Saturday, November 19, 2011

Why Voices of Singers Like Adele and John Mayer Are Stilled -

The rash of singers who have canceled concerts this fall to undergo throat surgery — Adele, Keith Urban, John Mayer — might suggest that touring takes a terrible toll on the vocal cords. Yet doctors who specialize on vocal issues point to something else to explain the cancellations: new diagnostic tools and surgical techniques.

Dr. Steven M. Zeitels, the Boston surgeon who operated on Adele to fix bleeding in her larynx, said that over the last 15 years the use of fiber-optic cameras that can scan the vocal cords for minuscule injuries and abnormalities has become common. It is now possible to spot problems like bleeding, nodules and cysts earlier and to take swift action to fix them, he said.

"Is there some epidemic? No," he said. "The only thing different happening is the singers know better how to take care of themselves, the doctors know better how to take care of them, and what has been happening always is just getting noticed."

Dr. Natasha Mirza, the director of the Penn Center for Voice and Swallowing at the University of Pennsylvania, added that improvements in laser surgery and imaging technology, which enables doctors to see smaller growths and hemorrhages than before, have also reduced the danger of scarring that can destroy a voice. "Done properly, they are actually pretty safe, these procedures," she said.

Physicians say that there is no doubt that professional rock and pop singers on extended tours run a substantial risk of damaging their voices. The strain of singing full-voiced for an hour and a half is intense — as hard on the larynx as a professional football game is on a lineman's body — and the vocal cords need time to recover after each performance. Dr. Zeitels, one of the leaders in his field, recommends that a rock singer not perform two nights in a row, though he concedes "that's just not feasible."

Singers on tour often do back-to-back concerts, sometimes performing four times a week. A lack of sleep and poor diet on the road can affect the voice, as can drinking and smoking, Dr. Mirza said. Some pop singers are also more susceptible to damaging their vocal cords because they have not had classical training, and their emotive, raw-sounding vocal techniques can place extra stress on tissues, she said.

Gary Bongiovanni, the editor of Pollstar, a concert industry trade publication, said that touring today was no harder on vocalists than it was 30 years ago.

What has changed, he noted, is that pop singers today make less money on album sales and consequently depend heavily on live concerts and the sales of merchandise for their income. Canceled dates hit them hard in the pocketbook.

"There is a lot of pressure to tour now, because that's how most artists make their money," he said. "It's not like you can release a record and just stay home and collect royalties."

Because vocalists today have a greater awareness of the dangers inherent in continuing to perform with damaged vocal cords, Mr. Bongiovanni said, "medical concerns are going to win the argument at the end of the day."

"There is a whole industry built around maintaining vocal health," he added.

John Mayer, the bluesy singer and songwriter, is a case in point. He underwent surgery in late October to remove a granuloma — a lesion caused when the body responds to repeated irritation — and was forced to delay the release of a new album, still unfinished, until next year, because he had to rest his voice for at least a month after the procedure.

Mr. Mayer's manager, Michael McDonald, said that his doctors had been monitoring the growth for six months, and that it was only after extensive periods of rest failed to remedy the problem that he opted for surgery.

Mr. Mayer never let the need to tour weigh on his decision to have surgery, he said. "John needs his voice to continue to work in the profession he's in," Mr. McDonald said in an e-mail. "We were willing to sit out 2012 if that's what it took."

Many high-profile pop singers made the same call this year. Adele, the 23-year-old British soul singer, was in the middle of a breakout, with her album "21" dominating the pop charts, when shecanceled nine shows on her North American tour during the summer, then canceled several high-profile performances in September. She told fans that doctors had warned she would risk losing her voice if she continued. This month she canceled the rest of the year's performances and underwent laser surgery.

Keith Urban, the country star, also chose to undergo surgery this month to remove a polyp from his vocal cords and then to rest his voice for an indefinite period, canceling concerts for the next three months.

These are hard decisions to make, Dr. Zeitels said. The singers he has worked with — among them Julie Andrews, Steven Tyler of Aerosmith and Roger Daltry of the Who — say they and other pop vocalists often feel compelled, out of loyalty to fans, to perform even when they have upper respiratory infections, which is similar to a sprinter's trying to run with an injured hamstring.

The most common problems for singers are benign polyps, cysts, granulomas and nodules, which are growths akin to calluses that develop on the vocal cords. All these can bleed under the demands of performance. The bleeding can lead to fibrosis, or scarring. The scars leave vocal cords less pliable and soft; the voice becomes hoarse and cracks.

Dr. Zeitels said the first tip-off for a singer was usually that his or her voice did not recover as quickly after a performance. A doctor used to look at the vocal cords using a handheld mirror, but in recent years small cameras attached to fiber-optic cables have been developed, which snake through the nose into the throat.

Surgical techniques have advanced too. When Dr. Zeitel operated on Adele this month, he used a recently developed laser that can stop bleeding without scarring the tissue. In the past a surgeon would cauterize the wound, sometimes with a carbon dioxide laser. But in recent years doctors at Harvard and Massachusetts General Hospital have started using a green laser that pulses light and heats the blood in the capillaries without damaging the surrounding tissue.

"You don't actually burn the vocal cord at all," Dr. Zeitels said.

Thursday, November 17, 2011

Health Care Saving by the Bundle -

On a typical night in the emergency room, a patient shows up short of breath, suffering from emphysema or heart failure or maybe both, as well as diabetes and high blood pressure. Doctors and nurses administer inhalers to ease his breathing and diuretics to take off excess fluid, and admit him to the hospital. Over the next few days, interns and residents furiously adjust his medications and fix his diet. He is discharged with a stack of prescriptions. A week or two later, chances are good he'll be right back in the emergency room.

A 2009 study in The New England Journal of Medicine showed that among Medicare patients, 20 percent were re-admitted to the hospital within 30 days of being discharged. We call these chronically ill patients frequent fliers.

What goes wrong? Just about everything. It is estimated that up to 40 percent of prescriptions go unfilled, and even when they are filled, patients often fail to take the medications as prescribed. Before blaming the patients, remember that many have multiple conditions and juggle 5 or 15 pills a day. Regulating a diet is difficult even for well-educated and motivated individuals. The typical Medicare patient sees 7 doctors a year; those with five or six chronic conditions see up to 10. They might forget to make an appointment, or be unable to keep it. If they do see a doctor, they probably have only 15 minutes to cram in all the issues they need to discuss.

The sickest 10 percent of patients consumes 64 percent of costs. Real savings require changing the way we care for these chronically ill patients.
With one-third of total health care expenditures spent on hospital care and about 20 percent spent on physician services and specialists each year, this is where the big money is — and where it can be saved. Although the United States spends more than $8,000 per person per year for health care, that money is not evenly distributed. Half the population — mostly young people and healthy adults — consumes just 3 percent of costs, while the sickest 10 percent consumes 64 percent. Real cost control requires changing the way we care for these high-cost patients with multiple chronic conditions. In particular, it requires preventing the avoidable complications that land them in emergency rooms and hospitals again and again.

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Tuesday, November 15, 2011

A Watch-and-Wait Treatment for Prostate Cancer -

With controversy raging over whether men should be screened for prostate cancer with the PSA blood test, the experience of one man in his 80s suggests an alternative to a simple yes-or-no response, as well as options for prevention and treatment that men of all ages might consider.

The man, a prominent New Yorker who for professional reasons asked that his name not be published, knew that the PSA was not recommended as a screening test for men over age 75 or for any man with less than a 10-year life expectancy. But although he was then 82, he said: "I insisted. I felt that age had nothing to do with it."

Now 85, he explained in an interview: "It's about how you feel, not how old you are. I feel like 60. I'm full of beans. With my energy level, my view of life, the 12 hours of work I do every day and the many cultural activities I enjoy, I ignore my age. And I didn't want to take any chances that prostate cancer would get in the way of all this."

He had the test, and when his PSA reading came back close to 5, he elected to have a biopsy (4 is the cut-off at which doctors usually recommend the procedure). It found an early-stage cancer on one side of the gland. Further analysis revealed a Gleason score of 7, suggesting that the cancer was somewhat more aggressive than slow-growing.

He was not considered a candidate for surgery and would not have wanted it in any case, but neither was he thrilled by the prospect of radiation treatments.

Instead, he consulted Dr. Aaron E. Katz, director of the Center for Holistic Urology at Columbia University Medical Center and author of "The Definitive Guide to Prostate Cancer." Dr. Katz's approach to this disease might be described as "more is less" — for most men with early-stage cancers that are not particularly aggressive, take the least invasive approach.

That could be what Dr. Katz calls "active surveillance with possible delayed intervention" should the cancer start to grow, or for someone like the elderly New Yorker who wanted the cancer out, a relatively new procedure called cryosurgery.

What Is Active Surveillance?

Prostate cancer is extremely common. The disease can be found in up to 30 percent of men over age 50. Most men who develop it do not die of it; rather, they die with it, often without knowing that it was present.

The development of the PSA test and its widespread use greatly increased diagnosis of this disease, often of cases that would never have become a clinical problem.

In such cases, doctors may suggest "watchful waiting" — repeated monitoring of the prostate with no treatment unless the cancer begins to progress.

Active surveillance, according to Dr. Katz, can be applied to men with a PSA under 10 and Gleason score under 7 who have early-stage disease and no evidence of cancer beyond the prostate. He describes the somewhat unconventional approach as follows:

¶ Making dietary changes that include reducing or eliminating red meat and dairy and eating lots of vegetables.

¶ Taking supplements of omega-3 fatty acids, vitamin D and herbal anti-inflammatory agents.

¶ Adopting an exercise program that includes aerobic exercise three times a week.

¶ Practicing a method of stress reduction like yoga or meditation.

¶ Getting a PSA test every three to four months and digital rectal exam every six months.

¶ Repeating a biopsy of the prostate every 12 to 24 months.

While definitive proof is lacking, the dietary and behavioral changes he suggests are based on both observational and clinical studies that have linked them to a reduced risk of developing an aggressive cancer and dying of the disease. For example, in 1993, Dr. Edward Giovannucci and colleagues at the Harvard School of Public Health documented a relationship between high intake of red meat and a greater risk of developing advanced prostate cancer among 51,529 men who had initially been cancer-free.

In another study of the same group of men followed for up to 16 years, Dr. Giovannucci and co-authors found a reduced risk of advanced and fatal prostate cancer among those who consumed lots of tomato sauce, a rich source of a protective substance called lycopene, and those who engaged in higher levels of vigorous physical activity.

To patients who choose active surveillance, Dr. Katz recommends fish, particularly oily ocean fish like salmon, Arctic char, Atlantic mackerel and sardines, as the best source of omega-3 fatty acids. Among other protective foods that he said can stabilize or reduce PSA levels and cancer progression are deeply colored fruits like pomegranates, red grapes, green tea, flaxseed and walnuts.

He also urges men to greatly increase their consumption of vegetables, especially the cruciferous vegetables like broccoli, cabbage, brussels sprouts, cauliflower and kale, and other dark green leafy vegetables like spinach and Swiss chard.

This dietary approach can foster weight loss, important because obese men are more likely to develop aggressive prostate cancers, and also protect against heart disease, the leading killer of American men.

For supplements, Dr. Katz said that with more than 75 percent of men deficient in vitamin D, he starts with a daily intake of 2,000 to 3,000 international units a day to normalize blood levels. Other supplements he has found to be clinically helpful include AHCC, a combination of medicinal mushrooms that enhance the immune response, and Zyflamend, a combination of 10 herbal extracts with anti-inflammatory properties that, based on laboratory and early clinical trials, he and others believe can counter precancerous prostate lesions and reduce cancer spread to bones.

Cryosurgery, a Therapy Option

Many men found through PSA testing to have prostate cancer are reluctant to delay definitive treatment. Yet, the most common procedures — surgical removal of the prostate and radiation — can be overkill for men with early-stage disease and often result in two debilitating problems: incontinence and impotence.

Dr. Katz is one of about 50 urologists in academic centers around the country who specialize in cryosurgery, an outpatient procedure covered by Medicare in which just the diseased part of the prostate is frozen, sparing healthy tissue and avoiding serious side effects. Should the disease recur, the procedure can be repeated.

The 85-year-old New Yorker had cryosurgery and continues to follow Dr. Katz's recommendations, so far with no evidence of cancer recurrence or spread.

"We're overtreating so many men in this country with nine weeks of radiation that costs Medicare $50,000 and with robotic surgery using machines that cost $2 million," Dr. Katz said. "This has got to stop. We need guidelines as to who should be treated. And before a PSA test is done, patients need to be educated about what the test really means and where it can lead."

These latter words were echoed in four articles recently published online by The New England Journal of Medicine, suggesting a more discriminating use of the PSA.