Saturday, May 14, 2011

What’s the Best Exercise? -

Let's consider the butterfly. One of the most taxing movements in sports, the butterfly requires greater energy than bicycling at 14 miles per hour, running a 10-minute mile, playing competitive basketball or carrying furniture upstairs. It burns more calories, demands larger doses of oxygen and elicits more fatigue than those other activities, meaning that over time it should increase a swimmer's endurance and contribute to weight control.

So is the butterfly the best single exercise that there is? Well, no. The butterfly "would probably get my vote for the worst" exercise, said Greg Whyte, a professor of sport and exercise science at Liverpool John Moores University in England and a past Olympian in the modern pentathlon, known for his swimming. The butterfly, he said, is "miserable, isolating, painful." It requires a coach, a pool and ideally supplemental weight and flexibility training to reduce the high risk of injury.

Ask a dozen physiologists which exercise is best, and you'll get a dozen wildly divergent replies. "Trying to choose" a single best exercise is "like trying to condense the entire field" of exercise science, said Martin Gibala, the chairman of the department of kinesiology at McMaster University in Hamilton, Ontario.

But when pressed, he suggested one of the foundations of old-fashioned calisthenics: the burpee, in which you drop to the ground, kick your feet out behind you, pull your feet back in and leap up as high as you can. "It builds muscles. It builds endurance." He paused. "But it's hard to imagine most people enjoying" an all-burpees program, "or sticking with it for long."

And sticking with an exercise is key, even if you don't spend a lot of time working out. The health benefits of activity follow a breathtakingly steep curve. "The majority of the mortality-related benefits" from exercising are due to the first 30 minutes of exercise, said Timothy Church, M.D., who holds the John S. McIlhenny endowed chair in health wisdom at the Pennington Biomedical Research Center in Baton Rouge, La. A recent meta-analysis of studies about exercise and mortality showed that, in general, a sedentary person's risk of dying prematurely from any cause plummeted by nearly 20 percent if he or she began brisk walking (or the equivalent) for 30 minutes five times a week. If he or she tripled that amount, for instance, to 90 minutes of exercise four or five times a week, his or her risk of premature death dropped by only another 4 percent. So the one indisputable aspect of the single best exercise is that it be sustainable. From there, though, the debate grows heated.

"I personally think that brisk walking is far and away the single best exercise," said Michael Joyner, M.D., a professor of anesthesiology at the Mayo Clinic in Rochester, Minn., and a leading researcher in the field of endurance exercise.

As proof, he points to the work of Hiroshi Nose, M.D., Ph.D., a professor of sports medical sciences at Shinshu University Graduate School of Medicine in Japan, who has enrolled thousands of older Japanese citizens in an innovative, five-month-long program of brisk, interval-style walking (three minutes of fast walking, followed by three minutes of slower walking, repeated 10 times). The results have been striking. "Physical fitness — maximal aerobic power and thigh muscle strength — increased by about 20 percent," Dr. Nose wrote in an e-mail, "which is sure to make you feel about 10 years younger than before training." The walkers' "symptoms of lifestyle-related diseases (hypertension, hyperglycemia and obesity) decreased by about 20 percent," he added, while their depression scores dropped by half.

Walking has also been shown by other researchers to aid materially in weight control. A 15-year study found that middle-aged women who walked for at least an hour a day maintained their weight over the decades. Those who didn't gained weight. In addition, a recent seminal study found that when older people started a regular program of brisk walking, the volume of their hippocampus, a portion of the brain involved in memory, increased significantly.

But let's face it, walking holds little appeal — or physiological benefit — for anyone who already exercises. "I nominate the squat," said Stuart Phillips, Ph.D., a professor of kinesiology at McMaster University and an expert on the effects of resistance training on the human body. The squat "activates the body's biggest muscles, those in the buttocks, back and legs." It's simple. "Just fold your arms across your chest," he said, "bend your knees and lower your trunk until your thighs are about parallel with the floor. Do that 25 times. It's a very potent exercise." Use a barbell once the body-weight squats grow easy.

The squat, and weight training in general, are particularly good at combating sarcopenia, he said, or the inevitable and debilitating loss of muscle mass that accompanies advancing age. "Each of us is experiencing sarcopenia right this minute," he said. "We just don't realize it." Endurance exercise, he added, unlike resistance training, does little to slow the condition.

Resistance training is good for weight control, as well. In studies conducted by other researchers, a regimen of simple weight training by sedentary men and women led to a significant decrease in waist circumference and abdominal fat. It also has been found to lower the risk of developing diabetes and cardiovascular disease. Counterintuitively, weight training may even improve cardiovascular fitness, Phillips said, as measured by changes in a person's VO2max, or the maximum amount of oxygen that the heart and lungs can deliver to the muscles. Most physiologists believe that only endurance-exercise training can raise someone's VO2max. But in small experiments, he said, weight training, by itself, effectively increased cardiovascular fitness.

"I used to run marathons," he said. Now he mostly weight-trains, "and I'm in better shape."

But there's something undignified and boring about a squats-only routine. And the science supporting weight training as an all-purpose exercise approach, while provocative, remains inconclusive. Is there a single activity that has proved to be, at once, more strenuous than walking while building power like the squat?

"I think, actually, that you can make a strong case for H.I.T.," Gibala said. High-intensity interval training, or H.I.T. as it's familiarly known among physiologists, is essentially all-interval exercise. As studied in Gibala's lab, it involves grunting through a series of short, strenuous intervals on specialized stationary bicycles, known as Wingate ergometers. In his first experiments, riders completed 30 seconds of cycling at the highest intensity the riders could stand. After resting for four minutes, the volunteers repeated the interval several times, for a total of two to three minutes of extremely intense exercise. After two weeks, the H.I.T. riders, with less than 20 minutes of hard effort behind them, had increased their aerobic capacity as much as riders who had pedaled leisurely for more than 10 hours. Other researchers also have found that H.I.T. reduces blood-sugar levels and diabetes risk, and Gibala anticipates that it will aid in weight control, although he hasn't studied that topic fully yet.

The approach seems promising, since most of us have minimal time to exercise each week. Gibala last month published a new study of H.I.T., requiring only a stationary bicycle and some degree of grit. In this modified version, you sprint for 60 seconds at a pace that feels unpleasant but sustainable, followed by 60 seconds of pedaling easily, then another 60-second sprint and recovery, 10 times in all. "There's no particular reason why" H.I.T. shouldn't be adaptable to almost any sport, Gibala said, as long as you adequately push yourself.

Of course, to be effective, H.I.T. must hurt. But a study published last month found that when a group of recreational runners practiced H.I.T. on the track, they enjoyed the workout more than a second group of runners who jogged continuously for 50 minutes. The H.I.T. runners, the study's authors suspect, were less bored.

The only glaring inadequacy of H.I.T. is that it builds muscular strength less effectively than, say, the squat. But even that can be partially remedied, Gibala said: "Sprinting up stairs is a power workout and interval session simultaneously."Meaning that running up steps just might be the single best exercise of all. Great news for those of us who could never master the butterfly.

Friday, May 13, 2011

Why Your Stitches Cost $1,500 – Part One

The United States has fallen behind other nations, failing to provide affordable health care to its citizens. Americans spend $477 billion a year MORE on health care than other advanced countries. So why do we pay so much compared to other wealthy nations? This infographic is part one in a two part series which dissects the state of our health care system and presents some alarming numbers.

The real reasons why our health care costs are so high - Roger Ebert's Journal

Thursday, May 12, 2011

Desperate Americans Buy Kidneys From Peru Poor in Fatal Trade - Bloomberg

Luis Picado's mother remembers the day her son thought he had won the lottery. He came home to their tin-roofed cinder-block house in a Managua, Nicaragua, slum and said he'd found a way to escape poverty and start a new life in the United States.

An American man had promised to give Picado, a 23-year-old high school dropout who worked as a construction laborer, a job and an apartment in New York if he'd donate one of his kidneys. He jumped at the deal, his mother says.

Three weeks later, in May 2009, Picado came out of surgery at Managua's Military Hospital, bleeding internally from the artery doctors had severed to remove his kidney, according to medical records. His mother, Elizabeth Tercero, got on her knees next to her son's bed in the recovery room and prayed, Bloomberg Markets magazine reports in its June issue.

"I told my boy not to worry, that I would take care of him," Tercero, 49, says. "But it was too late." Picado bled to death as doctors tried to save him, according to a coroner's report. "He was always chasing the American dream, and finally, it cost him his life," she says.

Matthew Ryan, the American man, suffered a similar fate. Ryan, a 68-year-old retired bus company supervisor in New York, died two months after receiving Picado's kidney in the same hospital.

Nicaraguan postmortem reports cited the transplant as a cause of death for both men. Prosecutors in Managua are now investigating whether anyone broke a Nicaraguan law that prohibits paying a donor for an organ.

Illicit Market

The two men were participants in a growing and illicit market for organ transplants that spans the globe. Every year, about 5,000 gravely ill people from countries including the U.S., Israeland Saudi Arabia pay others to donate an organ, says Francis Delmonico, a Harvard Medical School professor and surgeon. The practice is illegal in every country except Iran, Delmonico says.

Affluent, often desperately ill patients travel to countries such asEgypt, Peru and the Philippines, where poor people sell them their organs. In Latin America, the transplants are usually arranged by unlicensed brokers. They're performed -- for fees -- by accredited surgeons, some of whom have trained at the world's leading medical schools.

The global demand for organs far exceeds the available supply. In the U.S., 110,693 people are on waiting lists for organs, and fewer than 15,000 donors are found annually.

Americans who go abroad for illicit transplants can contract infections or HIV from unhealthy donors, posing a public health threat when they return, Delmonico says.

More ...

Wednesday, May 11, 2011

Bad consequences from good ideas - Rx for Danger - The Buffalo News

The rising use of prescription painkillers represents the best and worst of medicine.

A movement in recent decades to treat pain more aggressively has brought relief to many patients, allowing them to work and live better-quality lives.

But it has exacted a steep price -- an epidemic of drug overdoses, deaths and narcotic drugs diverted to illegal street sales.

"We've got two big public health problems -- millions of people in pain who can benefit from opioids and the exponential rise in prescription drug abuse. The drugs aren't dangerous. But they have to be used thoughtfully," said Steven Passik, a clinical psychologist at Memorial Sloan-Kettering Cancer Center in Manhattan.

Passik and other pain care experts recall that it wasn't so long ago when doctors were reluctant to treat pain with prescription narcotics. No more.

Physicians prescribed 257 million opioids in 2009, an amount that translates into billions of doses. Opioid sales in the United States increased 627 percent from 1997 to 2007, according to data presented recently by the Centers for Disease Control and Prevention.

What happened illustrates how something created to do good can also have unintended bad consequences.

The spread of hospice in the 1970s brought attention to the undertreatment of pain in cancer patients. In response, the prescribing of opioids to cancer patients and those near death became accepted practice.

Physicians and advocacy groups then pushed for greater use of narcotics to treat longer-term pain in patients with noncancer ailments as well. They were aided by the conventional wisdom at the time, based on what little research was available, that said opioids rarely caused addiction or other problems.

Attitudes about pain and its treatment began to change.

In the 1990s, health care organizations issued broad principles for the management of chronic pain. Others promoted pain relief as a patient right.

States passed laws and rules to lessen fear among doctors of criminal charges or professional sanctions.

By 2001, the Department of Veterans Affairs adopted the American Pain Society's concept of pain as the "fifth vital sign," encouraging physicians to assess for pain just as they would check a pulse. The Joint Commission, which accredits hospitals and nursing homes, also started using guidelines requiring the measurement of pain.

Meanwhile, pharmaceutical companies aggressively promoted painkillers to doctors, many of whom receive little or no training in pain management or drug addiction.

Critics cite Purdue Frederick, parent company of Purdue Pharma, to show how marketing amplified the availability of prescription narcotics. In 2001 alone, the company spent $200 million to promote OxyContin, a drug that abusers crushed to defeat its extended-release action.

Purdue denied such a connection in 2007 when three executives pleaded guilty to a misdemeanor charge that the company misled doctors by claiming OxyContin was less addictive than other painkillers because it was long-acting.

"It's hard to overstate the devastation OxyContin brought to the coal states. There was a tsunami of addiction," said Dr. Art Van Zee, a Virginia physician who has written about Purdue.

But perspectives vary on the issue, and doctors bear the ultimate responsibility for making medical decisions.

Ellen Battista, a Buffalo pain specialist, cautioned against overemphasizing the role of drug companies.

"The pharmaceutical industry doesn't take our pens and write prescriptions," she said.

All the influences led more doctors, often encouraged by patients, to prescribe opioids more often and in larger doses to more people in pursuit of an elusive goal -- the end of pain.

Unfortunately, it turned out that treating cancer patients with prescription painkillers was not the same as treating pain in the general population. The risks and benefits of long-term narcotic use for chronic pain proved to be much trickier than originally thought, requiring a cautious approach and closer supervision of patients.

"The medical community underestimated its power to make things worse. We created a culture that says existential suffering can be treated by a pill, procedure or device," said Dr. Alex Cahana, a pain specialist involved in developing new regulations in Washington State.

Increasingly, physicians were being duped by patients, while others were either out of date with appropriate opioid prescribing, dishonest or disabled by the drugs themselves.

"When you look back, there was a rallying cry to treat chronic pain more effectively," said Aaron M. Gilson, senior researcher at the University of Wisconsin's Pain & Policy Studies Group. "But there wasn't a firm foundation of education, skills or research to do it."

Tuesday, May 10, 2011

Caring for an Ill Spouse, and for Other Caregivers -

Monday morning can be a downer, but for the dozen women and men in our support group, it's a highlight of our week. That's when we gather to speak candidly of what is unspeakable in polite society or even among closest friends and family.

We are the spouses or partners of people with dementia, an umbrella term for several degenerative, fatal brain diseases, of which Alzheimer's is by far the most common. We are their primary caregivers; their lives depend on us.

Living with someone with dementia, who must be watched every minute, eventually becomes the central focus of a caregiver's life, as independence and freedom are replaced by stress and exhaustion. The members of our group, mostly in their 80s, are worn out by caring for their mates. Yet so lively are our Monday meetings that it sometimes takes two volunteer social workers to keep order: "Wait! Wait! One person at a time!"

Often down or drained when we assemble, we part after 90 minutes buoyed and energized, week after week, year after year. (For me, four years and counting.) Not even a spouse's death keeps members away; a year after the funeral, our widows and widowers must be prodded to make way for those waiting to join.

According to the Alzheimer's Association, there are 15 million family members and friends providing unpaid care to people with dementia; hundreds of thousands of them meet regularly in support groups like ours to exchange information and understanding available nowhere else. Because science understands so little about dementia, we are the experts.

(To find a caregiver support group, contact the Alzheimer's Association, your local hospital or the Well Spouse Association, a nationwide group for people caring for spouses or partners.)

Our collective experience is a priceless resource. At a basic level, we exchange advice for keeping our partners from wandering off and techniques for bathing, calming and medicating them. We discuss ways to handle theirhallucinations and incontinence, the mere mention of which often spooks outsiders. We share advice on what to tell the police, and what not to tell them, to keep them from hauling our sometimes violent mates to a psychiatric ward.

But our group's deepest value lies beyond such practical matters. We speak of feelings and problems too sensitive or fraught to discuss outside. We recount the disappearance of old friends, whose discomfort around our spouses keeps them away. We mourn the loss of companionship and sex.

We guiltily admit to bouts of irrepressible anger in face of the intransigence and aggression typical of dementia. We speak about our children and stepchildren — some attentive and devoted, some interfering or remote.

And knowing that dementia is a terminal disease, together we contemplate death — our spouses' and our own. When should we refuse treatments or call in hospice? What will become of our loved ones if we die first? How will we manage our own final years as we rapidly exhaust our resources? These are deeply personal, in some ways political questions that science cannot answer.

One retired schoolteacher among us recalls that she was once too proud, shy and overwhelmed to consider joining a support group. (Me too.) But after tentatively trying out our group in desperation, she stayed for a decade.

Her first reward was the group's urging that she find outside help to provide some relief. Then, over the years, the group was her sounding board when her husband became violent, emerged from a hospitalization unable to walk, lost his powers of speech, could no longer feed himself. As he approached the end, she asked the group to ponder with her whether to have a feeding tube inserted into his stomach.

After he died, she joined a bereavement group, then flew to Paris for a week. But when she returned, it was to our group — people who understood her and to whom she still had valuable knowledge to convey.

Since I joined it, our group has had an 80 percent turnover, mainly through death. Though our members have ranged from liberal to conservative and from financially secure to dependent on Medicaid, the distinctions that matter most are how long ago we received the dread diagnosis and what problems we are dealing with now.

With doctors unable to help us and Medicare reimbursement largely off limits, we turn to each other to learn what lies ahead as each of us descends the steps toward widowhood. Such grim knowledge occasionally causes a newcomer to bolt. But for those who remain, our support group is our lifeline.

When the last Congress unanimously endorsed a comprehensive plan to combat Alzheimer's disease, the lawmakers named improved caregiving as a major goal. If they are serious, they will vigorously promote support groups like ours and take advantage of our collective, hard-won experience.

Alix Kates Shulman's most recent book is "To Love What Is: A Marriage Transformed," a memoir about her husband's dementia.

Monday, May 9, 2011

The Secrets of Sleep - National Geographic Magazine

Cheryl Dinges is a 29-year-old Army sergeant from St. Louis. Her job is to train soldiers in hand-to-hand combat. Specializing in Brazilian jujitsu, Dinges says she is one of the few women in the Army certified at level 2 combat. Level 2 involves a lot of training with two attackers on one, she explains, with the hope of "you being the one guy getting out alive."

Dinges may face an even harder fight in the years ahead. She belongs to a family carrying the gene for fatal familial insomnia. The main symptom of FFI, as the disease is often called, is the inability to sleep. First the ability to nap disappears, then the ability to get a full night's sleep, until the patient cannot sleep at all. The syndrome usually strikes when the sufferer is in his or her 50s, ordinarily lasts about a year, and, as the name indicates, always ends in death. Dinges has declined to be tested for the gene. "I was afraid that if I knew that this was something I had, I would not try as hard in life. I would allow myself to give up."

FFI is an awful disease, made even worse by the fact that we know so little about how it works. After years of study, researchers have figured out that in a patient with FFI, malformed proteins called prions attack the sufferer's thalamus, a structure deep in the brain, and that a damaged thalamus interferes with sleep. But they don't know why this happens, or how to stop it, or ease its brutal symptoms. Before FFI was investigated, most researchers didn't even know the thalamus had anything to do with sleep. FFI is exceedingly rare, known in only 40 families worldwide. But in one respect, it's a lot like the less serious kinds of insomnia plaguing millions of people today: It's pretty much a mystery.

If we don't know why we can't sleep, it's in part because we don't really know why we need to sleep in the first place. We know we miss it if we don't have it. And we know that no matter how much we try to resist it, sleep conquers us in the end. We know that seven to nine hours after giving in to sleep, most of us are ready to get up again, and 15 to 17 hours after that we are tired once more. We have known for 50 years that we divide our slumber between periods of deep-wave sleep and what is called rapid eye movement (REM) sleep, when the brain is as active as when we're awake, but our voluntary muscles are paralyzed. We know that all mammals and birds sleep. A dolphin sleeps with half its brain awake so it can remain aware of its underwater environment. When mallard ducks sleep in a line, the two outermost birds are able to keep half of their brains alert and one eye open to guard against predators. Fish, reptiles, and insects all experience some kind of repose too.

All this downtime comes at a price. An animal must lie still for a great stretch of time, during which it is easy prey for predators. What can possibly be the payback for such risk? "If sleep doesn't serve an absolutely vital function," the renowned sleep researcher Allan Rechtschaffen once said, "it is the greatest mistake evolution ever made."

More ...

Gov't finds nursing homes misuse antipsychotics - CBS News

Anyone who's ever been through it will tell you that putting a loved one in a nursing home is one of the toughest decisions you'll ever have to make. You hope and pray your relative will be well-cared for.

But a troubling new report from the government finds that, all too often, nursing homes are giving antipsychotic drugs to patients who should not be getting them.

CBS News chief investigative correspondent Armen Keteyian reports Debra Burchard moved her ailing father William Killingsworth into a Northern California nursing home in September 2005. Within
days - she says- he had completely changed.

"Eyes glassed over with sweating, cracked mouth," Burchard said. "How did that happen in three days?"

Less than four weeks after entering the nursing home, Killingsworth was dead. Burchard blames, in part, an antipsychotic drug the nursing home inappropriately gave her father who suffered from dementia.

"He was laying in his bed, unresponsive," Burchard said. "I just looked at him and thought what's going on?"

Antipsychotic drugs like Seroquel, Risperdal and Zyprexa were never approved for elderly patients with dementia.

In fact, in 2005 the FDA gave them its most severe warning - noting an increased risk of sudden death in patients with dementia.

Now, a new government study has found that 88 percent of the time Medicare paid for antipsychotic drugs in nursing homes - they went to patients with dementia.

The report by the Health and Human Services inspector general also found that antipsychotic drugs were given to nursing home residents "unnecessarily" over 300,000 times between January and June 2007, with more than half of those drugs (150,106) given "in excessive dose."

"The use of anti-psychotic drugs when they are not necessary is a form of restraint," said Dr. David Zimmerman, University of Wisconsin. "It's a form of chemical restraint."

The Department of Health and Human Services also says it's "very concerned" that there are "financial incentives for unnecessary drug use." In the past those incentives have led to charges of "kickbacks" between nursing homes, pharmacies and a drug company.

Dr. Kenneth Brubaker represents nursing home medical directors and agrees antipsychotics are being used too often. He says the problem is staff turnover and training.

"Oftentimes lack of training, lack of adequate workforce, whatever else it might be - we tend to shortcut it by going to drugs," Brubaker said.

"I wish I would have said, 'what are you giving him? How much are you giving him?'" Burchard said.

Instead Burchard sued and settled. She's using some of the money to create a nursing scholarship in memory of her father.

Doctor Grumpy in the House - blog

My patients and practice drive me NUTS!

Some days I'm so sick of patient shenanigans, the stupidity of insurance companies, and just the daily insanity of this field that I write this blog as my gripe forum.

I'm a neurologist, and sometimes seem to attract some remarkably "special" folks. I have no idea why. It just seems that weird crap happens to me or my patients. So this is where I vent about it.

Patient Commando’s debut play hits close to home for Zal Press | National Post

When Zal Press was 29 years old, he went to the hospital with a pain in his gut that felt like he had "a cat trapped in [his] stomach trying to claw its way out.
"A doctor came up to me as I was lying in the hospital and he says to me, 'Mr. Press, you have a serious illness. You have Crohn's disease,' " Press recalls. "I couldn't even spell Crohn's, I had never heard of it. All I wanted was a pill so I could get on with my life."
Thirty years later, Press has moved on with his life, but he certainly hasn't forgotten about Crohn's. About two years ago, he set off on a journey to try and get involved in changing the Canadian health-care system and the way patients perceive chronic illness.
"I became attracted to patient advocacy and patient empowerment and this whole new movement of this educated, informed, Internet-aware patient who's engaged in their own health care," he says.
Last year, after giving up a successful art business, Press started Patient Commando, a theatre production company that uses storytelling and humour to empower patients. The company's debut production is a performance of Cancer Can't Dance Like This, Daniel Stolfi's comedic dramatization of his two-year battle with cancer.
The production has been staged in Toronto and Montreal since its premier at Second City last May. To date, Cancer Can't Dance Like This has raised more than $60,000 for cancer research.
"Patient Commando is a great organization that is all about putting the power of health in the hands of the patient," Stolfi says. "Many times, people dealing with illness are led blindly through treatment with little say in the process. … By sharing stories that come directly from the mouth of the patient we can gain a much better understanding of what a patient is going through and how they are feeling in all aspects of treatment."
Patient Commando is the only entertainment company in Canada producing theatre, workshops, video and speaking presentations with a focus on the patient experience.
"Everyone has a story to tell," Press says. "And the very act of telling our stories makes us feel good. And when the stories are funny, when they come from a place of honesty and they're well-told, they have the power to change people's lives."
Dr. Sandy Buchman, a palliative care physician and president-elect of the College of Family Physicians of Canada, agrees, and suggests that healthcare providers will also stand to benefit from this kind of endeavor.
"Often the doctor-patient relationship is two-dimensional," Buchman says. "We are dealing only with the disease rather than the whole illness experience. … It's beneficial for us to get a fresh perspective and lighten our own lives, too."
Cancer Can't Dance Like This runs May 12 at Toronto's Glenn Gould Studio. For more information, visit's-debut-play-hits-close-to-home-for-zal-press/

Medical Wonder: Meet the CEO Who Rebuilt a Crumbling California Hospital | Fast Company

A doctor is beaten and strangled to death by a patient, the body left on the floor for half an hour before a janitor happens across it. A mental patient hangs herself with her own clothes tied to the top of a toilet stall. HIV-infected blood is tossed out with the regular trash. Wright L. Lassiter III was thinking, Why should I take this job? There was more: Nurses who followed doctors' orders only when they felt like it. Millions of dollars in losses year after year. A culture that favored blame over accountability. A sad parade of feckless executives -- 10 CEOs in 11 years. It was 2005 and Lassiter was next in line.

Lanky, charismatic, and a rising star in the health-care industry, Lassiter could have become just one more executive casualty when he took the job as CEO of the Alameda County Medical Center in Oakland, California, and its flagship, Highland Hospital. Instead, he did what seemed impossible: He turned a shockingly mismanaged urban safety-net hospital system in one of America's most violent cities into a model for other public hospitals. He trimmed costs without any significant cutback in services -- in fact, services have been greatly expanded. A new $668 million hospital building is under construction. Six years on, the center has turned a positive margin every year but the last, when a new auditor required it to set aside more money for pension costs; so far, it is on target to break even this year.

No one is pretending that ACMC is immune from the severe financial problems facing public hospitals. Atlanta's Grady Health System is facing a $30 million shortfall. Miami's Jackson Health System is in even worse straits: It lost $93 million in fiscal 2010 and is on track to lose another $78 million this year; cash on hand is down to 19.6 days. Over the past 20 years, the number of public hospitals has declined by more than 25%, to 1,072. With federal budget cuts looming, states going broke, and local governments preparing for the worst of it to roll downhill and bury them, public institutions are going to have to learn to manage better. Forty-seven-year-old Lassiter and his team's accomplishment in Oakland shows it is possible for even the most dysfunctional public hospitals to shake themselves awake, serving the public and respecting taxpayers' dollars at the same time. Says Thomas Rundall, a health-policy and management professor emeritus at the University of California, Berkeley: "It's a model for how a publicly owned hospital with a challenging payer mix can be profitable."

Highland sits on a small hill above a low-income residential neighborhood in inner-city Oakland. Hidden by trees from the nearby freeways, it's barely visible to suburban commuters heading toward the Bay Bridge to jobs in San Francisco.

The site is an architectural hodgepodge: the cream-colored Spanish baroque towers of the oldest building, erected in 1927; a recently built clinical center wrapped in green glass; a huge gray block in the Brutalist style, slated for a teardown as the new hospital rises.

Walk inside, past the ever-present county-sheriff squad cars, and you may see some gangbangers and gunslingers, crackheads and crazy people, and the other stock characters who lend drama to every inner-city public hospital. Mostly, though, you'll just see sick poor people -- mainly blacks, Latinos, Asians -- the unemployed, and the working poor sitting under fluorescent lights, waiting for their turn to see a doctor or nurse.

"Ten years ago, if you said in 2011 I'd be working in a public-hospital system, I would have said, 'Not likely,' " Lassiter says. "A worthy cause, yes, but not my kind of thing." At 6-foot-5, he is scrunched against a little round conference table in his office at Highland; papers are strewn across his desk, reports and journals piled on the floor. It looks more like an academic's college office than the lair of a corporate CEO.

In 2002, he was climbing the executive ranks at a large private-hospital system in Dallas. Then the CEO of JPS Health Network in Fort Worth, which serves the poor and uninsured in Tarrant County, recruited him as VP of operations and charged him with making a system that never turns anybody away as good as any private one. A challenge that big, Lassiter decided, could be his kind of thing.

The son and grandson of ordained ministers, Lassiter had what he calls a "small-town Southern upbringing" in Tuskegee, Alabama. His father is an educator, his mother a nurse. Tuskegee in the 1970s remained starkly segregated, which Lassiter realized at age 12, when his family moved to Columbia, Maryland, outside of Washington, D.C. "My first day driving around, I saw blacks and whites holding hands as couples," he recalls. "I asked my mom, very innocently, 'Is that okay, what they're doing?' "

His own life revolved around the Baptist religion, school, and sports. He credits one basketball coach, "a white guy in his sixties who chewed tobacco and spewed expletives," with teaching him the joys of hard labor. The coach drove the team out to help on his farm. "Today, a white coach taking a truck full of black kids to work on his farm would get fired," he says. "But I got a lot of discipline from that."

He remembers the two months he lived with his father at a YMCA in Schenectady, New York, as the most formative period of his youth. His father had just taken a job as president of the local community college, and the family had yet to move into their new house. A star basketball player, he was greeted at his new high school as what the newspapers called "the Jumping Jack from Wilde Lake," and, according to his father, a red carpet "lined with pretty girls on both sides" was rolled out. Living at the YMCA embarrassed the young Lassiter at first, but he now says it turned into "an unusual bonding experience" that kept him from getting a big head.

"I'm a professor of business ethics," says his father, Wright Jr., 77, chancellor of the Dallas County Community College District. "I've always emphasized he needs to be a good 'servant leader,' someone who's not into work simply for the personal benefit, but for the greater good."

Although Lassiter takes his father's advice seriously, he says that the "servant" idea can be misapplied in a public-hospital setting. "The attitude at a public hospital often is 'We're doing God's work. We get to feel good about being a martyr. Don't worry about execution. Don't worry about service. We're doing God's work.' "

As soon as he made his move from Fort Worth to Oakland, Lassiter made clear that God's work wouldn't get done unless the place stopped losing money and shaped up fast.

ACMC was a poster child for public-hospital dysfunction. The doctor's murder and the patient's suicide pointed out serious operational lapses, but the core problem was financial: Year after year, according to the Alameda County Grand Jury, the place lost millions beyond what it took in from the government, charities, paying customers, and other sources. (California is one of a handful of states that make grand juries the watchdogs of county government.) The grand jury described management as "a shambles."

CEO after CEO failed to stanch the bleeding, even after Alameda County voters passed a half-cent sales-tax hike to stabilize the system's finances. In 2004, the hospital board brought in Cambio Health Solutions to rescue the institution. Cambio's plan to cut 300 jobs and slash patient services was a political nonstarter. A one-day strike was energized by a visit from Jesse Jackson. Highland already was overcrowded; nobody in the community wanted services reduced. After 18 months and a fee of $3.2 million, Cambio departed. When Lassiter signed on in 2005, the place was still losing $1 million a month.

He quickly began building a new management team, including COO Bill Manns, who was hired from Providence Hospital in Southfield, Michigan, near Detroit. At Manns's suggestion, they immediately commenced a grassroots money hunt, which Lassiter now calls "the foundation of our success." The pair gathered the top 85 managers, formed them into a dozen teams, and gave them 16 weeks to find $21 million in cost cuts and new revenue. Lassiter says he told them: "It's up to you. We barely know where the restrooms are, so we're not going to solve this problem. You're going to solve it."

To encourage fresh thinking, Lassiter and Manns devised "odd-couple arrangements," putting together doctors, nurses, techs, and other managers. The teams drilled into vendor contracts and challenged their own habits. Take the kit used to test newborns' umbilical-cord blood, a $96.50 item. A simpler tool does the same job for 29¢. Is the more-expensive device better? How much better does it have to be to be worth the extra $96.21? ACMC had been choosing the premium option, at a cost of $322,000 a year. Now, the teams decided, ACMC could not afford it.

Looking for new revenue, they identified areas the system was especially good at -- like rehabilitation and diabetes care -- and came up with ways to treat more patients more efficiently. Lassiter also pushed the creation of an electronic network that links dozens of community clinics to the health center, significantly boosting referrals to its best services.

Only after the teams had found every dollar in savings and new revenue did Lassiter and Manns consider layoffs. As a result, instead of the service reductions and hundreds of job cuts the consultant Cambio had recommended, ACMC sliced only about 80 positions, found other work for many employees whose jobs had been eliminated, and began expanding services. Together the cuts and the revenue increases amounted to $23 million.

"That's what really got the buy-in" from the unions on layoffs, Manns says. "We looked at everything else first. What can you say to that?"

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Doctors’ orders: A hearing test for every newborn - The Globe and Mail

Every child born in Canada should be screened for hearing loss shortly after birth, Canada's baby doctors say.

In a position statement being issued Monday, the Canadian Paediatric Society is calling on all provinces to implement universal newborn hearing screening, saying that testing and early intervention prevents severe and costly developmental delays.

"Virtually every developed country has a screening program. It's shameful that Canada doesn't," Dr. Hema Patel, a staff pediatrician at Montreal Children's Hospital and lead author of the statement, said in an interview.

Only Ontario and British Columbia have universal programs, and Quebec has announced plans to create one. Other provinces tend only to test babies at high risk of hearing loss, such as preemies and those suffering serious infections like meningitis.

The CPS said a "comprehensive and linked system of screening, diagnosis and intervention" is needed and because health is a provincial responsibility, the group called on the provinces to unite their efforts to create a national program.

Hearing loss is one of the most common congenital disorders, affecting about five in every 1,000 newborns, but about half of those affected have no obvious risk factors.

"We had no clue our son had something wrong with his hearing," said Jennifer Beer, a Toronto mother.

Her son Harry was tested by the midwife shortly after birth and then referred to a public health nurse and an audiologist for further testing.

By three months, he was diagnosed with bilateral moderately severe hearing loss and fitted with hearing aids. Harry, now aged four, has normal linguistic skills and he has also learned American Sign Language at his preschool.

"I can't imagine what life would have been like if he hadn't been screened," Ms. Beer said. "It wasn't all sunshine and daisies but we got an early diagnosis and Harry got the help he needed."

Dr. Patel said early diagnosis of hearing loss is essential so that a child can acquire language skills – either spoken or ASL. But, where there is no universal screening, children tend not to be diagnosed before age two – when toddlers generally start speaking – and often not until they attend school.

"When there is hearing loss, parts of the brain don't develop so there is a profound, life-long effect," Dr. Patel said.

The principal one is difficulty learning, and that is costly. A Quebec study estimated that a universal hearing program would result in an annual savings of $1.7-million in that province alone because special education classes are much more costly than treating hearing loss – $17,904 annually for a hard-of-hearing student compared with $4,808 for a hearing student.

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Sunday, May 8, 2011

The Weakness That Wouldn’t Go Away -

A fiercely independent and active 76-year-old woman spent the past decade caring for her aged mother, who died at 99. Weeks after her mother's death, the woman collapsed at home. She was found to have bleeding from a collection of abnormal blood vessels (known as AVMs, or arteriovenous malformations) in her colon. In the months after, the patient's red-blood-cell count returned to normal, but she never regained her old energy and strength. She told her daughters that she was weaker and more tired than she had ever been in her life.

Dr. Susan Wiskowski, a family physician in Hartford, was the woman's doctor. Until recently, the patient was in good health for her age, with only a few medical problems: high blood pressure, which was controlled with one medication; hypothyroidism, treated with Synthroid; and cataracts, which had been surgically repaired. Now, out of the blue, she was experiencing rapid weight gain, swelling and weakness in her legs, which made it hard to walk.

Possible Diagnoses: Heart disease can manifest as weakness and fatigue, particularly in the elderly. The patient was referred to a cardiologist. An elevated white-blood-cell count was detected during the bleeding episode. She was sent to a hematologist.

The hematologist's report was unrevealing. The cardiologist found no coronary-artery disease but noted a partly obstructed heart valve, which, though longstanding, might be contributing to the patient's fatigue.

A couple of weeks after the cardiac work-up, the patient's behavior became erratic and strange. Despite her complaints of weakness, she veered between bursts of activity — endlessly cleaning her house, giving large dinner parties — and days of isolation and fatigue. She was sometimes elated, telling her four daughters that she'd found where heaven was located. She began to talk about giving away her possessions. One afternoon she seemed completely out of control. A neighbor called 911, and the patient was rushed by ambulance to St. Francis Hospital in Hartford.

In the emergency room, doctors discovered an extensive hematoma on the patient's right groin and leg, which developed after a cardiac catheterization she had as part of her work-up. She was admitted to the hospital.

A psychiatrist diagnosed hypomania and started the patient on several medications to stabilize her mood.

The patient complained of severe weakness, which made minor chores difficult. A neurologist performed nerve-conduction tests, which revealed damage in the region where the nerves meet the muscle. He suggested that the injury might be a postviral neuropathy, an unusual reaction to a recent infection. He told her it should improve with time. The specialist sent her to physical therapy, but the weakness persisted.

Walking became extremely painful, and within weeks she needed a wheelchair to get around. Dark purple lesions appeared on the back of the patient's hand and arms. A daughter took pictures of the lesions and showed them to the patient's doctor. After seeing the images, Wiskowski recommended that she take her mother to the emergency room right away.

After the case was posted on The New York Times Well Blog on April 20, more than 500 readers weighed in.

Many readers thought there could be something wrong with her diet.

Katherine of Cambridge, Mass., suggested that she might have a niacin (vitamin B3) deficiency, which could cause what doctors refer to as the four D's: diarrhea, dermatitis (rash), dementia and death: "Could it be pellagra?"

Patrick H. worried about the lack of a different B vitamin: "I will take a stab and go with B12 deficiency."

Iron and vitamin C were also among the suspects. Amy of Ohio read up on the patient's symptoms: "I just learned that high iron deposits can decrease insulin secretion, and that, in turn, would elevate her glucose levels. . . . My diagnosis: iron poisoning."

Others focused on the timing of this illness. Diana of Long Island, N.Y., offered: "I'm going to go out on a limb here and say it may be due to chronic stress. It was mentioned that the patient just lost her mother, and she was her primary caregiver. Having helped my mother with my grandmother (who has Alzheimer's), I know that stress can cause very odd symptoms and do major damage to the body."

Josie of St. Louis suggested: "[Her] mother's death triggered depression, also eliminated need for treatment with high-blood-pressure medicine. Unneeded blood-pressure medicine aggravated psychosis and caused bleeding and skin spots."

The first correct answer came 54 minutes after the case was posted online. Elizabeth Neary, a pediatrician from Madison, Wisc., wrote, "Sounds like Cushing's syndrome. . . . Rash looks like ecchymoses [bruises] — personality changes are common, as is weakness and edema."

By the time the answer was posted the next morning, 18 readers had nailed the diagnosis and five others were on the verge. The most commonly cited wrong diagnosis was porphyria — a group of inherited diseases that usually present with a combination of abdominal pain, psychiatric symptoms and skin findings. It was a thoughtful suggestion, although porphyrias usually show themselves by early adulthood.

When the patient's daughters were told to take their mother to the emergency room, they took her to Waterbury Hospital in Waterbury, Conn., to see a friend of theirs, Dr. Rachel Lovins. Lovins, who met their mother some years earlier, didn't recognize the woman who sat before her in a wheelchair.

As she watched the E.R. doctor examine the patient, Lovins noted reddish purple stretch marks on the patient's abdomen. Suddenly, the whole case made sense. These stretch marks, known as striae, are a result of the thinning of the skin caused by excess cortisol. It's a classic finding in Cushing's syndrome.

Cushing's syndrome was first described by Dr. Harvey Cushing, a neurosurgeon, in 1932. In this disease, the adrenal glands churn out too much cortisol, a hormone involved in our body's response to stress. Cortisol helps maintain blood pressure, reduces the immune system's inflammatory response and increases blood-sugar levels. Long-term exposure to an excess of this hormone, however, can cause weight gain, osteoporosis, diabetes, high blood pressure, muscle weakness, memory loss and psychiatric disease. It causes the skin to weaken, making it susceptible to injury and bleeding, which occurred in her colon, or bruising, which occurred on her hands.

After Lovins saw the striae, the patient was tested for Cushing's, and her cortisol level was very high — eight times the normal level. Usually this disease is caused by a tumor in the pituitary gland in the brain, which in turn causes the adrenal gland to overproduce cortisol. Surgical removal of the tumor is the cure. But in this patient's case, doctors couldn't find the tumor; it was too small. Since the tumor couldn't be removed, the patient was started on a medication to prevent the overproduction of cortisol.

When making a diagnosis, doctors frequently cite the principle of Occam's razor: the simplest answer is most likely to be the right answer, and a single diagnosis is more likely than a collection of diagnoses. This principle, however, doesn't necessarily hold with older patients. High blood pressure is seen in 80 percent of those over age 70. Nearly half over 60 are overweight. A quarter are depressed. One in six Americans over age 40 will have cataracts in one or both eyes. Given these numbers, having a 76-year-old patient with all of these distinct diseases — as was the case with this patient — is common, and a doctor might not feel the need to look for a single, unifying disease process.

As one of her daughters wrote in an e-mail to friends: "We were told that her psychological state, her neurological problem, her circulation issues and her excessive bleeding were an unrelated bunch of unfortunate circumstances conspiring to make this woman ill. It happens when you are old, we were told more than once." This thinking was familiar to many readers. Jonquil of Utopia wrote: " 'It happens when you are old' is such a dangerous diagnosis, yet it's given every day. . . . G.P.'s need to be better trained in geriatrics."

Readers know that this column often reads like a detective story in which a single criminal (one disease) is responsible for a variety of crimes (symptoms). As a result, the reader has an advantage over a doctor, who has to figure out which patient, out of all those she has seen that day, has many individual problems without a unifying cause, and which will need Occam's razor. While that distinction may not be sufficient, it is the necessary start of diagnosis.

Physician, Heel Thyself -

It was morning rounds in the hospital and the entire medical team stood in the patient’s room. A test result was late, and the patient, a friendly, middle-aged man, jokingly asked his doctor whom he should yell at.

Turning and pointing at the patient’s nurse, the doctor replied, “If you want to scream at anyone, scream at her.”

This vignette is not a scene from the medical drama “House,” nor did it take place 30 years ago, when nurses were considered subservient to doctors. Rather, it happened just a few months ago, at my hospital, to me.

As we walked out of the patient’s room I asked the doctor if I could quote him in an article. “Sure,” he answered. “It’s a time-honored tradition — blame the nurse whenever anything goes wrong.”

I felt stunned and insulted. But my own feelings are one thing; more important is the problem such attitudes pose to patient health. They reinforce the stereotype of nurses as little more than candy stripers, creating a hostile and even dangerous environment in a setting where close cooperation can make the difference between life and death. And while many hospitals have anti-bullying policies on the books, too few see it as a serious issue.

Today nurses are highly trained professionals, and in the best situations we form a team with the hospital’s doctors. If doctors are generals, nurses are a combination of infantry and aides-de-camp.

After all, patients are admitted to hospitals because they need round-the-clock nursing care. We administer medications, prep patients for tests, interpret medical jargon for family members and double-check treatment decisions with the patient’s primary team. Nurses are also the hospital’s front line: we sound the alert if a patient takes a serious turn for the worse.

But while most doctors clearly respect their colleagues on the nursing staff, every nurse knows at least one, if not many, who don’t.

Indeed, every nurse has a story like mine, and most of us have several. A nurse I know, attempting to clarify an order, was told, “When you have ‘M.D.’ after your name, then you can talk to me.” A doctor dismissed another’s complaint by simply saying, “I’m important.”

When a doctor thoughtlessly dresses down a nurse in front of patients or their families, it’s not just a personal affront, it’s an incredible distraction, taking our minds away from our patients, focusing them instead on how powerless we are.

That said, the most damaging bullying is not flagrant and does not fit the stereotype of a surgeon having a tantrum in the operating room. It is passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults.

And because doctors are at the top of the food chain, the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.

Such an uncomfortable workplace can have a chilling effect on communication among staff. A 2004 survey by the Institute for Safe Medication Practices found that workplace bullying posed a critical problem for patient safety: rather than bring their questions about medication orders to a difficult doctor, almost half the health care personnel surveyed said they would rather keep silent. Furthermore, 7 percent of the respondents said that in the past year they had been involved in a medication error in which intimidation was at least partly responsible.

The result, not surprisingly, is a rise in avoidable medical errors, the cause of perhaps 200,000 deaths a year.

Concerned about the role of bullying in medical errors, the Joint Commission, the primary accrediting body for American health care organizations, has warned of a distressing decline in trust among hospital employees and, with it, a decline in the quality of medical outcomes.

What can be done to counter hospital bullying? For one thing, hospitals should adopt standards of professional behavior and apply them uniformly, from the housekeepers to nurses to the president of the hospital. And nurses and other employees need to know they can report incidents confidentially.

Offending parties, whether doctors or nurses, would be required to undergo civility training, and particularly intransigent doctors might even have their hospital privileges — that is, their right to admit patients — revoked.

But to be truly effective, such change can’t be simply imposed bureaucratically. It has to start at the top. Because hospitals tend to be extremely hierarchical, even well-meaning doctors tend to respond much better to suggestions and criticisms from people they consider their equals or superiors. I’ve noticed that doctors otherwise prone to bullying will tend to become models of civility when other doctors are around.

In other words, alongside uniform, well-enforced rules, doctors themselves need to set a new tone in the hospital corridors, policing their colleagues and letting new doctors know what kind of behavior is expected of them.

This shouldn’t be hard: most doctors are kind, well-intentioned professionals, and I rarely have a problem talking openly with them. But unless we can change the overall tone of the workplace, doctors like the one who insulted me in front of my patient will continue to act with impunity.

I wish I could say otherwise, but after being publicly slapped down, I will think twice before speaking up around him again. Whether that was his intention, or whether he was just being thoughtlessly callous, it’s definitely not in my patients’ best interest.

Theresa Brown, an oncology nurse, is a contributor to The Times’s Well blog and the author of “Critical Care: A New Nurse Faces Death, Life and Everything in Between.”

Blubrry - The Moth Podcast - Andy Borowitz: An Unexpected Twist

A man navigates the medical system with humor.