller or larger dose was needed than had been expected, Dr. Benjamin says. Those findings underscore that children's reactions to medicines can be very different than those of adults. Long-term effects of drugs in kids are almost never known, since pediatric studies, like those in adults, tend to be relatively short.

More ...

Seeking the Connectome, a Mental Map, Slice by Slice -

Dr. Lichtman and his team of researchers at Harvard have built some unusual contraptions that carve off slivers of mouse brains as part of a quest to understand how the mind works. Their goal is to run slice after minuscule slice under a powerful electron microscope, develop detailed pictures of the brain's complex wiring and then stitch the images back together. In short, they want to build a full map of the mind.

The field, at a very nascent stage, is called connectomics, and the neuroscientists pursuing it compare their work to early efforts in genetics. What they are doing, these scientists say, is akin to trying to crack the human genome — only this time around, they want to find how memories, personality traits and skills are stored.

They want to find a connectome, or the mental makeup of a person.

"You are born with your genes, and they don't change afterward," said H. Sebastian Seung, a professor of computational neuroscience at the Massachusetts Institute of Technology who is working on the computer side of connectomics. "The connectome is a product of your genes and your experiences. It's where nature meets nurture."

The task is arduous and years from fruition, and even the biggest zealots acknowledge that their work may not pay off. But connectomics has gotten some meaningful financing: In September, theNational Institutes of Health handed out $40 million in grants to researchers at Harvard, Washington University in St. Louis, the University of Minnesota and the University of California, Los Angeles, to pursue connectomics. Together, their research efforts comprise the Human Connectome Project.

Since the 1970s, researchers have only had one connectome to play with — that of a worm with a measly 300 neurons. Now they are trying a mouse brain, with its 100 million neurons. So far the notion of creating a human-scale connectome — which would illuminate all of the connections among more than 100 billion neurons and unravel the millions of miles of wires in the brain — has proved too daunting.

The task at hand is somewhat similar to trying to untangle a bowl of spaghetti. Each individual spaghetti strand may touch tens of other strands as it weaves in a contorted fashion through the bowl. In this case, the researchers want to do the equivalent of seeing where all the strands connect at the atom level.

And because the brain's wiring is so densely packed, building a connectome stands as one of the most formidable data collection efforts ever concocted. About one petabyte of computer memory will be needed to store the images needed to form a picture of a one-millimeter cube of mouse brain, the scientists say. By comparison, it takes Facebook about one petabyte of data storage space to hold 40 billion photos.

"The world is not yet ready for the million-petabyte data set the human brain would be," Dr. Lichtman said. "But it will be."

Neuroscientists say that a connectome could give them myriad insights about the brain's function and prove particularly useful in the exploration of mental illness. For the first time, researchers and doctors might be able to determine how someone was wired — quite literally — and compare that picture with "regular" brains. Surgeons armed with a connectome might also be able to make more calculated cuts in the brain.

"The connectome project is going to show where all the white matter — all the connecting fibers — are," said Stanley Klein, a professor of optometry and vision science at the University of California, Berkeley. "The whole goal in something like a surgery for epilepsy is to delicately slice out some of the white matter without removing any cortex."

Dr. Klein says he has "zero question" that this type of surgery could benefit from developing a connectome.

Other scientists doubt that the results will match the effort. The comparisons to the genome prove haunting, and critics suggest that the connectome fans are wasting valuable research dollars and setting themselves up for a huge letdown.

"There are people that argue we still just don't know enough about the brain to know where to look for insights," said Bradley Voytek, a researcher at the Helen Wills Neuroscience Institute at the University of California, Berkeley. "They also contend that there is no possible way you can build a full connectome in any realistic time frame."

What's more, even if the researchers succeed, they will only produce a static picture of a brain frozen in time, rather than something that shows how a brain responds to different types of stimuli.

Scientists around the world, including Stephen J. Smith, a neuroscience professor at Stanford, and Gerald M. Rubin, a researcher with the Howard Hughes Medical Institute, have pushed past the naysayers and developed varying techniques for mapping the brains and nervous systems of human as well as other creatures.

"There are some people who say, 'Maybe you don't need this information, and given the expense of it, maybe you should put it off,' " said Dr. Lichtman, a professor of molecular and cellular biology at Harvard. "It's a fair controversy."

More ...

The Decline Effect and the Scientific Method : The New Yorker

On September 18, 2007, a few dozen neuroscientists, psychiatrists, and drug-company executives gathered in a hotel conference room in Brussels to hear some startling news. It had to do with a class of drugs known as atypical or second-generation antipsychotics, which came on the market in the early nineties. The drugs, sold under brand names such as Abilify, Seroquel, and Zyprexa, had been tested on schizophrenics in several large clinical trials, all of which had demonstrated a dramatic decrease in the subjects' psychiatric symptoms. As a result, second-generation antipsychotics had become one of the fastest-growing and most profitable pharmaceutical classes. By 2001, Eli Lilly's Zyprexa was generating more revenue than Prozac. It remains the company's top-selling drug.

But the data presented at the Brussels meeting made it clear that something strange was happening: the therapeutic power of the drugs appeared to be steadily waning. A recent study showed an effect that was less than half of that documented in the first trials, in the early nineteen-nineties. Many researchers began to argue that the expensive pharmaceuticals weren't any better than first-generation antipsychotics, which have been in use since the fifties. "In fact, sometimes they now look even worse," John Davis, a professor of psychiatry at the University of Illinois at Chicago, told me.

Before the effectiveness of a drug can be confirmed, it must be tested and tested again. Different scientists in different labs need to repeat the protocols and publish their results. The test of replicability, as it's known, is the foundation of modern research. Replicability is how the community enforces itself. It's a safeguard for the creep of subjectivity. Most of the time, scientists know what results they want, and that can influence the results they get. The premise of replicability is that the scientific community can correct for these flaws.

But now all sorts of well-established, multiply confirmed findings have started to look increasingly uncertain. It's as if our facts were losing their truth: claims that have been enshrined in textbooks are suddenly unprovable. This phenomenon doesn't yet have an official name, but it's occurring across a wide range of fields, from psychology to ecology. In the field of medicine, the phenomenon seems extremely widespread, affecting not only antipsychotics but also therapies ranging from cardiac stents to Vitamin E and antidepressants: Davis has a forthcoming analysis demonstrating that the efficacy of antidepressants has gone down as much as threefold in recent decades.

For many scientists, the effect is especially troubling because of what it exposes about the scientific process. If replication is what separates the rigor of science from the squishiness of pseudoscience, where do we put all these rigorously validated findings that can no longer be proved? Which results should we believe? Francis Bacon, the early-modern philosopher and pioneer of the scientific method, once declared that experiments were essential, because they allowed us to "put nature to the question." But it appears that nature often gives us different answers.

More ...

Monday, December 27, 2010

Prominent Toronto doctor lauds provincial narcotics strategy -

Rick Glazier has seen the toll that narcotics abuse takes on two fronts – in his medical practice and in his own family.

His 18-year-old son Daniel, who struggled with depression and anxiety, died from an accidental overdose of the highly addictive painkiller OxyContin last year.

In the face of stigma and shame associated with addictions, the prominent Toronto doctor is making his family's story public in hopes it will help see new provincial plans aimed at combatting narcotic abuse through to fruition.

Glazier sat in the public gallery at Queen's Park on Wednesday as Health Minister Deb Matthews introduced new legislation to create a registry to track the prescribing of narcotics and controlled substances in Ontario.

"What Dr. Glazier has experienced first-hand is happening to families province-wide. The facts are staggering," Matthews said, noting that since 2004 the number of oxycodone-related deaths in the province has nearly doubled, as have narcotic-abuse related admissions to treatment and addiction services

Daniel was 14 when Glazier and his wife learned the teen was struggling with mental health problems and taking drugs like marijuana and ecstasy to self-medicate. Within a year, the teen's drug use became more indiscriminate and he was taking anything he could in an effort to feel normal.

Glazier's medical credentials are many, but even he couldn't find local treatment resources for his son. The doctor is a senior scientist at the Institute for Clinical Evaluative Sciences, core scientist at the Centre for Research on Inner City Health at St. Michael's Hospital, a family physician and a professor of family medicine at the University of Toronto.

Because of a severe shortage of treatment beds for young people struggling with both mental health problems and addictions, Glazier sent Daniel to a residential treatment facility in Utah. The teen stayed there for two years, finally returning home clean in 2008. He enrolled in George Brown College and appeared to have turned over a new leaf.

But on July 24, 2009, about a year after Daniel's return, Glazier and his wife were eating lunch at a roadside chip wagon during a drip up north to Algonquin Park when his pager went off. It was the police, calling to say Daniel had been found unresponsive that morning at the Toronto youth residential facility where he had been staying.

It was later learned Daniel had relapsed two weeks earlier and was buying OxyContin and Percocet off the streets. Toxicology tests found he had died from oxycodone toxicity. He had seen his psychiatrist and therapist the day before and showed no signs of being suicidal.

Like many addicts, Daniel hid his symptoms well. And like many young people, he felt invulnerable to the dangers of drugs.

"You couldn't have any idea of how much guilt and how much angst has been involved," Glazier said, his voice choking with emotion.

In the time since Daniel's death, Glazier heard that a panel of experts had been commissioned by the province to make recommendations on a narcotics strategy. He got in touch and asked if he could help. He was in turn asked if he'd be willing to have Daniel's story made public to raise awareness of the issue.

He sat down with his wife and two daughters and they made a decision collectively: "The main purpose (of the strategy) is to prevent these kinds of deaths and this kind of suffering and we felt we had to do what we could to support it, even if it meant being in an emotional and difficult place."

The legislation, if implemented, would lead to the creation of a registry that would issue an alert when someone tries to get the same drugs from different doctors or fills multiple prescriptions at different pharmacies. It would also identify doctors and pharmacists who are prescribing or dispensing too many drugs, ultimately making fewer drugs available on the streets.

The new narcotics strategy is also aimed at educating the health-care sector about appropriate prescribing and dispensing, and there are plans to increase addiction treatment resources.

Glazier's insights into the issue are also informed by his work. Addicts often walk into his Sherbourne St. practice asking for painkillers. He and his colleagues have a policy of not prescribing such drugs during a patient's first visit to discourage the practice of doctor-shopping.

Some say the province's strategy is long overdue. Ontario has the highest rate of narcotics use in Canada, but five other provinces have done more to monitor usage. As well, 41 American states have already enacted legislation to monitor prescription drugs.

Back in 2000, Richmond Hill mother Penny Long lobbied the province to create such a monitoring registry a year after her daughter died of an accidental overdose. Karly, 29, had bipolar disorder and in the week before she died went to emergency departments, walk-in clinics and doctors' offices and managed to obtain hundreds of drugs, including painkillers.

"She was double-doctoring and stockpiling because she was terrified she would run out. She was addicted and no one was helping her . . . ," Long said.

Long said she is pleased the province is finally creating a registry, but wonders how many lives could have been saved had it been done earlier.

"It's a wonderful step forward, but why did it have to take 10 years?"

Sunday, December 26, 2010

Bioethics Discussion Blog - Dr. Maurice Bernstein

What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior? Write about them here.. and I will too!

Those readers of Knol may recognize me as the moderator of the Bioethics Discussion Blog which is now starting its 5th year. On the blog, I set the topics and await for my visitors to write their comments on the ethical issues described. Since I don't want to bias or direct my visitor's responses, I usually do not regularly express my own views on the topic. I thought it would be worthwhile using the format of Knol to let the readers set the topic and if I find that I have enough experience or knowledge to contribute to the topic, I would try. My experience is that of 50 years of medical practice and over 20 years of teaching first and second year medical students and participating in hospital clinical ethics committees.

My MRI Experience - Jerry DeNuccio - Open Salon

Yesterday morning I had an MRI, an experience that, were I a Calvinist, would have convinced me of that faith's two fundamental propositions: that I had, in some way unknown to me but blindingly apparent to omniscient Providence, sinned grievously; and that no affliction is unaccompanied by the catalyzing grace needed to overcome it.

My appointment was scheduled for 6:45 a.m. Now, an MRI before breakfast, before, even, I've managed to shake off the burrs of sleep and insert the day's coffee IV, strikes me as a squalid defilement of all that is human. Why so early? I live in a rural community and the nearest hospital is located in the county seat some 15 miles up the road. The county hospital does not have an MRI scanner, but a truck bearing one comes every other Tuesday, and on this particular Tuesday it was beginning its rounds at my county's hospital. I arrived at 6:30, knowing that when I reported to the reception desk I'd be spending approximately 15 minutes answering the same questions I've answered on previous visits, filling out the same forms I've filled out on previous visits, and signing various documents confirming that I've been told this or shown that—all of which I've done on previous visits. I then took a seat in the waiting room and picked up a stray copy of Midwest Living, just to scan, for I expected to be MRIed at any moment.

At 7:15, the hospital's lab technician asked me to follow him to the lab so he could draw some blood to test for something or other. "Wait a minute," I said, "I've been to my doctor's office twice in the past week and both times she drew blood. And one hour after the last visit, I got a phone call from her nurse telling me they hadn't drawn enough. So, I had more drawn just yesterday at the local clinic. I'm getting a little tired of being poked, penetrated, and tapped. I feel like a toothpicked cocktail frank in a medical buffet." Truth be told, I'm no High Nooned Gary Cooper when it comes to needles. Perhaps I suffer from aichmophobia, the fear of sharp, pointed objects. No doubt, I am an exuberant sulker; as Voltaire observed, I take "pleasure in complaining" and "delight in viewing only evil." But, he checked his records and, sure enough, he had the blood the test required. Next, he began reading a series of questions, all of which, I quickly saw, had to do with surgeries that would have implanted some ferric object inside me—screws, stents, pumps, and the like. After the 5thquestion, I said, "Look, let's save ourselves some time. Other than a tonsillectomy when I was 3 years old, I have never had surgery of any kind." He was, however, a man indentured to the fierce banality of a process for which he was merely a carrier, not the creator. He continued asking, dutifully checking the "no" boxes, and had me sign a form saying I'd been asked the questions. Then back to the waiting room and Midwest Living, which I now began to read.

In the middle of an article about a corporate executive who had fled his Manhattan suite for small town Iowa living and designer bird-house building, I was called for my MRI. It was 8:05. "You know," I told the two attendants who walked me to the truck, "I was told my appointment was at 6:45, and I'm not a little pissed off that I've had to wait an hour and twenty minutes. Now, I know these things happen, and it's probably not your fault, but, damn, an hour and twenty minutes!" "Oh, I'm sorry," one of the attendants said; "it seems a miscommunication occurred between your doctor's office and the MRI scheduler." A "miscommunication occurred." Such a convenient use of the passive voice; how cleverly it obscures assigning anyone fault, how sly its practiced use in hemming the ragged edge of a patient's anger. Well, I was having none of it. I'm not an English teacher for nothing. "That may well be the case," I said, "but, you know, I'm not in the mood to be Strother Martined." They looked perplexed. "You know, the actor who played the warden in Cool Hand Luke? His tag line is, `What we got he-ah is a failure to communicate." They hadn't seen the movie.

The MRI itself, believe it or not, was a warm Pacific slipstream in the thin, cold current of my wintery discontent. Stretched comfortably on the table, covered in two blankets, head padded in place, the on-call bulb firmly grasped in my right hand, I was gingerly slid into the center of the machine—birth in reverse, a return to the womb. Sure, instead of the soothing beat of the maternal heart, I heard only the cacophonous clang of jackhammer staccato and the stiletto chir of dial-tone buzz, but I tried to imagine it as the atonal music of a John Cage or Arnold Shoenberg. Imagination, however, deals with the essence behind reality, and when that ear-assaulting clangor proved impossible to get behind, I resorted to a strategy I have used intermittently in the past in similar situations: a recurrent fantasy involving Salma Hayek and cellophane—a fantasy so potent that, with five minutes to go in the procedure, it got me through being slid out for yet another poking and penetrating, this one with some strange brew to "provide contrast." Fantasy does not genuflect to the imperial demands of reality. Fantasy is dissociation from reality. I've always been good at dissociating.

And then, finally, I am released from the magnetic womb, rebirthed, released into a world where breakfast and a Mr. Coffee machine await. "Good job, Jerry," one of the attendants said, "we've got clear images." This, of course, was the verbal equivalent of a lollipop, my "good job" being only my capacious talent for lying still. Little did they know the role Salma played in that stillness. I did worry briefly that the images I had conjured might, somehow, leave a residue, a resonance, in those magnetically-generated images of my brain, and that, if they did, they had the potential for being WikiLeaked. That could prove embarrassing. Is the mind in the brain? Detached immaterially from it? Well, that's a cirque du soleil of debates, best left to the experts. I shrugged it off as a kind of wrestling beneath my weight class.

It is reported that French novelist Honore de Balzac carried a cane upon which was written, "I smash all obstacles." Upon hearing that, Franz Kafka declared his cane should read, "All obstacles smash me." Were it not for Salma, the efflorescent Salma, the luminescent Salma, the Salma who redeemed my MRI experience with the magnetic resonance of fantasy, I would have exited that MRI scanner truck, halt and hobbled, leaning heavily on Kafka's cane.

Saturday, December 25, 2010

Choosing pathology gives two doctors unique learning opportunity with Cuyahoga County Coroner's Office |

CLEVELAND, Ohio -- Dr. Elizabeth Douglas orbited the cool, stiff body on its steel gurney, and examined the 42-year-old man's fleshy canvas of faded tattoos like an art aficionado in a gallery.

She committed each to her notes in painstaking detail and debated whether to use the word "cowboy" or "bandit" to characterize the dull, smudgy image of a horseman midgallop.

But that would be the last time the doctor would let herself consider who the man on the gurney once was -- at least for the next two hours, while Douglas ferreted out a cause of death among his organs and entrails.

Douglas and her counterpart Dr. Jimmie K. Smith, in their fourth month of a yearlong fellowship with Cuyahoga County Coroner Frank Miller's office, have learned that surviving in the world of forensic pathology means cauterizing the heart strings -- acknowledging the sentimental details of each case and moving on to the biology beneath, the science and mechanics of death.

Douglas and Smith, both 32, are among the less than 4 percent of medical school graduates who choose this grim specialty, according to industry research.

The doctors turned down fields such as anesthesiology, pediatrics and internal or family medicine to devote their talents to diagnosing the dead and serving, as Douglas describes it, as the primary care physician for the bereaved.

The coroner's office, which serves 16 counties and conducts as many as 3,000 case investigations a year with 1,200 to 1,500 autopsies, so far has proved to be worthy training grounds for the green doctors.

Already each has performed nearly 100 autopsies at the coroner's office near University Circle in Cleveland --- about twice as many as in the four years they spent as general pathology residents at major hospitals.

And the fellows have worked on some of the region's highest-profile cases.

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The Strange Happiness of the Emergency Medic - Esquire

There is your life before the truck, and there is your life after the truck. An apprenticeship with paramedics shows what it really means to have a bad day.

My first body came on my first shift. It was a Friday night, dark and cold, the wind whipping across the empty fields. We were at a rollover on a country road. Someone had drifted too far into the snow on the shoulder and gone into a ditch. There had been two occupants, but somehow they were fine, not a scratch on them. On the way back to the ambulance — here in Ottawa, the paramedics call them trucks — we stopped to look inside their car, which was still on its roof. There were two barbells that had banged around in there and settled on the ceiling. We were ducking our ears into our coats and talking about how lucky the people were not to get brained when the radio squawked.

Serving a region with a population of just over one million, the Ottawa Paramedic Service answered more than 103,000 calls last year. The calls come over the radio in bunches. In my first five minutes inside the truck, there were calls for a woman having a seizure in a grocery store, an eight-week-old boy choking, a homeless man found unconscious in an alley, an elderly man with difficulty breathing, a possible heart attack in a chicken restaurant. If you just sat inside that truck listening to the radio, you'd believe the world was falling apart. It's madness. But even in the midst of all that screaming and chaos, there are calls that stand out. A Code 4 is a life-threatening emergency, lights and sirens. A Code 4 VSA — vital signs absent — is lights and sirens and a little bit more. This call was a VSA, a woman stretched out in the darkness to our west. Darryl and I jumped into the truck and bucked it.

Darryl Wilton was my mentor and partner. He's thirty-six, tall with a shaved head. If you could request a particular paramedic when you dialed 911, you would ask for him. He's been in the truck for twelve years, and he has seen a lot of things. As part of my training, he showed me published and unpublished media photographs from some recent calls to make sure I had the stomach for the work. He didn't want to have to treat me, too. ("The barrel-over-the-falls effect," he called the bilious uprush that rookies suffer.) There was the motorcycle wreck in which a husband and wife were launched across an intersection like crash-test dummies. There was the poor bastard who had been pulled into a printing press by his right arm. That's when I was introduced to the term "degloving." The guy had lost every shred of skin from his fingertips to his shoulder. His arm looked like an illustration in an anatomy textbook, a collection of red muscle and white flashes of bone and ligament.

I understood there would be my life before I spent time in the truck and my life after. We raced through the night, and I tried to prepare myself. Darryl prepared, too, but in a different way. He switched his brain into its most methodical gear. It was almost as though he were treating patients in advance of seeing them. "Time is tissue," he said. With every minute that passes before treatment, more body parts that should be pink turn white or blue, and white or blue equals death. As we listened to updates on the radio, he'd ask me what I thought about what was coming, and he would gently guide me toward the likely reality. Code 4's that came in just after snowstorms were often heart attacks — someone goes out to shovel and his heart can't handle the exertion. VSAs early in the morning were often unworkable, because chances were that the victim had died in the night, hours before he was discovered. Then the Code 4 would become a Code 5. "There's clinically dead, which we can work with," Darryl said. "And there's obviously dead, which we can't."

We knew this woman was elderly and laid out in her garage. It was a little after 7:00 p.m., which gave us a few possibilities. It had been snowing pretty hard, so maybe she had a shovel in her hands. (Paramedic calls follow the seasons: Summer sees an increase in trauma; winter brings a spike in medical calls.) Or maybe she fell on a patch of ice and hit her head. Darryl worried that she might have gone down sometime in the afternoon and not been found until someone returned home from work. We both reached into the box between us and pulled out blue nitrile gloves.

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Friday, December 24, 2010

Meet the Ethical Placebo: A Story that Heals | NeuroTribes

A provocative new study called "Placebos Without Deception," published on PLoS One today, threatens to make humble sugar pills something they've rarely had a chance to be in the history of medicine: a respectable, ethically sound treatment for disease that has been vetted in controlled trials.

The word placebo is ancientcoming to us from the Latin for "I shall please."As far back as the 14th Century, the term already had connotations of fakery, sleaze, and deception. For well-to-do Catholic families in Geoffrey Chaucer's day, the custom at funerals was to offer a feast to the congregation after the mourners sang the Office for the Dead (which contains the phrase placebo Domino in regione vivorum, "I shall please the Lord in the land of the living"). The unintended effect of this largesse was to inspire distant relatives and former acquaintances of the departed to crawl out of the woodwork, weeping copiously while praising the deceased, then hastening to the buffet. By the time Chaucer wrote his Canterbury Tales, these macabre freeloaders had been christened "placebo singers."

In modern medicine, placebos are associated with another form of deception — a kind that has long been thought essential for conducting randomized clinical trials of new drugs, the statistical rock upon which the global pharmaceutical industry was built. One group of volunteers in an RCT gets the novel medication; another group (the "control" group) gets pills or capsules that look identical to the allegedly active drug, but contain only an inert substance like milk sugar. These faux drugs are called placebos.

Inevitably, the health of some people in both groups improves, while the health of others grows worse. Symptoms of illness fluctuate for all sorts of reasons, including regression to the mean. Since the goal of an RCT, from Big Pharma's perspective, is to demonstrate the effectiveness of a new drug, the return to robust health of a volunteer in the control group is considered a statistical distraction. If too many people in the trial get better after downing sugar pills, the real drug will look worse by comparison — sometimes fatally so for the purpose of earning approval from the Food and Drug Adminstration.

For a complex and somewhat mysterious set of reasons, it is becoming increasingly difficult for experimental drugs to prove their superiority to sugar pills in RCTs, which was the subject of an in-depth article I published inWired called "The Placebo Problem," recipient of this year's Kavli/AAAS Science Journalism of the Year award for a magazine feature.

Only in recent years, however, has it become obvious that the abatement of symptoms in control-group volunteers — the so-called placebo effect — is worthy of study outside the context of drug trials, and is in fact profoundly good news to anyone but investors in Pfizer, Roche, and GlaxoSmithKline. The emerging field of placebo research has revealed that the body's repertoire of resilience contains a powerful self-healing network that can help reduce pain and inflammation, lower the production of stress chemicals like cortisol, and even tame high blood pressure and the tremors of Parkinson's disease.

Jumpstarting this network requires nothing more or less than a belief that one is receiving effective treatment — in the form of a pill, a capsule, talk therapy, injection, IV, or acupuncture needle. The activation of this self-healing network is what we really mean when we talk about the placebo effect. Though inert in themselves, placebos act as passwords between the domain of the mind and the domain of the body, enabling the expectation of healing to be translated into cascades of neurotransmitters and altered patterns of brain activity that engender health.

That's all well and good, but what does it mean in the real world of people getting sick? You can hardly expect the American Medical Association to issue a wink and a nod to doctors, encouraging them to prescribe sugar pills for seriously disabling conditions like chronic depression and Parkinson's disease. Meanwhile, more and more studies each year — by researchers like Fabrizio Benedetti at the University of Turin, author of a superb new book called The Patient's Brain, and neuroscientist Tor Wager at the University of Colorado — demonstrate that the placebo effect might be potentially useful in treating a wide range of ills. Then why aren't doctors supposed to use it?

The medical establishment's ethical problem with placebo treatment boils down to the notion that for fake drugs to be effective, doctors must lie to their patients. It has been widely assumed that if a patient discovers that he or she is taking a placebo, the mind/body password will no longer unlock the network, and the magic pills will cease to do their job.

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Thursday, December 23, 2010

Google Adds the Human Body to Its Search Functions -

On Dec. 16, Google released the first version of its Body Browser, a simulation of the human body. Users can travel, as in the 1980s movie "Innerspace," through various layers of human anatomy, zooming in on internal organs, navigating around bones and peeling back layers of the human body until all that's left are the stringy tangles of the nervous system.

The Body Browser works only in browsers that support WebGL, a new 3-D graphics tool that is appearing in the latest versions of popular browsers like Chrome 9 Beta from Google and Firefox 4 Beta. With WebGL, users do not need plug-ins like Flash or Java — the browser itself can handle complex graphics tasks.

The Body Browser is still a work in progress. Presently, only a female figure is available, and some of the controls are a bit balky. But the ability to zoom straight into a body and fly through it is remarkable — not to mention addictive.