Saturday, October 30, 2010

Health Care’s Lost Weekend - Op-Ed -

Doctors, like most people, don't love to work weekends, and they probably don't enjoy being evaluated against their peers. But their industry can no longer afford to protect them from the inevitable. Imagine a drugstore open only five days a week, or a television network that didn't measure its ratings. Improving the quality of health care and reducing its cost will require that doctors make many changes — but working weekends and consenting to quality management are two clear ones.

That's why an effort at New York University Langone Medical Center to institute both of these changes is so important. If it succeeds, it will help point the way to the health care system of the future.

First, weekends. It's never good to be hospitalized, but you really don't want to be hospitalized on a weekend. There are fewer doctors around, and people admitted on Saturdays and Sundays fare relatively poorly.

One study in 2007 found, for example, that for every 1,000 patients suffering heart attacks who were admitted to a hospital on a weekend, there were 9 to 10 more deaths than in a comparable group of patients admitted on a weekday. The weekend patients were less likely to quickly receive the invasive procedures they needed — like coronary artery bypass grafts or cardiac catheterization.

It's not just a safety issue but, for less life-threatening medical problems, also a matter of convenience. Wouldn't it be nice to be able to schedule your elective surgery on a Saturday if you wanted? Most hospitals don't offer that option.

And then there are the economics of a $750 billion-a-year industry letting its capacity sit idle a quarter or more of the time. If hospitals were in constant use, costs would fall as expensive assets like operating rooms and imaging equipment were used more fully. And if the workflow at existing hospitals was spread more evenly over the entire week, patients could more often enjoy the privacy of single-bed rooms.

N.Y.U.'s first step toward seven-day service has been to keep certain functions going all weekend, like radiology study interpretation, magnetic resonance imaging and elective cardiac surgery. The cancer center also now provides some treatments on weekends. And some procedures, like elective Caesarean sections, are offered on Saturdays. So far, the doctors involved are on board.

A second innovation is quality assessment and management. As the saying goes, if you can't measure it, you can't manage it — or improve it. That's why the federal government is now making key investments to encourage hospitals, clinics and doctors to adopt health information technology and report statistics on quality of care.

Robert Grossman, the dean and chief executive of N.Y.U. Langone, has gathered data from around the medical center into a "management dashboard." This allows him to monitor not only financial information like operating margins and cash balances but also detailed quality data on individual doctors like 30-day hospital readmission rates and the number of infections associated with invasive procedures.

The patterns he has been able to discern this way have been eye-opening. The dashboard data revealed, for instance, that on any given day a disproportionately small number of eligible patients were discharged before noon, so that many people were kept in the hospital longer than necessary. Further analysis revealed a key reason: several routine procedures that some patients need before leaving, like the insertion of central catheters, were not performed in the morning. The medical center has since begun to offer the procedures earlier, and the percentage of discharges before noon has increased significantly.

So far, so good. But will these initiatives become a permanent part of the culture? And if the strategies do survive, how much difference can they make in the cost and quality of care?

N.Y.U. has historically not stacked up that well in cost comparisons with other hospitals. The Dartmouth Atlas of Health Care, which tracks data on regional variations in Medicare costs, suggested that from 2001 to 2005 a Medicare beneficiary's care at N.Y.U. during the final two years of his life cost taxpayers more than $100,000 — roughly twice the cost at America's most efficient hospitals.

The Dartmouth data also indicate that the N.Y.U. patients received no clear benefit for the higher cost. They saw, on average, more than 14 different doctors, compared with fewer than 10 for patients at the most efficient hospitals. But the extra visits did not seem to produce better outcomes. In fact, seeing more doctors may have caused harm, as patients ran the risk of side effects and complications from additional tests, treatments and medicines.

N.Y.U. will know that its innovations in weekend operations and doctor assessment are working if, in time, they help improve the cost-effectiveness of care. If they do, it's important that any practices found effective be adopted widely. Better ways of spreading such innovations will be the focus of my next column. In health care, experimentation is the mother of improvement.

2 Brothers Await Broad Use of e-Medical Records -

There is no silver bullet for reforming America's health care system, but medical experts have long agreed that digital patient records and electronic prescribing can help improve care and curb costs.

It seems straightforward. Just combine technology skills with investment money, and then develop innovative products. But to date, the push for a digital revolution in doctors' offices has brought mostly frustration for the many companies big and small that are trying to conquer the field.

Just ask the Doerr brothers — John Doerr, the well-known venture capitalist who was an early backer of Google and Amazon, and Dr. Tom Doerr, a physician and software designer.

Dr. Doerr founded a software company in 1999, beginning with an electronic prescribing product and later adding electronic health records. His brother is the largest investor. After more than a decade, the venture has fewer than 500 doctors using its software.

The experience, Mr. Doerr said, has been "a long, slow march." And Dr. Doerr conceded, "It's been a lot harder getting to a business that is self-sustaining than I had imagined."

But the Obama administration's economic stimulus package contained an ambitious program to encourage the market for electronic health records, with billions in incentive payments to buy and use digital patient records — and eventually penalties for the failure to do so.

The Doerrs' software company is only one of many hoping to cash in on the national mandate for digital medical records. The companies range from giants like General Electric to specialists like Athenahealth that cater to small physician practices.

They, like the Doerrs, are betting that the law will help create a turning point for the economics of digital health records, opening the door to rapid adoption by doctors and a thriving business at last.

The brothers are also betting that Internet technology and Apple's iPad can make electronic records far easier to use and less expensive. Last week, they introduced a new product, Nimble, to allow doctors to manage patient information by connecting their iPads to data centers managed by the Doerrs' software company, ClearPractice.

The Doerrs' aging start-up is unusual in that it has evolved to extend its reach in health care beyond technology. The lessons it has learned along the way are a microcosm of the challenge of applying technology to health care.

To attack the problem of wayward financial incentives, the Doerrs bought a Medicare Advantage health maintenance organization, Essence Healthcare, in 2007, and shifted it toward paying doctors for helping make patients healthier. It now covers 50,000 people in six states.

They also built up a medical analytics software company, which tracks procedures and patient results for payers, enabling them to manage outcomes instead of just costs. The software also mines data to help hospitals and doctors make more informed decisions about treatments.

Their target market is doctors in small practices, with 10 physicians or less — where digital records are used least. More than 70 percent of the nation's doctors are in such small practices.

The Doerrs' three companies are part of the Essence Group, based in suburban St. Louis, not far from where brothers grew up. Dr. Doerr, 53, is co-founder and head of clinical strategy of Essence, and Mr. Doerr, 59, is the largest shareholder.

Though a small private company, Essence has attracted the attention of some experts. Intrigued, Dr. Denis A. Cortese, former chief executive of Mayo Clinic and a professor at Arizona State University, joined the Essence board two months ago. It is trying to bring to small physician practices, he said, the kind of health care championed at Mayo.

"These guys may or may not be successful, but they've got the right ideas," Dr. Cortese said.

The goal, Dr. Doerr explained, is to deliver the better care and lower costs achieved by some large health care groups without being one. Essence, he said, is trying to combine technology tools, cooperative relationships between doctors and insurers, and financial incentives to create the "virtual equivalent" of an integrated system.

The goal also, of course, is to make money. Essence, though, does not have the look of a big winner anytime soon. It has 330 employees and yearly revenue of about $450 million. But the vast majority of the revenue comes from the Medicare insurer, which is like a regulated utility with modest profits.

If the Doerrs' venture is going to become a money-spinner someday, it will come from software, a business that can grow rapidly and profitably, if successful. For its new offering, ClearPractice worked closely with Apple to develop the Nimble, a service tailored for the iPad.

Using Nimble, doctors do not need other computers in their offices, since most of the software and patient information resides on remote computers in data centers managed by ClearPractice. A doctor's iPad connects to the patient data and software wirelessly, over the Internet, as if in a computer "cloud," as this fast-growing model of computing is known.

Doctors pay a subscription fee of up to $499 a month if they choose all the ClearPractice offerings — electronic prescribing, electronic health records and billing software.

"With the right software that is cloud-based, the iPad is going to be transformational in health care," Mr. Doerr said.

The right technology, medical experts say, can potentially overcome two major hurdles to the adoption of electronic health records by doctors: cost and complexity. Those obstacles are most pronounced in the market of doctors in small practices that the Doerrs are pursuing.

More ...

Doctor drain turns to gain: Physicians move north - National Post

For years, an exodus of doctors to the United States helped fuel Canada's growing shortage of medical staff, and gave emotional ammunition to opponents of Canadian-style health-care reform in the States.

But medical recruiters and migration statistics suggest a surprising new trend has emerged over the past few years: a net movement of physicians from the United States to Canada.

The reasons they are coming are equally unexpected: pay that is reportedly much better in some specialties; more freedom in their practices; and uncertainty about the impact of health reform in the United States.

"Canada is the number one spot in the world for doctors to come and work, live and play," said John Philpott, CEO of CanAM Physician Recruiting in Halifax. "Talking to physicians in the United States, they're shocked how much more money they can make in Canada."

The flip side of the equation seems to be true as well, with fewer Canadian doctors answering the call to practice in the States, once seen as a Mecca of better remuneration and more comfortable work environments.

"I have calls from American companies on a regular basis asking me to find them Canadian doctors, and I have to say 'that ship has sailed,' " said Susan Craig of Toronto-based Susan Craig Associates, which recruits doctors for both American and Canadian employers.

"We used to place an ad and we'd be flooded with doctors. That's not the case now."

Statistics released annually by the Canadian Institute for Health Information first suggested five years ago that the number of doctors returning to Canada after departing the country for other places was greater than the number leaving, ending a net out-migration that had lasted for more than a decade.

The impression remained, however, that Canadian doctors were still flocking to the United States. During the recent debate over the U.S. health-care reform proposals, opponents frequently cited Canada's system as an example to be avoided, and pointed to the supposed exodus of doctors southward as evidence that it was broken.

More detailed CIHI statistics reveal a different picture, however. The number of doctors returning to Canada from the U.S. specifically after working here previously has exceeded those going in the opposite direction every year since 2004.

On top of that, the number of American-trained doctors who came here for the first time jumped to 52 in 2008 from a low of nine in 1995. Neither set of statistics includes doctors trained in other countries who were working in the U.S. and left for Canada recently.

HealthForce Ontario, the provincial agency that recruits doctors and other medical workers, has lured an increasing cadre of MDs from the U.S. since it launched three years ago. The number jumped to 87 last year from 10 in 2007, and has already reached 66 by this July.

Health Match BC, a similar agency, attracted 19 U.S. doctors in 2008, 20 in 2009 and expects to top 30 this year, said CEO John Mabbott.

No one suggests, though, the numbers match the flight south of Canadian physicians during the 1990s.

At that time, provincial governments, worried about escalating health costs, concluded there was a surplus of doctors. Medical school enrollments were slashed, pay caps instituted and physicians discouraged from working in "over-serviced" areas.

The result by 2006 was that 12,000 Canadian-trained doctors — more than 10% of the total — were working in the States, noted a 2007 paper in the Canadian Medical Association Journal.

The ensuing doctor shortage in Canada prompted legislators to approve higher fees, increase enrollment and take other measures to improve doctors' lot.

"The situation here has improved radically and physicians here are treated with much more respect and care than they were previously," said Ms. Craig.

Private and public-sector recruiters say they are luring American-born doctors, Canadians who had long ago moved to the States, and physicians from other countries who trained and got licensed in the U.S., only to decide to work in Canada.

Comparing physician incomes in the two countries is not easy, given the different ways doctors are paid in various jurisdictions. Undisputedly some surgical and other specialities are still much better compensated in the States.

Some recruiters, though, say family doctors, pediatricians, emergency physicians and psychiatrists can make more for similar work in Canada — as much as $50,000 to $100,000 more, according to Mr. Philpott. He said he relocated one doctor from Wisconsin to Newfoundland, doubling her income in the process.

Psychiatrists can end up "significantly ahead" in Canada, echoed Ms. Craig, noting "the whole money thing has changed." Mr. Mabbott said some physicians from the States tell him, also, that they make more in B.C.

Money is not the only draw, however.

Many U.S. physicians are also fed up with a system in which private insurance companies fund most medical care, meaning they must deal with as many as 40 different firms to get paid. One study suggested that U.S. physicians spend 140 hours and $60,000 a year dealing with insurers, said Lynn Bury, recruitment director for HealthForce Ontario.

Some also see the Canadian system as allowing them to practise more freely, unfettered by private hospitals, insurance companies and HMOs, said Ms. Bury.

Mr. Mabbott said he is worried about the impact of U.S. health-care reform, designed to provide health coverage to 40 million uninsured Americans, and potentially create a demand for thousands more physicians.

Other recruiters, though, say the reform plan Congress approved this year has so far left some doctors fretting about the future and viewing Canada as a welcome escape.

Said Mr. Philpott: "Obama's health plan is scaring the life out of all the doctors in the United States."

Personalizing the M.D. - Inside Higher Ed

A hundred years after the release of the Flexner Report, which set many of the standards that still guide North American medical education, a report being published today aims to stimulate reforms to reshape medical schools and residency programs for the next century.

Commissioned by the Carnegie Foundation for the Advancement of Teaching -- the same group that sponsoredAbraham Flexner's early-20th century examination of all 155 medical schools in the United States and Canada -- the new report lays out the case for drastic reconsideration of how North American medical education works. Published in book form as Educating Physicians: A Call for Reform of Medical School and Residency (Wiley), the study is the culmination of four years of research and site visits to medical schools and teaching hospitals. It calls for major change and innovation -- "new approaches to shaping the minds, hands and hearts of physicians."

As the U.S. health care system has changed, a need has emerged for the medical profession to "rethink how we do education all over again," said one of the report's co-authors, David M. Irby, vice dean for education and a professor of medicine at the University of California at San Francisco School of Medicine. "The report speaks to both specific and general ways in which teaching and learning can be enhanced. But our intent here is to stimulate reform and to encourage innovation and creativity, and is less about specific requirements or changes we'd like to see."

Central to the report's recommendations is a shift away from the regimentation and regulation that created the four-year Doctor of Medicine degree and two-to-four-year residency toward a more flexible model that could adapt to students' interests and learning styles. For some students, that shift might translate into shorter time to degree or a briefer residency period.

"Medical school and residency need to shift from one-size-fits-all to a much more individualized program," said Molly Cooke, another co-author and a professor of medicine at the UCSF School of Medicine. "Students bring different dispositions, talents, career interests -- and medical education ought to support that." The report's third author, Bridget C. O'Brien, is an assistant professor of medicine at UCSF and a researcher in the university's Office of Medical Education.

Individualization, Irby acknowledged, "would be a huge challenge for the accrediting, licensing and certifying agencies who find it much more reassuring to focus on the number of weeks or months of training." But, he added, "by focusing on competencies -- the milestones at each level of training -- we can ensure that physicians are capable of doing what we'd like them to be able to do."

There would still be a core of skills and knowledge that all students would need to master, Cooke said, cautioning that individualization wouldn't translate into "people can go to medical school and just learn whatever." But it would be balanced with a "flexible component" aligned with students' professional interests, whether to become a bench researcher or a community health advocate.

By shifting to competency-based assessments, medical education could become more self-paced and less tied to how much time a student spends doing any one thing.

For some students, Cooke said, that might translate into a degree that takes fewer than four years to complete. For others, it might take longer. "It ought to take as long as it takes, but eight or nine years to get a doctorate, as is the case in some Ph.D. programs, that's a step in the wrong direction."

Texas Tech University said in March that it would begin offering a three-year primary care M.D., squeezing some of the traditional third-year clinical work into the second year of study and some of the fourth-year work into the third. At the time of the announcement, Irby told Inside Higher Ed that the move was well-aligned with the report's objectives. Less time to degree, he said, "ought to be an option for every student -- regardless of specialty."

But both he and Cooke stressed that they were not calling for a drop in standards. "We'd just be changing from specified time to specified quality of performance," Cooke said. "And in no way am I comfortable saying every degree should be reduced from four years to three years."

So far, Cooke said, feedback on the report has been mixed. When presenting before professors, deans and presidents last fall at a meeting of the Association of American Medical Colleges, "people were very enthusiastic."

But the groups that sponsor the United States Medical Licensing Examination, for instance, are likely to be less enthusiastic. "The oversight of medical education is very complicated and nobody means to be doing a bad job or to be a retrogressive influence, so to the extent that we say that the content of the three USMLE exams is not particularly helpful, that frankly tends to offend those groups," Cooke said. "But if we didn't stir things up a bit and really point out where we thought there were opportunities to significantly improve this enterprise, I don't think we'd be doing what we set out to do."

Matthew Stull, a recent graduate of the University of Pittsburgh School of Medicine who has put his residency on hold for a year to work as the American Medical Student Association's education and research fellow, said that just as "the Flexner Report was such a monumental wake-up call," the new report was "likely to be a very big deal in medical education."

The curricular flexibility the report calls for, he added, "was the most innovative thing" he had identified in the report and would, he thought, be well-received by medical students.

Doctors over-prescribe, test: report - National Post

Swayed by pharmaceutical sales reps and less than fully versed on new technology, family doctors may be prescribing drugs improperly and ordering too many expensive diagnostic tests, warns a new federal-provincial report.
Governments must give such primary-care physicians the tools to make better decisions if they want to corral spiralling health-care costs, says the Health Council of Canada in a report to be released on Monday.
"Our research points to inappropriate prescribing of drugs and over-use of diagnostic imaging," says the report, Decisions Decisions. "If there is no change in how family physicians are supported in their role as gatekeeper, we can expect a surge in health service use."
The council's head stressed the group is not attacking the competency of the doctors Canadians visit most often, but issuing a "call for action" to help them better assess a barrage of new medications and technologies.
Doctors need better, independent tutoring on optimum use of medication, and more help from radiologists to determine when MRIs, CT scans and other tests are needed, the report says.
The chief organization representing family physicians, however, said the negative appraisal of their work is simply not backed up by the facts, and overlooks research that suggests people with their own family doctor have the best health outcomes.
"All physicians, and anyone who is ordering tests and prescribing drugs, can make mistakes.... It is unfair to single out family physicians," said Dr. Cal Gutkin, CEO of the College of Family Physicians of Canada. "In some ways, it is irresponsible for them to do this."
In fact, he said new practice guidelines in certain areas require family doctors do preparatory work on patients, including ordering MRIs, before the patient is referred to the specialist. In other cases, treatment guidelines drafted by specialists, some of whom are heavily funded by pharmaceutical companies, have resulted in more patients receiving particular drugs, said Dr. Gutkin.
John Abbott, the Health Council's CEO, said family doctors are gatekeepers to the system, and their decisions trigger costs all down the line, through ordering tests, referring patients to specialists and prescribing drugs.
Helping them perform better "doesn't deny service, doesn't add costs," said Mr. Abbott. "It can improve service and improve cost and improve safety."
The report notes that the number of prescriptions filled at community pharmacies has soared 80% in the last decade to 483 million in 2009, with medication the second biggest and fastest growing cost in health care, at about $25-billion yearly. Large proportions of those pills are prescribed by family doctors, it says.
Some of the growth is tied to the aging population, and new pharmaceutical discoveries, the report says.
But studies show wide variations in prescribing patterns from region to region, and questionable prescribing for certain patient groups, pointing to inappropriate decisions by some family doctors, argues the council.
It said the doctors can be "heavily influenced" by the estimated 6,000 drug-firm representatives who pitch their products across Canada, and sometimes do not follow clinical-practice guidelines. They also are inundated with a constant influx of new drugs — almost 900 in the past five years.
The report recommends family physicians adhere more closely to those guidelines and adopt electronic prescribing, and that governments fund more "academic detailing" — drug reps who give doctors impartial assessments of medication.
The council notes that provinces have invested heavily in diagnostic imaging like MRI and CT scanning in recent years but that wait lists still persist.
As family doctors play an increasing role in ordering the scans, it cites estimates from the Canadian Association of Radiologists that as many as 30% of tests are inappropriate or unhelpful.

Thursday, October 28, 2010

Health & Medicine News, Articles, and Information from Scientific American

• Aging and the Elderly
• Allergies
• Alternative Medicine
• Alzheimer's Disease
• Anxiety and Panic Disorders
• Arthritis
• Autoimmune Disorders
• Bacteria & Viruses
• Cancer
• Cholesterol
• Cloning
• Depression
• Dermatology
• Drug Resistance
• Epidemics & Pandemics
• Exercise and Fitness
• Eyesight and Eye Health
• Federal Funding
• Gene Therapy
• Genetic Engineering
• Heart Disease
• Influenza
• Malaria
• Medical Ethics
• Medical Nanotechnology
• Mental Health
• Mood Disorders
• Nanotechnology
• Neurology
• Obesity
• Pediatrics
• Reproduction
• Respiratory Medicine
• Rheumatoid Arthritis
• Science Ethics
• Sleep
• Smoking
• Sports Medicine
• Stem Cells
• Vaccines

Observations: TED MED 2010: Technology and the People - Scientific American

On day two of TED MED, running between Oct. 27 and 30, three themes stood out: the difference between children and adults for therapies; the connection between animals, people and disease; and how genetics will shape healthcare.

Frances Jensen of Harvard University and Children's Hospital Boston explained the dramatic differences between developing and adult brains. With faster synapses, teens learn faster than adults, for instance. But as a consequence, they also "get addicted faster, longer and stronger than adults do," she said. Because teens have more synaptic material to affect, they suffer greater brain damage from alcohol than in adults. Differences in developing brain mean should have "no more hand-me-down drugs" for youths, added Jensen.

Signaling receptors are also very different in epileptic children and adults. "They might as well be different species," said Jensen, who added that we need age-specific therapies for epilepsy.

Barton Kamen of the American Cancer Society spoke of the general improvements in cancer survival in the past 35 years—except for 15- to 40-year-olds. Cancer kills 12 million patients a year worldwide, a trillion dollars in cost. "For 35 years I've been taking care of kids with cancer," said Kamen. "I've trying to put myself out of business." Nearly 70,000- 15 to 40-year-olds in U.S. every year diagnosed with cancer. "We lose 20 percent of them." Late diagnosis is one problem. Another factor, Kamen says, is that only a small proportion of youths get on clinical trials, impeding progress.

Better medicine regimens can help survival rates. One strategy Kamen said has met with success is "metronomic dosing": "finding the smallest dose that works and leaving it there." More info is available at and

A couple of speakers looked at the relation between animal health and human health. Harold Schmitz, chief science officer of Mars, noted that in 1957, when Sputnik was launched, the event triggered commitment to fundamental research. Many of today's technologies descended from those investments. Agriculture, food science, veterinary science, however, were passed by, he said. If we had invested, he said, "we wouldn't have problems mentioned this morning." He gave two examples of plants and animals benefiting human health: In 2000, flavinols, in fruits, vegetables and cocoa, were found to increase nitric oxide in vasculature. And in 2009, "We developed a partnership with NIH" for human-animal bond research, says Schmitz. People with pets suffer less stress.

Peter Daszak, president of EcoHealth Alliance and a disease ecologist, described risks of disease outbreaks from areas that have stressed ecosystems as well as zoos, because of living density. Essentially, where humans and animals are "in conflict" is where disease emerges, said Daszak. This is "good news, because if we're the cause, we can stop it." One example is monitoring pets. He said the "world's scariest animal" from a pathogen perspective is the adorable sugar glider, a kind of flying squirrel. "They are so cute, we want to keep them as pets," but they come from potential pandemic hotspots. An app called Pet Watch identifies pets that are the "most healthy" for us and for the environment.

Turning to the topic of genetics and health, George Church of Harvard University and Craig Venter of the Craig J. Venter Institute described growing gene sequencing and manipulation capabilities. "Why should we synthesize or make radically new genomes?" asked Church. "I would argue for safety and productivity." Helpful genes can be built in. Also, "We're not going to be sequencing your gene once but many times," added Church, to monitor different microbial components. is currently monitoring the genomes of 16,000 volunteers.

With the recent announcement in the journal Nature of the 1,000th genome sequenced, Venter noted that "What we need is 10 million" to truly understand human variation. We also need to study the human microbiome, which influences disease. Work by Venter and others on manipulation of DNA to create synthetic genomes will help in the study and treatment of disease. "NIH has funded our group to make synthetic pieces of every flu virus that's ever existed," said Venter. That could speed flu-vaccine development from several months to several weeks or days.


TEDMED celebrates conversations that demonstrate the intersection and connections between all things medical and healthcare related: from personal health to public health, devices to design and Hollywood to the hospital. Together, this encompasses more than twenty percent of our GNP in America while touching everyone's life around the globe.

TEDMED: Walt Mossberg Calls For Focus on Consumer Medical Tech - Health Blog - WSJ

The WSJ's consumer tech columnist Walt Mossberg has some health problems, namely diabetes and heart disease, he told the TEDMED crowd last night. And he'd really like it if the same kind of innovation he writes about could help out people like him.

"As we get diseases that [can] be managed, we need to take the kind of technology that's in this," he said, holding up his Apple iPad, and "put it into the hands of consumers to maintain their health or manage disease."

After all, the gadget he uses the most, Mossberg said, doesn't even begin with "i." It's his glucose meter, which he described as "a piece of crap" based on 1977-era technology. A product developer who "showed this to Steve Jobs [would] be fired immediately," he said.

Why? It doesn't connect to smart phones or mobile devices, or even to the internet; a reading involves an invasive fingerstick, which makes many people avoid testing their blood sugar and test strips are $1 each –  another deterrent to testing.

(Last year Mossberg did review one USB-equipped glucose meter, which he said was a step in the right direction.)

He challenged the medical tech world to come up with health devices that are directed at consumers, not just clinicians. Even medical iPad and iPod apps are either aimed squarely at physicians or fall into a more broad "health and fitness" consumer category that includes golf tips and baby naming.

"There's very little I can find that speaks to health problems," he says.

Do you agree? What's your dream intelligent medical consumer device?

The Age of Alzheimer’s -

Our government is ignoring what is likely to become the single greatest threat to the health of Americans: Alzheimer's disease, an illness that is 100 percent incurable and 100 percent fatal. It attacks rich and poor, white-collar and blue, and women and men, without regard to party. A degenerative disease, it steadily robs its victims of memory, judgment and dignity, leaves them unable to care for themselves and destroys their brain and their identity — often depleting their caregivers and families both emotionally and financially.

Starting on Jan. 1, our 79-million-strong baby boom generation will be turning 65 at the rate of one every eight seconds. That means more than 10,000 people per day, or more than four million per year, for the next 19 years facing an increased risk of Alzheimer's. Although the symptoms of this disease and other forms of dementia seldom appear before middle age, the likelihood of their appearance doubles every five years after age 65. Among people over 85 (the fastest-growing segment of the American population), dementia afflicts one in two. It is estimated that 13.5 million Americans will be stricken with Alzheimer's by 2050 — up from five million today.

Just as President John F. Kennedy, in 1961, dedicated the United States to landing a man on the moon by the end of the decade, we must now set a goal of stopping Alzheimer's by 2020. We must deploy sufficient resources, scientific talent and problem-solving technologies to save our collective future.

As things stand today, for each penny the National Institutes of Health spends on Alzheimer's research, we spend more than $3.50 on caring for people with the condition. This explains why the financial cost of not conducting adequate research is so high. The United States spends $172 billion a year to care for people with Alzheimer's. By 2020 the cumulative price tag, in current dollars, will be $2 trillion, and by 2050, $20 trillion.

If we could simply postpone the onset of Alzheimer's disease by five years, a large share of nursing home beds in the United States would empty. And if we could eliminate it, as Jonas Salk wiped out polio with his vaccine, we would greatly expand the potential of all Americans to live long, healthy and productive lives — and save trillions of dollars doing it.

Experience has taught us that we cannot avoid Alzheimer's disease by having regular medical checkups, by being involved in nourishing relationships or by going to the gym or filling in crossword puzzles. Ronald Reagan suffered the ravages of this disease for a decade despite the support of his loving family, the extraordinary stimulation of his work, his access to the best medical care and his high level of physical fitness. What's needed are new medicines that attack the causes of the disease directly.

So far, only a handful of medications have been approved by the Food and Drug Administration to treat Alzheimer's, and these can only slightly and temporarily modify symptoms like forgetfulness, disorientation and confusion. None actually slows the underlying neurodegeneration.

In the mid-1980s, when our country finally made a commitment to fight AIDS, it took roughly 10 years of sustained investment (and about $10 billion) to create the antiretroviral therapies that made AIDS a manageable disease. These medicines also added $1.4 trillion to the American economy. The National Institutes of Health still spend about $3 billion a year on AIDS research, while Alzheimer's, with five times as many victims, receives a mere $469 million.

Most of the medical researchers who study Alzheimer's agree on what they have to understand in order to create effective drugs: They must find out how the aberrant proteins associated with the disease develop in the brain. They need to model the progression of the illness so they can pinpoint drug targets. And ultimately they must learn how to get drugs to move safely from the blood into the brain.

A breakthrough is possible by 2020, leading Alzheimer's scientists agree, with a well-designed and adequately financed national strategic plan. Congress has before it legislation that would raise the annual federal investment in Alzheimer's research to $2 billion, and require that the president designate an official whose sole job would be to develop and execute a strategy against Alzheimer's. If lawmakers could pass this legislation in their coming lame-duck session, they would take a serious first step toward meeting the 2020 goal.

Medical science has the capacity to relegate Alzheimer's to the list of former diseases like typhoid, polio and many childhood cancers. But unless we get to work now, any breakthrough will come too late to benefit the baby boomers. Whether the aging of America turns out to be a triumph or a tragedy will depend on our ability to fight this horrific disease and beat it before it beats us.

Sandra Day O'Connor is a retired associate justice of the Supreme Court. Stanley Prusiner, who received the 1997 Nobel Prize in Medicine, is the director of the Institute for Neurodegenerative Diseases at the University of California, San Francisco. Ken Dychtwald, a psychologist and gerontologist, is the chief executive of a company that consults with businesses about the aging world population.

Wednesday, October 27, 2010

Medical Blogs | HCPLive

HCPLive's "Blogs" sections feature a diverse selection of medical industry observers who are dedicated to providing you with content that you can relate to and resources that can help you save time. You'll find a unique blend of information that includes topics like managed care, chronic disease care, financial wisdom, and more. Perhaps just as important, you'll also find anecdotes and musings by your colleagues that you can relate to. - iPhone/iPad Medical Apps Review | Part of the HCPLive Network

iMedicalApps is an independent online medical publication written by a team of physicians and medical students who provide commentary and reviews of mobile medical technology and applications.

Breast Cancer Tales: The Inspirational vs. the Actual — Books -

Before penicillin came along, syphilis was known in medical circles as "the great mimicker," a stealthy disease able to mangle the human body in virtually all known ways. "Know syphilis and you know medicine," professors would tell their students.

Exactly the same thing might be said of breast cancer these days — but not in the same circles. Rather, it is the social scientists who get to contemplate the full panorama of human reaction to disease by studying the fallout from a single one: all the shades of anguish and anger, the posturing, the politics and the cartloads of wishful thinking, all wrapped up in a big pink ribbon.

Less than 50 years ago, breast cancer was hardly discussed in polite company. Now it is the most visible disease around, especially in October, when beribboned pink products flood the market in honor of Breast Cancer Awareness Month (now in its 25th year).

Millions suit up in pink and run or walk for the cause. Others find the display repellent: After her own breast cancer diagnosis, the social critic Barbara Ehrenreich wrote a widely applauded article for Harper's in 2001 rejecting all the pink symbolism as infantilizing and saccharine, the badge of a forced sisterhood created for purely commercial ends.

In "Pink Ribbon Blues," Gayle A. Sulik, a sociologist and an expert in women's studies, now makes similar points in a critique that is far more comprehensive than Ms. Ehrenreich's, if somewhat less engaging. Her book treads an interesting middle ground between the academic and the journalistic as she analyzes giant hunks of information and opinion, and also interviews patients to illustrate her points.

Like Ms. Ehrenreich, Ms. Sulik takes issue with the "she-ro" of the breast cancer movement — an idealized patient who is assertive and boundlessly optimistic, and remains feminine and sexy despite the depredations of disease and treatment. This paragon often uses a diagnosis of breast cancer as a catalyst for a personal transformation; she begins to "take time for me," discovers "what's important in life" and comes out of the experience a changed and better person.

The movement has turned "the shoulds and should nots of survivorship" into a tyranny, Ms. Sulik argues, leaving many women with breast cancer as depressed by their failure to be uplifted and transformed as by any other facet of the experience. "This is not the breast cancer story people want to hear," one said sadly, after telling her own.

Meanwhile, the multiplying scientific uncertainties of the disease are often at odds with the consumer movement's talking points. Mammograms early and often? In truth, mammography is a mediocre screening tool, while the best treatment for the early-stage disease it often uncovers remains extremely controversial. For all the money raised by pink projects, improvement in breast cancer survival rates has been relatively modest.

Further, the disease now constitutes such a huge profit center for so many industries that the conspiracy-minded are beginning to conclude there is an actual cabal against finding a cure.

Throughout Ms. Sulik's comprehensive summary of the giant "cancer marketplace," the names that recur are Susan G. Komen and Nancy G. Brinker, the sisters who made the pink ribbon what it is today. Shortly after Ms. Komen died of breast cancer in 1980, Ms. Brinker began a fund-raising effort that has grown into a multimillion-dollar operation, encompassing races all over the world, hundreds of corporate sponsorships and that inevitable pink ribbon.

Or, actually, two ribbons. The first, modeled on the red ribbon that denotes AIDS, remains in the public domain, but in 2007 Ms. Brinker introduced ribbon No. 2, this one copyrighted, presumably to cement her market share.

It is no surprise that this consummate strategist has herself produced a memoir of her career in the breast cancer biz. The surprise is that her book is almost impossible to put down. The woman is clearly breathtakingly good at public relations, both in deed and, with some help from a co-author, in word.

Two pretty little girls, Suzy and Nanny, live happily in 1950s Illinois with Mommy and Daddy (now in her 60s, Ms. Brinker refers to her parents in just this way). Were they really the iconic postwar American family, or is Ms. Brinker just blowing stardust in our eyes? After a while, immersed in the story, you don't really care. Suzy Komen is painted in sure, fond strokes as one of those magnetic young women who own every room they enter. At age 34 she finds a breast lump. A surgeon removes it, sews her up, assures her he "got it all." Three years later she's dead.

Ms. Brinker details every step she has taken in the intervening years to fulfill her promise to the dying Suzy to "make things better." The book wanders through personal setbacks (like her own mastectomy for early-stage cancer) and corporate triumphs (like "Pinking the Pyramids" with Egypt's first breast cancer race). She also tells the stories of many breast cancer she-ros, most of them young and very heroic.

At the end comes a scene of cinematic impact: Ms. Brinker takes Ms. Komen's two young granddaughters to tea at (where else?) the American Girl store in Manhattan, and tells Suzy's little namesake to "take care of your sister."

There isn't a dry eye in the house. This is surely how illness should read: triumphant, assertive, can-do. Ms. Sulik's complicated uncertainties are a real downer by comparison. The inspirational and the actual, the wish-it-were and the how-it-is: don't read one of these books without the other.

How "Breast Cancer Awareness" Campaigns Hurt | Center for Media and Democracy

October is Breast Cancer Awareness month. Pink ribbons abound at department stores, grocery stores, gas stations, shopping malls and many other places. But the big "awareness" push may be misplaced. After all, lung cancerkills twice as many women each year as breast cancer -- more women every year in the U.S. die from lung cancer than from breast, uterine, and ovarian cancers combined. In 2009 alone, 31,000 more women died of lung cancer than breast cancer. But there aren't any ribbons, theme-colored products, corporate promotions, colored car magnets, festivals or fundraisers to make people aware of lung cancer's devastating toll, or to support lung cancer victims or raise money for a cure.

Why not?

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Tuesday, October 26, 2010

Lies, Damned Lies, and Medical Science - Magazine - The Atlantic

In 2001, rumors were circulating in Greek hospitals that surgery residents, eager to rack up scalpel time, were falsely diagnosing hapless Albanian immigrants with appendicitis. At the University of Ioannina medical school's teaching hospital, a newly minted doctor named Athina Tatsioni was discussing the rumors with colleagues when a professor who had overheard asked her if she'd like to try to prove whether they were true—he seemed to be almost daring her. She accepted the challenge and, with the professor's and other colleagues' help, eventually produced a formal study showing that, for whatever reason, the appendices removed from patients with Albanian names in six Greek hospitals were more than three times as likely to be perfectly healthy as those removed from patients with Greek names. "It was hard to find a journal willing to publish it, but we did," recalls Tatsioni. "I also discovered that I really liked research." Good thing, because the study had actually been a sort of audition. The professor, it turned out, had been putting together a team of exceptionally brash and curious young clinicians and Ph.D.s to join him in tackling an unusual and controversial agenda.

Last spring, I sat in on one of the team's weekly meetings on the medical school's campus, which is plunked crazily across a series of sharp hills. The building in which we met, like most at the school, had the look of a barracks and was festooned with political graffiti. But the group convened in a spacious conference room that would have been at home at a Silicon Valley start-up. Sprawled around a large table were Tatsioni and eight other youngish Greek researchers and physicians who, in contrast to the pasty younger staff frequently seen in U.S. hospitals, looked like the casually glamorous cast of a television medical drama. The professor, a dapper and soft-spoken man named John Ioannidis, loosely presided.

One of the researchers, a biostatistician named Georgia Salanti, fired up a laptop and projector and started to take the group through a study she and a few colleagues were completing that asked this question: were drug companies manipulating published research to make their drugs look good? Salanti ticked off data that seemed to indicate they were, but the other team members almost immediately started interrupting. One noted that Salanti's study didn't address the fact that drug-company research wasn't measuring critically important "hard" outcomes for patients, such as survival versus death, and instead tended to measure "softer" outcomes, such as self-reported symptoms ("my chest doesn't hurt as much today"). Another pointed out that Salanti's study ignored the fact that when drug-company data seemed to show patients' health improving, the data often failed to show that the drug was responsible, or that the improvement was more than marginal.

Salanti remained poised, as if the grilling were par for the course, and gamely acknowledged that the suggestions were all good—but a single study can't prove everything, she said. Just as I was getting the sense that the data in drug studies were endlessly malleable, Ioannidis, who had mostly been listening, delivered what felt like a coup de grâce: wasn't it possible, he asked, that drug companies were carefully selecting the topics of their studies—for example, comparing their new drugs against those already known to be inferior to others on the market—so that they were ahead of the game even before the data juggling began? "Maybe sometimes it's the questions that are biased, not the answers," he said, flashing a friendly smile. Everyone nodded. Though the results of drug studies often make newspaper headlines, you have to wonder whether they prove anything at all. Indeed, given the breadth of the potential problems raised at the meeting, can any medical-research studies be trusted?

That question has been central to Ioannidis's career. He's what's known as a meta-researcher, and he's become one of the world's foremost experts on the credibility of medical research. He and his team have shown, again and again, and in many different ways, that much of what biomedical researchers conclude in published studies—conclusions that doctors keep in mind when they prescribe antibiotics or blood-pressure medication, or when they advise us to consume more fiber or less meat, or when they recommend surgery for heart disease or back pain—is misleading, exaggerated, and often flat-out wrong. He charges that as much as 90 percent of the published medical information that doctors rely on is flawed. His work has been widely accepted by the medical community; it has been published in the field's top journals, where it is heavily cited; and he is a big draw at conferences. Given this exposure, and the fact that his work broadly targets everyone else's work in medicine, as well as everything that physicians do and all the health advice we get, Ioannidis may be one of the most influential scientists alive. Yet for all his influence, he worries that the field of medical research is so pervasively flawed, and so riddled with conflicts of interest, that it might be chronically resistant to change—or even to publicly admitting that there's a problem.

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When Hormone Creams Expose Others to Risks -

Veterinarians around the country are reporting a strange phenomenon: spayed dogs and cats, even some puppies and kittens, are suddenly becoming hormonal.

In female pets, the symptoms resemble heat: swollen genitals, bloody discharge and behavioral problems. Male animals are showing up with swollen breast tissue and hair loss. Standard treatments and even repeated operations have had no effect.

Now vets have identified the culprit. The pets were all owned by women who used hormone creams on their hands, arms and legs to counter symptoms ofmenopause. Animals who licked or cuddled their owners, or rubbed up against their legs, were being inadvertently exposed to doses of hormone drugs.

These anecdotal reports, about 20 of which were first collected by theVeterinary Information Network, a news service for veterinarians, suggest that many women are not taking proper precautions when using topical hormone products — putting not only pets but also family members at risk for hormone exposure.

"The dogs are licking and rubbing the treated area and absorbing the drug, which is putting them back into heat," said Dr. Terry Clekis, a veterinarian in Bradenton, Fla. Dr. Clekis has seen about five cases of pet exposure to menopause creams, including a dog that appeared to go into heat about six months after being spayed.

Dr. Clekis feared he had left remnants of ovarian tissue behind after the spaying. So he repeated it, but found nothing. It was his wife, chatting with the pet owner, who discovered she was using a hormone cream. Once the owner took precautions against exposing her pet, the symptoms disappeared.

The Food and Drug Administration issued a warning in the summer after eight children exposed to the estrogen spray Evamist showed signs of prematurepuberty like nipple swelling and enlarged breasts. The agency also received two reports of dogs exposed to Evamist, and last year it issued another warning after eight children were exposed to topical testosterone.

Use of topical estrogen, n the form of creams, sprays and gels, has surged since a major government study linked oral menopause drugs with a higher risk of heart attacks and cancer.

Last year, doctors wrote 440,000 prescriptions for brand-name topical estrogen products alone, nearly triple the 2006 figure, according to IMS Health, a drug information service. And those numbers do not capture the estimated one million women using compounded hormone creams, which are custom-mixed by pharmacists and have been widely promoted as an alternative to commercial menopause drugs — even though the F.D.A. has said these so-called bio-identical hormones are no safer than hormones from drug companies. (The compounds' popularity surged after the former sitcom star Suzanne Somers wrote two books claiming they delivered many health benefits.)

Dr. Cynthia A. Stuenkel, an endocrinologist at the University of California, San Diego, and a former president of the North American Menopause Society, said the society was surveying its members to collect case reports of inadvertent hormone exposure to pets or children. The problem, she added, is that the doctors who prescribe the drugs typically treat older women, but the doctors who see the problems are pediatricians and veterinarians.

"We need to connect the dots between these groups so pediatricians and vets think of it early before subjecting these children and animals to extensive testing," she said. But some vets say women aren't forthcoming about the use of hormone drugs because it simply doesn't occur to them that it might be related to a pet's problem.

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Monday, October 25, 2010

When a Cancer Therapy Puts Others at Risk -

Doctors told Ann B. Maddox that she had thyroid cancer and that the cure was to swallow radioactive iodine, to kill the malignant cells. She traveled 500 miles from her home in Fayetteville, N.C., for treatment at Johns Hopkins Hospital in Baltimore.

Then began a problem: what do you do when you cannot go home and you are radioactive?

There are about 40,000 new cases of thyroid cancer a year, and most patients are treated with radiation, which makes them potentially dangerous to people around them for up to a week.

The question of where they should spend that time is drawing new concern from doctors, public health officials and regulators.

In 1997, the Nuclear Regulatory Commission dropped a requirement that such patients be quarantined in the hospital. Instead, patients can be released right after their treatment, when they are at their most radioactive.

And while most people go right home, one patient in New York boarded a bus for Atlantic City, N.J., and set off a radiation alarm in the Lincoln Tunnel. And about 5 percent of patients do what Ms. Maddox did: check into a hotel.

"There weren't many choices, really," said Ms. Maddox, who is 72. The night before her treatment, in 2003, she stayed with her daughter in Delaware, but her daughter was pregnant, and fetuses and children are especially vulnerable to radiation. Johns Hopkins had no place for her to spend the night, she said. Getting on an airplane was out of the question because of the dose of radiation she would give other passengers. And there was concern about what would have happened if, as many patients do, she vomited the radioactive contents of her stomach.

Instead, her husband, Bryce, booked a room at a hotel in Newark, Del. "I pretty much went in the back door," Ms. Maddox said. When they hit the road the next day, heading home, she sat as far as possible from her husband, in the third row of seats in their Honda Odyssey minivan. "I'm sure we looked like we'd had some kind of spat," she said.

Fortunately, like most thyroid cancer patients, she needed only a single dose of radiation to get rid of the cancer.

Scientists have estimated that, depending on the amount of radioactive drug given to a thyroid patient, a secondhand dose could exceed an average American's annual level from all natural sources, and three or four times the safe level recommended for a pregnant woman.

One person alarmed about the situation is Representative Edward J. Markey, Democrat of Massachusetts, whose office has been studying the issue. He accuses the Nuclear Regulatory Commission of turning a blind eye to the problem.

"My investigation has led me to conclude that the levels of unintentional radiation received by members of the public who have been exposed to patients that have received 'drive through' radiation treatments may well exceed international safe levels established for pregnant women and children," Mr. Markey said in a statement.

The Nuclear Regulatory Commission took up the issue at a meeting last Wednesday. James G. Luehman, a staff official who helps monitor the safe handling of radioactive materials used in medicine, said his agency might have made a mistake in dropping the quarantine requirement. The idea was that letting people return home to recuperate would cut costs, benefit the patients and allow doctors with no quarantine facilities to perform the treatment.

The agency knew that relatives and strangers would get a radiation dose from such patients, Mr. Luehman said, but it assumed that the doses to people like hotel clerks and chambermaids would be random and that no one was likely to be exposed repeatedly. He recommended that the commission study whether such patients tended to stay at certain hotels near major medical centers, but no conclusion about such a study was reached on Wednesday.

New York City has gone a step further. Last June, it advised radiologists and endocrinologists, "Do not advise patients to go to a hotel." A few states have similar policies.

There are simple precautions that patients can take to reduce the risks sharply: stay several feet away from other people and keep them from contact with the patient's saliva, urine and other body fluids.

Radiation from patients decreases both as the iodine dose is flushed out of their bodies and as it loses strength.

Many radiation experts doubt that radioactive thyroid patients represent a public health problem. "We're talking about really small doses," said Dr. Henry D. Royal, the associate director of nuclear medicine at the Mallinckrodt Institute of Radiology at Washington University, in St. Louis.

"Who is it going to harm?" added Dr. Royal, who is on the executive board of the American Nuclear Society. "Show me some measurement that you've made, that this really happens."

But the issue has, in fact, stirred considerable concern among endocrinologists and others involved in nuclear medicine. Dr. Gregory A. Brent, the president of the American Thyroid Association, said that his group had spent two years trying to develop guidance for doctors on how to advise patients, but that there was no data about the risks of secondhand radiation to work from.

The risk seems hypothetical, he said. "You can imagine the pregnant woman working in a hotel, cleaning up urine," he said. "One can generate scenarios. But from what we know and what has been looked at, that hasn't been the case."

The staff of Mr. Markey, who is chairman of the Energy and Environment subcommittee of the House Committee on Energy and Commerce, has been gathering reports of contamination. In Maryland and Massachusetts, for example, patients have put contaminated items in the trash, and the trucks that collected it set off alarms at dumps.

After thyroid treatment, patients are advised not to hug children or pregnant women, or to sleep next to another person, for several days — depending on the size of the dose.

They are even advised against eating chicken wings or whole apples, because the bones or the core will be contaminated with radioactive saliva.

Hospital isolation is still the practice in Europe. Patients can be hospitalized in the United States, but only if they try hard.

For example, Janis Lewis, of Roanoke, Va., took her 16-year-old daughter for an iodine dose in June, soon after thyroid cancer was diagnosed.

The girl, whose name Ms. Lewis asked not be published, gets motion sickness even in normal circumstances, she said, and she asked at the endocrinologist's office if her daughter could be admitted overnight. She was told that was not possible, and that her medical insurance would not pay for it.

But Ms. Lewis eventually determined that her insurance would cover the expense if a doctor said hospitalization was medically necessary; but the hospital involved had no isolation rooms for thyroid cancer patients.

She gave up on that hospital. "I wasn't comfortable driving her home three and a half hours in the car," said Ms. Lewis, an occupational therapist.

Instead, she found another doctor, at Washington Hospital Center, in the District of Columbia, where her daughter stayed overnight, and did, in fact, vomit radioactive material all night.

Outpatient treatment is often appropriate, Ms. Lewis said, but "in some cases, it's gone too far."

Sunday, October 24, 2010

Social networks and the influence we have on others' health behaviors -

The old folk concept that our personal health behaviors rub off on those around us has received a staggering amount of scientific support of late. Over the last few years, study after study has shown that weight gain, drug and alcohol use, even loneliness and depression aren't islands unto themselves but are powerfully contagious — capable of spreading within our social networks just as germs scatter after a sneeze.

If your friends are smokers, you tend to light up too, studies show. If they're overweight, then your belt also feels a bit tight. If they're happy, chances are you're smiling too. And on and on.

Many public health leaders now believe this growing science of social networks can be used to improve health and well-being on a broad, population-sized scale. Some see the approach as a promising new front against the day's most urgent health problems, such as obesity, smoking and suicide.

"We've come to realize more and more that how people live and function in social networks is really important to health," says Deborah Olster, acting director of the Office of Behavioral and Social Sciences Research at the National Institutes of Health. What's less clear, at least so far, is the best way to nudge people toward healthy habits and away from destructive ones. Results from experiments are mixed — some efforts work, others don't. In March, the NIH issued a funding opportunity for scientists studying how to improve public health through social networks.

Public health programs could tap into social networks in two main ways, says Dr. Nicholas Christakis of Harvard Medical School, co-author with James Fowler of UC San Diego of the 2009 book "Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives."

One approach, says Christakis, is to manipulate the network of connections people have. Artificial social groups — think Weight Watchers — could be created to urge unhealthy members toward more healthful behaviors.

A second approach, which Christakis considers far more promising, is to manipulate existing networks so that positive health messages become "contagious." In this model, public health programs would target key members of a social group in an effort to influence the network at large.

When social scientists talk of "networks," they mean any social circle in which people trade ideas, share experiences and generally touch each other's lives — neighborhoods, offices, classrooms or online communities such as Facebook.

Identifying the most influential or popular people within these networks has become easy, Christakis says, due to advances in data analysis. The trick is to identify which members could give positive health efforts the best bang for the buck and to create the best design for such programs.

In a study published in 2003 in the American Journal of Public Health, led by USC professor of preventive medicine Thomas Valente, sixth-graders participated in an eight-week smoking-prevention program. The intervention was taught to groups of students (the "networks," in this case) by class-nominated peers, teacher-nominated peers or random peers. All told, class-nominated peer leaders conducted the program most effectively, with students in these networks reporting less intention to smoke and lower smoking rates one year later.

But a follow-up study, also led by Valente, had less success. This time, Southern California high schoolers took part in a 12-lesson drug-abuse intervention. The program had a greater effect on health behavior when led by an influential, student-nominated peer than when led by a teacher — but with a caveat. Drug use declined only in relatively drug-free social circles; for those whose friends included drug users, the program actually elevated drug use, the researchers reported in the journal Addiction in 2007.

The mixed findings suggest to Valente, who's done some of the leading work on network-based health interventions, that programs may need different designs based on the type of social network they're intended to help. This important point, he adds, has been entirely ignored in all work on health promotion.

"You can't divorce the content of the program from the people delivering it," he says. "The message is really the messenger."

Valente is part of a new effort, led by Peter Wyman of the University of Rochester, to study how effectively key network members can implement a suicide prevention program called Sources of Strength. The intervention familiarizes students with suicide-coping resources and encourages them to seek help for suicidal friends. Peer leaders at 36 high schools in New York and North Dakota will learn the program and then introduce it into their social circle — the "network." Over the course of the five-year study, the researchers expect that students in these networks will seek more help than students in control groups, resulting in fewer suicide attempts.

Network interventions might be effective against obesity too, says economist Scott Carrell of UC Davis. In a recent study, Carrell and collaborators examined the spread of fitness habits in students at the Air Force Academy. The researchers found that the probability of a student being classified "unfit" tripled once half the student's social network fell out of shape.

The finding underscores that network influences work in both directions — for good or for bad — but Carrell sees an opportunity in the results. "If you make that 'unfit' person more healthy," he says, "that suggests you will also increase the fitness levels of everyone else in the group."

All these efforts depend on a key scientific concern: to craft strong social-network interventions, researchers must first be certain that one person's health behavior has a direct, causal effect on another's, says Jason Fletcher of Yale University's School of Public Health. For some behaviors, such as smoking or drinking, the direct network effect is quite apparent, Fletcher says. But for others, such as obesity, the case is less clear.

In a 2007 issue of the New England Journal of Medicine, Christakis and Fowler reported that obesity spread through social ties in one's neighborhood. They analyzed a real-world network population of more than 12,000 people living in Framingham, Mass., who were followed for 32 years, and concluded that overweight people tended to create overweight friends.

That finding, though intriguing, doesn't prove cause and effect, Fletcher argues. Environmental factors could have been a big influence: Maybe two neighbors are obese not as a result of their social connection but because a fast-food chain opened at the end of their street. Friend selection matters too: Maybe overweight people seek each other and cluster together rather than directly influencing one another's behavior. (Christakis says his study did consider these factors.)

A new study, presented in June at a conference of the American Society of Health Economists, tried to tackle this cause-and-effect dilemma by studying college roommate assignments — which are random in terms of mental health. The researchers, led by Daniel Eisenberg of the University of Michigan, then tracked the health behaviors of the 775 male and 867 female participants.

They found preliminary evidence for depression contagion only in male networks and for anxiety contagion only in female groups. Additionally, Eisenberg found plenty of support for the spread of binge drinking, but none for happiness.

Such a finding could help public health leaders build depression programs specifically for college-age males, Eisenberg says, but does throw some cold water on the notion that hanging around happy people is bound to make you more happy.

Ultimately, experts agree, as understanding about the structure and flow of social networks improves, so will health interventions. Sorting out the details is a matter for science — for the average person, it's enough to know that improving the health of loved ones often means leading by example.

"An easy thing to say would be 'Choose your friends wisely,' " says Olga Yakusheva of Marquette University, who has found that weight-loss behaviors can be contagious among college women. "I'd like to say, 'Choose your behaviors wisely,' because they're going to impact people around you.",0,7197587.story


Cases - A Liver Attack Leads to a Simpler Life -

I first met my liver the night it tried to kill me.

I was at home in Hawaii, alone, relaxing after a dinner of leftovers from a party I hosted the night before: macaroni and cheese with manchego and chorizo, tossed greens, a glass of Rioja and a dark-chocolate truffle to finish. It was my favorite meal, and this was the last time I would eat it.

The attack started innocently, in the form of body aches. It progressed rapidly to nausea, vomiting and dizziness. Pain knifed through my gut. I pulled up my T-shirt and found a lump swelling below my ribs. The bigger it swelled, the harder it was to breathe. I panicked and called my husband, Adam, an M.I.T. professor who lived in Boston at the time. We had commuted all six years of our relationship. Hearing his voice calmed me down enough to act.

A friend drove me to the E.R., where I promptly blacked out. I woke up later in a hospital bed, my swollen body plugged with tubes. Doctors informed me that my levels of the enzymes AST and ALT were sky high, signs that my liver was severely damaged and heading toward failure. The cause eluded tests. It took days to convince them that I wasn't an alcoholic.

Until that night my liver had done its work uncomplainingly and unnoticed, securely out of mind. But pain trumps denial.

As Dr. Gregory J. Gores, chairman of gastroenterology and hepatology at the Mayo Clinic in Rochester, Minn., explained in an interview, the liver provides innate immunity, which mounts the first response to invaders; absorbs nutrients and fats; and orchestrates many of the chemical reactions that sustain life. Its functions are so vital that nature endowed it the power to completely regenerate within months of injury. But if the liver fails, a transplant is the only option short of death.

The doctors sent me home the next day and called to check on me between twice-weekly clinic visits while they searched for the cause. But I wasn't safe alone because I could lose consciousness at any moment. Adam cleared his schedule and rushed to my side, remaining there for two months as my body and pride deflated — along with my old self-sufficient life.

This new reality took a few days to sink in. The pain was excruciating, but many drugs work only when the liver does. In my agony I ignored my doctor's words of caution and swallowed narcotic painkillers left over from a root canal. My liver retaliated by invading my dreams: I was flying a plane when, disguised as my co-pilot, it seized control and shot me in the face.

Then it ordered my new diet: organic rice porridge and broth. I survived on that for three months, twitching with cravings for sugar, bacon and spices. I hallucinated those into my bowl of bland white mush. My allergies vanished, and I lost 33 pounds.

In the second week my liver began barking at smells and substances I'd barely noticed before. I considered myself an earthy minimalist, but my house turned out to be a chemical minefield. I developed a doglike olfactory sense that guided me as I sniffed, recoiled and pointed out to Adam what had to go. He tossed out most of our bathroom and kitchen products, along with everything preserved or petroleum-based. (Even now, I continue to detect obscure odors, including what people eat and when they've had sex.)

Of course, there was nothing we could do about the metallic gases billowing from Kilauea volcano. My liver summoned me to cleaner air. The gall! Not even my husband had asked me to choose between him and Maui. But my liver wouldn't negotiate.

The cause of my liver attack remains a mystery, despite the efforts of a half dozen doctors in Hawaii and California. They poked and tested for every infectious agent they could, for cancer and even for some mental disorder. Nothing explained my symptoms.

Finally an infectious-disease specialist reached a diagnosis by elimination: hepatitis E.

The virus thrives in northern Brazil, spreading to people through contaminated water or animals. Two months before the attack, while I was touring the Amazon rain forest, a native boy pressed a wild sloth into my arms. It sneezed on me.

Though hep E remains the likely culprit, I don't know for sure because there is no clinical test. No matter to my liver. Whatever had assaulted it, it was no longer able to absorb the battering of modern life.

I caved in to my liver's demands. I switched to acupuncture for pain relief and help sleeping. I learned to eat like an old monk, take naps and meditate. I added the blood tests for AST and ALT to my annual physical. I followed my nose and left Hawaii, moving to Southern California with Adam. We spend evenings cuddling on the couch with our big dogs, my liver never happier. It's a less tainted, simpler life entirely on my liver's terms, and I'll take it.