Thursday, December 29, 2011

Durezol And Durasal, Don't Get Them Mixed Up, FDA Warns - MedWatch

Eye drug Durezol (difluprednate ophthalmic emulsion) and wart remover Durasal (salicylic acid) may sound similar, but getting them mixed up can happen, and with potentially serious consequences, the Food and Drug

Durezol is prescribed for patients with inflammation linked to eye surgery.

The FDA informs that it has received several reports of Durezol and Durasal mix-ups. Fortunately, the mistakes were spotted before the patient received their prescriptions in most cases.

The FDA adds that health care professionals have complained about the names of the two drugs, saying they sound too similar, and worry about potential medical errors.

Pharmacists should be especially vigilant when filling Durezol prescriptions, the Agency adds. The risk of injury is much greater if an eye-surgery patient gets the wart remover, than the other way round. Even so, errors in either direction should be avoided.

When drugs are submitted to the FDA for approval, the Agency carefully screens their proprietary names for similarities. However, Durasal (salicylic acid) is an OTC medication that did not undergo the approval process. That is why the two names exist side-by-side in the pharmacies.

Durasal came onto the market not long after the FDA approved Durezol.

The FDA has written to Elorac Inc. regarding removing Durasal from the market. Elorac has not responded, neither has it issued any kind of recall.

Pharmacists, doctors, other healthcare professionals and patients should check the drug's packaging and label information carefully.

Any medications that appear to have a potential for confusion regarding their names should be reported to theFDA's MedWatch Safety Information and Adverse Event Reporting program. Patients and doctors should also report any side effects linked to Durezol or Durasal usage to MedWatch.

Chocolate bar for lunch? Is this an ‘occupational hazard’? - The Globe and Mail

You're working late, and eating dinner from a vending machine yet again.

Could your diet of Twinkies and Cheetos be a job hazard?

If you're a shift worker, it could well be, according to the medical journal PLoS Medicine.

An editorial in this month's issue of the journal makes a case for thinking about unhealthy eating as a new occupational health hazard. It highlights research that shows an association between shift work and an increased risk of type 2 diabetes.

While a disruption of circadian rhythms (which regulate one's metabolism) and a negative impact on sleep are contributing factors, workers' eating patterns "are obvious targets for intervention," the editorial says.

According to a press release, "Shift work is notoriously associated with poor patterns of eating, which is exacerbated by easier access to junk food compared with more healthy options."

The editorial points out that shift work is expected to become more common as the realm of work increasingly extends around the clock. And shift work, it says, has the potential to speed up the progression of the global epidemic of obesity and diabetes.

The editorial notes that employers and legislators have taken steps to reduce workers' exposure to tobacco smoke, suggesting they should tackle unhealthy eating in a similar manner, and make it easier and cheaper for workers to eat well. One workplace, the Cleveland Clinic, has taken a lead in this area, it says.

In an effort to keep health-care costs in check, the Cleveland Clinic in Ohio took a hard line to improve the health of its employees, The Washington Post reported earlier this year. It fired physicians who refused to quit smoking. It eliminated almost all fried foods, sugary sodas and trans fats from its campus. It offered free fitness and stress-management classes to its workers. And it began keeping track of its employees' blood pressure, lipids, blood sugar, weight and smoking habits. If any of these are "abnormal," the clinic requires that a doctor certify that the employee is taking measures to control them or else they don't receive an insurance rebate.

Wednesday, December 28, 2011

A young woman struggles with oxy addiction and recovery - Tampa Bay Times


When her mom came to pick her up for drug court that morning, Stacy Nicholson was still high.

She staggered to the door, fumbled with the bungee cord that kept it closed, blinked back the sunlight.

"You ready?" asked her mom.

Stacy and two of her cousins had been holed up for months in this rundown house, shooting crushed-up pain pills. Used syringes littered an end table. Stacy's mom had kept telling her: Someone in this house is going to die.

Stacy, then 28, knew she was right. Days before, she had told her mom she was tired of stealing and doctor shopping to get pills. She was in trouble for skipping her last court date, so today, she planned to turn herself in.

"Okay," Stacy said. "Let's go."

She twisted her long, honey-colored hair into a knot. Zipped her sweatshirt. Underneath, she was wearing two bras, a tank top, two white T-shirts and three pairs of panties.

She wanted to be sure she would have a change of underwear in jail.

COURTROOM 10 WAS PACKED when Stacy and her mom, Sherry Alkire, slid into the back row. It was Feb. 1, a Tuesday.

More than 100 women, most 20 to 40 years old, filled the wooden benches. Some were visibly pregnant. Others trailed toddlers. Many of the women struggled to hold up their heads.

Just before 9 a.m., a thin, chestnut-haired woman in a black robe strode through the back door. "All rise!" called the bailiff. "The honorable Judge Dee Anna Farnell presiding."

The judge raised her arms and smiled. "Welcome to Ladies' Day," she said. America's first all-female drug court was in session.

Soon the judge called Stacy's name. Stacy slouched down the aisle, clasped her hands behind her back and hung her head.

Eighteen months earlier, she had been arrested for using a fake prescription to buy oxycodone, the painkiller she had been snorting or shooting for four years. The charge carried a possible five-year prison sentence.

The judge had offered a deal: Plead guilty and go on probation. If you go through rehab, if you go to 12-step meetings and get a job and stay sober, you can stay out of jail — and have your felony record wiped clean.

For a while, Stacy had tried. But then she failed a drug test, stopped going to counseling, started skipping court. Now she faced a sentence of 10 years instead of five.

The judge could send her to a long-term treatment facility or halfway house. Or she could put her in prison for violating her probation.

Farnell asked Stacy about her children. Stacy said her 12-year-old daughter had been staying with her paternal grandparents for almost a year. Her mom was taking care of her 2-year-old son.

"What are you going to test positive for today?" asked the judge.

Stacy shuffled her Air Jordan slides. "Well, I've been smoking and drinking. So marijuana and alcohol." She paused. "And benzos. And maybe …"

The judge shook her head. "Okay," she said. "What do you want to do? Do you want to opt out? Or keep trying?"

Stacy wanted what a lot of addicts want: to get clean, but also to get high. She wanted to have her kids back, but also to have no responsibility. She wanted to feel better, and to feel nothing.

She wiped her nose on her shoulder, looked up and said, "I want to keep trying."

PRESCRIPTION DRUG abuse kills 40 Americans every day. That's more than a threefold increase in the last decade, according to the U.S. Centers for Disease Control and Prevention.

Oxycodone is the deadliest drug of all. An opiate found in such painkillers as OxyContin and Percocet, it's prescribed after surgeries and car wrecks, and to people in chronic pain.

Others take it just for the high. The drug works by blocking the spinal cord's pain receptors. It doesn't make the pain go away, but prevents people from feeling it, creating a sense of euphoria. Soon, they need to take more to get the same pleasurable escape.

Oxy makes junkies out of people who would never buy from a street dealer. It is everyman's high, heroin in a pill.

Of all the oxycodone prescribed in America in the first half of last year, 98 percent was dispensed in Florida. According to the state medical examiner's office, an average of seven Floridians die from prescription drug overdoses every day — more than from car accidents.

In recent years, Pinellas has lost more people to prescription drugs than any other county in the state — 249 just last year. That's an increase of 60 over the year before.

"Everyone knows someone who has gone through this addiction and you just feel so helpless. It's a horrible, vicious disease," said Pinellas County sheriff's spokeswoman Marianne Pasha.

"These aren't Dumpster-diving drug addicts," she said. "These people are getting their pills from doctors. It's the person in line beside you at Publix, the woman next to you in the pew at church."

A few years ago, drug court Judge Farnell started seeing more and more women charged with prescription drug abuse. By 2009, almost half of her drug court defendants were women.

That year, Pinellas County received a $900,000, three-year federal grant to fund substance abuse treatment for women in drug court.

That's how Tuesdays became "Ladies' Day."

Instead of punishing the women, the judge offers them a chance to start over. They come to court once a month. She creates incentives for them: Do yoga, run a 5K, quit smoking, and we'll waive your $52 monthly probation fee. She makes sure they know how to get a bus pass. If she gets a bad vibe about a boyfriend, she'll order a woman to steer clear of him.

She tells defendants, "You can do this. It's going to be hard. But it will be worth it."

When a woman slips, the judge scolds her and sends her back to jail to detox. Then she offers another chance.

About 500 defendants came to court on Ladies' Days this year. St. Petersburg Times journalists attended week after week. They interviewed dozens of women. They followed addicts as they bounced between jail and treatment, stayed in abandoned houses, looked for jobs and stumbled toward recovery or relapse.

One woman let the journalists follow her all year.

Stacy Nicholson grew up in St. Petersburg. A streetwise, Southern-fried tomboy, she loves the Florida Gators, Chevy pickups, Lil Wayne and Toby Keith. She believes in dream catchers and her Gemini horoscope, craves Cocoa Puffs and smokes Newports. She never wears makeup, always spritzes on Victoria's Secret body spray. When it comes to men, she likes the smell of trouble.

Her history of drug use and dysfunction stretches back to puberty. She tried marijuana at 13 and alcohol at 14, had her first baby at 16 and her second, with a different man, at 27.

But the pursuit of the oxy buzz erased any chance of a productive life.

For addicts, using quickly becomes a necessity, not a choice. Getting the next pill becomes more important than work, friends, family, even food. The addict's values shift to justify whatever it takes to get more oxys. Hard workers can no longer hold jobs. Smart students drop out. Good moms neglect their kids, drain their bank accounts, steal from family members.

If addicts stop using, they suffer horrible symptoms: vomiting, headaches, intense bone pain. That's why many are afraid to even try to get sober. They need to stay high so they don't crash.

After Stacy got hooked, she lost her personality, spark, motivation. Every new boyfriend was a red flag, but she never saw it. She dragged her kids from bad apartments to cheap motel rooms, and finally gave them up.

In Judge Farnell's court in February, Stacy entered what everyone agreed was a fight for her life. She could get better, or she could become one of Florida's seven a day.

She had a lot going for her: a mother who supported her even after all the times Stacy had broken her heart. Two children who desperately needed her love and attention. A treatment program backed by almost $1 million in taxpayer money. Drug counselors who wanted her to succeed. Other recovering addicts eager to share their experiences at 12-step meetings. An empathetic judge who was willing to give Stacy chance after chance, if only she would try.

Working against her: a little blue pill and Stacy's need to numb herself with it.

More ...

The High Cost of Failing Artificial Hips -

The most widespread medical implant failure in decades — involving thousands of all-metal artificial hips that need to be replaced prematurely — has entered the money phase.

Medical and legal experts estimate the hip failures may cost taxpayers, insurers, employers and others billions of dollars in coming years, contributing to the soaring cost of health care. The financial fallout is expected to be unusually large and complex because the episode involves a class of products, not a single device or just one company.

The case of Thomas Dougherty represents one particularly costly example. He spent five months this year without a left hip, largely stuck on a recliner watching his medical bills soar.

In August, Mr. Dougherty underwent an operation to replace a failed artificial hip, but his pelvis fractured soon afterward. The replacement hip was abandoned and then a serious infection set in. Some of the bills: $400,776 in charges related to hospitalizations, and $28,081 in doctors' bills.

"I'm sitting here on a La-Z-Boy meant for someone who is 80 and I'm 55," said Mr. Dougherty, who lives in Groveland, Ill., and works at Caterpillar, the heavy equipment manufacturer. His bills are "five times as much" as he paid for his home.

The so-called metal-on-metal hips like Mr. Dougherty's, ones in which a device's ball and joint are made of metal, are failing at high rates within a few years instead of lasting 15 years or more, as artificial joints normally do. The wear of metal parts against each other is generating debris that is damaging tissue and, in some cases, crippling patients.

The incidents have set off a financial scramble. Recently, lawsuits and complaints against makers of all-metal replacement hips passed the 5,000 mark. Insurers are alerting patients that they plan to recover their expenses from any settlement money that patients receive.Medicare is also expected to try to recover its costs.

While his insurer has covered his bills so far, Mr. Dougherty said he was preparing to sue his surgeon, who may have implanted the device incorrectly, and Johnson & Johnson, which produced his artificial hip, to help recoup some of the insurer's money.

"All these payers want to be paid back," said Matt Garretson, the founding partner of the Garretson Resolution Group, a firm in Cincinnati that manages product liability cases.

Until a recent sharp decline, all-metal implants accounted for nearly one-third of the estimated 250,000 hip replacements performed each year in the United States. Some 500,000 patients have received an all-metal replacement hip, according to one estimate. A new study found that no new artificial hip or knee introduced during a recent five-year period — implants that included some of the all-metal hips — were more durable than older devices, and 30 percent were worse.

One troubled all-metal model, implanted in 40,000 patients in the United States, was recalled last year by the DePuy division of Johnson & Johnson. As of October, some 3,500 patients had filed a lawsuit involving that device.

There is no data on the number of all-metal hips that have failed prematurely in this country because the outcomes of orthopedic procedures are not formally tracked by the government or private companies.

But extrapolating from overseas data and the estimate of metal hip use here, tens of thousands of patients in the United States may have to undergo operations over the next decade to replace the implants, said Dr. Art Sedrakyan, a researcher at Weill Cornell Medical College of Cornell University, who is studying the hip problem.

A decade ago, Sulzer Orthopedics paid a record $1 billion to settle claims by 6,800 patients who received artificial hips and knees that were contaminated with industrial oil during the manufacturing process. "We have been dwarfed by this," said Teresa Ford, a lawyer who worked at Sulzer at the time and is now in private practice.

Device producers have taken differing stances to covering patient expenses. Zimmer Holdings, which says its all-metal implants are safe, has settled hundreds of patient claims, lawyers involved in those cases say. Also, DePuy is covering costs related to the device it recalled last year, the A.S.R., or Articular Surface Replacement.

DePuy would not comment on how much it had paid in recall-related costs. But a spokeswoman, Mindy Tinsley, said in a statement that DePuy was working with patients and insurers.

Things have not gone smoothly for everyone who has taken DePuy's payment offer. One patient, Paula Laverty, received a hospital bill for $41,578 and a call from the facility warning her that the bill would be turned over soon to a collection agency.

Ms. Laverty, of Cape Elizabeth, Me., said she spent weeks calling the firm handling claims related to DePuy's A.S.R. She said she eventually learned that the implant maker had paid the hospital $18,000 for her replacement procedure and that the $41,578 represented the remaining charges.

This month, DePuy made an additional payment to the hospital, according to Ms. Tinsley, the company spokeswoman.

Along with A.S.R.-related cases, DePuy also faces over 560 lawsuits in connection with the all-metal version of another hip model, called the Pinnacle, the device that Mr. Dougherty received. Because the company says that the model is performing well, costs for its replacement are being borne by Medicare, insurers or patients themselves.

To recoup their expenses, insurers typically notify patients through lawyers that they expect to be reimbursed from any settlement money that patients receive, rather than pursue their own lawsuits with the device makers. Also, Medicare is expected to enforce new laws next year that will make it easier for the agency to recover taxpayer dollars spent treating patients injured by problem drugs and medical devices, legal experts said.

Still, some patients are weathering some of the financial impacts on their own. While Charmin McCune, a teacher in Wylie, Tex., is recuperating well from a recent replacement operation, she said that she and her husband, also a teacher, have had more than $12,000 in expenses that have not been covered by insurance.

Mr. Dougherty, the Illinois patient, underwent a procedure this month to get a new hip implant. All went well, he said, so he hopes to spend next year back on his feet and at work.

"You can't do anything," he said of his current situation. "You see your wife doing everything for you. It is just not right."

Monday, December 26, 2011

Robert Ader, Who Linked Stress and Illness, Dies at 79 -

Dr. Robert Ader, an experimental psychologist who was among the first scientists to show how mental processes influence the body's immune system, a finding that changed modern medicine, died on Tuesday in Pittsford, N.Y. He was 79.

His death followed a long illness and complications of a fracture suffered in a fall, his daughter Deborah Ader said.

Dr. Ader, who spent his entire career as a professor of psychiatry and psychology at the University of Rochester School of Medicine and Dentistry, conducted some of the original experiments in a field he named himself, psychoneuroimmunology.

His initial research, in the 1970s, became a touchstone for studies that have since mapped the vast communications network among immune cells, hormones and neurotransmitters. It introduced a field of research that nailed down the science behind notions once considered magical thinking: that meditation helps reduce arterial plaque; that social bonds improve cancer survival; that people under stress catch more colds; and that placebos work not only on the human mind but also on supposedly insentient cells.

At the core of Dr. Ader's breakthrough research was an insight already obvious to any grandmother who ever said, "Stop worrying or you'll make yourself sick." He demonstrated scientifically that stress worsens illness — sometimes even triggering it — and that reducing stress is essential to health care.

That idea, now widely accepted among medical researchers, contradicted a previous principle of biochemistry, which said that the immune system was autonomous. As late as 1985, the idea of a connection between the brain and the immune system was dismissed in an editorial in The New England Journal of Medicine as "folklore."

"Today there is not a physician in the country who does not accept the science Bob Ader set in motion," said Dr. Bruce Rabin, founder of the Brain, Behavior and Immunity Center at the University of Pittsburgh Medical Center, who considered Dr. Ader a mentor. "He attracted interest in the field and made it possible to prove that 'mind-body' is real."

Dr. Ader said his breakthrough began in 1975 with what he called "scientific serendipity."

He and a fellow researcher, Dr. Nicholas Cohen, were conducting an unrelated experiment about taste aversion involving rats and saccharine-sweetened water when they stumbled on a mysterious phenomenon.

In the experiment, one group of rats was given sweetened water accompanied by an injection that caused stomach aches. (A control group got only the sweetened water.) When the injections stopped, and the rats that had experienced stomach aches refused to drink the water, researchers force-fed them with eye-droppers in order to complete the experiment's protocols.

Dr. Ader and Dr. Cohen had expected the conditioned rats to refuse the drink. They had not anticipated that forcing them to drink would eventually kill them, however, which it did, some time afterward.

The two reviewed their protocols and guessed that the drugs used in the injections might have had some bearing on the deaths. They could have used any drug that caused stomach pain without doing serious harm. But the researchers discovered that they had unwittingly picked Cytoxan, which besides causing stomach aches suppresses the immune system. At first they suspected that the rats had died from an overdose of Cytoxan. Then they determined that the dosage the rats received had been too low to support that explanation.

So they developed a theory, which became a landmark of medical science as further experiments proved it correct: The rats died because the mere taste of saccharine-laced water was enough to trigger neurological signals that did indeed suppress their immune systems — exactly as if they had been overdosed with Cytoxan. The rats succumbed to bacterial and viral infections they were unable to fight off. It was an example of the so-called placebo effect, only in this case it did not fool the brain into thinking it had been given something beneficial but rather the opposite.

The findings were "incontrovertible," Anne Harrington, a Harvard professor of the history of science, wrote in the 1997 book "The Placebo Effect."

"The fact that he had achieved this in rats rather than humans was a further blockbuster," she continued, "because it undermined the frequent assumption that placebo effects were a product of peculiarly human interpersonal processes."

Robert Ader was born on Feb. 20, 1932, in the Bronx, the older of two sons of Mae and Nathan Ader. His father, who owned a liquor wholesale company, died in a car accident in 1945 when Robert was a teenager. After graduating from the private Horace Mann School in the Riverdale section of the Bronx, he received his bachelor's degree from Tulane University and, in 1957, his Ph.D. in psychology from Cornell.

Soon after, he became an assistant professor in the department of psychology at the University of Rochester, where he went on to hold many teaching and research posts. He retired in July as a professor emeritus of psychosocial medicine.

Besides his daughter Deborah, he is survived by his wife, Gayle; three other daughters, Janet, Rini and Leslie Ader; and a grandson.

Since he inaugurated the study of psychoneuroimmunology (usually referred to as PNI), Dr. Ader had to defend its premise against doubters in the medical establishment and later to disassociate it from New Age therapies that he called "flaky" because they had not been grounded in solid scientific experimentation.

Deborah Ader, a psychology researcher, said a sense of modesty had been at the core of her father's curiosity as a scientist.

"My father used to say, 'I just didn't know any better,' " she said, recounting how he had described his pioneering research.

He told her, she recalled, "I didn't know the immune system wasn't supposed to be connected to the brain."

Affluent Children Are More Physically Fit Than Poor Ones -

Every Monday, Sycamore Valley Elementary in Danville challenges its students to run a "Smile Mile" together after school. Some parents even run with their children. Photos of the student joggers' grinning faces are posted in the cafeteria. On a recent Monday afternoon, there were 41 smiling faces on the wall.

Students at Sycamore Valley have a lot to be happy about when it comes to their physical fitness. Fifth graders there got the best scores among all of their Bay Area peers on the 2011 statewide Physical Fitness Test.

Eighty-three percent of the fifth graders tested at Sycamore Valley aced the test by receiving healthy scores on all six different measurements — of aerobic capacity, abdominal strength, upper body strength, trunk strength, body composition and flexibility, most of them gauged through physical activity. One part of the Physical Fitness Test measures a child's body composition, usually through body mass index, which is calculated using weight and height and is used to determine who is overweight.

Statewide, only 31 percent of public school students performed as well, according to the California Department of Education.

An analysis of state data by The Bay Citizen revealed a large variation in how fifth graders in Bay Area elementary schools perform on the test. The schools that performed the best have few students from low-income families, for reasons that experts say are not surprising. At Sycamore Valley Elementary, in an affluent suburban community, not a single student was eligible to receive a free or reduced-price lunch because of low family income last year, according to the state's data.

Across the Bay, in San Francisco's Mission district, none of the fifth graders at Cesar Chavez Elementary School received six healthy scores on the test. More than a quarter of them were found to "need improvement" on every measure of fitness.

At Cesar Chavez, where Spanish is the first language for many, more than 85 percent of the students are eligible to receive free or reduced-price school lunches. In the school district that includes Cesar Chavez, Hispanic and black students are less likely to receive healthy scores than their Asian and white peers, the state data show.

Students at Sycamore Elementary have a dedicated "physical education specialist" on campus to help them train for the test. Those at Cesar Chavez do not.

"There is an inequity problem with the availability of quality physical education between schools of varying socioeconomic status," said Drisha Leggitt, executive director of the California Association for Health, Physical Education, Recreation and Dance, a nonprofit organization.

Robert O'Brien, Sycamore Valley's physical education specialist, who favors shorts even when the temperature dips into the 40s, is fond of slogans like "exercise, not extra fries." He leads students as young as 6 in sit-ups, jumping jacks, push-ups and running, striving to get all of them moving, while giving their classroom teachers time to prepare other lessons.

All 21 of the elementary schools in the San Ramon Valley Unified School District, in which Sycamore Valley is located, have a physical education specialist like Mr. O'Brien.

"Having dedicated physical education teachers can make a big difference in students' performance on the test," said Linda Hooper, an education, research and evaluation consultant for the California Department of Education.

The San Francisco Unified School District has just 15 physical education specialists for all 76 of its elementary schools. Spread thin, they work with about half the schools at any time. According to Michelle Zapata, the physical education program administrator for the district, Cesar Chavez was among the 38 schools that had no physical education specialist on campus.

Advocates for child health warn that failing to teach children how to be active and healthy will have long-term consequences.

"It comes as no surprise whatsoever that such enormous inequities would be present," said Dr. Harold Goldstein, executive director of the California Center for Public Health Advocacy, a nonprofit organization. "It is grossly unjust and will have health and economic impacts on the state of California for generations to come."

Sycamore Valley Elementary maintains a focus on health outside of physical education class time. Parents are not allowed to bring in cupcakes or other potentially fattening treats to celebrate birthdays. Instead, gifts of pencils or erasers to classmates are substituted.

Parents also contribute financially. Fund-raising pays for a twice-a-week movement class for kindergarteners that is not required by the state. In the fall, the school's Parent Teacher Association gave Mr. O'Brien a $375 grant to buy new basketball hoops, and he also leads an after-school sports camp that helps raise money to buy sports equipment.

Each fall, the PTA holds a "fun run" fund-raiser, in which students are sponsored to run laps during school. It raised nearly $10,000 this year.

Even the school's location supports fitness. It is next to a park, near a sweeping open space of rolling hills dotted with oaks. The park features a play structure, a basketball court, a bocce court and athletic fields, where Mr. O'Brien sometimes holds physical education lessons.

Many elementary school students in the suburbs also play sports outside school, including basketball and lacrosse.

Rebecca Adams, president of the Sycamore Valley Elementary PTA, said her children, who are in the first and third grades, participate in indoor soccer, swimming, gymnastics, baseball and softball, depending on the season.

Not all their activities are organized by adults. "A lot of kids play outside in their front yard," said Ms. Adams, who lives less than a mile from the school. In-line skating, biking and tag are popular.

"My kids play outside all the time," she said.

At Cesar Chavez Elementary School, physical education lessons, taught by classroom teachers, are held on a fenced-in blacktop lot below a huge, colorful mural of the school's namesake. In the mural, Mr. Chavez, the late civil rights leader, is surrounded by a crowd of children as he carries a banner that reads "Help me take responsibility for my own life so I can be free at last."

On the urban school's blacktop, the basketball rims have no nets. "We don't have a field or a park next door," said Catalina Rico, the school's principal.

Most of the students' parents, many of whom are immigrants, cannot give extra money to help beef up its programs. Some families are homeless, and many others are struggling financially.

"A lot of our kids have been traumatized by poverty, violence, their parents being deported," Ms. Rico said.

For those families, regular exercise in a safe place after school may be out of reach.

If parents are working two jobs, Ms. Rico said, "who is going to take them to the park?"

Thursday, December 22, 2011

Opting to track, not treat, early prostate cancer | Lubbock Avalanche-Journal

WASHINGTON — John Shoemaker visited six doctors in his quest to find the best treatment for his early stage prostate cancer — and only the last one offered what made the most sense to the California man: Keep a close watch on the tumor and treat only if it starts to grow.
Very few men choose this active surveillance option. Yet Shoemaker is one of more than 100,000 men a year deemed candidates for it by a government panel. That's because their prostate cancer carries such a low risk of morphing into the kind that could kill.
The risk for them is so low, in fact, that specialists convened recently by the National Institutes of Health say it's time to strip the name "cancer" off these small, lazy tumors.
In the meantime, the panel wants more of those men offered the option of delaying treatment until regular check-ups show it's really needed. That endorsement promises to fuel efforts by the Prostate Cancer Foundation and a few other groups to spread the word to the newly diagnosed.
Shoemaker's journey shows how difficult that may be, from doctors who don't even bring it up to the fear factor.
"With prostate cancer, you hear the "C'' word, so to speak, and people freak out," says Shoemaker, 69, a businessman from Los Altos, Calif., who was intent on examining all his options.
Five years after his diagnosis — and five biopsies plus numerous blood tests and ultrasound scans later — Shoemaker's happy he found a surgeon who argued against immediate treatment. He's confident his prostate tumor hasn't grown, and avoided the pain and side effects of surgery or radiation.
Some 240,000 men a year in the U.S. are diagnosed with prostate cancer.
Earlier this month, the NIH-appointed panel found that most have the low-risk kind, a legacy of using problematic PSA blood tests to screen healthy men for possible signs of this slow-growing cancer that will affect most men's prostates if they live long enough.
Yet 90 percent of such men choose immediate treatment such as surgery or radiation, risking serious and long-lasting side effects, such as impotence or incontinence, without good evidence about who will live longer as a result. One recent study tracked 731 men diagnosed with early stage prostate cancer for 10 years and found no difference in survival between those who had surgery and those who weren't treated unless they went on to develop cancer symptoms, an older option known as watchful waiting.
Active surveillance is much more aggressive than watchful waiting — men get regular scans, blood tests and biopsies to check the tumor, although the NIH panel found the degree of monitoring can vary by medical center. Active surveillance is designed to monitor men closely enough that they can get curative treatment quickly if it looks like they'll need it, well before any symptoms would begin.
"It's not treatment versus no treatment; it's about timing of treatment," Shoemaker's physician, Dr. Peter Carroll of the University of California, San Francisco, told the NIH. He's a well-known prostate cancer surgeon who also leads one of the country's few large active-surveillance programs, tracking more than 900 men for over five years. Most are treatment-free so far, and none has gone on to die of prostate cancer.
What's the advice for men? The NIH panel said men with a PSA level less than 10 and a Gleason score that's 6 or less are candidates for this type of active surveillance. The Gleason score measures how aggressive prostate cancer cells look under the microscope. Urologists can provide those numbers.
Then what? Today, what men decide to do next largely depends on the advice of the specialist they wind up seeing, and many either don't offer active surveillance or present it in a negative way, as doing nothing, the NIH panel learned. There's also the patient's instinctive "get it out" reaction.
Enter the National Proactive Surveillance Network — at — a collaboration of two large active-surveillance programs, at Johns Hopkins University and Cedars-Sinai Medical Center, with the Prostate Cancer Foundation. First, it aims to educate men about active surveillance.
Within a few months, an interactive section of the site will be added to link men with doctors who offer active surveillance and track how they fare with input straight from the patients themselves, said Hopkins' Dr. H. Ballentine Carter.
"To me, it's an individualized approach rather than the one-size-fits-all approach of treating everyone," Carter says.
Beyond whether and how men choose surveillance, behavioral scientist Kathryn Taylor of Georgetown University wants to know how they decide to stick with it. About a quarter of men abandon the observation approach within two or three years, and as many as half by five years, the NIH panel learned. It's not clear how much of that was because they needed treatment, and how much was just the anxiety or getting tired of repeat biopsies.
Taylor is beginning a study of 1,500 newly diagnosed, low-risk prostate cancer patients at Kaiser Permanente in Northern California to see how many are told about active surveillance and what helped or hindered their decision.
"Living with untreated cancer is very difficult," she says, "and not everybody can do it, not surprisingly."

Doctor and Patient: A Medical School More Like Hogwarts -

It's been clear for several years now that while aspiring doctors may start medical school as happy and as healthy as their non-doctoring peers, four years later they aren't.

More than 20 percent end up with depression, more than half suffer from burnout, and in any given year, as many as 11 percent contemplate suicide. All of these statistics, of course, bode poorly for patients. Doctors who are burned out are more likely to make errors and to lose sight of the altruism that led them to go into medicine in the first place.

Fortunately, the subtext of this growing body of data — that there is something toxic about the medical education process — has not been lost on the educators who run this country's medical schools. Some have hired mental health experts for their institutions, created counseling centers and set up confidential Web sites and hot lines; others have developed elective courses in meditation and mindfulness, switched from letter grades to pass-fail systems and revamped class schedules to foster better work-life balance.

Despite the good intentions, their efforts continue to be stymied by one thing: Students aren't participating. As one educator recently told me, "I keep seeing the same 10 students at all these events, and I'm not even sure they're the ones we need to be reaching."

But one medical school, Vanderbilt, in Nashville, appears to be succeeding, with a Student Wellness Program that includes activities like yoga classes, community service events, healthy cooking classes, forums on nutrition and sleep, and a mentoring program that pairs senior students with newer ones. The key to its success? Empowering and partnering with those who have the most at stake — the medical students themselves.

Aside from an annual daylong retreat and a weekly medical humanities course, "most of the ideas are generated by the students themselves," said Dr. Scott M. Rodgers, the associate dean of medical student affairs, who started the program with a group of students six years ago and continues to be its guiding force. "We just try to come up with any necessary money."

One example of this unique collaboration is the program's college system, which assigns students to one of four "colleges," each with its own set of faculty advisers. Instituted nearly five years ago and intended simply as an improvement over a traditional but more random advising program, the new system was also set up in a way that allowed Vanderbilt students to introduce innovations.

They ran with it. Drawing on cultural cues that resonated with their peers — in this case the Harry Potter stories — they took an active role in naming the colleges after former medical school deans and imbued each with a particular personality. Completing the picture were artfully designed crests, designated college colors and devised mottos in Latin that range from the more noble ("Primus Inter Pares," or "First Among Equals") to the tongue-in-cheek put-down ("Commodum Habitus Es," or "You Have Just Been Owned").

As college loyalties began to develop, students organized friendly competitions that promoted healthy habits and community service. These events culminated four years ago in the first College Cup, a now annual weekend affair where pride runs deep. Amid bagpipes and a marching band, colleges vie to outdo one another in events like a 5-K run, an "Iron Chef"-style cooking competition and a trivia contest.

"These programs keep you from putting your whole self-worth on the next exam," said Kathleen Weber, a first-year student who was also quick to point out the superiority of her own college, Batson.

There are critics, however, who charge that with so much to learn in so little time, medical students — and their future patients — would be better served if they expended more, not less, effort on studies. Others have voiced concern that students end up feeling a "reverse pressure" to choose extracurricular activities over studying.

But proponents are quick to counter that medical students in general aren't people who must be persuaded to study. What they need is encouragement to balance academic dedication with the self-care that will sustain them in the long run. "You can't keep running on fumes," said Dr. Johanna N. Riesel, a former medical student at Vanderbilt now in her second year of surgical training at Massachusetts General Hospital in Boston. "You have to learn how to maintain some sense of equilibrium and sanity in a relatively insane process."

While no one yet knows the long-term effect of Vanderbilt's innovations – or, for that matter, of any programs designed to promote "wellness" — Dr. Rodgers and his colleagues and students at Vanderbilt remain committed to their initiatives. For them, the implications of medical student depression and burnout are simply too important to ignore.

"It's a challenge for anyone to stay healthy and happy," Dr. Rodgers said. "But when doctors are able to stay healthy and happy, that means patients get physicians who are more compassionate and selfless. They end up with doctors who really have the energy to invest time in them."

Tuesday, December 20, 2011

Close to Home

As Patient Records Are Digitized, Data Breaches Are on the Rise -

One afternoon last spring, Micky Tripathi received a panicked call from an employee. Someone had broken into his car and stolen his briefcase and company laptop along with it.

So began a nightmare that cost Mr. Tripathi's small nonprofit health consultancy nearly $300,000 in legal, private investigation, credit monitoring and media consultancy fees. Not to mention 600 hours dealing with the fallout and the intangible cost of repairing the reputational damage that followed.

Mr. Tripathi's nonprofit, the Massachusetts eHealth Collaborative in Waltham, Mass., works with doctors and hospitals to help digitize their patient records. His employee's stolen laptop contained unencrypted records for some 13,687 patients — each record containing some combination of a patient's name, Social Security number, birth date, contact information and insurance information — an identity theft gold mine.

His experience was hardly uncommon. As part of the 2009 stimulus bill, the federal government provides incentive payments to doctors and hospitals to adopt electronic health records. Some 57 percent of office-based physicians now use electronic health records, a 12 percent jump from last year, according to the Centers for Disease Control.

An unintended consequence is that as patient records have been digitized, health data breaches have surged. The number of reported breaches is up 32 percent this year from last year, according to the Ponemon Institute, a security research group. Those breaches cost the industry an estimated $6.5 billion last year. In almost half the cases, a lost or stolen phone or personal computer was responsible.

In a blog post, Mr. Tripathi describes the days after the theft as a "vortex." Fresh in his mind was a similar, albeit smaller, breach at Massachusetts General Hospital just months earlier in which a hospital employee left detailed clinical records for 192 patients on a subway. The breach had cost the hospital $1 million in settlement fees.

"We're a nonprofit with 35 people on staff," says Mr. Tripathi. "A million-dollar fine would have decimated us."

Mr. Tripathi says his nonprofit had just enacted a policy requiring that all patient files be encrypted, but had yet to decide on an encryption provider. All that stood between a determined computer thief and his patient data was a few passwords.

Mr. Tripathi went to work assembling a crisis team of lawyers and customers and a chief security officer. They hired a private investigator to scour local pawnshops and Craigslist for the stolen laptop. The biggest headache, he says, was deciphering how much about the breach his nonprofit needed to disclose.

Health organizations are required by federal law to report data breaches that affect more than 500 people to the Department of Health and Human Services. The department's Office of Civil Rights publishes the equivalent of a data breach "Wall of Shame" on its Web site — which today includes 380 breaches affecting more than 18 million people.

Mr. Tripathi said he quickly discovered just how many ways there were to count to 500. The law requires disclosure only in cases that "pose a significant risk of financial, reputational or other harm to the individual affected." His team spent hours poring over a backup of the stolen laptop files. Of the nearly 14,000 patient records on the stolen laptop, most records did not warrant disclosure. In 2,777 cases, for instance, a record listed only a patient's name.

Complicating matters were liability rules. In the eyes of the law, Mr. Tripathi's nonprofit is a contractor that acts on behalf of health providers. The legal burden of protecting patient data actually falls on his clients: the physicians and hospitals who entrusted his nonprofit with their files.

"The laws create a perverse outcome," he says. "It was our fault, but from a federal perspective, it wasn't our breach."

Mr. Tripathi narrowed down the group of patients whose data put them at serious risk for identity theft to 998 people across seven physician practices. Only one practice broke the 500-patient threshold requiring disclosure on the Department of Health and Human Services Web site.

His office got to work notifying the affected patients of the data breach. They offered free credit monitoring — though less than 10 percent took them up on the option — spending a total of $6,000.

In the aftermath, Mr. Tripathi says his company destroyed all patient data on mobile devices and temporarily prohibited employees from removing patient data from clients' offices. The company now mandates that all data be encrypted, and employees are required to tell health providers what data they will need to access and how they plan to use it.

He never found the stolen laptop, and the incident, all told, cost his nonprofit $288,000.

In many ways, Massachusetts eHealth Collaborative got off easy. In October, a desktop computer containing unencrypted records on more than four million patients was stolen from Sutter Health, a nonprofit health system based in Sacramento. A rock was thrown through a window to gain access to the computer. The theft is now the subject of two class-action suits, each of which seeks $1,000 for each patient record breached.

"Breaches are going to be one of the big challenges as more physicians and hospitals adopt electronic health records," Mr. Tripathi says. "We're entering a brave new world."

Sunday, December 18, 2011

Should dentists offer health screenings? – - Blogs

Each year, nearly 20 million men, women and children in the United States fail to see a family physician or similar health care professional, but they do pay at least one visit to the dentist, according to a new study in the American Journal of Public Health.

For this segment of the population, dentists may be the only doctors in a position to spot the warning signs of chronic illnesses, such as diabetes, and provide referrals or advice to prevent serious complications, says Shiela M. Strauss, Ph.D., the lead author of the study and an associate professor at New York University's Colleges of Dentistry and Nursing.

Oral or dental abnormalities can signal a broad range of body-wide health problems, including HIV, sexually transmitted diseases, eating disorders, and substance abuse, in addition to diabetes. In a previous study, for instance, Strauss and her colleagues found that 93% of patients with gum disease (such as gingivitis) also met the criteria that should trigger blood-sugar screening under American Diabetes Association guidelines.

"I'm not advocating for dentists to become general health care providers," Strauss says. But, she adds, dentists can easily measure blood pressure and administer simple screening questionnaires - both of which could potentially make a big difference to the health of someone at risk for diabetes who hasn't seen a doctor recently.

In the new study, Strauss and her team analyzed data from the Medical Expenditure Panel Survey, a nationally representative government-sponsored survey of health care use. In 2008, the researchers found, roughly one-quarter of adults did not see a physician, nurse practitioner, or other general health care provider - but of that group, 23% did see a dentist. The pattern was similar among children.

It's not clear what's leading these people to see a dentist but skip medical care. Most of the adults - and nearly all of the kids - had health insurance, so lack of coverage can't fully explain it. In fact, the authors note, the dentist-only group was "quite diverse" ethnically, socioeconomically and geographically.

It could be that dental problems - unlike some chronic diseases - are often too painful to ignore, Strauss says, or it could be that dentists are simply better than doctors at reminding patients when it's time for a checkup.

Getting dentists in the habit of screening for health conditions will probably require changes to dental-school curricula, the researchers say. However, dentists and dental hygienists are typically already trained to check blood pressure and conduct other types of general medical screening.

And while they might be hesitant to take on more patient responsibilities, Strauss says, doing so may have unexpected benefits. She points to the experience of some Swedish dentists who participated in an insurance plan that required them to implement diabetes screening for their patients.

"The reputation got out there that these were dentists that really cared about the patients," she says. "It was an initial investment of a bit more time on the part of the dentist, but it reaped great rewards for them in terms of growing their practice."

Friday, December 16, 2011

As Doctors Use More Devices, Potential for Distraction Grows -

Hospitals and doctors' offices, hoping to curb medical error, have invested heavily to put computers, smartphones and other devices into the hands of medical staff for instant access to patient data, drug information and case studies.

But like many cures, this solution has come with an unintended side effect: doctors and nurses can be focused on the screen and not the patient, even during moments of critical care. And they are not always doing work; examples include a neurosurgeon making personal calls during an operation, a nurse checking airfares during surgery and a poll showing that half of technicians running bypass machines had admitted texting during a procedure.

This phenomenon has set off an intensifying discussion at hospitals and medical schools about a problem perhaps best described as "distracted doctoring." In response, some hospitals have begun limiting the use of devices in critical settings, while schools have started reminding medical students to focus on patients instead of gadgets, even as the students are being given more devices.

"You walk around the hospital, and what you see is not funny," said Dr. Peter J. Papadakos, an anesthesiologist and director of critical care at the University of Rochester Medical Center in upstate New York, who added that he had seen nurses, doctors and other staff members glued to their phones, computers and iPads.

"You justify carrying devices around the hospital to do medical records," he said. "But you can surf the Internet or do Facebook, and sometimes, for whatever reason, Facebook is more tempting."

"My gut feeling is lives are in danger," said Dr. Papadakos, who recently published an article on "electronic distraction" in Anesthesiology News, a journal. "We're not educating people about the problem, and it's getting worse."

Research on the subject is beginning to emerge. A peer-reviewed survey of 439 medical technicians published this year in Perfusion, a journal about cardio-pulmonary bypass surgery, found that 55 percent of technicians who monitor bypass machines acknowledged to researchers that they had talked on cellphones during heart surgery. Half said they had texted while in surgery.

About 40 percent said they believed talking on the phone during surgery to be "always an unsafe practice." About half said the same about texting. The study's authors concluded, "Such distractions have the potential to be disastrous."

Doctors and medical professionals have always faced interruptions from beepers and phones, and multitasking is simply a fact of life for many medical jobs. What has changed, doctors say, especially younger ones, is that they face increasing pressure to interact with their devices.

The pressure stems from a mantra of modern medicine that patient care must be "data driven," and informed by the latest, instantly accessible information. Annual investment in gadgets and other technology by hospitals and doctors has soared into the billions of dollars.

By many accounts, the technology has helped reduce medical error by, for example, providing instant access to patient data or prescription details.

Dr. Peter W. Carmel, president of the American Medical Association, a physicians group, said technology "offers great potential in health care," but he added that doctors' first priority should be with the patient.

Indeed, doctors and nurses face growing pressures to listen carefully to patients, provide customer service and show empathy as they look for subtle cues that might explain an illness.

"The computer has become a good place to get a result, communicate with other people," said Abraham Verghese, a doctor and professor at the Stanford University Medical Center and a best-selling medical writer. "In the interest of preventing medical error, it's a good friend."

At the same time, he said, the wealth of data on the screen — what he frequently refers to as the "iPatient" — gets all the attention.

"The iPatient is getting wonderful care across America," Dr. Verghese said. "The real patient wonders, 'Where is everybody?' "

It is hard to know the precise impact that distracted doctoring has on patient care, because it is hard to measure. But at least one example puts the risks in sharp relief.

Scott J. Eldredge, a medical malpractice lawyer in Denver, recently represented a patient who was left partly paralyzed after surgery. The neurosurgeon was distracted during the operation, using a wireless headset to talk on his cellphone, Mr. Eldredge said.

"He was making personal calls," Mr. Eldredge said, at least 10 of them to family and business associates, according to phone records. His client's case was settled before a lawsuit was filed so there are no court records, like the name of the patient, doctor or hospital involved. Mr. Eldredge, citing the agreement, declined to provide further details.

Others describe multitasking as relatively commonplace.

"I've seen texting among people I'm supervising in the O.R.," said Dr. Stephen Luczycki, an anesthesiologist and medical director in one of the surgical intensive care units at Yale-New Haven Hospital. He said he had also seen young anesthesiologists using the operating room computer during surgery.

"It is not, unfortunately, uncommon to see them doing any number of things with that computer beyond patient care," Dr. Luczycki said, including checking e-mail and studying or entering logs on a separate case. He said that when he was in training, he was admonished to not even study a textbook in surgery, so he could focus on the rhythm and subtleties of the procedures.

When he uses computers in the intensive care unit, he regularly sees what his colleagues were doing before him.

"Amazon, Gmail, I've seen all sorts of shopping, I've seen eBay," he said. "You name it, I've seen it."

Dr. Luczycki is also a huge fan of technology's positive impact on medicine. So, too, is Dio Sumagaysay, administrative director of 24 operating rooms at Oregon Health and Science University hospitals, even though he has heard about or witnessed instances of people using devices during critical moments.

In early 2010, he heard several complaints that doctors or nurses were using their phones to check or send e-mails even though they were part of a team intubating a patient before surgery.

Mr. Sumagaysay established a policy to make operating rooms "quiet zones," banning any activity that was not focused on patient care. He later had to reprimand a nurse he saw checking airline prices using an operating room computer during a spinal operation.

Medical professionals say young doctors can be particularly susceptible to distraction because they have grown up being constantly connected.

At Stanford Medical School, for example, all students now get iPads, which they use to read medical texts and carry with them in hospitals but are also admonished not let get in the way of their work.

"Devices have a great capacity to reduce risk," Dr. Charles G. Prober, senior associate dean for medical education at the school, said. "But the last thing we want to see, and what is happening in some cases now, is the computer coming between the patient and his doctor."

Thursday, December 15, 2011

Emergency contraceptives over the counter: Are they more dangerous than other drugs? - Slate Magazine

Health and Human Services Secretary Kathleen Sebelius overruled the FDA's recommendationthat emergency contraception be made available over the counter to patients of all ages on Wednesday. Her argument was that its effects on 11-year-olds have not been thoroughly studied. Critics pointed out that many over-the-counter drugs are far more dangerous than emergency contraceptives. What's the most dangerous drug you can buy without a prescription?
It's hard to say. As far as the Explainer can tell, no researcher has ever compared the fatality rates of every drug available over the counter—probably because the number of deaths from overdose of antacids and many other products is so small as to make the study a waste of time. There is, however, a large body of research on pain relievers. Analgesic overdoses are pretty common in the United States. In 2000, poison-control centers received more than 130,000 calls from people who believed they had taken a dangerous amount of an over-the-counter painkiller. Nearly one-half of those calls concerned acetaminophen, best known as the active ingredient in Tylenol. Approximately 0.2 percent of those cases ended in death. That's higher than the reported death rate for nonsteroidal anti-inflammatory drugs like Advil (ibuprofen) and Aleve (naproxen), but lower than the fatality rate for aspirin. (Aspirin is technically in the same category, but is often separated for research purposes.)* However, most of the aspirin deaths appear to have been suicides, while accidental overdose is more common than intentional overdose for acetaminophen. Between the years 1990 and 1998, 458 people died from taking too much acetaminophen.*
Pseudoephedrine, a very common cold medication, is also implicated in a number of deaths every year. In 2004, for example, poison-control centers reported 21 deaths in which the chemical was involved. However, most of those patients took a cocktail of drugs—often including acetaminophen—and many of the cases were ruled suicides. It's also not entirely correct to call pseudoephedrine an over-counter drug. A 2005 act of Congress forced retailers to move it behind the counter because of its use in the production of methamphetamine.
Of course, many other drugs can be fatal if you go way overboard. Even Epsom salts, which are commonly used as a laxative, can cause cardiac arrest. A hospital in Scotland reported a case of attempted suicide by Epsom salts in 2009. The woman ingested an incredible 4.4 pounds of the stuff. She suffered some acute cardiac complications, but doctors were able to save her.

It's not easy to determine the fatal dose of over-the-counter drugs. Take the example of acetaminophen. A person's ability to handle the drug depends on a variety of factors, including the condition of their liver, how much they've eaten, and whether they take the pill in conjunction with alcohol. (Bad idea.) Compared to other over-the-counter drugs, acetaminophen has a relatively narrow safety margin—that is, the difference between a safe-but-effective dose and an overdose is relatively small. Doctors have reported liver failure from as little as 2.5 grams in a day, which is 1.5 grams less than the approved limit.

The FDA has considered reducing the approved daily dose (PDF) of over-the-counter acetaminophen, but that wouldn't help in all cases. Many patients don't realize how much of the drug they're taking. Those who are prescribed the painkiller Percocet, for example, might take over-the-counter acetaminophen as an adjunct for different or breakthrough pain. The problem is that Percoset contains acetaminophen, and the combination can easily put them over the dose limit.
What's the fatal dose of emergency contraceptive? Nobody knows. The drug certainly has side effects, like nausea, vomiting, dizziness, fatigue, and the like. Women who use the morning-after pill as their regular form of contraception can also experience some menstrual irregularities. But no one has taken a fatal dose of Plan B.