Saturday, October 13, 2012

Is the afterlife full of fluffy clouds and angels? - Telegraph

Have you ever noticed that more people come back from Heaven than from Hell? We have all read those astonishing reports of near-death experiences (NDEs, as the aficionados call them) – the things that people say have happened to them when they almost, but don't quite, shuffle off the coil.
They are nearly always pleasant and deeply reassuring in a saccharin-soaked way. Lots of spinning down warm, dark tunnels to the sound of celestial music; lots of trips along country lanes lined with hedges, towards the light of a welcoming cottage at the end of the road; lots of tumbling down Alice-in-Wonderland rabbit holes, but without the damaging effects of gravity.
True, Dr Maurice S Rawlings Jr, MD, heart surgeon in Chattanooga, Tennessee, and author of To Hell and Back, did have patients who reported very nasty NDEs after they came back on his operating table. Booming noises; licking flames and all that Mephistophelian stuff. But perhaps that tells us more about the challenges of living in Chattanooga, Tennessee, than about the metaphysics of life after death.
Predictably, the amazingly consistent, remarkably heaven-like experiences recounted by the majority of NDE-ers (yes, that really is what the experts call them) have been summarily dismissed by materialist sceptics – like me. Of course the brain does funny things when it's running out of oxygen. The odd perceptions are just the consequences of confused activity in the temporal lobes.
But NDEs have taken on a new cloak of respectability with a book by a Harvard doctor. Proof of Heaven, by Eben Alexander, will make your toes wiggle or curl, depending on your prejudices. What's special about his account of being dead is that he's a neurosurgeon. At least that's what the publicity is telling us. It's a cover story in Newsweek magazine, with a screaming headline: "Heaven is Real: a doctor's account of the afterlife".
Just as you'd expect from a doctor, his account is precise and detailed. In the autumn of 2008, he contracted a very rare bacterial meningitis that he says made his brain "shut down" and put his "higher-order brain functions totally offline". The soup-like state of Dr Alexander's brain was, he writes, "documented by CT scans" (although CT scans don't say anything about the activity of the brain) and "neurological examinations".
Although the neurons of his cortex were "stunned to complete inactivity by the bacteria", his conscious self journeyed into another world. There was wonderful music and light. There were clouds, "big, puffy, pink-white ones that showed up sharply against the deep blue-black sky". And there were angels (well, perhaps birds): "flocks of transparent, shimmering beings".
But then it gets really weird. It turns out that he wasn't alone. "For most of my journey, someone was with me. A woman." She had a lovely face and golden brown tresses, and she was dressed appropriately for a Cecil B DeMille movie, in peasant costume, in subtle shades of "powder blue, indigo, and pastel orange-peach". She was quite a stunner. She looked at Dr Alexander "with a look that, if you saw it for five seconds, would make your whole life up to that point worth living, no matter what had happened in it so far". It was a look "beyond all the different compartments of love we have down here on earth".
Well, many of us, after a couple of pints in the pub with our chums, might say that we've had that kind of experience; but not with a woman flying on a butterfly wing, as Dr Alexander's companion was. Although he "still had little language function" he was able to chat with the peasant lady, asking (understandably) where he was and why he was there. He was overwhelmed by the answers, which "came instantly in an explosion of light, colour, love, and beauty that blew through me like a crashing wave".
After the clouds and the angels and the peasant lady, Dr Alexander went on to a "pitch-black" void, "brimming with light" from a "brilliant orb" that acted as an interpreter, explaining that the "universe itself was like a giant cosmic womb".
You might have sensed a subtle hint of scepticism in my account. As Eben Alexander says, he considers himself a faithful Christian, and it's therefore not surprising that he interpreted the chaos in his brain when he was almost dying in terms of his model of the afterlife.
His, and the multitude of other memories reported by people who have been close to death, have to be seen first through the prism of hard science. The crucial question is not whether such astounding experiences should lead us to abandon materialist accounts of brain function, but whether materialist accounts can possibly explain them.
Dr Peter Fenwick, senior lecturer at King's College, London, consultant at the Institute of Psychiatry, and president of the British branch of The International Association for Near Death Studies, acknowledges that there are deep problems in interpreting first-person memories of experiences that are supposed to have happened when the brain was out of action. Since the lucky survivor can only tell you about them after the event, how can we be sure that these things were perceived and felt at the time that their brains were messed up, rather than being invented afterwards?
The same problem applies to dreams, indeed to any memory. Memory is notoriously fallible, and is treacherously easily misled by expectation. The cognitive psychologist Elizabeth Loftus has done brilliant experiments showing how the recall of real experiences can be transformed by what people think should have happened, and by what they are told might have happened.
In 150 years the science of perception has taught us that the way we appreciate the world around us is as much dependent on our expectations, our experiences, our inferences, as it is on the hard evidence of images on our retinas or vibrations in our ears. Remember the occasions when you have seen a face in the flickering flames of a fire, or been certain that you saw a person in the distance as you walked along at night – only to discover that the face in the fire disappears with the next burst of flame and the person in the dark is just a letterbox.
Is it not significant that the NDEs of Christians are full of Biblical metaphor? Either this confirms the correctness of their particular faith or it says that NDEs, like normal perception and memory, are redolent of culture, personal prejudice and past experience. Perhaps if Eben Alexander were a Muslim, there would have been the mythical 72 virgins on the butterfly wing, rather than the bucolic one. If he were a Buddhist he would be called a de-lok, a person who has seemingly died, but who travels into bardo – an afterlife state – guided by a Buddhist deity.
What Dr Alexander and his PR people claim is that his description of the afterlife is more authentic because he is a neurosurgeon. But when there is no evidence except the word of the beholder, a scientist's accounts are no more reliable than those of anyone else. Would we literally believe the contents of a scientist's dream because he or she has a PhD? If a scientist sees the lines of a visual illusion as wonky, should we believe that they really are wonky?
Science has progressed by challenge and disagreement. But what is needed to consider seriously the kinds of claims made by Dr Alexander is not flowery prose and hyperbolic headlines. It's hard evidence.
But I am trying (not very convincingly, I know) to keep an open mind. I remember the story of the nobleman who asked the Zen Master Hakuin, "What happens to the enlightened man at death?"
"Why ask me?" said Hakuin.
"Because you're a Zen master."
"Yes, but not a dead one."

Colin Blakemore is Professor of Neuroscience and Philosophy, School of Advanced Study, University of London

Stanford Medicine 25 - Stanford University School of Medicine

Welcome to the Stanford Medicine 25 website. Remember, this site is NOT the Stanford Medicine 25; it is only a map to a territory, one that must be explored in person! The Stanford Medicine 25 consists of hands-on sessions in small groups. You can't substitute for that, and we don't try to. However, this site provides a place to go to remind ourselves of what we have learned, or are about to learn in a hands-on session.

Why the Stanford Medicine 25?

• We recognized that after a med school physical diagnosis course, there is little emphasis on these skills in the 3rd and 4th years of medical school or in an internal medicine residency.
• In the absence of a high-stakes clinical bedside final exam (as opposed to a high-stakes multiple choice exam), there is little impetus for people to learn and master bedside skills—truth is, you can be board certified in internal medicine and no one hasreally ascertained that your technique in doing an ankle reflex allows you to accurately say a reflex is truly absent. (You will be surprised how most 'absent' reflexes become 'present' when you learn good technique.) Does it matter? It does to us.
• In observing students and residents perform physical diagnosis maneuvers at the bedside, we observe that though they know the theory, their technique may prevent them from eliciting the sign reliably.
• We find a real hunger among our residents in internal medicine to sharpen their skills at the bedside.
• Many diseases (almost all of dermatology for instance) are diagnosed by bedside exam. In neurology for example, even if the CT and MRI reveals a lot to you, only your exam can tell you what the functional consequence is in terms of motor or sensory loss or cognitive deficit.
• For evidence-based medicine fans, a cautionary note here: we are not trying to prove anything, but we do want to be sure that when people write in the chart "reflexes intact" or "cranial nerves intact" or "S1 and S2 heard, no m or g" that it is not a form of fiction, but represents an accurate observation.


Thyroid Exam
A good thyroid exam depends above all on knowledge of anatomy and proper technique.

Gait Abnormalities
Abnormal gaits are commonly seen in the hospital and elsewhere. Many of them should be recognizable on sight and it would be a shame to subject a person to a CAT or MRI for lack of recognition. We review a number of abnormal gaits and their disease associations.

Examination of the Spleen
An enlarged spleen can be easily missed. It is a prime example of how technique matters and even with the best technique, the spleen is not easily felt.

Examination of the Liver
The liver, unlike the spleen is easily located when enlarged and its surface can be readily felt.

Liver Disease, Head to Foot
Many if not most of the signs of liver disease are paradoxically to be found outside the abdomen. The clinician needs to be able to elicit and recognize these signs and here we review them from head to foot.

Ascites & Venous Patterns
The simple act of observing venous patterns and the direction of venous flow on the abdomen can help us to differentiate inferior vena cava obstruction from portal hypertension from portal hypertension. The techniques for detecting ascites are reviewed here.

Knee Exam
The knee is one of the most common causes of joint pain. A good knee exam helps us to rule out serious conditions such as a septic or inflammatory joint space and can also help make an accurate anatomical diagnosis of ligament or meniscus injury.

Shoulder Exam
Careful examination of the shoulder can provide valuable information and help the physician determine when image studies may or may not be helpful.

Lymph Node Exam
Do you know what a "shotty" lymph node is? Do you keep your nails neatly trimmed? Learn this and other tips from our experts and watch them perform a meticulous lymph node exam.

Deep Tendon Reflexes
Subtle changes in your technique can elicit an otherwise absent deep tendon reflex. Having a proper reflex hammer helps. Here we review those subtle techniques to improve on this import exam skill.

Cerebellar Exam
A number of signs and symptoms correlate with cerebellar disease and the clinician needs to be able to elicit them from head to foot.

Fundoscopic Exam
When it comes to an ophthalmoscopic exam there's more to it than meets the eye! Here we take a look at the various ophthalmoscopes available to internists and review their proper use.

Pulmonary Exam
The pulmonary exam is more than simple auscultation--in fact percussion and inspection often tell you much more than auscultation. Knowing the normal boundaries of percussion and the surface anatomy is critical.

Precordial Movements
Palpation is a critical part of the cardiac exam. The size and the character of the PMI (PMI) can speak volumes and predict the presence of an S3 or 4.

Cardiac Second Sounds
The second sounds and their variations can tell us volumes about everything from pulmonary or systolic hypertension to bundle-branch block.

Neck Veins & Wave Forms
Identifying an elevated jugular venous pulse will almost always affect your management of a patient. An understanding of waveforms can help you recognize everything from canon "a" waves of complete heart block to "ventricularization" of the "v" wave in tricuspid regurgitation.

BP & Pulsus Paradoxus
An accurate and reproducible blood pressure reading is a basic clinical skill. We review that skill and discuss how to test for pulsus paradoxus.

Ankle Brachial Index
Measuring an ankle brachial index is a simple skill that can be done at the bedside and give you helpful information about a patient's peripheral circulation. This technique is reviewed here.

The Hand in Diagnosis
The hands are a window to the body, and changes in the hands are linked to a plethora of illnesses. Recognizing these phenotypic expressions of disease is a basic clinical skill.

Bedside Ultrasound
With improvement in technology, the bedside ultrasound is becoming frequent in use. Here we discuss the principles and basics of bedside ultrasound.

Rectal Exam
A rectal exam is important to help rule out prostate issues, diagnosing causes of perirectal pain and looking for distal rectal masses. As the saying goes, "If you don't put your finger in, you will put your foot in!"

Pupillary Responses
The pupillary response requires a complex integration of nerve fibers. An abnormal pupillary response can be a harbinger for disease or simply a benign process. We review the physiology behind this reflex and discuss situations where it will be abnormal.

Involuntary Movements
There are many types of involuntary movements and the diagnosis rests on observation and knowledge of the types of involuntary movements and their causes.

Internal Capsule Stroke
A stroke within the internal capsule leads to a unique number of physical exam findings. We review these changes and compare them with strokes in other locations.

The Tongue in Diagnosis
Changes in the tongue occur in many situations. Systemic disease such as amyloidosis or lymphoma will affect its size and color. Localized infections may suggest underlying immune disorders. Nutritional deficiencies will cause abnormalities.

Friday, October 12, 2012

Lance Armstrong and Our Doping Nation -

An anemia drug has likely harmed hundreds of thousands of patients, soiled the reputations of two Fortune 500 companies and shamed one of our legendary sports heroes, the cyclist Lance Armstrong. Only that last part was at issue in the United States Anti-Doping Agency report, released on Wednesday, that laid out the astonishing evidence against him. It didn't explain the seductive power of the drug — an artificial blood booster called erythropoietin, or EPO for short — or how our health care providers and our culture pushed its irresponsible use.

EPO is a naturally occurring hormone that stimulates the production of red blood cells. As any anemic can tell you, without sufficient red blood cells we become exhausted, unhealthy and depressed. Those who couldn't make natural EPO, like dialysis patients and people without functioning kidneys, had to rely on blood transfusions to get it.

But that changed during the biotech drug rush of the 1980s, when a start-up called Amgen found a way to genetically engineer the hormone. After patenting its artificial EPO, Amgen formed a partnership with the marketing mavens at Johnson & Johnson and boomed into the world's largest biotech company.

Hailed as a wonder drug, EPO looked innocuous — 3,000 units of clear liquid swirling in a glass vial. To athletes, those tinkling vials also represented a way to "goose" the oxygen-carrying component of blood, increasing stamina. And really, what red-blooded American doesn't crave more energy? Our literature is rife with fictional drugs that bestow superhuman abilities — like the "spice" found in Frank Herbert's "Dune" — and so is our history; leaders from Grover Cleveland to John F. Kennedy used cocaine, "pep pills" or amphetamines.

But those energy boosts came with bad side effects. Not so, it seemed, with EPO, which was seen as safer than ephedrine, less risky than coke and more effective than a double espresso.

Before long, Amgen and Johnson & Johnson were selling two EPO brands — Epogen and Procrit. (Those who biked the short races called criteriums joked it was for "pro-crit riders.") By the '90s, in addition to cyclists, runners, skiers and other endurance athletes were injecting the stuff regularly — and illegally. All they had to do was pay a black-market dealer in Amsterdam or Marseille, France.

But it wasn't until 1994 that the marketing of these drugs burst into the mainstream. Amgen and Johnson & Johnson began trying to expand the uses of their energy-boosting drugs to include treatment for fatigue, depression and quality-of-life issues. Commercials depicted old, slow-moving people who, after a shot of Procrit, displayed a zest for life, and a young cancer patient, who after an EPO injection happily returned to work.

The aggressive marketing worked. Soon, exhausted but otherwise healthy people were begging doctors for a shot of what one Amgen executive called "red juice."

And many doctors went along with these off-label promotions, even though regulators hadn't approved them. Indeed, in March 2007, Congressional hearings revealed that many oncologists were profiting. The drug makers paid doctors to prescribe the blood booster in high doses to unwitting patients. Some earned honorariums for speaking to their peers about the unapproved, off-label uses; others pocketed "education grants," or joined marketing studies that never quite addressed the safety of high doses even as they recommended them. The two drug companies were told to stop paying doctors for overprescribing, but that flew in the face of our cultural belief: if a little of something is good, then a lot must be better.

Increasingly, scientists were discovering that EPO doping doesn't work so well — in fact it can be lethal. Yes, it multiplies your red blood cells. But too many red blood cells turn your blood to sludge and make the heart work overtime. The drug raised the risks of strokes, blood clots and heart attacks. Even worse was that EPO could potentially multiply cancer cells. In fact, just last year, regulators warned most patients they should try and stay off the red juice completely.

But it's too late. We live in a world where the 7-year-old reality TV star Honey Boo Boo feels the need to drink "go-go juice" (a blend of Mountain Dew and Red Bull) just to maintain her energy and ratings; where a seven-time winner of the Tour de France feels emboldened to lie repeatedly about doping; where doctors would risk the health of their patients to make them better, quicker, and to make themselves richer.

It's too bad about Lance Armstrong. But the real shame is that, in our get-rich, quick-fix, more-is-better culture, we are all culpable in this blood-doping scandal — both on and off the race course.

Kathleen Sharp is the author of "Blood Medicine: Blowing the Whistle on One of the Deadliest Prescription Drugs Ever."

Thursday, October 11, 2012

Breast cancer surgery rate differences 'raise questions' - Health - CBC News

Mastectomy rates for breast cancer vary widely across Canada, according to a new report.

Thursday's report by the Canadian Institute for Health Information showed differences in the use of all surgical treatments for breast cancer. About 22,000 women in Canada have surgery for breast cancer each year.

Most of the breast cancer patients studied were treated for invasive disease. (iStock)
"These findings raise questions about how Canadian women are exercising their treatment options and the resultant quality of care," the report's authors concluded, based on data from 2007–2008 to 2009–2010.

Mastectomy rates ranged from 69 per cent in Newfoundland and Labrador to 26 per cent in Quebec.

The differences decreased only slightly when age, income and travel time to a cancer centre were considered, the institute said.

Generally, clinical practice guidelines recommend breast conserving surgery, also called lumpectomy, and radiation therapy for the majority of women with breast cancer. Lumpectomy and radiation are less invasive and are associated with fewer complications with similar survival to mastectomy.

Dr. Geoff Porter, a professor of surgery at Dalhousie University in Halifax, called the report an important step in understanding differences in breast cancer surgery.

"We can only really understand where we're going if we know where we are," Porter said. "I think that's just very valuable when you think about optimizing the quality of breast cancer care. We need to know those patterns and trends so that we can see whether they're changing."

Porter said that the high rates of mastectomies and re-excisions or repeated surgeries if lab tests show that residual tumours may be present, could be higher in Newfoundland and Labrador because of differences in how the surgeries are counted in that province.

In many areas in Canada, core biopsies with a needle are used to make a diagnosis. In Newfoundland and Labrador, the tumour itself may be removed for the diagnosis and that surgery could be counted as the first one, he said.

Porter said the report offers a powerful way to look at breast cancer in the population. The tradeoff is that clinical data, such as the size of tumour and its stage, weren't included.

The type of surgery can also vary with income. In the report, women living in the least affluent areas had the highest rates of mastectomy. Long courses of radiation are generally recommended after lumpectomies and travel time appeared to significantly reduce use of less-invasive surgery, the authors said.

A third of mastectomies in Ontario were done as day surgeries but fewer than two per cent in Alberta and Saskatchewan were done that way.

"The extent of this variation raises interesting questions regarding the organization of care and resources issues."

The report was prepared by CIHI and the Canadian Partnership Against Cancer.

Wednesday, October 10, 2012

Contaminated drug draws attention to steroid injection procedure Physicians divided on value of low-back steroid injections - The Boston Globe

The discovery that a potentially tainted drug is linked to 119 cases of meningitis nationwide has fueled debate among doctors about widespread use of the back-pain treatment, which has little proven longterm benefit.

Use of the medication, a ­steroid injected near the spine to quell inflammation, has ­increased in part because of the demands of an aging population and the relatively few risks associated with the injections when compared with surgery and other treatments, which ­also carry no guarantee of success.

Patients and doctors often saw a so-called lumbar injection as a safe alternative, until the outbreak of fungal meningitis cases tentatively linked to the injectable steroid supplied by a compounding pharmacy in Framingham.

"What one can say from 10,000 feet is that these are one of the most overused procedures in the United States," said Dr. Steven J. Atlas, a primary care internist and director of Primary Care Research & Quality Improvement Network at Massachusetts General Hospital. "I think it reflects the fact that treatments for low back pain and low back pain conditions often don't provide the ­relief that patients are wanting or looking for, and they in desperation or hope look to procedures that may offer them the magic cure."

A 2007 study in the medical journal Spine found that there was a greater than 200 percent increase in steroid injections administered for back pain in two different ways between 1994 and 2001. It concluded that fewer than half were performed for medical problems for which there was the strongest evidence they worked.

The steroid drug, methylprednisolone acetate, is not approved by the US Food and Drug Adminstration for use in epidural injections for back pain, but physicians are ­allowed to use drugs "off-label" for unapproved uses.

Critics of the injections say that patients overestimate the benefit they will receive from a treatment, and the injections are often used to treat ailments other than those most likely to respond to the steroid treatment. But proponents say that subgroups of patients can benefit from the injections.

Dr. Ray Baker, president of the International Spine Intervention Society, said word of mouth, not just the aging population, has probably helped drive the increase in injections. His analysis of Medicare data found almost 2.5 million injections in that patient population in 2011, and he estimated that they probably make up about half of injections administered last year in the United States.

"The vast majority of practitioners are trying to very conscientiously use these injections on their patients to increase their activities and functions," Baker said. "We have a pretty expectant population; we have a population of baby boomers that are not aging in a wheelchair or in a rocking chair. These are people that are playing tennis and golf and running into their 80s."

The Cochrane Review, an ­organization that analyzes the strength of medical evidence, published a review in 2010 of 18 randomized trials. Just two of the studies were deemed to show benefits greater than possible harm. The ­review concluded that there was not strong evidence for or against the use of the treatments. The review added it could not rule out the possibility some groups of patients would benefit.

"I would say that there does seem to be consensus that at least in well-selected patients with . . . spinal pain that ­involves nerve dysfunction or nerve root dysfunction, that they at least provide some benefit and the controversy revolves about how much benefit and the duration of benefit," said Dr. Steven P. Cohen, a professor of anesthesiology at Johns ­Hopkins School of Medicine.

For patients, the matter can be more clear-cut. Josephine Kendall, an 80-year-old from Methuen, said her lower back pain had gotten so bad that she could only lie down. She has to go to dialysis three days a week, and tasks as simple as bringing home groceries had become unbearable.

Two and a half years ago, she began receiving injections at New England Baptist Hospital, which she said transformed her life, for three months at a time.

When she heard the news about the possibly tainted drugs, Kendall asked her physician whether she was receiving injections supplied by the same company. She was not, and she said it has not changed her mind at all about whether to continue receiving injections.

"I can't exist without them; let's put it that way," she said.

Physicians said they had been inundated with calls from patients wondering if they had received the drug from New England Compounding Center. Some said that patients who were eligible for an injection were forgoing the procedure now.

Dr. Carol Hartigan, a physiatrist at the spine center at New England Baptist, said Tuesday that more than one patient she had seen who was a candidate for an injection has declined to receive it for now.

She noted that while anecdotally, individual patients can report dramatic improvement, it is crucial to evaluate the effectiveness of an injection and that she looks for at least a 50 percent improvement that lasts three months.

"Clinicians and patients can really exaggerate the response out of hope, Hartigan said. "So many people we see come in with this list and litany of injections they've had," and they still aren't fixed, she said. "We want the quick fix sometimes."

A Genetic Test for Exercise -

Research has confirmed that people's physiological responses to exercise vary wildly. Now a new genetic test promises to tell you whether you are likely to benefit aerobically from exercise. The science behind the test is promising, but is this information any of us really needs to know?
The new test, which is being sold by a British company called XRGenomics, is available to anyone through the company's Web site and involves rubbing inside your cheek with a supplied swab and returning the tissue sample to the company. Results are then available within a few weeks. It is based on a body of research led by James Timmons, a professor of systems biology at Loughborough University in England, and colleagues at the Pennington Biomedical Research Center in Louisiana and other institutions.
That original research, published in a landmark 2010 study, looked into the genetics of why some people respond to endurance exercise so robustly, while others do not. Some lucky men and women take up jogging, for example, and quickly become much more aerobically fit. Others complete the same program and develop little if any additional endurance, as measured by increases in their VO12 max, or their body's ability to consume and distribute oxygen to laboring muscles.
For the 2010 study, Dr. Timmons and his colleagues genotyped muscle tissue from several groups of volunteers who had completed 6 to 20 weeks of endurance training. They found that about 30 variations in how genes were expressed had a significant effect on how fit people became. The new test looks for those genetic markers in people's DNA.
"The idea is to help people to understand why" they might be progressing more slowly in an exercise program than their training partners are, says Dr. Timmons, one of the founders of XRGenomics.
After he appeared on a BBC science program last year, in the course of which the host was revealed to be a "low" responder, according to his gene profile, Dr. Timmons was inundated with e-mails and calls requesting the test, he says. At that point, he and several colleagues filed a patent (still pending) for the gene markers and brought the test to market.
It joins other, less-sophisticated exercise-related gene test kits already available over the counter. These tests, which are not monitored by the Food and Drug Administration, typically rely on a single gene marker and claim to be able to predict whether you - or your child - will have success as a distance runner, say, or as a power-based athlete, like a sprinter.
Their actual predictive value, based on the best currently available genetic science, "is approximately zero," says Claude Bouchard, a professor of genetics at Pennington, who was the senior author of the 2010 study with Dr. Timmons, but has no involvement with XRGenomics. (He is a paid consultant for another company, Pathway Genomics, that offers gene tests only through physicians.)
The new test is almost certainly more reliable, with "a much stronger scientific basis than any of the previous exercise-related DNA test kits," says Tuomo Rankinen, a professor of genetics at Pennington, who, like Dr. Bouchard, was an author of the original gene study but has no involvement with XRGenomics. But, he adds, it relies on VO12 max, just one measure of how someone responds to exercise, so it has severe limits.
The new test will not tell you, for example, how exercise might affect your blood pressure over the long haul, Dr. Rankinen says, or whether your insulin sensitivity might change, or whether you'll lose weight. The genetic markers related to these health responses to exercise are quite different from those related to VO12 max, he says.
In other words, the scientific understanding of how our DNA affects our overall bodily response to exercise is in its infancy.
Which does not mean that anyone curious - and deep-pocketed - enough to take the test should refrain from doing so. At present the basic test kit costs about $318 (199 British pounds) for genotyping and a brief accompanying report. For about $478, you receive a more extensive explanation of the findings, along with customized exercise recommendations from the company's scientific advisory board. The report might suggest, Dr. Timmons says, that if you are a "low" responder to endurance exercise, you should concentrate on resistance training or otherwise refocus your training.
"What we hope," he says, is that the test and report "will encourage people to keep exercising" who might otherwise have quit when running or swimming didn't make them more fit.
On the other hand, some people might look on the news that they are a "low" responder to endurance training as a license to quit working out altogether, he acknowledges.
But Dr. Bouchard says that that would be the worst message to take from any gene testing. "This is a good test, as far as it goes," he says. But genes will never be destiny.
In the original 2010 gene study, the authors concluded that the gene profile they'd uncovered accounted for at least 23 percent of the variation in how people responded to endurance training, which, in genetic terms, is a hefty contribution. That leaves perhaps 77 percent of how you respond to exercise consciously up to you.

After Losing St. Vincent’s Hospital, Manhattan Sees Rise in Clinic Care -

The demise of St. Vincent's Hospital in Greenwich Village two years ago has led to a struggle for health care supremacy in some of New York's most distinctive neighborhoods, offering a glimpse, in the process, at what might be the future of urban medicine.

Without building a hospital, one large chain, Continuum Health Partners, is establishing a beachhead in Chelsea and the Village by connecting with outpatient clinics, trying to dominate the market and create a feeder network for its hospitals in other neighborhoods. It is joining forces not just with traditional clinics but also with newer experiments like doctors working out of drugstores. A competitor, NYU Langone Medical Center, is expanding its physician practices downtown, and like Continuum, it has hired dozens of stranded St. Vincent's doctors.

Several walk-in "urgent care" centers have also rushed into the vacuum left by St. Vincent's in Lower Manhattan, hoping to show that they are more efficient and consumer-friendly than a hospital-based system, but some have already begun to form relationships with the hospitals.

"We are still trying to figure out if we are a threat or an asset to each other, and we are probably both," said Dr. Alicia Salzer, co-founder of Medhattan, an urgent care center that opened in 2011 near ground zero at Liberty Street and Trinity Place.

The immediate fight is to win market share, the loyalty and business of the area's many affluent and well-insured residents. But the demise of St. Vincent's has also turned Lower Manhattan into a laboratory for health care reform. The new clinics and the maneuvering by large chains are anticipating an expansion of the number of people with insurance and changes in the way that health care is delivered and paid for. And they are testing the notion, long held by health planners, that the city can survive with fewer hospitals.

Many doctors and some Village residents were dismayed when St. Vincent's went bankrupt and closed, and consider the new health care choices in the area to be less than adequate.

"As a physician and general internist, other than a laceration, I would never send a patient to the urgent care center," said Dr. David Kaufman, who trained at St. Vincent's and spent more than 30 years working there.

But in its waning days, St. Vincent's was filling far fewer beds than it did during the AIDS crisis, and as is the case at other hospitals, many patients using its emergency room did not need emergency care, driving up costs.

While it is impossible to know whether local residents are worse off without the hospital, one 2009 study by analysts for the RAND Corporation found no adverse impact on quality, and significant cost savings, in the newer models of care.

The study looked at patients in a large Minnesota health plan who received care for sore throats, ear infections and urinary tract infections — common complaints at retail clinics like the ones in drugstores. It found that the cost of care was 30 percent to 40 percent lower in those clinics than in physician's offices and urgent care centers, and 80 percent lower than in emergency departments, mainly because of lower reimbursement rates and less laboratory testing. It found that the rate of preventive care and overall quality of care was actually worse for patients who patronized emergency rooms for those ailments.

The researchers did raise concerns that the proliferation of urgent and retail care might lead people who otherwise would nurse minor illnesses at home to seek medical attention, raising the costs of health care to society. And they suggested that without good communication between different types of care, the health system might become even more fragmented.

"So you have more cooks over the pot, and that lack of continuity is a real frustration," said Dr. Ateev Mehrotra, a policy analyst at RAND, an associate professor at the University of Pittsburgh School of Medicine and the lead author of the study, published in the Annals of Internal Medicine.

As for worries that urgent care or retail clinics might miss serious diseases like cancer, Dr. Mehrotra said that the rarity of complications made that concern hard to assess, but that "there would be a lot of malpractice suits, and we haven't seen that."

Executives at Continuum, which runs five hospitals in New York City, say they expect their expansion into the community to form the foundation of an accountable care organization, a new model of care supported by the federal law that seeks to move patients out of hospitals as much as possible, and to reward health care organizations for working together to improve quality and cut costs.

From Eighth Street in the Village to 26th Street in Chelsea, between Ninth Avenue and Union Square, a patient can now choose from a dozen clinics or medical practices that have been opened or expanded by Continuum or are affiliated with it.

Continuum has also taken over the former St. Vincent's cancer center on 15th Street, and it has established a clinic with a focus on H.I.V. patients on 17th Street, renovating several floors and filling them with colorful pop art. Half of the doctors at the clinic, called the Center for Comprehensive Care, were hired from the old St. Vincent's H.I.V. program.

"Urgent care centers are opening at the pace of Starbucks, and we are affiliating with as many of them as we can," said Adam Henick, senior vice president of Ambulatory Care and Medical Enterprise for Continuum.

Continuum has also become affiliated with doctors practicing out of 13 Duane Reade drugstores in Manhattan and Brooklyn, and has a contract to expand to 20 within the next year or so, and to 50 within four years, said Dr. James A. D'Orta, chairman and chief executive of Consumer Health Services, which manages the practices in the pharmacies.

No money changes hands in the Duane Reade affiliations, Mr. Henick said, but there are indirect benefits for both sides. The hospital system checks doctors' credentials and provides — and bills for — laboratory, radiology and imaging services prescribed by the Duane Reade doctors. The system also gets a potential trove of patients referred by the clinics. The Duane Reade clinics earn the cachet of being associated with major hospitals, and as with other affiliated practices, the Duane Reade patients are given expedited access to Continuum specialists and direct access to hospital admission if needed.

While one goal of the federal health care overhaul is to move nonemergency patients from hospitals to cheaper outpatient care, there is significant cost variation among clinics, even among those that are part of Continuum's loose network. In a byzantine patchwork of state and federal law, some specialized clinics — especially those treating H.I.V. or geriatric patients — can be reimbursed several times as much for a patient visit as are private practices and urgent care centers.

Officials at NYU Langone Medical Center on the East Side said that they, too, were trying to expand their downtown market.

"Everything is intensely competitive and everyone is everywhere," said Dr. Andrew W. Brotman, its senior vice president and vice dean for clinical affairs and strategy.

The hospital system with perhaps the most to lose from the competition is the North Shore-Long Island Jewish Health System. It is renovating the 160,000-square-foot O'Toole building, across from the old St. Vincent's, as a free-standing emergency room, which expects to handle 50,000 visits a year. It will operate as an extension of Lenox Hill Hospital, a North Shore affiliate on the Upper East Side.

But the emergency room is not scheduled to open until 2014. Over the summer, North Shore was forced to close an interim clinic it had opened in Chelsea with a $9.4 million state grant. The clinic attracted an average of only two patients a day, which a hospital spokesman, Terry Lynam, attributed to its limited hours and "the proliferation of urgent care" in the neighborhood.

Michael J. Dowling, chief executive of North Shore, said he believed there was room to work collaboratively with Continuum and other health care providers in the neighborhood.

"Good hospitals are important, but you don't need more than you need," Mr. Dowling said. "In many cases, we've been addicted to inpatient beds. We can't be addicted to them in the future."

Word of the new options is trickling out, and some patients say they are not mourning St. Vincent's.

Michelle McKenzie, a social worker, said going to the St. Vincent's emergency room often meant hours of waiting and, in recent years, run-down facilities. She found Medhattan, the urgent care center, advertised on the bulletin board at Public School 3, where her 7-year-old son, Ian Etheridge, is a student. She has gone there to be treated for an allergic breakout of hives, and her husband took their son there a few months ago when he cut his forehead on the playground and needed stitches.

"I was seen immediately," Ms. McKenzie said. "It wasn't crazy chaotic like St. Vincent's was. I only had to tell my story once, and I was treated by the same physician I told my story to."

Dr. Charles Carpati, former chief of intensive care at St. Vincent's, now at Lenox Hill Hospital, said the community seemed to be coping without the old hospital.

"It's been very hard to show that people are dying because St. Vincent's is no longer there," Dr. Carpati said.

Tuesday, October 9, 2012

Bayer aspirin: How a struggling painkiller was reborn as a heart medicine and earned billions for Bayer. - Slate Magazine

Say you have a headache. Your fever's rising. Your back is aching. What do you take? Probably ibuprofen (MotrinAdvil), maybe acetaminophen (Tylenol), possibly naproxen (Aleve). Together, those drugs comprise nearly four-fifths of the $2 billion-plus over-the-counter pain relief market, prospering from aggressive ad campaigns and cheap manufacturing costs.
But say you're having a heart attack. What do you take now?
If you've been listening to the advice of medical professionals for the past few decades, you'll pop an aspirin while you wait for the ambulance. And if you've been listening closely, you've already been taking it every day. Aspirin's benefit to heart-attack victims is common knowledge these days, while its effectiveness as a painkiller, or analgesic, is increasingly overlooked.
That's no problem for Bayer, aspirin's first modern manufacturer, which has rebranded its product as a "Wonder Drug" and made it a staple for aging baby boomers across the Western world. The rebranding triggered a remarkable resurgence for the company whose signature product once appeared doomed.
Aspirin as a painkiller is old news. The ancient Egyptians wrote of the medical benefits of willow in the Ebers Papyrus, a text sold to an American antiques dealer by grave robbers in 1862. Willow contains salicylate, a key aspirin component, and the Egyptians had probably learned to use it as a salve and a tonic (although their preferred pain relief method was getting drunk). A few thousand years later in the mid-18th century, the English Rev. Edward Stone rediscovered willow's healing powers but failed to bring his finding to a wider audience. It wasn't until the late 1890s that a small German drug and dye factory called Bayer properly synthesized aspirin's various ingredients into a single drug. (Bayer faced stiff competition from another extremely popular new pain reliever called heroin.)
Eventually Bayer secured international patents for aspirin, shipping the product across the globe and turning a massive profit. But their patents were dissolved in Britain and Australia during World War I, opening up the market to a glut of generic competitors. This wasn't the only challenge posed to aspirin by the war, as Diarmuid Jeffreys recounts in Aspirin: The Remarkable Story of a Wonder Drug. Facing a British embargo of phenol, a necessary ingredient of aspirin, Bayer nearly ceased production of aspirin in its German factories. Confronting pharmaceutical catastrophe, the German government covertly deployed a former Bayer employee to the United States to buy surplus phenol from the country's most prolific producer of the chemical, Thomas Edison. The Great Phenol Plot was exposed and the brand's reputation was ruined in America. Soon after, the U.S. government snatched Bayer's American holdings, nullified its patents and trademarks, and sold everything to Sterling Products, who owned the company's American branch until 1994.
The German branch of Bayer, Bayer AG, survived the war only to be bought up by the mega-corporation IG Farben in 1925. The corporation was dissolved in 1952 after many of its leaders were convicted of war crimes. Its factories—run by slave laborers—had produced the Zyklon B used to kill Jews in concentration camps. Bayer AG endured the dissolution of its parent company only to find itself steadily losing its market shares to new painkillers acetaminophen and ibuprofen. After surviving two world wars, the brand faced death at the hands of the free market.
Then a small miracle occurred: In the late 1960s, two British medical researchers, John O'Brien and Peter Elwood, uncovered studies by John Vane and Harvey Weiss suggesting that aspirin could improve heart health. Intrigued, O'Brien and Peter developed a theory that aspirin could prevent blood platelets from clumping up around the heart. These clumps are liable to burst, allowing blood clots to form and prevent blood flow to heart, causing a heart attack. By preventing these clots from forming, O'Brien and Elwood postulated, aspirin enables blood flow to the heart to remain steady, seriously reducing the risk of heart attack. In several medical trials, the researchers proved that a daily dose of aspirin taken by a heart attack survivor significantly decreases his risk of a second attack, confirming their hypothesis.
The small sample size of their study cast doubt on its conclusions. In 1980, however, a British statistician named Richard Peto published a meta-analysis with apparently irrefutable evidence that aspirin had a positive effect on the heart, at least in male patients.
Bayer took note. By this point, Bayer Aspirin's pain relief market share was hovering at around 6 percent, a precipitous drop from its former dominance. Bayer's parent company in the United States, Sterling Products, jumped at the chance to rebrand its product as a vital tool in the fight against heart attacks. In 1983, Sterling lobbied the FDA for the ability to advertise aspirin's cardiovascular benefits on the product's labels. The company won the battle and soon began to rebrand its product as a life saver. Soon after, a slew of studies suggested that an aspirin a day could prevent the first occurrence of a heart attack—not only a second—and that an aspirin taken during a heart attack increases the victim's chance of survival. Other researchers demonstrated aspirin's effectiveness in preventing strokes, inhibiting blood clots from blocking blood to the brain. Aspirin was no longer limited to the pain relief market. It had become a market all its own.
Bayer's profits have risen accordingly. In 1994, the German branch of Bayer bought back its American holdings from Sterling Products for $1 billion, uniting the company for the first time since World War I. In 2011, the company doubled its profits from the previous year, to $3.3 billion.
For a company nearly left for dead three times in a century, that's an impressive comeback.

Institute for Healthcare Improvement

The Institute for Healthcare Improvement (IHI) believes that everyone deserves safe and effective health care, and we have been working with health care providers and leaders throughout the world to fulfill that promise.

An independent not-for-profit organization based in Cambridge, Massachusetts, IHI focuses on motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals; and ensuring the broadest possible adoption of best practices and effective innovations.

Institute of Medicine - National Academy of Sciences

The Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public.

The IOM asks and answers the nation's most pressing questions about health and health care.

Our aim is to help those in government and the private sector make informed health decisions by providing evidence upon which they can rely. Each year, more than 2,000 individuals, members, and nonmembers volunteer their time, knowledge, and expertise to advance the nation's health through the work of the IOM.

Many of the studies that the IOM undertakes begin as specific mandates from Congress; still others are requested by federal agencies and independent organizations. While our expert, consensus committees are vital to our advisory role, the IOM also convenes a series of forums, roundtables, and standing committees, as well as other activities, to facilitate discussion, discovery, and critical, cross-disciplinary thinking.

The Things We Carried, Then and Now -

The Doctor's Bag for the New Millennium

When I was a medical student in Madras, India, in the late 1970s, my uncle, a retired physician, still made occasional house calls. In his early years he delivered babies in dimly lighted huts, often resorting to high forceps on the head - something that is rarely done now. His compounder - the man who would compound his prescription of mistura carminativa and dispense it in corked glass bottles - carried my uncle's medical bag. It was almost like a trunk - a mobile office. The compounder became so experienced from watching my uncle that he secretly began a practice of his own, delivering babies and even applying forceps.
My uncle's doctor's bag from his halcyon days was long gone by the time I was a medical student staying in his house; it had been replaced by a newish model, a small tan suitcase with square corners and latches on the top. When it was opened, two shelves magically unfolded. The medicinal odor that emanated was so powerful it could deliver a buzz.
One shelf held the sterilized syringes, needles, cotton swabs and alcohol that were the bread and butter of a doctor's trade in India - every patient wanted an injection, and doctors were destined to disappoint if they didn't oblige. The other shelf held ampules of adrenaline, Coramine, theophylline and other emergency medications as well as rows of bright orange vitamin B12 ampules - a dramatic injectable placebo.
The bottom of the bag was stuffed with bottled medications, a blood pressure cuff and instruments that my uncle rarely used: Foley catheters, hemostats and the like. I had carried that bag for him more than once and been there when he jabbed adrenaline into a desperately wheezing patient and produced immense relief.
A few years later, when I was an intern in Tennessee, my attending physician and mentor, Steven Berk, carried a leather doctor's bag, one he had toted around since his medical school days. His bag, unlike my uncle's, was small - the size of a loaf of bread, or perhaps a bit bigger - just enough to carry his ophthalmoscope, blood pressure cuff, reflex hammer and a few other things. It was well worn.
The bag became a fetish for me. It embodied all the qualities I admired about the man: He was a careful listener, and he examined patients thoroughly and well. In the Mountain Home Veterans Hospital in Tennessee, which had a large domiciliary and nursing home population, he made original observations about pneumonia in the elderly and became a pioneer in the field.
When I became Dr. Berk's chief resident, three years later, I bought a similar bag even though it was prohibitively expensive on a resident's salary. Mine was stiff, and despite lots of rubbing with neatsfoot oil it remained hard and unyielding.
A year later, in 1983, I was a fellow in infectious diseases at Dr. Berk's alma mater, Boston University and Boston City Hospital. I noticed that in Boston the doctors who carried bags were a shrinking minority - often older, and often the best physicians. Neurologists favored them - more tools to carry, I presumed. Medical students were no longer routinely buying doctor's bags. I stopped carrying mine; my white coat held most of what I needed, and now that ophthalmoscopes came in penlight size, or were mounted on walls, I had eliminated the bulkiest item I needed to carry.
I never got rid of my doctor's bag. Inventorying its contents recently, it was as if I were gazing into a diorama from the early '80s: eye drops to dilate the pupil, prescription pads, a pocket EKG book and EKG calipers, pens, measuring tape, penlights, laminated cards with algorithms on them for various conditions - and everything, of course, with a pharmaceutical company logo on it; no one felt compromised by that sort of stuff.
As the years have passed, I now find myself in a minority of physicians who wear white coats. For those who do, the coat is not a repository of instruments, but a ceremonial robe.
Not so for me; my coat bulges with what I carry: a Queen Square reflex hammer with a bamboo stem (given to me by the widow of my medical school professor who read something I wrote in Granta about her late husband and the way he brandished that hammer; she arranged to meet in a London train station to present it to me), a stethoscope (a bulky, three-headed monster made by Tycos that I love), a tuning fork (frequency of 128 to test vibration), a magnifying glass (to study nail fold capillaries), an Optyse pocket ophthalmoscope, a penlight, a pocket Snellen eye chart, tongue depressors, hand gel, triplicate prescriptions, laminated billing and coding guides, packets of chewing gum....
The coat must weigh at least five pounds. But as a believer, I must walk the talk, carry the tools. I believe that a good bedside examination of a hospitalized patient has a high diagnostic yield: It can reveal the more obvious diagnoses and can guide judicious use of subsequent blood and imaging tests. But the exam also is a ritual, an important one, which when done well validates the patient's complaints and places its locus on the body, and not on a computer screen.
Recently, two of my colleagues at Stanford, John Kugler and Errol Ozdalga, who work with me in what we call the "bedside medicine group," persuaded me to add three tools to my armamentarium.
Dr. Kugler taught me to use a Vscan: a pocket ultrasound machine, which allows a great view of the heart, and adds volumes to what the stethoscope can discern. Dr. Ozdalga taught me to use the PanOptic ophthalmoscope, an instrument that looks a bit like a large revolver; it allows a beautiful view of the retina, and especially its blood vessels, far better than my conventional ophthalmoscope. One look in an eye and I have a sense of the status of the arteries in the kidney, the heart. The PanOptic can also be hooked up to an iPhone to take great pictures.
The third tool I carry around is an iPad: It is a great way to demonstrate anatomy to patients, to take pictures and to pull up videos on a Web site that Dr. Ozdalga has developed, which teaches and reinforces for residents and students specific techniques for examining patients:
Carrying these three new additions can cramp my fingers, and it is not always easy to find a place to set these down when examining a patient.
Dr. Kugler showed me his modified messenger bag in which he carries his instruments. I've seen similar models made by Chrome, Vega and Eagle Creek - and I've just placed my order. I will soon be able to unburden my coat pockets.
As technology advances and gets more portable, I see us bringing more tools to the bedside, and therefore spending more time with patients, instead of sending them hither and thither to diagnostic suites. The more time with the patient, the better.
This is how you will know us, the doctors of the next millennium: by the things we carry.