Friday, April 15, 2011

Using Hypnosis to Gain More Control Over Your Illness -

KIRSTEN RITCHIE, 44, is no stranger to surgery — nearly 20 years ago, doctors removed four tumors from her brain. She remembers the operation and its aftermath as "horrific."

So the news that she needed brain surgery again was hardly welcome. Determined to make her second operation a better — or at least less traumatic — experience, Ms. Ritchie, an insurancemarketing representative in Cleveland, turned to an unusual treatment.

At the Cleveland Clinic's Center for Integrative Medicine, she had four hypnosis sessions in the month before her procedure, during which she addressed her fear of the coming surgery. She also practiced self-hypnosis every day.

Eventually, she said, "I got to a place where I felt a sense of trust instead of fear."

In February, doctors removed a plum-sized tumor from her brain. But there the similarity to her previous experience ended. Ms. Ritchie woke up from the procedure, she said, feeling "alert and awesome." She ate a full dinner that night and went home in two days.

"My neurosurgeon was stunned at how little medication I required before and after surgery, and how quickly I bounced back," she said.

Ms. Ritchie attributes her speedy recovery and calm state to her hypnosis sessions. Used for more than two centuries to treat a host of medical problems, particularly pain management and anxiety, hypnosis is now available to patients at some of the most respected medical institutions in the country, including Stanford Hospital, the Cleveland Clinic, Mount Sinai Medical Center and Beth Israel Medical Center in New York.

Some critics find the research into mind-body therapies unconvincing, but their skepticism has not deterred patients like Ms. Ritchie. And there are researchers who say they believe that by helping patients feel in better control of their symptoms, hypnosis can reduce the need for medication and lower costs.

"It is an effective and inexpensive way to manage medical care," said Dr. David Spiegel, director of the Center on Stress and Health at Stanford University School of Medicine and a leading authority on hypnosis.

A study by radiologists at Harvard Medical School, published in 2000, found that patients who received hypnosis during surgery required less medication, had fewer complications and shorter procedures than patients who did not have hypnosis. In a follow-up study in 2002, the radiologists concluded that if every patient undergoing catheterization were to receive hypnosis, the cost savings would amount to $338 per patient.

"When patients are groggy from anesthesia drugs, it costs more to recover them," said Dr. Elvira Lang, an associate professor of radiology at Harvard Medical School and a lead author of both studies. "Hypnosis calms patients."

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Thursday, April 14, 2011

When Children With Autism Become Adults -

As the explosion of children who were found to have autism in the 1990s begins to transition from the school to the adult system, experts caution about the coming wave.

"We estimate there are going to be half a million children with autism in the next 10 years who will become adults," said Peter Bell, executive vice president for programs and services of the advocacy group Autism Speaks.

Services for adults with autism exist, but unlike school services, they are not mandated, and there are fewer of them. Combined with shrinking government budgets, the challenges are daunting.

"We are facing a crisis of money and work force," said Nancy Thaler, executive director of the National Association of State Directors of Developmental Disabilities Services. "The cohort of people who will need services — including aging baby boomers — is growing much faster than the cohort of working-age adults that provide care."

To help parents navigate this difficult journey, in January Autism Speaks introduced a free Transition Tool Kit for parents and their adolescent children with autism. The kit includes information about such critical issues as community life, housing, employment and developing self-advocacy skills. The tool kit can be customized by state for those who register online.

"There is a time you have to get over this hump where you are essentially acknowledging that your child is going to have autism for the rest of his life," said Mr. Bell, the father of an 18-year-old son with autism. "Our hope with this kit is to help parents to start planning and not get frozen."

Many young adults with autism have transitioned into large residential systems, whether group homes or institutions, offering round-the-clock services. But waiting lists can be long. And increasingly, in an effort to stem costs, states are moving away from the group home model into family-based care, a trend that started about 10 years ago.

"If an individual needs 24-hour services, the staffing ratio is one to one," said Charlie Lakin, who heads the Research and Training Center on Community Living at the University of Minnesota. "That means fewer people will get served, resulting in long waiting lists for other families." Nationwide, 59 percent of people who receive autism services are living with their families, according to Mr. Lakin.

Living with one's family may not always be best for a person with autism. Nor is it what many families, who assume their grown child will move into a group home, for example, envision for their future. But options are limited, and given the high demand for out-of-home residential services, Mr. Lakin said, "families really need to think about a longer and more central involvement in their adult child's life than they have in the past."

The good news is that many states are providing more support for people with autism who live with their families. They are also giving families greater flexibility and control over budgets with so-called consumer-controlled services, which reimburse families that hire friends or relatives, rather than outside caregivers, for regular care.

Connecticut and Arizona, for example, pay for care provided by family members, a growing trend. Other states, like Pennsylvania, have programs in which contracts are issued for people with autism to live with other families. And Vermont and New Hampshire pioneered a model of providing funding directly to families.

Some families have pooled their own money and entered into cooperatives with other families, a challenge that can take years. Families with children who have developmental disabilities "are relentless advocates and have been the most successful at garnering resources and services," Ms. Thaler said. "I think it may be the vulnerability of people with developmental disabilities that evokes in families and professionals a level of extraordinary empathy that makes them powerful advocates."

Among the most powerful advocates are siblings of those with developmental disabilities. "Sibs have always played a really important role; we just haven't identified them as sibs," Mr. Lakin said. "We've identified them as agency leaders and social workers occupationally. But the real impulse of their work is that they were a sibling."

Don Meyer, the founder and director of the Sibling Support Project and the creator of Sibshops, a network of programs for young siblings of children with special needs, said: "Parents need to share their plans for their special-needs child with their typically developing kids. After Mom and Dad are no longer there, it is likely it will be the brothers and sisters who will ensure their sibling leads a dignified life, living and working in the community."

Mr. Lakin said: "It's really about having people live the best life they can, in the place and with the people they want to live with. There's no magic to that."

Bring on the magicians.

Do Cellphones Cause Brain Cancer? -

On Jan. 21, 1993, the television talk-show host Larry King featured an unexpected guest on his program. It was the evening after Inauguration Day in Washington, and the television audience tuned in expecting political commentary. But King turned, instead, to a young man from Florida, David Reynard, who had filed a tort claim against the cellphone manufacturer NEC and the carrier GTE Mobilnet, claiming that radiation from their phones caused or accelerated the growth of a brain tumor in his wife.

"The tumor was exactly in the pattern of the antenna," Reynard told King. In 1989, Susan Elen Reynard, then 31, was told she had a malignant astrocytoma, a brain cancer that occurs in about 6,000 adults in America each year. To David Reynard, the shape and size of Susan's tumor — a hazy line swerving from the left side of her midbrain to the hindbrain — uncannily resembled a malignant shadow of the phone (but tumors, like clouds, can assume the shapes of our imaginations). Suzy, as she was known, held her phone at precisely that angle against her left ear, her husband said. Reynard underwent surgery for her cancer but to little effect. She died in 1992, just short of her 34th birthday. David was convinced that high doses of radiation from the cellphone was the cause.

Reynard v. NEC — the first tort suit in the United States to claim a link between phone radiation and brain cancer — illustrated one of the most complex conceptual problems in cancer epidemiology. In principle, a risk factor and cancer can intersect in three ways. The first is arguably the simplest. When a rare form of cancer is associated with a rare exposure, the link between the risk and the cancer stands out starkly. The juxtaposition of the rare on the rare is like a statistical lunar eclipse, and the association can often be discerned accurately by observation alone. The discipline of cancer epidemiology originated in one such a confluence: in 1775, a London surgeon, Sir Percivall Pott, discovered that scrotal cancer was much more common in chimney sweeps than in the general population. The link between an unusual malignancy and an uncommon profession was so striking that Pott did not even need statistics to prove the association. Pott thus discovered one of the first clear links between an environmental substance — a "carcinogen" — and a particular subtype of cancer.

The opposite phenomenon occurs when a common exposure is associated with a common form of cancer: the association, rather than popping out, disappears into the background, like white noise. This peculiar form of a statistical vanishing act occurred famously with tobacco smoking and lung cancer. In the mid-1930s, smoking was becoming so common and lung cancer so prevalent that it was often impossible to definitively discern a statistical link between the two. Researchers wondered whether the intersection of the two phenomena was causal or accidental. Asked about the strikingly concomitant increases in lung cancer and smoking rates in the 1930s, Evarts Graham, a surgeon, countered dismissively that "the sale of nylon stockings" had also increased. Tobacco thus became the nylon stockings of cancer epidemiology — invisible as a carcinogen to many researchers, until it was later identified as a major cause of cancer through careful clinical studies in the 1950s and 1960s.

But the most complex and most publicly contentious intersection between a risk factor and cancer often occurs in the third instance, when a common exposure is associated with a rare form of cancer. This is cancer epidemiology's toughest conundrum. The rarity of the cancer provokes a desperate and often corrosive search for a cause ("why, of all people, did I get an astrocytoma?" Susan Reynard must have asked herself). And when patients with brain tumors happen to share a common exposure — in this case, cellphones — the line between cause and coincidence begins to blur. The association does not stand out nor does it disappear into statistical white noise. Instead, it remains suspended, like some sort of peculiar optical illusion that is blurry to some and all too clear to others. (A similarly corrosive intersection of a rare illness, a common exposure and the desperate search for a cause occurred recently in the saga of autism and vaccination. Vaccines are nearly universal, and autism is relatively rare — and many parents, searching to explain why their children became autistic, lunged toward a common culprit: childhood vaccination. An avalanche of panic ensued. It took years of carefully performed clinical trials to finally disprove the link.)

The Florida Circuit Court that heard Reynard v. NEC was quick to discern these complexities. It empathized with David Reynard's search for a tangible cause for his wife's cancer. But it acknowledged that too little was known about such cases; "the uncertainty of the evidence . . . the speculative scientific hypotheses and [incomplete] epidemiological studies" made it impossible to untangle cause from coincidence. David Reynard's claim was rejected in the spring of 1995, three years after it was originally filed. What was needed, the court said, was much deeper and more comprehensive knowledge about cellphones, brain cancer and of the possible intersection of the two.

Allow, then, a thought experiment: what if Susan Reynard was given a diagnosis of astrocytoma in 2011 — but this time, we armed her with the most omniscient of lawyers, the most cutting- edge epidemiological information, the most powerful scientific evidence? Nineteen years and several billion cellphone users later, if Reynard were to reappear in court, what would we now know about a possible link between cellphones and her cancer?

To answer these questions, we need to begin with a more fundamental question: How do we know that anything causes cancer?

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Medicare Re-engineering Raises Tough Questions -

President Obama has deep disagreements with House Republicans about how to address Medicare's long-term problems. But in deciding to wade into the fight over entitlements, which he may address in a speech Wednesday afternoon, the president is signaling that he too believes Medicare must change to avert a potentially crippling fiscal crunch.

So the real issue now is not so much whether to re-engineer Medicare to deal with an aging population and rising medical costs, but how.

Even before they debate specific proposals, lawmakers across the ideological spectrum face several fundamental questions:

Will the federal government retain its dominant role in prescribing benefits and other details of the program, like how much doctors and hospitals are paid and which new treatments are covered? Will beneficiaries still have legally enforceable rights to all those services?

Will Medicare spending still increase automatically with health costs, the number of beneficiaries and the amount of care they receive? Or will the government try to limit the costs to taxpayers by paying a fixed amount each year to private health plans to subsidize coverage for older Americans and those who are disabled?

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Wednesday, April 13, 2011

Giving Doctors Orders -

Giving Doctors Orders

When my brother went into the hospital with pneumonia, he quickly contracted four other infections in the intensive care unit.

Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother's hospital gown.

"It could be anything," he said. "It could be my tie spreading germs."

I was dumbfounded. "Then why do you wear a tie?" I asked. He shrugged and left for rounds.

Michael died in that I.C.U. A couple years later, I read reports about how neckties and lab coats worn by doctors and clinical workers were suspected as carriers of deadly germs. Infections kill 100,000 patients in hospitals and other clinics in the U.S. every year.

A 2004 study of New York City doctors and clinicians discovered that their ties were contagious with at least one type of infectious microbe. Four years ago, the British National health system initiated a "bare below the elbow" dress code barring ties, lab coats, jewelry on the hands and wrists, and long fingernails.

The Centers for Disease Control and Prevention says that health care workers, even doctors and nurses, have a "poor" record of obeying hand-washing rules.

A report in the April issue of Health Affairs indicated that one out of every three people suffer a mistake during a hospital stay.

I saw infractions of the rules in the I.C.U. where Michael died, but I never called out anyone. I was too busy trying to ingratiate myself with the doctors, nurses and orderlies, irrationally hoping that they'd treat my brother better if they liked us.

Commenting on the new report on hospital errors, CNN's senior medical correspondent, Elizabeth Cohen, instructed viewers to "ask doctors and nurses to wash their hands" if they haven't.

"They sometimes will actually give you a hard time, believe it or not," she said, "and they say, 'My gloves are on. I'm clean.' 'Well, I didn't see you put those gloves on. What if you put those on with dirty hands?' "

I called Cohen, the author of "The Empowered Patient," to ask her the best way to confront those taking care of you or family members. She said that you have to get over the "waiter spitting in your soup scenario," that the medical professionals will somehow avenge themselves, by giving less attention, if you insult them.

"There are all sorts of reasons we default to being quiet," she said. "It is general etiquette not to correct another adult, especially when this is their profession. But when the consequences are so grave, you have to summon up your courage." You could say that you are a germaphobe, she suggested, and ask if they could please just indulge you?

Dr. Peter Pronovost of Johns Hopkins has been able to prove in a national program that you can curb infections and reduce mortality rates in I.C.U.'s by adhering to checklists, creating accountability and fostering a culture where patients, their families and even nurses and residents feel freer to challenge doctors.

"There's no doubt that it's really difficult to question physicians," Dr. Pronovost says. "It's hard even for me when my wife or my kids are ill. Many clinicians aren't the most welcoming. They give verbal or nonverbal clues to say, 'Hey, I have the answer.' We just need to change the culture. The patient really is the North Star."

I decided to work up my courage to give orders to unmindful doctors by starting with another group that has you at their mercy: cabdrivers.

They, too, can put our lives at risk by being heedless. Their constant yammering on cellphones can be just as dangerous as drunken driving, whether the calls are on hand-held or hands-free devices.

As Jane E. Brody noted in The Times, the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association has started a campaign against distracted driving. "Orthopedists would do very well, thank you," she wrote, "without the business generated by the 307,369 crashes that have occurred so far this year."

The other day, I finally asked a driver who was absorbed in animated conversation to hang up. But on my next cab ride when the same thing happened, I lost my nerve. I had read that Alec Baldwin was, not surprisingly, a master at demanding that cabdrivers get off their phones. I called and asked for some pointers.

"I tell them to shut off the radio, get off the phone and post their license, because very often the man driving the cab is not the guy on the license," he said. "If you get in a cab you don't feel comfortable in, get out of that cab."

I told Baldwin that I would start giving orders, when necessary, to cabdrivers and clinicians, even though I feared their wrath.

"Of course," mused the actor who so memorably played an evil doctor in "Malice," "cabdrivers don't put you under anesthesia."