Saturday, April 21, 2012

Time of optimism: A personal account from a Princess Margaret cancer patient | Believe It | Financial Post

In 2008, Raymund Ong was a Guelph University student studying zoology. Like many young adults, he had been so focused on getting into university and earning a degree that he hadn't really thought through what he would do after graduation. The further he got into his courses, the less focused his vision of the future became. Then one day, during mid-terms, he began experiencing severe abdominal pain — so much pain that he had trouble breathing. By the end of that week, his angst over his choice of education and career path would take a back seat to what would become one of the biggest trials of his young life.
When the pain started he initially chalked it up to mid-term stress, even though he typically doesn't get stressed. "And then I thought maybe it was all the work I'd been doing on my abdominals in the gym," Mr. Ong recalls.
He wasn't too concerned; he took a day to rest and pushed through. That weekend, he returned home to Toronto and went out with friends and the next day, a Sunday, he woke up in severe pain again. His mother rushed him to Emergency. He remained in hospital a few days before being diagnosed with leukemia. "I didn't even know what leukemia was," Mr. Ong says. "I had just turned 20. I was an extremely active person. I played volleyball. I jogged. I was learning about healthy eating, worked out three times a week. There was no family history of cancer. I didn't understand how I could be so sick."
Once diagnosed, Mr. Ong began chemotherapy at The Princess Margaret and the journey that would lead him to find his passion and a focus for his life. "I was an in-patient for 50 days, receiving chemotherapy treatment intravenously, and then as an out-patient," Mr. Ong says. "I lost my appetite, lost my hair and suffered two seizures. I also developed a blood clot on the right side of my brain that led to a stroke that paralyzed my entire left side." He would not regain full functionality until the end of his treatment on Jan. 5, 2011.
But there was another psycho-social aspect of the cancer and treatment that he hadn't anticipated. The emotional impact of the cancer and the chemotherapy took the form of mood swings, depression and anxiety. "Only my closest friends knew what was going on," Mr. Ong says. "I really wanted to control who knew and how much they knew because at that point, it was the only thing I could control. The Princess Margaret was fantastic in helping me deal with all that I was feeling. At first, I didn't seek emotional support. I thought I could take care of it myself. It wasn't until I got into a huge argument with my mother, who was breaking down because of all that was happening with me, that I saw I needed to deal with my emotions."
Mr. Ong approached his doctor at The Princess Margaret. It was a visit that changed everything. He soon met with a social worker at the hospital who directed him to a number of resources and support groups such as Gilda's Club and Young Adult Cancer Canada. "I began talking to other young adults diagnosed with cancer every month and through those meetings I was able to open up," Mr. Ong says.
Once his chemotherapy treatment was completed, he went on a retreat in Newfoundland with Young Adult Cancer Canada. "That retreat turned my life around. I'm so grateful to The Princess Margaret for leading me down that road and sharing their resources with me. On the trip I met a psychologist who is my psychologist today and who also connected me to ELLICSR: Health, Wellness and Cancer Survivorship Centre, (which is funded by The Princess Margaret Hospital Foundation)." It was here that Mr. Ong learned about how to eat healthy and the importance of lifestyle and healthy living for people living with cancer.
In September, 2011, Mr. Ong enrolled in the culinary management nutrition program at George Brown College. "It's a hybrid program that fills a niche no one is filling: combining culinary skills and nutrition. I'll graduate in 2013 and then I'll follow that up with another George Brown program in health and wellness," Mr. Ong says. "Once I started physiotherapy I saw exercise in a new light. I began to understand how much the body can do to heal itself."
In fact, through physiotherapy he regained the use of his hand and his overall physique improved. "In October, I ran a five-kilometre marathon raising money for Gilda's Club. The year before, I couldn't' even walk properly. My goal was to do it in under 34 minutes and my time was 30 minutes 42 seconds."
His life goal is to bring all the knowledge he's gaining about health and wellness to create exercise therapy programs and nutrition and healthy eating programs for young people with cancer. "Once I graduate I want to create a not-for-profit and raise awareness. Leukemia is an enigma. It's an ambiguous disease; there is no specific site to treat. And it's growing among young people. I'm still getting blood work now that chemotherapy is finished. I feel I'm cancer-free but there is still doubt. But I'm not going to let it affect my life. Throughout my journey The Princess Margaret has helped me overcome every obstacle, they led me to support, they brought me back to a healthy state physically and they connected me to my future path."


Friday, April 20, 2012

Program in Placebo Studies & the Therapeutic Encounter | Hosted at Beth Israel Deaconness Medical Center

For many years, the placebo effect was considered to be no more than a nuisance variable that needed to be controlled in clinical trials. Only recently have researchers redefined it as the key to understanding the healing that arises from medical ritual, the context of treatment, the patient-provider relationship and the power of imagination, trust and hope.

Although our biomedical health care system often considers these humanistic dimensions of care as secondary to the administration of pharmaceuticals and procedures, the emerging field of placebo studies is producing scientific evidence that these more intangible elements of medicine may fundamentally contribute to the improvement of patient outcomes.

The Program in Placebo Studies and the Therapeutic Encounter hosted at Beth Israel Deaconess Medical Center is the first research center to pursue placebo studies through interdisciplinary, translational research initiatives that bridge the basic, clinical and social sciences, as well as the humanities.

The Science and History of Treating Depression -

Few medicines, in the history of pharmaceuticals, have been greeted with as much exultation as a green-and-white pill containing 20 milligrams of fluoxetine hydrochloride — the chemical we know as Prozac. In her 1994 book "Prozac Nation," Elizabeth Wurtzel wrote of a nearly transcendental experience on the drug. Before she began treatment with antidepressants, she was living in "a computer program of total negativity . . . an absence of affect, absence of feeling, absence of response, absence of interest." She floated from one "suicidal reverie" to the next. Yet, just a few weeks after starting Prozac, her life was transformed. "One morning I woke up and really did want to live. . . . It was as if the miasma of depression had lifted off me, in the same way that the fog in San Francisco rises as the day wears on. Was it the Prozac? No doubt."

Like Wurtzel, millions of Americans embraced antidepressants. In 1988, a year after the Food and Drug Administration approved Prozac, 2,469,000 prescriptions for it were dispensed in America. By 2002, that number had risen to 33,320,000. By 2008, antidepressants were the third-most-common prescription drug taken in America.

Fast forward to 2012 and the same antidepressants that inspired such enthusiasm have become the new villains of modern psychopharmacology — overhyped, overprescribed chemicals, symptomatic of a pill-happy culture searching for quick fixes for complex mental problems. In "The Emperor's New Drugs," the psychologist Irving Kirsch asserted that antidepressants work no better than sugar pills and that the clinical effectiveness of the drugs is, largely, a myth. If the lodestone book of the 1990s was Peter Kramer's near-ecstatic testimonial, "Listening to Prozac," then the book of the 2000s is David Healy's "Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression."

In fact, the very theory for how these drugs work has been called into question. Nerve cells — neurons — talk to one another through chemical signals called neurotransmitters, which come in a variety of forms, like serotonin, dopamine and norepinephrine. For decades, a central theory in psychiatry has been that antidepressants worked by raising serotonin levels in the brain. In depressed brains, the serotonin signal had somehow been "weakened" because of a chemical imbalance in neurotransmitters. Prozac and Paxil were thought to increase serotonin levels, thereby strengthening the signals between nerve cells — as if a megaphone had been inserted in the middle.

But this theory has been widely criticized. In The New York Review of Books, Marcia Angell, a former editor of The New England Journal of Medicine, wrote: "After decades of trying to prove [the chemical-imbalance theory], researchers have still come up empty-handed." Jonathan Rottenberg, writing in Psychology Today, skewered the idea thus: "As a scientific venture, the theory that low serotonin causes depression appears to be on the verge of collapse. This is as it should be; the nature of science is ultimately to be self-correcting. Ideas must yield before evidence."

Is the "serotonin hypothesis" of depression really dead? Have we spent nearly 40 years heading down one path only to find ourselves no closer to answering the question how and why we become depressed? Must we now start from scratch and find a new theory for depression?

Science may be self-correcting, but occasionally it overcorrects — discarding theories that instead need to be rejuvenated. The latest research suggests that serotonin is, in fact, central to the functioning of mood, although its mechanism of action is vastly more subtle and more magnificent than we ever imagined. Prozac, Paxil and Zoloft may never turn out to be the "wonder drugs" that were once advertised. But they have drastically improved our understanding of what depression is and how to treat it.

Our modern conception of the link between depression and chemicals in the brain was sparked quite by accident in the middle of the last century. In the autumn of 1951, doctors treating tubercular patients at Sea View Hospital on Staten Island with a new drug — isoniazid — observed sudden transformations in their patients' moods and behaviors. The wards — typically glum and silent, with moribund, lethargic patients — were "bright last week with the happy faces of men and women," a journalist wrote. Patients laughed and joked in the dining hall, as if a dark veil of grief had lifted. Energy flooded back and appetites returned. Many, ill for months, demanded five eggs for breakfast and then consumed them with gusto. When Life magazine sent a photographer to the hospital to investigate, the patients could no longer be found lying numbly in their beds: they were playing cards or dancing in the corridors.

If the men and women at Sea View were experiencing an awakening, then a few hundred miles south, others at Duke's hospital encountered its reverse. In 1954, a 28-year-old woman was prescribed Raudixin to control her blood pressure. A few months later, she returned to the hospital, complaining of crying spells, dullness and lethargy. She felt futile, guilty and hopeless, she told her doctors. A few months later, when she returned, the sense of futility had turned into hostility. A 42-year-old woman prescribed Raudixin told her doctor that "God would cause her to become insane" before she could repent. The "feeling blue," as another patient described it, persisted until the drug was discontinued. At another hospital, one patient treated with Raudixin attempted suicide. Several people had to be admitted to psychiatric wards and administered electroconvulsive therapy before the symptoms were alleviated.

Psychiatrists and pharmacologists were quick to note these bizarre case reports. How, they wondered, could simple, seemingly unrelated chemicals like Raudixin or isoniazid produce such profound and opposite effects on mood? It was around this same time that scientists were learning that the brain itself was immersed in a soup of chemicals. In the early part of the century, scientists wondered how nerve cells talked to one another. By the late 1960s, evidence suggested that signals between neurons were carried by several chemicals, including the neurotransmitter serotonin. Might isoniazid and Raudixin have altered the levels of some neurotransmitters in the brain, thereby changing brain signaling and affecting mood? Strikingly so, scientists found. Raudixin — the "feeling blue" drug — drastically lowered the concentration of serotonin and closely related neurotransmitters in the brain. Conversely, drugs known to increase euphoria, like isoniazid, increased those levels.

These early findings led psychiatrists to propose a radical new hypothesis about the cause and treatment of depression. Depression, they argued, was a result of a "chemical imbalance" of neurotransmitters in the brain. In the normal brain, serotonin shuttled between mood-maintaining neurons, signaling their appropriate function. In the depressed brain, this signal had somehow gone wrong. The writer Andrew Solomon once evocatively described depression as a "flaw in love" — and certainly, the doctors using Raudixin at Duke had seen that flaw emerge grimly in real time: flaws in self-love (guilt, shame, suicidal thoughts), love for others (blame, aggression, accusation), even the extinction of a desire for love (lethargy, withdrawal, dullness). But these were merely the outer symptoms of a deeper failure of neurotransmitters. The "flaw in love" was a flaw in chemicals.

Powerful vindication for this theory came from the discovery of new medicines that specifically elevated serotonin concentrations. The first such drug, Zimelidine, was created by a Swedish researcher, Arvid Carlsson. Following Carlsson's lead, pharmaceutical chemists threw their efforts and finances into finding serotonin-enhancing drugs, and the new giants of the antidepressant world were born in rapid succession. Prozac was created in 1974. Paxil appeared in 1975, Zoloft in 1977 (the trade names were introduced years later).

In 2003, in Boston, I began treating a 53-year-old woman with advanced pancreatic cancer. Dorothy had no medical problems until she developed an ominous sign known to every cancer specialist: painless jaundice, the sudden yellowing of skin without any associated pinch of discomfort. Painless jaundice can have many causes, but the one that oncologists know best, and fear most, is pancreatic cancer.

In Dorothy's case, the mass in the pancreas turned out to be large and fist-shaped, with malignant extensions that reached backward to grip blood vessels, and a solitary metastasis in the liver. Surgical removal was impossible, chemotherapy the only option.

The suddenness of the diagnosis struck her like an intravenous anaesthetic, instantly numbing everything. As we started chemotherapy in the hospital, she spent her mornings in bed sleeping or staring out of the window at the river below. Most disturbing, I watched as she lapsed into self-neglect. Her previously well-kept hair grew into a matted coil. The clothes that she had worn to the hospital remained unchanged. There were even more troubling signs: tiny abrasions in the skin that were continuously picked at, food left untouched by the bedside table and a gradual withdrawal of eye contact. One morning, I walked into what seemed like a daily emotional flare-up: someone had moved a pillow on the bed, Dorothy had been unable to sleep and it was somehow her son's fault.

This grief, of course, was fully provoked by the somberness of her diagnosis — to not grieve would have been bizarre in these circumstances — but she recognized something troubling in her own reaction and begged for help. I contacted a psychiatrist. With her consent, we prescribed Prozac.

In the first weeks, we waited watchfully, and nothing happened. But when I saw her again in the clinic after a month and a half, there were noticeable changes. Her hair was clean and styled. Her cuts had disappeared, and her skin looked good. Yet she still felt sad beyond measure, she said. She spent her days mostly in bed. The drug certainly affected many of the symptoms of depression, yet had not altered the subjective "feeling" of it. It healed the flaws in her skin but not all the flaws in love.

Any sane reader of this case would argue that a serotonin imbalance was not the initiating cause of Dorothy's depression; it was, quite evidently, the diagnosis of a fatal disease. Should we be searching for a chemical cause and cure when the provocation of grief is so apparent?

Pause for a moment, though, to consider the physiology of a heart attack. A heart attack can be set off by a variety of causes — chronic high blood pressure or pathologically high levels of "bad" cholesterol or smoking. Yet aspirin is an effective treatment of a heart attack regardless of its antecedent cause. Why? Because a heart attack, however it might have been provoked, progresses through a common, final pathway: there must be a clot in a coronary artery that is blocking the flow of blood to the heart. Aspirin helps to inhibit the formation and growth of the clot in the coronary artery. The medicine is clinically effective regardless of what events led to the clot. "Aspirin," as a professor of mine liked to put it, "does not particularly care about your medical history."

Might major depression be like a heart attack, with a central common pathway and with serotonin as its master regulator? There was certainly precedent in the biology of the nervous system for such unifying pathways — for complex mental states triggered by simple chemicals. Fear, for instance, was found to involve a common hormonal cascade, with adrenaline as the main player, even though its initiators (bears, spiders or in-laws) might have little resemblance to one another.

But such a line of inquiry can't tell us whether the absence of serotonin causes depression. For that, we need to know if depressed men and women have measurably lower levels of serotonin or serotonin-metabolites (byproducts of serotonin breakdown), in their brains. In 1975, pathologists performed autopsies on depressed patients to measure serotonin levels. The initial findings were suggestive: depressed patients typically tended to have lower levels of brain serotonin compared with controls. But in 1987, when researchers in Scandinavia performed a similar experiment with newer tools to measure serotonin more accurately, serotonin levels were found to be higher in depressed patients. Further experiments only deepened these contradictions. In some trials, depressed patients were found to have decreased serotonin levels; in others, serotonin was increased; in yet others, there was no difference at all.

What about the converse experiment? In 1994, male subjects at McGill University in Montreal were given a chemical mixture that lowered serotonin. Doctors then measured the fluctuations in the mood of the men as serotonin levels dipped in the blood. Though serotonin was depleted, most of them experienced no significant alterations in their mood.

At first glance, these studies seem to suggest that there is no link between serotonin and depression. But an important fact stands out in the McGill experiment: lowering serotonin does not have any effect on healthy volunteers with no history of depression, but serotonin-lowering has a surprisingly brisk effect on people with a family history of depression. In these subjects, mood dipped sharply when serotonin levels dropped. An earlier version of this experiment, performed at Yale in 1990, generated even more provocative findings. When depressed patients who were already responding to serotonin-enhancing drugs, like Prozac, were fed the serotonin-lowering mixture, they became acutely, often profoundly, depressed. Why would serotonin depletion make such a difference in a patient's mood unless mood in these patients was, indeed, being controlled by serotonin?

Other experiments showed that though depressed patients generally didn't have consistently lower levels of serotonin, suicidal patients often did. Might contemplating suicide be the most extreme form of depression? Or is it a specific subtype of mood disorder that is distinct from all the other forms? And if so, might depression have multiple subtypes — some inherently responsive to treatment with serotonin-enhancing drugs and some inherently resistant?

We may not understand how serotonin-enhancing antidepressants work, but do we know whether they work at all?

In the late 1980s, studies examined the effect of Prozac on depressed subjects. Several of these trials showed Prozac reduced the symptoms of depression when compared with a placebo. Depression is usually assessed using a standardized rating scale of different symptoms. In general, some patients reported clinically meaningful improvements, although the effects were often small and varied from trial to trial. In real-world terms, such a change could be profound: a transformation in anxiety, the lifting of the ache of guilt, an end to the desire to commit suicide. But for other patients, the changes were marginal. Perhaps the most important number that emerged from these trials was the most subjective: 74 percent of the patients reported feeling "much" or "very much" better on antidepressants.

In 1997, a psychologist, Irving Kirsch, currently at the Harvard Medical School, set out to look at the placebo effect in relation to depression. In part, the placebo effect works because the psyche acutely modifies the perception of illness or wellness. Kirsch wondered how powerful this effect might be for drugs that treat depression — where the medical condition itself happens to involve an alteration of the psyche.

To measure this effect, Kirsch combined 38 trials that included patients who had been given antidepressants, placebos or no treatment and then applied mathematical reasoning to estimate how much the placebos contributed to the improvements in mood. The analysis revealed two surprises. First, when Kirsch computed the strength of the placebo effect by combining the trials, he found that 75 percent of an antidepressant's effect could have been obtained merely by taking the placebo. When Kirsch and his collaborators combined the published and unpublished studies of anti­depressants (they obtained the unpublished data from the F.D.A. via the Freedom of Information Act), the effects of the antidepressants were even more diluted — in some cases, vanishingly so. Now, the placebo effect swelled to 82 percent (i.e., four-fifths of the benefit might have been obtained by swallowing an inert pill alone). Kirsch came to believe that pharmaceutical companies were exaggerating the benefits of antidepressants by selectively publishing positive studies while suppressing negative ones.

But there are problems in analyzing published and unpublished trials in a "meta-trial." A trial may have been unpublished not just to hide lesser effects but because its quality was poor — because patients were enrolled incorrectly, groups were assigned improperly or the cohort sizes were too small. Patients who are mildly depressed, for example, might have been lumped in with severely depressed patients or with obsessive-compulsives and schizophrenics.

In 2010, researchers revisited Kirsch's analysis using six of the most rigorously conducted studies on antidepressants. The study vindicated Kirsch's conclusions but only to a point. In patients with moderate or mild depression, the benefit of an antidepressant was indeed small, even negligible. But for patients with the most severe forms of depression, the benefit of medications over placebo was substantial. Such patients might have found, as Andrew Solomon did, that they no longer felt "the self slipping out" of their hands. The most severe dips in mood were gradually blunted. Like Dorothy, these patients most likely still experienced sorrow, but they experienced it in ways that were less self-destructive or paralyzing. As Solomon wrote: "The opposite of depression is not happiness, but vitality, and my life, as I write this, is vital."

These slippery, seemingly contradictory studies converge on a surprisingly consistent picture. First, patients with severe depression tend to respond most meaningfully to antidepressants, while patients with moderate or mild depression do not. Second, in a majority of those who do respond, serotonin very likely plays an important role, because depleting serotonin in depressed patients often causes relapses. And third, the brain-as-soup theory — with the depressed brain simply lacking serotonin — was far too na├»ve.

More …

Tuesday, April 17, 2012

Toronto News: Six GTA hospitals won’t reveal fetal sex during ultrasound -

Toronto Star survey has found that six major hospitals in the GTA do not allow their ultrasound staff to reveal a baby's gender to expectant mothers.

And, whether by coincidence or by design, all six hospitals are located in or near areas with high concentrations of South Asian immigrants — one of the ethnic communities at the centre of a mounting concern over female feticide.

Female feticide — the practice of aborting female fetuses due to a preference for sons — is a known phenomenon in countries such as China and India, where it has been deemed a "crime against humanity."

But a growing body of research is stoking fears that the practice may have migrated to Canada. On Monday, a newly-released St. Michael's Hospital study found "concerning trends" to suggest female feticide could be happening in South Korean and Indian communities.

The starkest finding was in the category of Indian-born mothers with two previous children. Among their third children, the male-to-female ratio was 136 boys for every 100 girls; by comparison, the children of Canadian-born women have a sex ratio of just 105 boys for every 100 girls.

In January, the Canadian Medical Association Journal published an editorial calling on doctors to stop divulging fetal sex to mothers until the 30th week of pregnancy, when an unquestioned abortion becomes virtually impossible. (Generally, few abortions are performed after 20 weeks.)

The radical stance was widely criticized, however, and the Society of Obstetricians and Gynecologists issued a statement reaffirming its belief in the patient's right to know the gender of her child.

But for many expectant parents, it is their ultrasound sonographer — which most people erroneously refer to as an ultrasound technician — who announces the baby's sex. Although sonographers technically are not allowed to (they are not supposed to diagnose and gender is considered a diagnosis), the majority of major GTA hospitals allow it.

"The technician staff is pleased to share that happy news with family wanting that information," said Aaron Lazarus, a spokesperson for Lakeridge Health in Durham region. "We have a family-based model of care here."

Doctors say that about half of prenatal ultrasounds are done at hospitals, with the other half performed at outside clinics.

Of the 16 major hospitals in the GTA that perform prenatal ultrasounds, only six prohibit their sonographers from divulging fetal gender: William Osler Health System (which has hospitals in Etobicoke and Brampton), North York General, Scarborough Hospital, Rouge Valley (with hospitals in Scarborough and Ajax), Toronto East General, and Humber River Regional Hospital (which has three locations in the Jane and Finch area that will merge in 2015).

Some of these hospitals will indicate gender on their reports, but only at the request of the referring physician who can then tell the patient during a follow-up visit.

All six of these hospitals are located in or near communities with large South Asian populations. But hospital spokespeople dismiss this as nothing more than a coincidence and say they are just adhering to policies that have been in place for decades.

"Our diagnostic imaging lead said it has been in place for the 30 years they've been here," said Lorraine Lynch, spokesperson for William Osler Health System, in an emailed response. "We do not have any information or programs for the issue you are covering."

"This procedure has nothing to do with the populations we serve, but rather with the (sonographer's) scope of practice," said Marcelo Gomez-Wiuckstern, spokesperson for North York General.

But at Rouge Valley, female feticide is very much a concern for Raymond Goh, manager of diagnostic imaging. He said the hospital's policy has been in place for at least 13 years, so it isn't reaction to the community's population mix; that being said, however, the hospital takes the policy seriously because of the female feticide issue.

"From the radiologists' side, we have been debating about this for years because we are concerned about the issue of gender selection," said Dr. Raymond Goh. "We have been criticized, actually, by several of the referring doctors, the obstetricians and family doctors, for having such a firm stance on gender."

Goh said sonographers at Rouge Valley can record a baby's gender if they happen to notice it during the routine ultrasound. Their notes and scans are then passed along to a radiologist, who drafts a medical report for the referring physician.

Gender is not included on the report, however, unless a doctor has specifically requested it ahead of time. In Goh's opinion, this is because the referring physician is best-equipped to decide what information should be shared with the patient.

But even at hospitals where sonographers can tell, female feticide is an underlying concern. Radiologist Dr. Ants Toi at Mount Sinai agrees the issue has complicated policies around gender disclosure.

"There are some ethnic groups in particular that create a problem with knowing gender and that's highlighted things," he said.

Toi said he frequently interacts with patients and often asks if they want to know the gender — after all, many parents want it to be a surprise. But he will steer clear of the question altogether if something seems amiss.

"It's sort of a quiet patient assessment without asking any particular interview questions," he said. If I have any concern at all that this information may be used in a harmful way . . . I'll simply say I'm sorry, I can't see clearly enough."

Toi said he rarely finds cause for concern amongst his own patients but he does believe female feticide is likely occurring in Canada — and the issue puts medical practitioners in a tricky position.

"It's a social issue, ethical issue, and an issue of many beliefs. It's very difficult," he said.

Some medical practitioners would like a higher authority to provide clarity on the issue, but spokespeople for the Ministry of Health and College of Physicians and Surgeons of Ontario said they are currently not looking into the issue.

Bernard Dickens, a professor emeritus of health policy at the University of Toronto, wonders if it is even ethical to implement a blanket policy due to concerns over one segment of the population.

"Note the paradox that abortion for no reason — because it's untimely, unplanned, not wanted — that is acceptable. So then we've got the paradox that an abortion for no reason (is ok), but abortion for what seems to be a gendered or sex-based reason is not," he said.

"Making policies to deny that population what is important to them — in itself, it is a difficult ethical and legal question. Is that racial profiling, is that a form of racial discrimination?"

If hospitals are worried about female feticide, they should be conducting community consultations before shaping any policies, said Kripa Sekhar, executive director of South Asian Women's Centre in Toronto. While concerned about the possibility of female feticide, she believes more research should be done before conclusions can be reached.

"You want to protect women, but in the process are we looking at a small segment of women that might be profiled negatively and then a whole community becomes (stigmatized)?" she asked.

At Rouge Valley, Goh agrees there is no proof female feticide is being practised. But he believes there are enough red flags to warrant concern — and if female fetuses are being targeted, he would rather take a proactive stance than none at all.

"We need to find that evidence and if it is true, we need to help the girls," he said. "Ultimately, I think (sonographers) not telling is really trying to err on the safe side to protect the unborn."

Ultrasound at GTA Hospitals

Here are six major hospitals in the GTA that have a policy or practice restricting ultrasound sonographers from telling a patient the sex of the fetus:

Toronto East General Hospital

Sonographers cannot divulge gender because it is considered a diagnosis. Gender is also not included on the doctor's report, unless requested by a physician for a medically-relevant reason.

Rouge Valley Health System

Sonographers cannot divulge gender to parents and the information is not included on the radiologist's report for the doctor — unless a physician has requested it beforehand.

William Osler Health Centre

Sonographers will look for the fetal gender if requested by a physician or patient. The radiologist then notes the gender in the report for the doctor, who is responsible for informing the patient.

Humber River Regional Hospital

Sonographers do not provide gender results during the exam, nor is the information included on the radiologist's report for the doctor.

North York General Hospital

There is no policy in place but patients are "strongly encouraged" to follow up with their physicians for gender information. Sonographers are not to divulge gender because it falls outside their scope of practice.

Scarborough Hospital

There is no policy but hospital practice says sonographers cannot divulge gender, or any other diagnosis, during an ultrasound. It is also not the radiologists' practice to include gender on their reports.

Monday, April 16, 2012

Prominent neurosurgeon Charles Tator warns Senators captain Daniel Alfredsson against early return | Sports | National Post

A renowned Canadian neurosurgeon said the spate of headshots seen over the weekend in a handful of National Hockey League playoff games was "disheartening" given the steps that seem to have been made in raising concussion awareness this season.
Dr. Charles Tator, a neurosurgeon at Toronto Western Hospital who volunteers with ThinkFirst, a non-profit group aimed at brain and spinal cord injury prevention, said he watched a few of the games, and caught highlights of the others. Two suspensions have already been announced.
"It really is disheartening to see the level of violence and aggression that was displayed over the weekend, and in so many games," Tator said on Monday. "I thought we were making progress earlier in the season, but there's definitely been slippage. And it just points out that the fact we need an even better effort on the part of the professionals to improve the game and prevent injuries.
"Safety has taken a backseat in these playoffs."
On Sunday, the NHL announced it was suspending New York Rangers forward Carl Hagelin for three games for driving his elbow into Ottawa Senators captain Daniel Alfredsson's head Saturday night. Alfredsson left the game and has since confirmed he suffered a concussion, but he has also been listed as a game-time decision for Game 3 of Ottawa's Eastern Conference quarter-final series with New York on Monday.

Tator advised against returning to the lineup so quickly.
"It's not what we recommend," he said. "We recommend that there should be a six-step process that you go through after a concussion to determine whether you're ready to return to play."
That process requires one day in between levels to assess whether the player is healthy enough to return to play. The first level is complete physical and mental rest, and the final step is return to play.
"So if you have 24 hours between steps, it really means a week off," Tator said. "So, in our view, to try to give the brain enough opportunity to recover, we recommend a week."
Alfredsson has already missed time due to a concussion this season, after an earlier incident with the Rangers in October.
"He's probably doing himself a disservice by coming back too early," he said.
NHL disciplinarian Brendan Shanahan reportedly has hearings scheduled with two more players on Tuesday. He will meet with Pittsburgh Penguins forward James Neal twice, both for hits that targeted players with pre-existing concussion issues, having launched himself at Philadelphia Flyers forwards Claude Giroux and Sean Couturier during a cartoonishly violent game on Sunday.
"Our biggest stars continue to be wounded in the brain by the game," Tator said. "The game needs to change. We really need a big change in the game if we're going to preserve the game."

Sunday, April 15, 2012

Doctor and Patient: Are Women Less Satisfied With Their Care Than Men? -

Early on in my residency, a fellow surgeon-in-training revealed that she was switching fields. Her real love was not general surgery, she explained, but urology.
As she recounted the steps leading to her decision to focus on diseases of the urinary tract, I couldn't help wondering about her future practice. She might see an occasional woman or child; but most of her patients would be men.
I shared these thoughts with her, and she laughed. "Male patients have different expectations than female patients," she said. "Somehow, I think I'm a better fit as a doctor for men."
It wasn't the first time a colleague had made a sweeping generalization about patient care, but what struck me was how boldly she had emphasized differences between men and women. As medical students we were taught to care for all patients equally, and as young practicing doctors, most of us assumed that at least as far as gender was concerned, that meant treating everyone the same.
It turns out that my colleague was onto something.
In a study published this year in the journal Health Services Research, researchers analyzed the results of a survey that asked nearly two million patients how they felt about their hospitalization. Known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or Hcahps (pronounced "H-caps"), and administered to patients within six weeks of discharge, the survey consists of 27 questions about topics ranging from communication with nurses and doctors and responsiveness of hospital staff to general cleanliness and noise levels.

When the researchers divided the questionnaire results by the patients' sex, they discovered that men tended to be more positive over all about their hospital experiences. Women were less satisfied with staff responsiveness, their discussions with nurses, communication about medications and discharge plans and the general conditions of the hospital. Among men and women who were older or felt sicker, these differences were even more pronounced.
"What patients require when they are ill and feeling vulnerable is not the same," said Marc N. Elliott, the study's lead author and a senior statistician at the RAND Corporation in Santa Monica, Calif. "What's becoming clear is that we are not meeting the needs of female patients."
In some cases the extent to which male and female patients differed in their satisfaction levels was substantial, surprising even the researchers. "There was a fairly consistent gender gap," Dr. Elliott said. "But some of the differences were on the same magnitude as what you might see among patients from different ethnic groups or widely disparate socioeconomic backgrounds."
One of the more marked differences was the amount of information about medications or discharge plans that patients needed to feel sufficiently informed. Women generally wanted more information than they received, while men were satisfied with what they were told. There were also considerable disparities between men and women regarding cleanliness, with women inclined to be less satisfied with the hygiene of hospital surroundings.
The findings from this study underscore how complex addressing quality and patient experience can be. Currently, most health care improvement efforts tend to treat patients as a monolithic group. It's an oversight that can be attributed, at least in part, to the relative paucity of research and data on the patient experience.
That situation may change, as the Hcahps survey becomes linked to reimbursement and more hospitals begin administering the questionnaire to their patients. While some hospital administrators and clinicians are concerned about this prospect, Dr. Elliott and his colleagues believe their study is an indication of what this survey could help to do. By offering patients an opportunity to express their opinions, Hcahps might uncover issues that have gone unnoticed.
"Patients are hesitant to tell us what they are feeling because they don't want to be seen as confrontational," Dr. Elliott said. "To make substantial improvements, we need to get at that information."
He added: "Real quality improvement is not one-size-fits-all."

Life, Interrupted: The Patient in the Mirror -

Today, I'm writing from a hospital bed in New York City. I'm in the bone marrow transplant unit, where this week I've undergone 20 intensive chemotherapy treatments in anticipation of receiving my brother's stem cells. In the year since my diagnosis with leukemia, I've struggled to hold onto a sense of who I am while I watch the person in the mirror change.

In the oncology ward, I still felt invisible, flying under the radar with my waist-length hair and the nose ring I got when I was 14. In the waiting room at my second appointment, a man with a sleeveless shirt and a bandanna covering his hairless head leaned in toward my father, who's been bald since the '80s, and raised his fist in the air: "Live strong, brother," he said. Later, my dad and I had a good laugh about the mix-up — it helped ease our tight nerves for a moment. But I remember also feeling slighted, as though my terrible new disease wasn't being acknowledged.

Looking back, I call the first month after my diagnosis "the cancer bubble" because I wasn't showing obvious signs of my disease. I looked about the same — maybe a little more tired and pale than usual, but a stranger could never have guessed that I carried a secret, deep in my bones.

I remember my first day of chemo as if it were yesterday, hanging up my favorite summer dress like an athlete retiring a jersey. Within a few weeks, my waist had shrunk to a double zero — the size it was when I was in the sixth grade. My cheek bones jutting out. Rings under my eyes. Skin the color of chalk. And then there was my hair. My long, wavy hair — the same unruly locks I'd spent countless hours fussing over in front of a bathroom mirror — soon to be gone.

When I finally returned home after my five-week hospitalization, I could feel the stares of strangers on my bald head and thinning eyebrows. Everywhere I went, cancer spoke for me before I could say the first word. Once, I even overheard a child asking her mother why there was a boy in the girls' bathroom.

Cancer had given me a reverse celebrity status: all the attention for something you didn't want to be known for. I had crossed over into a new land, the land of Patient. And with every step I was feeling less like Suleika.

Now, here in the bone marrow unit, where I'm required to be in isolation to prevent infections, I'm surrounded 24/7 by the gaze of people who, first and foremost, are concerned with what I have — not necessarily who I am. Doctors in face masks stand over my hospital bed, peering down at me. Eyes and ties. And white lab coats. Voices without mouths discuss me as if I weren't in the room. They give the Patient a hospital gown. The Patient is talked at, looked at, probed, prodded and whispered about. But after all, it's their job to see me as Patient. The goal is to cure the Patient so she can return to being herself. But until then, it's hard not to feel like just a body.

As Patient, you cede control of a lot of your life to others — to your nurses and doctors, to their decisions and schedules. I'm thankful for their care — where would I be without it? But anyone who's been in the role of Patient can attest to the way it changes how you see yourself.

As I wait for my cure, I'm still a Patient. And while it's been only a year, I can hardly remember what not being one is like.

Crowd-Sourcing Brain Research Leads to Breakthrough -

In the largest collaborative study of the brain to date, scientists using imaging technology at more than 100 centers worldwide have for the first time zeroed in on genes that they agree play a role in intelligence and memory.

Scientists working to understand the biology of brain function — and especially those using brain imaging, a blunt tool — have been badly stalled. But the new work, involving more than 200 scientists, lays out a strategy for breaking the logjam. The findings appear in a series of papers published online Sunday in the journal Nature Genetics.

"What's really new here is this movement toward crowd-sourcing brain research," said Paul Thompson, a professor of neurology at the University of California, Los Angeles, and senior author of one of the papers. "This is an example of social networking in science, and it gives us a power we have not had."

The genes, which influence elements of brain size, may have subtle effects on how people think and behave, though many other factors, including education and general health, play a role in intelligence and could easily offset the effect of any single gene.

Still, size matters, in brain research at least as much as in brain function.

"I like this work a lot, because these guys finally did what needed to be done to take a real stab at merging imaging and genomics," said Dr. Matthew W. State, a professor ofpsychiatry at Yale, who was not one of the collaborators.

Brain imaging studies are expensive and, as a result, far too small to reliably tease out the effects of common gene variations. These effects tend to be tiny, for one thing, and difficult to distinguish from the background "noise" of other influences. And brain imaging is notoriously noisy: not only does overall brain size vary from person to person, for instance, but so do the sizes of specialized brain regions like the hippocampus, which is critical for memory formation.

To solve the numbers problem, Dr. Thompson and three geneticists — Nick Martin and Margaret Wright, both of the Queensland Institute of Medical Research in Australia, and Barbara Franke of the Radboud University Nijmegen Medical Center in the Netherlands — persuaded research centers around the world to pool their resources and create one large database. It included genetic and extensive brain imaging results from about 21,000 people. The team then analyzed the collective data to see whether any genes were linked to brain structure. As the study was being completed, the Thompson group learned that another consortium, led by Boston University researchers, was doing a similar analysis using its own large group.

The two teams' findings did not completely line up. One found size-related genes that the other did not. But they agreed on two findings: one gene that correlated strongly with overall brain size, and another that correlated with the rate at which the hippocampus atrophies, or shrinks, with age.

People who carried one variant of the overall-size gene had brains that were about 1 percent larger than those of people who carried another variant. The two variants are equally distributed — about half of people have one and half have the other.

In a separate analysis in Australia, Dr. Martin and Dr. Wright found that size correlated with I.Q. People with the larger brains scored slightly higher on a standardized test. The results are all averages, meaning that they hold for the group but say nothing about any individual. (Some very smart people have relatively small brains.)

The collaborators also found that about 10 percent of people carried a gene variant that correlated with a slightly accelerated rate of atrophy in the hippocampus. The hippocampi — there are two, each deep in the brain, one in the right side and one in the left, about level with the ears — are needed to form new memories. People with dementia often show pronounced atrophy in this region. The study was not set up to find a link between the gene variant and dementia, but experts suspect a connection.

The collaboration is not likely to lead to new treatments any time soon, the authors said, and, as always, the findings will need replication before they are conclusive. It is more a beginning than an end, and it illustrates how far the field has to go to get any real traction — and what it will take.

"It means sharing your data, pooling everything," Dr. Thompson said, "and this is not usually how scientists work."

Creeping Weakness - Interactive Feature -

"You need to see a doctor," the woman told her 27-year-old daughter. "Really," she insisted. "I'm worried." Her daughter, who lived several states away, was visiting, and when the mother happened to see her go up the stairs, she was struck by how odd this simple, everyday action looked. Her daughter's slender hips rocked from side to side as she moved up the steps. It was as if she had to lift her entire body to bring up each leg. Her mother was certain that something was wrong.


At first her daughter resisted. She felt fine, she told her mother. And if the stairs did seem a little tougher lately, it was because she hadn't been working out. But in truth, her friends had also commented about the way she went up stairs, and she had noticed a few worrisome things herself. She had recently gone skiing, for example, and even the easiest moves — maneuvers she mastered as a child — seemed strangely difficult. She couldn't turn; she couldn't even snowplow.

So when she returned home from her mother's, she made an appointment with her internist, who promptly sent her to a neurologist. When questioned by that doctor, the patient acknowledged that she was aware of some subtle changes in her strength for several years. In high school and early in her college career she was very active: she ran, swam, rowed. She hadn't been exercising regularly since college. But when she tried to complete the everyday tasks of normal life, she realized that they seemed harder.


On exam, the specialist noted that the patient had some clear weakness in her thigh muscles. Indeed, she couldn't stand from a seated position unless she used her hands to push herself up. Even when she walked on a level surface, her hips swung from side to side — like a subtle parody of some femme–fatale sashay.

When thinking about a patient who has weakness, it's essential to distinguish between symptoms resulting from a problem in the muscle itself and those caused by the nerves that control the muscle. If it's a problem in the nervous system, you have to figure out which part of the system is affected: Is it in the brain? In the spine? In the muscle itself? Each location suggests a different set of diseases.

The neurologist was also intrigued by another possibility: the patient's mother was suffering from untreated Lyme disease when her daughter was born. Could this be a congenital Lyme infection? She thought it was an idea worth looking into.

Which test would be the least helpful in evaluating this patient?

  • MRI of the brain

  • MRI of the spinal cord

  • Dopplers of the legs

  • An electromylograph (EMG)

  • An ELISA for Lyme disease

More ...