Saturday, August 14, 2010

Pharmacists Take Larger Role on Health Team -

Eloise Gelinas depends on a personal health coach.

At Barney’s Pharmacy, her local drugstore in Augusta, Ga., the pharmacist outlines all her medications, teaching her what times of day to take the drugs that will help control her diabetes.

Ms. Gelinas, a retired nurse, also attends classes at the store once a month on how to manage her disease with drugs, diet and exercise. Since she started working with the Barney’s pharmacists, she boasts that her blood sugar, bad cholesterol and blood pressure have all decreased. “It’s my home away from home,” she says.

While some of the services being offered to Ms. Gelinas resemble those found in an old-fashioned neighborhood drugstore, others reflect the expanding role of the nation’s pharmacists in ways that may benefit their customers and also represent a new source of revenue for the profession. Some health plans are even paying pharmacists to monitor patients taking regular medications for chronic illnesses like diabetes or heart disease.

“We are not just going to dispense your drugs,” said David Pope, a pharmacist at Barney’s. “We are going to partner with you to improve your health as well.”

At independent drugstores and some national chains like Walgreens and the Medicine Shoppe and even supermarkets like Kroger, pharmacists work with doctors and nurses to care for people with long-term illnesses.

They are being enlisted by some health insurers and large employers to address one of the fundamental problems in health care: as many as half of the nation’s patients do not take their medications as prescribed, costing nearly $300 billion a year in emergency room visits, hospital stays and other medical expenditures, by some estimates.

The pharmacists represent the front line of detecting prescription overlap or dangerous interaction between drugs and for recommending cheaper options to expensive medicines. This evolving use of pharmacists also holds promise as a buffer against an anticipated shortage of primary care doctors.

“We’re going to need to get creative,” said Dr. Andrew Halpert, senior medical director for Blue Shield of California, which has just begun a pilot program with pharmacists at Raley’s, a local grocery store chain, to help some diabetic patients in Northern California insured through the California Public Employees’ Retirement System.

Like other health plans, Blue Shield views pharmacists as having the education, expertise, free time and plain-spoken approach to talk to patients at length about what medicines they are taking and to keep close tabs on their well-being. The pharmacists “could do as well and better than a physician” for less money, Dr. Halpert said.

Some health insurers and large employers already pay for programs called medication therapy management, which typically involve face-to-face sessions between pharmacists and patients in retail stores or clinics. Pharmacists can be paid to track patients, monitoring cholesterol or blood glucose levels, for example, or prodding customers to change their diets or exercise. UnitedHealth Group has recently started working with pharmacists and health coaches at the Y.M.C.A. to counsel diabetic patients.

The idea of using pharmacists in this way began to gain popularity in 2006 when some Medicare plans started covering medication therapy management programs, paying $1 to $2 a minute to pharmacists to review patients’ medicines with them; this year, about one in four people covered by Medicare Part D prescription drug plans will be eligible, according to agency estimates. For example, a Medicare Part D plan covered Ms. Gelinas’s medication management session at Barney’s pharmacy.

More employers and insurers also pay for pharmacists to advise patients, a role that the new health care law encourages with potential grants for such programs. In Wisconsin, for example, community pharmacists and some health plans have banded together to create a joint program, the Wisconsin Pharmacy Quality Collaborative, to standardize medication therapy management and ensure quality care.

Meanwhile Humana, which first paid for pharmacists to work with Medicare patients, expanded its coverage a few years ago. About a third of the 62,000 pharmacies in its network offer these services, and the insurer says it is studying whether a pharmacist seeing a patient in person has more impact than a phone call.

The advent of these services has spawned a new industry of medication therapy management companies to run clinical pharmacy programs for health insurers, contracting with pharmacists and tracking the financial and health outcomes of their services. One such company, Mirixa, founded in 2006 by the National Community Pharmacists Association, does business with more than 40,000 pharmacies nationwide. Pharmacists and others see these joint efforts as vital to remain competitive with mail-order pharmacies.

More ...

Chronic pain can be 'paralyzing' for women -

The sensation began in Melanie Thernstrom's neck the same day she went for a long swim. It flowed down through her right shoulder to her hand, as if she had a blistering sunburn underneath her skin.

Thernstrom, 32 at the time, had a couple of doctor's appointments about it, but went along with a neurologist's suggestion that it would get better on its own.

"I felt increasingly worried, but somehow not in a way that enabled me to take further action, more in a way that paralyzed me," she said. "I think of pain like one of those sea animals that attacks you by paralyzing you first."

She's now 46, the mother of 9-month-old twins, and still dealing with the pain.

Around the world, chronic pain affects a larger proportion of women than men, said Jennifer Kelly of the Atlanta Center for Behavioral Medicine in Georgia. Doctors are finding that women have more recurrent pain and more disabilities from pain than men, she said. Kelly spoke at the convention of the American Psychological Association in San Diego, California, on Thursday.

Women's chronic pain also tends to be more intense and last longer than men's, she said. Pain-causing illnesses such as fibromyalgia, rheumatoid arthritis and irritable bowel syndrome are all more common in women than men, according to the International Association for the Study of Pain.

One possible reason that women bear this burden of pain is hormones, Kelly said. The menstrual cycle can be associated with changes in discomfort among women with chronic pain.

Pain also can have long-lasting consequences that scientists are just beginning to understand. A study in the September issue of the journal PAIN found that women who suffer menstrual cramps have significant brain structure changes compared with women who don't.. Other studies have also found abnormal brain structure changes in people with disorders such as chronic back pain and irritable bowel syndrome. Scientists do not yet know what these changes mean, or if they are reversible.

A 2008 study in the Journal of Neuroscience found that people with chronic pain have neurons firing too much in certain brain regions, which could lead to permanent damage. This may explain the repeated findings in other studies that chronic pain is linked to depression.

Women tend to focus on emotional aspects of pain, worrying about how it will affect their responsibilities, whereas men focus on the sensory aspect, Kelly said. That's why it is especially important for physicians to help women challenge their negative thoughts that make the situation worse, she said.

Thernstrom, who eventually found that she suffers from overlapping arthritic conditions, agrees that many patients with chronic pain need help changing their mind set about pain. She spent a long time feeling angry and frustrated because she was looking for a "magical cure," and despaired when interventions such as physical therapy and medications did not deliver complete, quick solutions.

"Part of what helped me was switching out the model in which I had to be pain free to be happy," Thernstrom said. "Realizing I can have some pain, just like it can be raining outside and I can be happy -- it's all a matter of what level the pain is at."

Despite men and women dealing with pain differently, doctors treat them the same for conditions such as rheumatoid arthritis, said Dr. Chaim Putterman, chief of rheumatology at Montefiore Medical Center and Albert Einstein College of Medicine in the Bronx, New York.

"We may be doing our patients a disservice by doing it that way, and perhaps there are gender-specific influences that need to be taken into account that we're not taking into account," he said.

More ...

Wednesday, August 11, 2010

IEEE Transactions on Haptics - Special Issue on Haptics in Medicine and Clinical Skill Acquisition

The clinical skills of medical professionals rely strongly on the sense of touch, combined with anatomical and diagnostic knowledge. Haptic exploratory procedures allow the expert to detect anomalies via gross and fine palpation, squeezing, and contour following. Haptic feedback is also key to medical interventions, for example when an anesthetist inserts an epidural needle, a surgeon makes an incision, a dental surgeon drills into a carious lesion, or a veterinarian sutures a wound. Yet current trends in medical technology and training methods involve less haptic feedback to clinicians and trainees. For example, minimally invasive surgery removes the direct contact between the patient and clinician that gives rise to natural haptic feedback. In addition, computer-based simulations are being used to provide objective performance evaluations and make training more efficient. The science and technology of haptics thus has great potential to affect the performance of medical procedures and learning of clinical skills. This special issue is about understanding the role of touch in medicine and clinical skill acquisition. Topics of interest include:

1. Haptic environment properties andhuman haptic perception as relevant to medical examinations and procedures: Characterization of the nature of haptic information, and how it is perceived, is necessary to understand how medical professionals use haptics to enable learning and achieve high levels of performance. Papers that explore haptic models of the patient, as well as perceptual or behavioral aspects of the haptic modality relevant to medical examinations and procedures, are solicited.

2. Haptic systems and the role of haptics in training and evaluating clinical skills: Haptic simulators address a growing need for effective training and evaluation of clinical skills. Such simulators can be applied in a wide variety of medical professions and disciplines, including surgery, interventional radiology, anaesthesiology, dentistry, veterinary medicine, and the allied health professions. These simulators rely on both technology development (devices, software, and systems) and an understanding of how humans use haptic feedback to perform established clinical skills or learn novel skills. Papers that address simulator development and/or evaluation from these perspectives are solicited.

3. Using haptics to improve the performance of medical interventions: Current trends in minimally invasive surgery (especially robot-assisted surgery) remove direct contact between the patient and the clinician. In addition, some medical interventions, such as percutaneous (e.g., needle- based) therapies, inherently provide little or confounded haptic feedback to the clinician. Bilateral teleoperators, tactile sensing/display devices, sensory substitutions systems, and other methods to enhance haptic feedback to a clinician could improve the performance of interventions. Papers that address technological approaches and their evaluation, as well as how humans use haptics (natural or with artificial haptic feedback) to accomplish medical tasks with better performance are solicited. Home Pages/TOH/PDF/cfp_toh_hmcsa.pdf

Tuesday, August 10, 2010

Night - Tony Judt (1948- 2010) - The New York Review of Books

I suffer from a motor neuron disorder, in my case a variant of amyotrophic lateral sclerosis (ALS): Lou Gehrig's disease. Motor neuron disorders are far from rare: Parkinson's disease, multiple sclerosis, and a variety of lesser diseases all come under that heading. What is distinctive about ALS—the least common of this family of neuro-muscular illnesses—is firstly that there is no loss of sensation (a mixed blessing) and secondly that there is no pain. In contrast to almost every other serious or deadly disease, one is thus left free to contemplate at leisure and in minimal discomfort the catastrophic progress of one's own deterioration.

In effect, ALS constitutes progressive imprisonment without parole. First you lose the use of a digit or two; then a limb; then and almost inevitably, all four. The muscles of the torso decline into near torpor, a practical problem from the digestive point of view but also life-threatening, in that breathing becomes at first difficult and eventually impossible without external assistance in the form of a tube-and-pump apparatus. In the more extreme variants of the disease, associated with dysfunction of the upper motor neurons (the rest of the body is driven by the so-called lower motor neurons), swallowing, speaking, and even controlling the jaw and head become impossible. I do not (yet) suffer from this aspect of the disease, or else I could not dictate this text.

By my present stage of decline, I am thus effectively quadriplegic. With extraordinary effort I can move my right hand a little and can adduct my left arm some six inches across my chest. My legs, although they will lock when upright long enough to allow a nurse to transfer me from one chair to another, cannot bear my weight and only one of them has any autonomous movement left in it. Thus when legs or arms are set in a given position, there they remain until someone moves them for me. The same is true of my torso, with the result that backache from inertia and pressure is a chronic irritation. Having no use of my arms, I cannot scratch an itch, adjust my spectacles, remove food particles from my teeth, or anything else that—as a moment's reflection will confirm—we all do dozens of times a day. To say the least, I am utterly and completely dependent upon the kindness of strangers (and anyone else).

More ...

Diagnosing Appendicitis Remains Complicated -

Let's start with "Madeline." In that classic children's story by Ludwig Bemelmans, published in 1939, the little French girl of the title is awakened in the night by severe abdominal pain, and the doctor races to get her to the operating table.

Enchanted by the book when I was Madeline's age (and later when I read it to my own children), I memorized the hospital's phone number as if I might someday need it: "And he dialed: DANton-ten-six — / 'Nurse,' he said, 'it's an appendix!' "

And then ambulance, surgery, waking up from anesthesia, 10 days in the hospital, and discharge (to the old house that was covered with vines). Oh, and a scar on her stomach.

When I was a resident, that was still the story, though hospital stays were generally shorter. Diagnosis was largely by medical history and physical exam; half a century after Madeline's experience, and a full century after appendicitiswas first described and named (in 1886, by Reginald Heber Fitz, a Harvard pathologist), there was still no way to know for sure whether a child's abdominal pain was caused by an inflamed appendix.

I remember the thrill of making the diagnosis my first time, in 1986 or '87. I saw the child in the emergency room and called the surgeons, and sure enough the child went to the operating room. The only thing was, he didn't have appendicitis; when they opened him up, they found a healthy appendix, which, of course, they removed.

But as the surgeons told us, that only showed we were all doing it right. The risk in missing acute appendicitis is that the child will "perf" — the inflamed appendix develops a perforation, and bowel contents leak into the abdominal cavity, making the surgery much more complex and dangerous.

So unless you took out a certain number of healthy appendixes (somewhere from 10 to 20 percent), you were sure to miss cases of acute appendicitis. We were taught that the ability to examine a child's abdomen was the hallmark of the good diagnostician, but we were reassured that even the best diagnosticians sometimes took a child to surgery for stomach cramps or gastroenteritis — a "negative appendectomy."

In the past decade, though, great strides have been made with imaging. At least in younger children, ultrasound can now show appendicitis clearly, or help rule it out. CT scans are even clearer, but they expose the patient to ionizing radiation that has led to recent concerns about future risks of cancer.

There have also been changes in the management of acute appendicitis. Some children with perforations no longer undergo those dramatic middle-of-the-night emergency operations.

Even so, appendicitis remains a source of diagnostic complexity. After all, young children are often unable to describe their symptoms. Steady or crampy, sharp or dull, the whole vocabulary of pain means little to a 3-year-old, who knows only that it hurts.

"The presentation in kids is a lot more ambiguous; you don't always get that classic story of migrating umbilical pain," said Dr. David G. Bundy, an assistant professor of pediatricsat Johns Hopkins and an expert on quality improvement and patient safety.

Almost 20 years after I started my residency, my own son, then 8 years old, woke in the night, crying with pain. When the doctors in the emergency room asked him to point to the spot that hurt the most, he indicated McBurney's point, on the lower right side of his abdomen, the classic site for appendicitis pain.

I was certain he would soon be in the operating room. But this was 2003, and a sophisticated scan not only showed that his appendix was normal and uninflamed, but also indicated where the pain was coming from: a piece of twisted abdominal tissue. It would get better by itself and he would be fine, the surgeon promised — and it did, and he was.

The surgeon, Dr. Craig W. Lillehei, is now an assistant professor of surgery at Harvard Medical School. I asked him how the diagnostic dilemma had changed over his career.

"One of the things we're struggling with in pediatrics is we've become too dependent on the CT scan," he said. "It's become very helpful in terms of identifying appendicitis, but it translates to radiation."

Nor has it been clearly shown that new imaging techniques reduce the overall rate of negative appendectomies in children. But doctors still worry about missing appendicitis, and the medical and legal consequences of sending a child home without doing a scan. Yet surely not every bellyache requires a CT.

More ...

Sunday, August 8, 2010

My Heart’s Long Surprise -

The scar, I was told, would be only a few inches long. After three weeks, I would feel well enough to take that trip to Madrid my family had planned. And when my surgeon, whom I adored, explained that he would just have to "stretch" my sternum to get to my heart, I never guessed that the stretching would be done with a saw, that the scar would measure 10 inches and that Spain would be out of the question.

Open-heart surgery at age 52 probably saved my life, but recovering from it was far more difficult than anyone had led me to believe. Everyone — especially those who should have known better — made it seem like a walk in the park. In the surgeon's waiting room, one guy coming back for a second round of heart surgery told me, "Don't worry. You'll be great." The last thing the social worker gave me was a white velour gym suit, as though I would be doing Pilates in days.

Instead, for months I couldn't get warm enough and shivered from a low-grade fever. My voice would go all wonky when I couldn't get a good breath. My heart made such a racket that it competed with the radio. An internal jumpiness lingered. For a long time, an alarm went off in my head when I tried to sleep: "Watch out! You don't want to do this. Remember what can happen when you lose consciousness." And more than two years later I am still missing some sensation in my little finger, where my hand was strapped to the operating table.

There has been a fair amount written about depression after open-heart surgery. There have also been studies about "pump head," a kind of cognitive impairment that may be related to being on the heart-lung machine. I don't think I had either, exactly. But it was a violent experience, one I hadn't really been prepared for, and I found myself thinking about death all the time. Once, I came home and said to my wife, "Do you know that when we die, we leave the kids forever?" "Yeah," she said. "It's tough, isn't it?" Another time I sat in a business meeting, looking around the table thinking, "Do all these people know they are going to die?"

Some of this was hard to talk about because I felt surrounded by a conspiracy of positivity. "You look great," someone would say. "Thanks, I'm feeling pretty good," I lied. A month later the same person would say, "You look so much better than you did a couple of weeks back. I thought you were a goner."

Shortly after surgery I went to a neighborhood party, and in a faltering voice I complained to one of my friends, a former nurse, about what I'd been through. "It's a tough recovery from what I understand," he admitted. "You're not going to feel well for a long time. Give it six months."

Six months? I was appalled. It had taken only a few hours for the doctors to open my chest, replace my aortic root, implant a bovine valve and stitch me up again — in essence, to save my life. But it took a full year before I felt as if I could really live that life. My heart was the least of my problems during those months; I was waiting on my mind and the rest of my body to recover.

I don't have a sure solution to offer. Get exercise. Hang out with family and friends. Read, sleep, pray. Give it time. But doctors, be realistic with your patients. Don't promise them Spain.

Trying Improv as Therapy for Those With Memory Loss -

Five of the six members of the Memory Ensemble were gathered in a nondescript conference room at Northwestern Memorial Hospital, ready to begin their weekly improvisational acting workshop.

"Where's Irv? We need Irv," one said.

"Oh, he's always late," said another. "He's very dependable that way."

At first glance, they could have been any group of energetic older Americans dipping their toes into amateur theater. But it was soon evident that this was not a social event: Ensemble members exhibited pronounced physical and verbal tics, abrupt lapses in conversation and other telltale signs of the cognitive disorders that characterizedementia and Alzheimer's disease.

A collaboration between the Feinberg School of Medicine at Northwestern University and the Lookingglass Theater Company, the Memory Ensemble is what organizers believe is a first-of-its-kind program that seeks to improve the quality of life for people dealing with the early stages of memory loss.

The seven-week pilot session is designed to give newly diagnosed participants a "safe and supportive environment where they can challenge themselves but still feel secure," said Christine Mary Dunford, an ensemble member at Lookingglass Theater.

Ms. Dunford co-founded the Memory Ensemble with Darby Morhardt, director of education and associate professor at the Cognitive Neurology and Alzheimer's Disease Center at Feinberg.

Dozens of creative programs like quilting, painting and ceramics provide patients and their caregivers opportunities to express emotions and, it is theorized, maintain cognitive function for as long as possible.

More ...

My Life in Therapy -

All those years, all that money, all that unrequited love. It began way back when I was a child, an anxiety-riddled 10-year-old who didn't want to go to school in the morning and had difficulty falling asleepat night. Even in a family like mine, where there were many siblings (six in all) and little attention paid to dispositional differences, I stood out as a neurotic specimen. And so I was sent to what would prove to be the first of many psychiatrists in the four and a half decades to follow — indeed, I could be said to be a one-person boon to the therapeutic establishment — and was initiated into the curious and slippery business of self-disclosure. I learned, that is, to construct an ongoing narrative of the self, composed of what the psychoanalyst Robert Stoller calls "microdots" ("the consciously experienced moments selected from the whole and arranged to present a point of view"), one that might have been more or less cohesive than my actual self but that at any rate was supposed to illuminate puzzling behavior and onerous symptoms — my behavior and mysymptoms.

To this day, I'm not sure that I am in possession of substantially greater self-knowledge than someone who has never been inside a therapist's office. What I do know, aside from the fact that the unconscious plays strange tricks and that the past stalks the present in ways we can't begin to imagine, is a certain language, a certain style of thinking that, in its capacity for reframing your life story, becomes — how should I put this? — addictive. Projection. Repression. Acting out. Defenses. Secondary compensation. Transference. Even in these quick-fix, medicated times, when people are more likely to look to Wellbutrin and life coaches than to the mystique-surrounded, intangible promise of psychoanalysis, these words speak to me with all the charged power of poetry, scattering light into opaque depths, interpreting that which lies beneath awareness. Whether they do so rightly or wrongly is almost beside the point.

More ...