Doctor and Patient: Finding the Patient in a Sea of Guidelines - NYTimes.com

Every Friday morning, the patient, a homeless man in his 60s, lumbered into one of our exam rooms, slipped off the running shoes he wore like bedroom slippers and gingerly lifted his swollen legs so we could remove the medicated bandages and examine the raw wounds on his inner ankles.

Those baseball-size leg ulcers were only one of his many medical problems. He also suffered from obesity and poorly controlled diabetes and blood pressure. Like his other doctors, I encouraged him to lose weight, watch his diet and take his diabetes medications, and stay on his blood pressure pills while making mental note of our medical aims — lower his body mass index to under 25, his hemoglobin A1C to under 7 and his systolic blood pressure to 130.

The reality, however, was that even getting to our clinic was a small triumph for him.

One morning, the clinic nurse approached me after I finished examining him. "Do you know what the problem is?" she whispered, as we watched the man shuffle out to the waiting room. "We keep trying to treat the guidelines rather than him."

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http://well.blogs.nytimes.com/2011/05/19/finding-the-patient-in-a-sea-of-guidelines/

The Voices of Childhood Cancer - NYTimes.com

Few health problems are as heartbreaking as a sick child, and the latest installment of Patient Voices offers a poignant glimpse into the world of childhood cancer.

You'll hear from parents of children who are in the midst of cancer treatment, parents who have lost children, a teenager coping with treatment and a young adult still living with the effects of childhood cancer.

Toshia Ramirez of Houston shares the story of her 7-year-old son, Jaiden, who recently learned he has a cancer that has engulfed his brain stem. He has been given 8 to 12 months to live, but a new treatment may extend his life as long as two years.

"We spend a lot of time on our knees, praying and asking God to let Jaiden be one of the miracles," said Ms. Ramirez. "We're hoping to get at least two years, give doctors more time to research other things and come up with another solution."

To hear more from the voices of childhood cancer click, on the audio-visual slide show, "Patient Voices: Childhood Cancer," and then please join the discussion below.

http://well.blogs.nytimes.com/2011/05/19/the-voices-of-childhood-cancer/

The 10 Most Prescribed Drugs

The 10 most prescribed drugs in the U.S. aren't the drugs on which we spend the most, according to a report from the IMS Institute for Healthcare Informatics.

The institute is the public face of IMS, a pharmaceutical market intelligence firm. Its latest report provides a wealth of data on U.S. prescription drug use.

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http://www.webmd.com/news/20110420/the-10-most-prescribed-drugs?src=RSS_PUBLIC

Elliot Krane: The mystery of chronic pain | Video on TED.com

We think of pain as a symptom, but there are cases where the nervous system develops feedback loops and pain becomes a terrifying disease in itself. Starting with the story of a girl whose sprained wrist turned into a nightmare, Elliot Krane talks about the complex mystery of chronic pain, and reviews the facts we're just learning about how it works and how to treat it.

http://www.ted.com/talks/elliot_krane_the_mystery_of_chronic_pain.html

Overweight women: Some South Florida ob-gyns turn away overweight patients - South Florida Sun-Sentinel.com

In a nation with 93 million obese people, a few ob-gyn doctors in South Florida now refuse to see otherwise healthy women solely because they are overweight.

Fifteen obstetrics-gynecology practices out of 105 polled by the Sun Sentinel said they have set weight cut-offs for new patients starting at 200 pounds or based on measures of obesity — and turn down women who are heavier.

Some of the doctors said the main reason was their exam tables or other equipment can't handle people over a certain weight. But at least six said they were trying to avoid obese patients because they have a higher risk of complications.

"People don't realize the risk we're taking by taking care of these patients," said Dr. Albert Triana, whose two-physician practice inSouth Miami declines patients classified as obese. "There's more risk of something going wrong and more risk of getting sued. Everything is more complicated with an obese patient in GYN surgeries and in [pregnancies]."

Plantation ob-gyn partners Jeffrey Solomon and Isabel Otero-Echandi turn down any woman weighing more than 250 pounds.

Solomon and Otero don't want to begin seeing heavy women and then have to send them to specialists if they later develop problems, said their office manager, who asked not to be named. The two doctors, like several of the others with weight cutoffs, declined to comment.

"This is not a high-risk practice," the office manager said. "They are not experts in obesity."

Turning down overweight people is not illegal for doctors, but the policy worried leaders of physician groups, medical ethics experts and advocates for the obese, all of whom said it violates the spirit of the medical profession.

"If I had that policy, I wouldn't have a practice. I'd lose half my patients," said Dr. Maureen Whelihan, a West Palm Beach ob-gyn. "We never turn down anyone. We would see them, and if we had to, we would refer them to a specialist."

Leaders of eight local, state and national medical associations said they had never heard of doctors turning away patients solely because of weight. Several said obese people with no other health issues do not need special treatment.

"No doctor should be unable to treat patients just because they are heavy," said Dr. Bruce Zafran, a Coral Springs ob-gyn.

So far, the weight cutoffs have been enacted only by South Florida ob-gyns, who have long complained of high numbers of lawsuits after difficult births and high rates for medical-malpractice insurance. More than half go without coverage.

Ob-gyns for years have declined to see pregnant women who are overweight, typically sending them to specialists. It's new for them to turn down overweight women who are not pregnant, physician groups said.

Several ob-gyn offices said their ultrasound machines do not give good images of internal anatomy in obese women, making it harder to diagnose some medical problems.

The Plantation office manager said weight limits are not uncommon at offices owned, like hers, by the Coconut Grove medical services company VitalMD.

VitalMD treasurer Kerry Kuhn, an ob-gyn in Coral Springs, said he was unaware of his doctors setting weight limits, adding the company has nothing to do with doctor decisions.

"This is individual choice by a doctor," Kuhn said. "Doctors know who they want to treat."

Physicians, like any business, can decline service to whomever they choose for any reason — including personality conflicts — as long as it's not discriminatory. The American Medical Associationadvises doctors that they cannot reject patients because of race, gender, sexual orientation or infectious diseases.

Doctors also are allowed to drop patients, if they believe they lack the medical skills to properly treat them. They must send notices and refer them to other doctors.

But decisions about patients typically are made after assessing the individual's condition during an exam, not by ruling out an entire group, said Dr. Robert Yelverton, a board member of the Florida Obstetric and Gynecologic Society. He said he would discourage physicians from excluding the obese.

"Do I think it's a good policy? No," Yelverton said. "Overweight people need doctors. I don't know where a patient in that situation would go if every practice had that policy."

The AMA and the ob-gyn group declined to comment on doctors setting weight limits. A spokesman for the Obesity Action Coalition in Tampa said the restrictions sound like discrimination.

"This completely goes against the principles of being a doctor," James Zervios said. "Health care professionals are there to help individuals improve their quality of health, not stigmatize them according to their weight."

http://www.sun-sentinel.com/health/fl-hk-no-obesity-doc-20110516,0,333407.story

Transplant Recipients of Julio Garcia’s Organs Gather in Thanks - NYTimes.com

Mirtala Garcia laid a hand on Sebastiao Lourenco's chest, then pressed her ear there for a moment.

"That's my heart," she said. "It's still beating for me."

Although she had just met Mr. Lourenco, she had known his heart for a long time. It had belonged to her husband, Julio, who died from a brain hemorrhage in March 2010, at the age of 38. Mrs. Garcia donated her husband's organs, and the family's loss led to a second chance for Mr. Lourenco, 57.

But he was not the only one. Seven or eight other people who urgently needed transplants also received organs from Mr. Garcia, an unusually large number. (The average from organ donors is about three.) Even more unusual, his family and a group of recipients met on Wednesday in a highly emotional gathering at the Manhattan headquarters of the New York Organ Donor Network, which coordinated the transplants.

The story of the Garcias and the people whose lives were saved by one man's donated organs provides a close look at the charged world of transplants and organ donation, where people on the transplant list know they may die waiting, and the families of brain-dead patients are asked, at perhaps the most painful time in their lives, to look beyond their own grief and allow a loved one's organs to be removed to help strangers.

There are nowhere near enough donor organs for all the people who need transplants. Nearly 111,000 are on waiting lists in the United States, but last year, only 28,663 transplants were performed, according to the United Network for Organ Sharing, which oversees the transplant system nationwide. This year, 6,000 to 7,000 people are expected to die waiting.

Last week, Mrs. Garcia and her children, 5, 11 and 18, who all live in Stamford, Conn., met four of the recipients of her husband's organs for the first time. A fifth recipient also attended, one of two people with renal failure, both members of the Garcias' church, whom Mrs. Garcia chose to receive kidneys.

Mrs. Garcia addressed a room packed with recipients, families, doctors, nurses, her minister and his family and network employees. She spoke briefly through an interpreter. She said her husband had had a big heart and would be very proud "to give life after death." No one would ever forget him, she said.

Elaine R. Berg, president of the donor network, said: "These meetings don't happen that frequently. I've been here 11 years, and if it's once a year that's a lot. I've never met five recipients from one donor. It's highly unusual."

In many cases recipients or donor families, or both, choose to remain anonymous, Ms. Berg said. Recipients may send thank-you letters through the network, but they and donors do not often choose to meet.

"It's pretty intimidating and pretty emotional," Ms. Berg said. "Some people cannot bear it."

But she said that meeting the recipients can bring solace to donor families.

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http://www.nytimes.com/2011/05/17/health/17organ.html?

In Optogenetics, Buttons for Neural Switchboards - NYTimes.com

Treating anxiety no longer requires years of pills or psychotherapy. At least, not for a certain set of bioengineered mice.

In a study recently published in the journal Nature, a team of neuroscientists turned these high-strung prey into bold explorers with the flip of a switch.

The group, led by Dr. Karl Deisseroth, a psychiatrist and researcher at Stanford, employed an emerging technology called optogenetics to control electrical activity in a few carefully selected neurons.

First they engineered these neurons to be sensitive to light. Then, using implanted optical fibers, they flashed blue light on a specific neural pathway in the amygdala, a brain region involved in processing emotions.

And the mice, which had been keeping to the sides of their enclosure, scampered freely across an open space.

While such tools are very far from being used or even tested in humans, scientists say optogenetics research is exciting because it gives them extraordinary control over specific brain circuits — and with it, new insights into an array of disorders, among them anxiety and Parkinson's disease.

Mice are very different from humans, as Dr. Deisseroth (pronounced DICE-er-roth) acknowledged. But he added that because "the mammalian brain has striking commonalities across species," the findings might lead to a better understanding of the neural mechanisms of human anxiety.

David Barlow, founder of the Center for Anxiety and Related Disorders at Boston University, cautions against pushing the analogy too far: "I am sure the investigators would agree that these complex syndromes can't be reduced to the firing of a single small neural circuit without considering other important brain circuits, including those involved in thinking and appraisal."

But a deeper insight is suggested by a follow-up experiment in which Dr. Deisseroth's team directed their light beam just a little more broadly, activating more pathways in the amygdala. This erased the effect entirely, leaving the mouse as skittish as ever.

This implies that current drug treatments, which are far less specific and often cause side effects, could also in part be working against themselves.

David Anderson, a professor of biology at the California Institute of Technology who also does research using optogenetics, compares the drugs' effects to a sloppy oil change. If you dump a gallon of oil over your car's engine, some of it will dribble into the right place, but a lot of it will end up doing more harm than good.

"Psychiatric disorders are probably not due only to chemical imbalances in the brain," Dr. Anderson said. "It's more than just a giant bag of serotonin or dopamine whose concentrations sometimes are too low or too high. Rather, they likely involve disorders of specific circuits within specific brain regions."

So optogenetics, which can focus on individual circuits with exceptional precision, may hold promise for psychiatric treatment. But Dr. Deisseroth and others caution that it will be years before these tools are used on humans, if ever.

For one, the procedure involves bioengineering that most people would think twice about. First, biologists identify an "opsin," a protein found in photosensitive organisms like pond scum that allows them to detect light. Next, they fish out the opsin's gene and insert it into a neuron within the brain, using viruses that have been engineered to be harmless —"disposable molecular syringes," as Dr. Anderson calls them.

There, the opsin DNA becomes part of the cell's genetic material, and the resulting opsin proteins conduct electric currents — the language of the brain — when they are exposed to light. (Some opsins, like channelrhodopsin, which responds to blue light, activate neurons; others, like halorhodopsin, activated by yellow light, silence them.)

Finally, researchers delicately thread thin optical fibers down through layers of nervous tissue and deliver light to just the right spot.

Thanks to optogenetics, neuroscientists can go beyond observing correlations between the activity of neurons and an animal's behavior; by turning particular neurons on or off at will, they can prove that those neurons actually govern the behavior.

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http://www.nytimes.com/2011/05/17/science/17optics.html?pagewanted=all