Friday, January 21, 2011

iPad health care use by doctors, a comprehensive infographic

MobiHealthNews released a comprehensive infographic on physician use of the iPad, a distillation of their report on the issue.

The iPad has been covered previously on this site. The form factor holds tremendous potential, as this Dartmouth physician noted, "the iPad offers a 'low profile' that doesn't seem intimidating to patients during exams." That's especially important as it can allow doctors to maintain eye contact with their patients, versus the more intrusive laptop.

The bottom line remains, however: it's all about the apps.  Especially those that interact with patient electronic medical records is where the iPad holds the most promise.  Software will be the major determinant in how quickly physicians will take to Apple's tablet.

Furthermore, young doctors need embrace it. That's starting already, with some medical schools giving their students free iPads. Future widespread physician adoption is necessitated by today's medical students viewing it as an indispensable tool as they train.

A Century of Vaccine Scares -

Despite overwhelming evidence to the contrary, roughly one in five Americans believes that vaccines cause autism — a disturbing fact that will probably hold true even after the publication this month, in a British medical journal, of a report thoroughly debunking the 1998 paper that began the vaccine-autism scare.

That's because the public's underlying fear of vaccines goes much deeper than a single paper. Until officials realize that, and learn how to counter such deep-seated concerns, the paranoia — and the public-health risk it poses — will remain.

The evidence against the original article and its author, a British medical researcher named Andrew Wakefield, is damning. Among other things, he is said to have received payment for his research from a lawyer involved in a suit against a vaccine manufacturer; in response, Britain's General Medical Council struck him from the medical register last May. As the journal's editor put it, the assertion that the measles-mumps-rubella vaccine caused autism "was based not on bad science but on a deliberate fraud."

But public fear of vaccines did not originate with Dr. Wakefield's paper. Rather, his claims tapped into a reservoir of doubt and resentment toward this life-saving, but never risk-free, technology.

Vaccines have had to fight against public skepticism from the beginning. In 1802, after Edward Jenner published his first results claiming that scratching cowpox pus into the arms of healthy children could protect them against smallpox, a political cartoon appeared showing newly vaccinated people with hooves and horns.

Nevertheless, during the 19th century vaccines became central to public-health efforts in England, Europe and the Americas, and several countries began to require vaccinations.

Such a move didn't sit comfortably with many people, who saw mandatory vaccinations as an invasion of their personal liberty. An antivaccine movement began to build and, though vilified by the mainstream medical profession, soon boasted a substantial popular base and several prominent supporters, including Frederick Douglass, Leo Tolstoy and George Bernard Shaw, who called vaccinations "a peculiarly filthy piece of witchcraft."

In America, popular opposition peaked during the smallpox epidemic at the turn of the 20th century. Health officials ordered vaccinations in public schools, in factories and on the nation's railroads; club-wielding New York City policemen enforced vaccinations in crowded immigrant tenements, while Texas Rangers and the United States Cavalry provided muscle for vaccinators along the Mexican border.

Public resistance was immediate, from riots and school strikes to lobbying and a groundswell of litigation that eventually reached the Supreme Court. Newspapers, notably this one, dismissed antivaccinationists as "benighted and deranged" and "hopeless cranks."

But the opposition reflected complex attitudes toward medicine and the government. Many African-Americans, long neglected or mistreated by the white medical profession, doubted the vaccinators' motives. Christian Scientists protested the laws as an assault on religious liberty. And workers feared, with good reason, that vaccines would inflame their arms and cost them several days' wages.

Understandably, advocates for universal immunization then and now have tended to see only the harm done by their critics. But in retrospect, such wariness was justified: at the time, health officials ordered vaccinations without ensuring the vaccines were safe and effective.

Public confidence in vaccines collapsed in the fall of 1901 when newspapers linked the deaths of nine schoolchildren in Camden, N.J., to a commercial vaccine allegedly tainted with tetanus. In St. Louis, 13 more schoolchildren died of tetanus after treatment with the diphtheria antitoxin. It was decades before many Americans were willing to submit to public vaccination campaigns again.

Nevertheless, the vaccination controversy of the last century did leave a positive legacy. Seeking to restore confidence after the deaths in Camden and St. Louis, Congress enacted the Biologics Control Act of 1902, establishing the first federal regulation of the nation's growing vaccine industry. Confronted with numerous antivaccination lawsuits, state and federal courts established new standards that balanced public health and civil liberties.

Most important, popular resistance taught government officials that when it comes to public health, education can be more effective than brute force. By midcentury, awareness efforts had proven critical to the polio and smallpox vaccination efforts, both of which were huge successes.

One would think such education efforts would no longer be necessary. After all, today's vaccines are safer, subject to extensive regulatory controls. And shots are far more numerous: as of 2010, the Centers for Disease Control recommended that every child receive 10 different vaccinations. For most Americans, vaccines are a fact of life.

Still, according to a 2010 C.D.C. report, 40 percent of American parents with young children have delayed or refused one or more vaccines for their child. That's in part because vaccines have been so successful that any risk associated with their use, however statistically small, takes on an elevated significance.

It also doesn't help that, thanks to the Internet, a bottomless archive of misinformation, including Dr. Wakefield's debunked work, is just a few keystrokes away. All of which means the public health community must work even harder to spread the positive news about vaccines.

Health officials often get frustrated with public misconceptions about vaccines; at the turn of the last century, one frustrated Kentucky health officer pined for the arrival of "the fool-killer" — an outbreak of smallpox devastating enough to convince his skeptical rural constituency of the value of vaccination.

But that's no way to run a health system. Our public health leaders would do far better to adopt the strategy used by one forward-thinking federal health official from the early 20th century, C. P. Wertenbaker of the Public Health and Marine-Hospital Service.

As smallpox raged across the American South, Wertenbaker journeyed to small communities and delivered speech after speech on vaccinations before swelling audiences of townsfolk, farmers and families. He listened and replied to people's fears. He told them about the horrors of smallpox. He candidly presented the latest scientific information about the benefits and risks of vaccination. And he urged his audiences to protect themselves and one another by taking the vaccine. By the time he was done, many of his listeners were already rolling up their sleeves.

America's public health leaders need to do the same, to reclaim the town square with a candid national conversation about the real risks of vaccines, which are minuscule compared with their benefits. Why waste another breath vilifying the antivaccination minority when steps can be taken to expand the pro-vaccine majority?

Obstetricians, midwives and pediatricians should present the facts about vaccines and the nasty diseases they prevent early and often to expectant parents. Health agencies should mobilize local parents' organizations to publicize, in realistic terms, the hazards that unvaccinated children can pose to everyone else in their communities. And health officials must redouble their efforts to harness the power of the Internet and spread the good word about vaccines.

You can bet that Wertenbaker would have done the same thing.

Michael Willrich, an associate professor of history at Brandeis University, is the author of the forthcoming "Pox: An American History."

Sports Psychologist Says NFL's "Warrior Culture" Has To Change Before The Concussion Problem Can Be Fixed

It took the NFL a long while to get it's act together regarding concussions, but it's starting to make progress. 

Sharon Chirban, a sports psychologist at a concussion clinic associated with Children's Hospital in Boston, says that at first the NFL was ignoring data and overtures by medical and psychological experts that showed the severity of the league's concussion problem, but recently it has reversed course.

"I often think cynically that it's politics and money — and it's not that I think the NFL wouldn't want to value player health, but they are often slow in responding to player health as the number one reason to introduce new technology."

It seems obvious that the NFL should have been making every effort to prevent severe head injuries for a long time, but Chirban makes a good point that the culture of football rewards acts of toughness and bravery over a player's health.

"It seems so obvious outside of the culture of sports, but I do fully appreciate that that sports ethic has really overvalued sacrificing the body for the outcome," Chirban says.  "That's just been part of the culture.  I can speak in two ways about it.  It's about time, and I get it. 

The concussion issue won't be solved overnight, but there have been encouraging signs of change.  Chirban says that players are starting to handle concussions with more caution than before.

"It's no longer humiliating to be out for concussions.  It used to be a badge of honor – 'Yeah, I was seeing stars but I went back in and I made this play.'  The players have placed their own health in higher regard."

The NFL has worked to increase awareness this season and has been levying more consistent fines on defenders that deliver blows to the head.  Those efforts will be aided by the implementation and improvement of various new technologies. 

Next season, the league will place sensors in NFL helmets that measure the g-force of impact.  If a player were hit hard enough, the sensor would provide a numerical reading that indicates the player has suffered a concussion. 

The next step could be the wide-scale implementation of impact testing, a neuro-psychological assessment already used by the Steelers when they were testing Ben Roethlisberger a few years ago.  The instrument could go a long way toward judging when it is safe for concussed players to return to action.

It's impossible to say whether the NFL's increased efforts have had a major affect yet, but there is reason for hope.  More concussions were reported in 2010 than ever before as the league has been working to protect players from returning too early when the consequences could be dangerous.  It's part of a "collective voice of people putting players' health before wins and losses.

Concussions will never be eliminated from a game as violent as football, but Chirban thinks that there will be major progress over the next few years.  She compares simple prevention measures like sensors in helmets to seat belts in cars. 

"It becomes part of the industry standard because we just get it that we have to force people to be cautious, otherwise they can cause injury or death to themselves or others in unnecessary ways.  So when you legislate something like a seat belt – seat belts still don't stop whiplash.  But they can provide a standard that keeps people safer.  As long as people drive cars there is going to be whiplash and as long as people play football there are going to be concussions... What we can do is make it safer."

Chirban says the key is to maximize prevention, improve recovery, and make sure that players don't return to the field before it's healthy to do so. 

While Chirban certainly wants the concussion problem fixed in the NFL, the league's increased attention to head injuries also has a major impact on youth sports.  Youth and high school leagues around the country now require medical clearance for any athlete that suffers a head injury to return to the field.  Chirban thinks the NFL's influence on concussions extends even farther than that.

"If your favorite player is out for four playoff games because they actually had a concussion and it's taken seriously, those developing athletes are more likely to take their own health seriously.  So it has a dramatic impact on the culture of football."

If Chirban is right, and that culture is actually beginning to change, we may see major progress in the treatment and prevention of concussions in the coming years. 

"I get why this takes so long, because there's really a culture change happening as well."

Thursday, January 20, 2011

Lindros: Players' disdain for each other poisonous - The Globe and Mail

His words are measured and without self-pity. Yes, he will add his voice to those crying out for more respect among National Hockey League players, but attempts to get Eric Lindros to connect his own history of concussions to what Sidney Crosby is going through, or about to go through, get nowhere.

After a career ruined by six concussions and resulting political battles with a game and power structure that didn't want to know what it was really dealing with, Lindros is all too aware that each concussion, let alone each person's response to it, is unique, both in terms of rehabilitation and reintegration into the game. The star player is targeted; the third or fourth-liner worries about his job. Culture change? Good luck with that.

"What happens is you get tagged as being concussion prone, and there's a huge decline in the respect you get because of it," Lindros said in a telephone interview on Wednesday. "It's people trying to make their name, you know? It's little things that occur after the play, like when it switches out of the corner and the play goes up the ice and you're spinning around heading back up to back check and – bam! You know … where they kind of catch you."

Is culture change coming to the NHL as a result of Crosby's concussion? Or could it be that the only thing that has now happened is that Crosby has just had a target put on his back for the rest of his career? The answer depends on whether NHL players and agents realize how utterly daft they look.

Forget the owners. Forget Gary Bettman or Colin Campbell. They live in a muddle of money and rules and politics; by nature they can't see the forest for the trees. They are lost causes. The agents are speaking up – some of them, at least – but mostly to throw the issue in the lap of the National Hockey League Players' Association.

Note to the agents: You want change? Spend some money and get everybody together at the all-star game and go behind a locked door. Keep the press out. Turn off the BlackBerries. And read your players the riot act. Stress zero tolerance for a shot to the head, any hit above the shoulders. Then lobby for Draconian suspensions. If a few players get screwed for clearly accidental hits? Too bad. The game will go on without them.


"Well, we used to talk about this all the time when I was at the players' association," Lindros says, his voice trailing off.

You wait for the next statement. It never comes.

Lindros believes the seminal moment for the discussion of concussions and sports occurred in October of 2009 when the iconic CBS newsmagazine 60 Minutes devoted a segment to concussions among NFL players and a possible link to early-onset dementia. "That's when the big push finally started, it seems," Lindros said. "The pressure initially was on the NFL. But then it moved to other organizations."

Is this the NHL's come-to-Jesus moment? As Lindros noted, it is both "ironic and unfortunate" that it appears as if it's taken a concussion sustained by the game's biggest name to create at least a sense of movement. Once upon a time he was that name – or one of them – and nobody seemed to learn much from the lesson that was his career.

So let's see what happens the first time Crosby is back on the ice and in a vulnerable position, with some rock-head circling. "Guys take liberties," Lindros said matter-of-factly. That they do, and until that stops, there will be no culture change. Just lost opportunity and, most likely, more lost careers.

The NHL can't say it wasn't warned.

Crosby’s injury raises concerns about unpredictable concussion symptoms - The Globe and Mail

It was the way Sidney Crosby struggled to his feet after being blindsided in the Winter Classic game that convinced neurologist Richard Wennberg the star centre had sustained a concussion.

"To see it was painfully obvious. The telling sign was when he tried to get up," said Dr. Wennberg, a University of Toronto concussion expert who also acts as a consultant to the National Hockey League's Players' Association.

Mr. Crosby's right foot slipped behind him as he got back on his feet, Dr. Wennberg said, and his mouth guard slipped out of his mouth – subtle signs that that the hit from Washington Capitals winger David Steckel jarred Mr. Crosby's brain.

So how could Mr. Crosby have been allowed to finish the Winter Classic and continue playing the next week?

The short answer is that he displayed none of the classic symptoms of concussion, which would have caused officials to pull him from the game. If trainers or doctors see one or more of those symptoms, they'll typically withdraw the player and ask him questions to determine whether he's okay.

Mr. Crosby had a sore neck, but experts say that alone is not usually a sign of a concussion. Concussions are not visible injuries and athletes are notoriously loath to admit to weakness or be pulled out of games.

The danger is that when the NHL's most famous player was hit a few days later, making his return to the game uncertain, his risk of more damage would have been increased if he had already suffered a concussion on Jan. 1, according to neuroscientists.

Critics are growing increasingly vocal in saying that if the rules for when a player is pulled out of a game after a hit to the head were followed in Mr. Crosby's case, perhaps the rules need to be changed. And this week, even Mr. Crosby's agent called on the league to consider making all contact with the head illegal.

Dr. Wennberg said he understands the pressure on the team trainer not to remove a star player from such a high-profile game, especially since Mr. Crosby didn't report of any of the constellation of symptoms used to assess whether a player has a concussion, including dizziness, headache, nausea and vomiting, blurred vision and confusion.

As such, Mr. Crosby's case illustrates the difficulties – and broad array of occasionally contradictory expert medical opinion – in assessing what is an uncommonly tricky and unpredictable injury.

Charles Tator, an eminent University Health Network neurosurgeon and leading authority on concussions, reviewed a video of the Jan. 1 hit, but couldn't tell whether Mr. Crosby sustained a concussion from what he nonetheless described as a "highly offensive, vicious hit."

It takes an experienced professional about five minutes to assess whether a player likely suffered a concussion, he said. They have to be inquisitive and ferret out symptoms.

"You need to ask some searching questions about how a player is functioning," said Dr. Tator, who is also based in Toronto.

More ...

1 in 5 Cancer Survivors Suffers Chronic Pain, Study Finds

More than 40 percent of cancer survivors experience pain, and the risk is highest among black and female patients, finds a new study.

Researchers at the University of Michigan Health System surveyed nearly 200 U.S. cancer survivors and found that 43 percent had experienced pain since their diagnosis, and 20 percent suffered chronic cancer-related pain at least two years later.

Among white patients, the most significant source of pain was cancer surgery (53.8 percent), and among black patients the greatest source of pain was cancer treatment (46.2 percent), according to the report.

In addition, the study found that compared to men, women had more pain, more pain flare-ups, more disability due to pain and were more depressed because of pain.

The authors also noted that black patients were more likely to report greater severity of pain and more pain-related disability, and also expressed more concern about harmful pain treatment side effects.

The study was released online in advance of publication in an upcoming print issue of the journal Cancer.

"All in all, the high prevalence of cancer and pain and now chronic cancer pain among these survivors, especially blacks and women, shows there's more work to be done in improving the quality of care and research," lead author and pain medicine specialist Dr. Carmen R. Green, a professor of anesthesiology, obstetrics and gynecology and health management and policy at the University of Michigan, said in a university news release.

Poor pain management may be the result of patient and physician attitudes and lack of knowledge, the researchers suggested. For example, patients and doctors may minimize pain complaints because they're worried about the pain medication side effects, such as addiction, or fear that pain is a sign that the cancer has gotten worse.

"When necessary and appropriate there are a variety of therapies available to address pain and improve [patients'] well-being," Green said.

Wednesday, January 19, 2011

Patient Voices: Rare Diseases - Interactive Feature -

Living with any disease can be a trial, but patients with rare conditions face a host of uniquely difficult challenges. Simply getting an accurate diagnosis can be an enormous task, and many with poorly understood illnesses struggle with isolation and loneliness. Here six men and women talk about how their lives have been most affected by rare conditions.

One in 16 U.S. surgeons consider suicide: survey | Reuters

A considerable number of U.S. surgeons struggle with thoughts of suicide, with burnout and past medical errors as possible reasons, according to a survey covering thousands of surgeons.

A team led by Tait Shanafelt of the Mayo Clinic in Rochester, Minnesota found that more than 6 percent of surgeons had thought about killing themselves within the past year.

Among those aged 55 to 64, the number was three times higher than national levels for that age group.

"What we are seeing through this work is that there is a high amount of burnout and stress among America's physicians, with potentially serious consequences for both physicians and their patients," Shanafelt said.

"It isn't necessarily that having thoughts of suicide endangers patient health, but some of the same root causes, particularly burnout, do appear to have a strong relationship with quality of care."

In a survey published last year, Shanafelt's team found that surgeons who reported high degrees of emotional exhaustion on the job also had higher odds of making major errors when they dealt with patients.

The same survey, based on responses from more than 7,900 physicians, for the current study, which appears in the Archives of Surgery.

While younger surgeons had rates of suicidal thinking that were similar to those in the general population, between 6 and 7 percent, those older than 45 were at increased risk.

Among those 55 to 64 years old, 7 percent of surgeons had considered suicide within the past year, compared to about 2 percent of the general population.

Doctors who felt burned out, or said they'd made a "major medical error" in the past 3 months, were more prone to suicidal thoughts.

Married surgeons, and those working in large university-based medical centers, were at lower risk for suicidal thoughts.

The survey also showed that only a fourth of the troubled surgeons had sought professional help, with most saying they hadn't out of fear of losing their medical license.

Instead, some chose to self-prescribe antidepressants or have friends do it for them.

"We've known for some time that physicians are at greater risk for suicide than other professions, although why that is has never really been understood," Shanafelt told Reuters Health.

According to the National Institutes of Mental Health, there were about 11 suicide deaths per 100,000 Americans in 2007.

Statin benefits questioned in low-risk patients | Reuters

People without heart disease should think twice before taking cholesterol-lowering statins, British researchers warn in a report out Wednesday.

While the popular drugs require a prescription in the US, they are sold over the counter in England, and one in three Brits over 40 are currently using them, according to researchers from the London School of Hygiene & Tropical Medicine.

In a review of the medical literature, they found the drugs did appear to slash deaths ever so slightly in patients at low risk of heart disease. But many of the reports they looked at -- all but one funded by drugmakers -- were flawed.

In particular, while all the studies focused on benefits, only half provided information on the side effects of the drugs, said Dr. Shah Ebrahim, whose group's findings are published by the Cochrane Collaboration, an international organization that evaluates medical research.

"There is evidence that the reports cherry-picked the best outcomes for presentation," he added, "which will tend to inflate apparent benefits of treatment."

Ebrahim and colleagues found 14 trials that tested statins in more than 34,000 patients, most of whom were considered at low risk of heart attack and strokes -- the world's top killers.

Pooling the results, they estimated that treating 1,000 people with statins for one year would lower the number of deaths from nine to eight.

Statins -- including Pfizer's Lipitor and AstraZeneca's Crestor -- help prevent new heart attacks in people who've already had one, but the effects are less certain in individuals at lower risk.

The drugs also appeared to reduce the number of heart attacks and strokes -- fatal and not -- and the need for surgery.

While there appeared to be no difference in side effects between trials participants taking dummy pills and statins, the researchers say those results aren't credible.

"Any appraisal we can make of adverse events is biased by failure to report these events," Ebrahim said in an e-mail to Reuters Health.

"We believe that trial funders, investigators and journal editors have failed to provide adequate information to doctors and their patients to assess the benefits and harms of statins in primary prevention."

One statin, a generic drug called simvastatin, is already available in low doses over the counter at pharmacies in Britain without a prescription, at a cost of only a few pence per pill.

But Ebrahim advised people to think twice before buying the drug, even if they have raised cholesterol levels.

"If you have self-prescribed a statin, buy it "over the counter" in a pharmacy, or do not know your level of risk and are taking a statin, get a check of your level of cardiovascular risk and discuss your decision with your family doctor," he urged.

Pfizer said it was still reviewing the new report, but noted that the safety and efficacy of Lipitor has been studied in more than 80,000 patients.

"Managing cardiovascular disease risk factors is complicated, and prescribing decisions should be based on a physician's full assessment of each patient's individual risk factors and needs," said spokesman MacKay Jimeson.

Dr. Franz Messerli, who heads the hypertension program at two New York hospitals, St. Luke's and Roosevelt, echoed the cautious message from the British researchers.

While statins are pretty safe drugs, Messerli said, they may cause muscle and joint pain in some patients. And their long-term effect on muscle tissue is unknown.

"If you have a very small benefit, you better make sure that the downside is minimal," he told Reuters Health.