Tuesday, January 7, 2014

The Brain, in Exquisite Detail - NYTimes.com

ST. LOUIS — Deanna Barch talks fast, as if she doesn't want to waste any time getting to the task at hand, which is substantial. She is one of the researchers here at Washington University working on the first interactive wiring diagram of the living, working human brain.

To build this diagram she and her colleagues are doing brain scans and cognitive, psychological, physical and genetic assessments of 1,200 volunteers. They are more than a third of the way through collecting information. Then comes the processing of data, incorporating it into a three-dimensional, interactive map of the healthy human brain showing structure and function, with detail to one and a half cubic millimeters, or less than 0.0001 cubic inches.

Dr. Barch is explaining the dimensions of the task, and the reasons for undertaking it, as she stands in a small room, where multiple monitors are set in front of a window that looks onto an adjoining room with an M.R.I. machine, in the psychology building. She asks a research assistant to bring up an image. "It's all there," she says, reassuring a reporter who has just emerged from the machine, and whose brain is on display.

And so it is, as far as the parts are concerned: cortex, amygdala, hippocampus and all the other regions and subregions, where memories, fear, speech and calculation occur. But this is just a first go-round. It is a static image, in black and white. There are hours of scans and tests yet to do, though the reporter is doing only a demonstration and not completing the full routine.

Each of the 1,200 subjects whose brain data will form the final database will spend a good 10 hours over two days being scanned and doing other tests. The scientists and technicians will then spend at least another 10 hours analyzing and storing each person's data to build something that neuroscience does not yet have: a baseline database for structure and activity in a healthy brain that can be cross-referenced with personality traits, cognitive skills and genetics. And it will be online, in an interactive map available to all.

Dr. Helen Mayberg, a doctor and researcher at the Emory University School of Medicine, who has used M.R.I. research to guide her development of a treatment for depression with deep brain stimulation, a technique that involves surgery to implant a pacemaker-like device in the brain, is one of the many scientists who could use this sort of database to guide her research. With it, she said, she can ask, "how is this really critical node connected" to other parts of the brain, information that will inform future research and surgery.

The database and brain map are a part of the Human Connectome Project, a roughly $40 million five-year effort supported by the National Institutes of Health. It consists of two consortiums: a collaboration among Harvard, Massachusetts General Hospital and U.C.L.A. to improve M.R.I. technology and the $30 million project Dr. Barch is part of, involving Washington University, the University of Minnesota and the University of Oxford.

Dr. Barch is a psychologist by training and inclination who has concentrated on neuroscience because of the desire to understand severe mental illness. Her role in the project has been in putting together the battery of cognitive and psychological tests that go along with the scans, and overseeing their administration. This is the information that will give depth and significance to the images.

She said the central question the data might help answer was, "How do differences between you and me, and how our brains are wired up, relate to differences in our behaviors, our thoughts, our emotions, our feelings, our experiences?"

And, she added, "Does that help us understand how disorders of connectivity, or disorders of wiring, contribute to or cause neurological problems and psychiatric problems?"

The Human Connectome Project is one of a growing number of large, collaborative information-gathering efforts that signal a new level of excitement in neuroscience, as rapid technological advances seem to be bringing the dream of figuring out the human brain into the realm of reality.

Worldwide Study

In Europe, the Human Brain Project has been promised $1 billion for computer modeling of the human brain. In the United States last year, President Obama announced an initiative to push brain research forward by concentrating first on developing new technologies. This so-called Grand Challenge has been promised $100 million of financing for the first year of what is anticipated to be a decade-long push. The money appears to be real, but it may come from existing budgets, and not from any increase for the federal agencies involved.

A vast amount of research is already going on — so much that the neuroscience landscape is almost as difficult to encompass as the brain itself. The National Institutes of Health alone spends $5.5 billion a year on neuroscience, much of it directed toward research on diseases like Parkinson's and Alzheimer's.

A variety of private institutes emphasize basic research that may not have any immediate payoff. For instance, at the Allen Institute for Brain Science in Seattle, Janelia Farm in Virginia, part of the Howard Hughes Medical Institute, and at numerous universities, researchers are trying to understand how neurons compute — what the brains of mice, flies and human beings do with their information. The Allen Institute is now spending $60 million a year and Janelia Farm about $30 million a year on brain research. The Kavli Foundation has committed $4 million a year for 10 years, and the Salk Institute in San Diego plans to spend a total of $28 million on new neuroscience research. And there are others in the U.S. and abroad.

To be sure, this is not the first time such a focus has been placed on brain research. The 1990s were anointed the decade of the brain by President George H. W. Bush. Strides were made, but many aspects of the brain have remained mysterious.

There is, however, a good reason for the current excitement, and that is accelerating technological change that the most sanguine of brain mappers compare to the growing ability to sequence DNA that led to the Human Genome Project.

Optogenetics is one new technique that has been transformative. It uses light to turn on different parts of the brain in laboratory animals to open and shut modified genes. Powerful developments in microscopy made possible movies of brain activity in living animals. A modified rabies virus can target one brain cell and mark every other cell that is connected to it.

"There is an explosion of new techniques," said Dr. R. Clay Reid, a senior investigator at the Allen Institute, who recently moved there from Harvard Medical School. "And the end isn't really in sight," said Dr. Reid, who is taking advantage of just about every new technology imaginable in his quest to decipher the part of the mouse brain devoted to vision.

Charting the Brain

Of the many metaphors used for exploring and understanding the brain, mapping is probably the most durable, perhaps because maps are so familiar and understandable. "A century ago, brain maps were like 16th-century maps of the Earth's surface," said David Van Essen, who is in charge of the Connectome effort at Washington University, where Dr. Barch works. Much was unknown or mislabeled. "Now our characterizations are more like an 18th-century map."

The continents, mountain ranges and rivers are getting more clearly defined. His hope, he said, is that the Human Connectome Project will be a step toward vaulting through the 19th and 20th centuries and reaching something more like Google Maps, which is interactive and has many layers.

Researchers may not be looking for the best sushi restaurants or how to get from one side of Los Angeles to the other while avoiding traffic, but they will eventually be looking for traffic flow, particularly popular routes for information, and matching traffic patterns to the tasks the brain is doing. They will also be asking how differences in the construction of the pathways that make up the brain's roads relate to differences in behavior, intelligence, emotion and genetics.

The power of computers and mathematical tools devised for analyzing vast amounts of data made such maps possible. The gathering tool of choice at Washington University is an M.R.I. machine customized at the University of Minnesota.

An M.R.I. machine creates a magnetic field surrounding the body part to be scanned, and sends radio waves into the body. Unlike X-rays, which are known to pose some dangers, M.R.I. scans are considered to be safe. It is one of the few methods of noninvasive scanning that can survey a whole human brain.

There are a variety of ways to gather and interpret information in an M.R.I. machine. And different types of scans can show both basic structure and activity. When a volunteer is trying to solve a memory problem, the hippocampus, the amygdala and the prefrontal cortex are all going to be involved. An M.R.I. machine can detect the direction of information flow, in a technique called diffusion imaging. In that kind of scan, the movement of water molecules shows not only activity, but which way the traffic is headed.

A Path to Research

For Dr. Barch, 48, another kind of interest in the human brain put her on the path to Washington University. "I always knew I wanted to be a psychologist," she said — specifically, a school psychologist. But as an undergraduate at Northwestern, she excelled in an abnormal psychology class, and the professor recruited her to do research.

"When I graduated from college, I decided to become a case manager for the chronically mentally ill for a year to kind of suss out, 'Do I want to do more clinical work or research?' " she said. "That was a great experience, but it really made me realize that research is the only way you're going to have an impact on many lives, rather than sort of individual lives."

She obtained her Ph.D. in clinical psychology at the University of Illinois at Urbana-Champaign. but then did postdoctoral study in cognitive neuroscience at the University of Pittsburgh and Carnegie Mellon University. Her years in graduate school in the 1990s coincided with the development and use of the so-called functional M.R.I., which can show not just static structure, but the brain in action.

"I got into the field when functional imaging was just at its very beginning, so I was able to learn on the ground floor," she said.

She moved to Washington University after her postdoctoral research partly because of the number of people there working on imaging, including Dr. Marcus E. Raichle, a pioneer in developing ways of watching the brain at work.

As a professor at Washington University and a leader of one of five teams there working on the Human Connectome Project, Dr. Barch focuses her research on the way individual differences in the brains of healthy people are related to differences in personality or thinking.

For instance she said, people doing memory tasks in the M.R.I. machine may differ in competitiveness and commitment to doing well. That ought to show up in activity in the parts of the brain that involve emotion, like the amygdala. However, she points out that the object of the Connectome Project is not to find the answers to these questions, but to provide the database for others to try to do so.

'Pretty Close'

The project at Washington University requires exhaustive scans of 1,200 healthy people, age 22 to 35, each of whom spends about four hours over two days lying in the noisy, claustrophobia-inducing cylinder of a customized M.R.I. machine. Sometimes they stare at one spot, curl their toes or move their fingers. They might play gambling games, or try memory tests that can flummox even the sharpest minds.

"In an ideal world, we would have enough tasks to activate every part of the brain," she said. "We got pretty close. We're not perfect, but pretty close."

Over the two days, the research subjects spend another six hours taking other tests designed to measure intelligence, basic physical fitness, tasting ability and their emotional state.

The volunteers (and they are all volunteers, paid a flat $400 for their time and effort) can also be seen in street clothes, doing a kind of race around two traffic cones in the sunlit corridor of the glass-walled psychology building, with data collected on how quickly they complete the course.

Or they can be glimpsed padding down a hallway in their stocking feet from the M.R.I. machine to an office where a technician dabs their tongues with a swab dipped in a mystery liquid, then asks them to identify the intensity and quality of the taste.

In the same office, they type in answers to cognitive tests, and to a psychological survey, for which they are left in solitude because of the personal nature of some of the questions: how they feel about life, how often they are sad. The results are confidential, as are all the test results.

So far almost 500 subjects have gone through the full range of tests, which amounts to about 5,000 hours of work for Dr. Barch and others in the program.

So far, data has been released for 238 subjects, and it is available to everyone for free through a web-based database and software program called Workbench.

The sharing of data is characteristic of most of the new brain research efforts, and particularly important to Dr. Barch.

"The amount of time and energy we're spending collecting this data, there's no possible way any one research group could ever use it to the extent that justifies the cost," she said. "But letting everybody use it — great!"

The Elusive Brain

No one expects the brain to yield its secrets quickly or easily. Neuroscientists are fond of deflecting hope even as they point to potential success. Science may come to understand neurons, brain regions, connections, make progress on Parkinson's. Alzheimer's or depression, and even decipher the code or codes the brain uses to send and store information. But, as any neuroscientist sooner or later cautions in discussing the prospects for breakthroughs, we are not going to "solve the brain" anytime soon — not going to explain consciousness, the self, the precise mechanisms that produce a poem.

Perhaps the greatest challenge is that the brain functions and can be viewed at so many levels, from a detail of a synapse to brain regions trillions of times larger. There are electrical impulses to study, biochemistry, physical structure, networks at every level and between levels. And there are more than 40,000 scientists worldwide trying to figure it out.

This is not a case of an elephant examined by 40,000 blindfolded experts, each of whom comes to a different conclusion about what it is they are touching. Everyone knows the object of study is the brain. The difficulty of comprehending the brain may be more aptly compared to a poem by Wallace Stevens, "13 Ways of Looking at a Blackbird."

Each way of looking, not looking, or just being in the presence of the blackbird reveals something about it, but only something. Each way of looking at the brain reveals ever more astonishing secrets, but the full and complete picture of the human brain is still out of reach.

There is no need, no intention and perhaps no chance, of ever "solving" a poet's blackbird. It is hard to imagine a poet wanting such a thing. But science, by its nature, pursues synthesis, diagrams, maps — a grip on the mechanism of the thing. We may not solve the brain any time soon, but someday achieving such a solution, at least in scientific terms, is the fervent hope of neuroscience.


Bad Year for Boars -Diana Hardeman - What I Learned Today

Last week I had a stroke. I'm a healthy 30-year old woman and I had a stroke. It was wild.

One minute I was getting ready to finish Christmas shopping, and the next I lost all feeling on the right side of my body and was unable to speak. Three days in ICU over Christmas and I'm a-okay now and on the road back to 100%. But, man, it was one heck of an experience.

I was so fascinated by the whole thing that I decided to write about it. I've published my account on Medium here: Bad Year for Boars

Below is my original unedited version. If you've read any of my past posts you'll be able to see the effects of the stroke - in functionality on my right hand with typing, as well as some cognitive disparities in getting sentences out coherently.

Bad Year for Boars - UNEDITED

I awoke suddenly from a loud, dark, and intense Space Mountain like dream. I saw a hospital goown, arms clad in iv's, and surses surrounding someone. The person had fained, was being revived, and bring back to bed. I felt I were watching watching it in the ghird party, a scene first person scene froma movie. Quickly, though, I realized this was no movie, this was no dream – oh man, this was me. Iwas an ICU patient in this hpstal. And it was Christmas Eve.

Two days earlier I had a stroke. After an awesome 75 degree California winter mornig spent surfing with my dad, boyfriend, and the dolhinss, I was at my parent's home getting ready to go fnish up some Christmas shopping. While in my bathroom getting rready, I recognized that something was very wrong.

My right arm seemed no longer a part of my body. I coouldn't contrl it, it was limp at my side, likthe worst dead arm you can imagine ,but completely out of nowhere. Mmy boyfirned was just coming to chec on what time we are leaving and I xiested the bathroom, slumpted on the ground, and told him what was going on.. Except I didn't. I couldn't . What I was saying in my head came out as jioggberish,. . Words firmed in my head could nto get out of my mouth. I felt stupid and even laughed at myself a bit, saying 9it's ok I'ts ok to him, thinking it might just go away., let's not make a big deal about it. but then the reminder that something was vert wribg set in again. In a whisper, I finally go the words "call my dad" out , at least so I thought. He did, my parents happened to be right outside about ready to run errands themselves,. My father, a physician, ran up the stairs to find me and when he saw me nnoldoing my hand and unable t speak, called for an ambulance. By now I was crying, perhaps in hysterics, as the numbness had seeped from my earm to my whle right side. I stopped tying ti speak, it was frustrating and piutless, and ooked ito Reecee's eyes saying to him with mine, "I may not walk again. I may die." I had no idea why this was happening, but I thought to mysekl, "no, that can't happen I gotta fight iut" and ckicked off my boots to tried to keep moving my leegs and focus omy mond on not dying.

The paramedics quickly arrived and as they did pulled mbe on to the stretcher and carried me down the sairs into the anbkace , it sank in that this was happening. man, was I bummed. This should 't be happening to me.

In case you don't know me, Hi. Im Diana. I'm a 30 year old lady. Itallerthan your average girl, thinner tha your average girl, and and active than your average girl. Yeah I run an ice crea business for a living, but like to thing I'm healthier than your average girl too. No priorn medical history. Nothing.

my first ever ride in an ambulance was uneventful – the hops;ital is a 5 minute drive from my folks' house. By now I had somehow regained some ability to sspeak and answered the EMT's incessant questionsining. still stuumbling over my words, even laughin at my mstakes.

Arriving at the hospital it was straight into the CT Scan, weyre I had plent of time to ty lay very still and reflect. Woulld I be satisfiected with life if I had died fight now? Am I doing what I am supposed top be doing in life? Have I been nice enough? A good enough friend/sibling/daughter/partner? Or, Man, how different will it be if I cannot function the way I am used to What the hell is going on?

Which is tge first ting I said to my family upon returning to the ER: "Well, what the hell?"

"Yeah, what the hell" my dad said, "This shoudn't be happeing to you."

The dotor urmised it was a stroke based on my syptoms, ad the CT scan showed on uternal bleeding so he aadministered TPA intravaneisly. TPA is a protein that breaks down blood clots and improves the flow of oxygen to the brain. See, if you are a stroke victim, you're suffering from a lack of oxygen to the brain, either due to a hemogage or due to a blood clot that blocks the blood flow. After about 1 minute of being deprived of oxygen, brain gissue ceases to function. Itstartsto die. If left without oxygen for any longer than about 3 hours, it's irresversible –ndead. So there's a short 3-hour wondeow that the TPA needs to be administerd to be effective - the sooner the better, really. Once the TPA was administered the doctor conferred woth my dad, as colleagues, and I I overheard him say "You know exactly where she is going." The dreaded ICU.

For years my father has encouraged a healthy lifestyle, usging us to "Stay out of tge ICU" as much as we can hel; it. My whole life actually. He's even now written a book about it. And I've heeded his advice my whole life, living a healthy, active, vegetarian lifestyle as Ive previously descrubed. . But never had I really understhood hs warnings until I was an ICU patient. Its torturous, and I don't ever want to go back.

I was a champ though, if I do say so myself, and took everything in stride. The tw hour turned 50n hour bed redst The iv's I my arms the oxyyge tubes in t\my odes, the wakeup calls every 15 miutes half hour then hour to do the same tests to stest my speech and moveme t in my fight side. The ultrasounds of my heart and legs to look for any abnormalitieities. The f'ig TEE, transesophagael echocardiogram where they stuck a probe down my throat to cheyc o8ut my eart , which turns out it has a hole. Which also turns out abit 25% of people have the same hole. The MRI which confirmed stroke wth a big white section of unoxygenated brain tissue in the top left part of the brain as well as a smaller stroke at the very bacy of the train (yes, not one but TWO strokes). It was a wild ride.

We were going on day 3 and still didn't know the cause of the stoke though. Was I on birth control was the first question I had been asked. Thank goodness my answer was no - I opted against birth control pillls after readying about the pussible health detriments caused by it, namely stroke because it is a known cause of thrommbisis, aka blodd clotting.

Had I hurt neck? No. Well it hurt a bit in my short nap on tmy flght from NY to CA last week butnothing abnormal. And defitely not surfing, our session was a breeze. And sure I'd done yoga last week and did do that weird back on a block, neck on a block thing,but it hadn't huirt or anything. Other tha that, sadl I've let my atcitivy level slide in favor of working lately.

Was it due to that hole in my heart? Which caused a blood clot whihch broke off and ejaded up to my brai ? Unlikely since it's such a connom abnormalitilit, but pissibly.

Was it a blood clot in my legs from sitting on the plane for so long? The unstrasounds showed no sign of clots, and man was I glad for that because I know everyone wouljd have been mad at me for searing my heels on the plane.

One final test to get to the bottom of it would be an angiogram, cutting a slit in my femur (at the pelvis), sicking a tacheteri into my vein, which would travel up with the blook flow to my neck and shoot dye in the veins which would show in a xray whether there was a tear in my neck that coud have caused a blood clot which could have broken off and gone to my brain.

The thing is – all that would do woujd give us an answer. It wouldn't affect the treatment for the troke going forward (which is asprin for life, and blood thiners for the time being, as well as limiated activity (bye bye snowboard season)). And it's a rather invasive procedure, as you can see. Do so you do it, or do you not?

And herein lies ones of tge oribems of edicie, you know? Theres no right answer. Dr. F, a neeufologist and family friend said don't do it, ther'es no need. My doctor, Dr. F said definitely do it . Dr K said don't' do it. And Dr M said do it, it's the last possible test ti find the cause.

Ultimately, I didn't want another test, I wanted to get the needles out of my arms and getthee geck out of thyere. It was Christmas eve, my boyfriend and I hgad flown home for thhe holiday, I was pumpted to cance around the Cgrstnas tree with my wole familt who comes oever every eyar. But I cimplied with whgatever was recomme ded and when my dad said lets do it ,I said lets do it.

Two doses oofanteshtsia and one angiogram later, ad we had our culprit. A tiny disseccieection in the carverous part of my left internal carotid artery. Aka a tiny tear on the inside of the artery on my neck. Actually it was 2 angiograms bc thehey had to go in and check the right side to be sure it actually was a tear, since it was so tiny.

So – long stort short — I had somehow in the lat 3 months ingured my neck.. A a blood clot had formed in the dissected (injured) artery, and on the afternoon of December 21, that blood clot brke off and went up to my brain, causing an acute embolic ischemic stroke.. It blocked the supply of bloog to ta portion of the left side of my brain and the affected neurons cased to function a dbega to die. Sice the left side of the brain controls the rightside of the body and right handed people typically have their language enter on the left, my right arm and my sppech also ceased t function. Oncet he TPA was injected, the clot began to dissipiate allowing oxyen to travel to those neurns again, and my speech and arm functionarlity to return. Not mmediatley though – some of the brain tissue was permanentlyt damaged from the stroke. So it took two full days for my arm to come out of numbness, and as you can see if you read my original account, it's taking a bit to get my typing and other right hand functionality back on track. What 's wild is that it will get back to normal – the neurons that surround the damaged tussiue step in an start to pick up the slack. so it's just a matter of time and traing them how to do the things the other guys used to do. Fascicating, huh?

So to finish the story, we left off post angiogram on Christmas Eve. Unfortunately I didn't get to gohome that day because I fainted on my first time standing on my own. That's where we started this whole account (remember? SpaceMontain, nurses arrounding who I realized was me?). But another nnght and a few medusa style brain tests later, and I was free on Christmas morning. I was stoked.

I'm titling this postn "Bad year for boars" because at the beginning of this year, my best friends mother warned him it would be a bad year anyone born in the year of the boar, 18873„ since 2013 was the year of the bbnake according to the Chinese calendar. Throughout the ytear, we joked abut how bad of a year it was, with our trivial matters. I even got shirts made for us for Chistmas that read "BAD YEAR FOR BOARS." (which I had ironically worn for the first time on th emornig of my stroke).

But this isn't a Carpe Diem story – to remind us all to appreciate what we have, it could all be taken away in the blink of an eye, don't' sweat the small stuff. Though of course my sense of the sunon my face, or sand on my toes is a bit more highhtened and appreciated.

It's not a cautoinaary tale – to stay healthy if you don't want to go through what I did. This was a wild fluke and– like I won the lottery but in reverse – and had noting to do with my health. (Though I do imagimy my healthy has something to do with my resilience and revovery.) And I'm not advsiting to stop doing fun or active things to save your neck (literally), though I will Tell you that you can tear an artery from plenty of sports, from yoga head poses, from cracking yoru neck, from putting your head back at the hair salon, even from throwing back a shot! So ya, know – be careful!

And it isn't a lets be one with the universise and everything happens for a reason account. Though there is smoething uncanny about the events that led up to the incident and the fortunate (fortitudeoft he) time place, and peope involved.

It's just a account. About my body and my brain. And the crazy way it all works.


Monday, January 6, 2014

When Doctors ‘Google’ Their Patients - NYTimes.com

I remember when I first looked up a patient on Google. It was my last day on the bone marrow transplant unit, back when I was an intern. As I stood before the patient, taking her history, she told me she had been a painter and suggested I look up her work on the Internet. I did, and I found her paintings fascinating. Even though our paths crossed fleetingly, she is one of the few patients I vividly remember from that time.

Google has taught me other things, too, things that don't come up during the routine history-taking or medication checks of my usual doctor-patient interactions. I learned recently, for example, that one of my patients had been an Olympic gold medalist and world-record holder in the 1960s. Knowing more about my patients as people helps build empathy.

Doctors do "Google" their patients. In fact, the vast majority of physicians I know have done so. To my generation, using a search engine like Google comes as naturally as sharing pictures of our children or a recent vacation on a social networking site like Facebook. But it surprises me that more physicians don't pause and think about what it means for the patient-doctor relationship.

What if one finds something that is not warm and fuzzy? I recently read about a case in which a 26-year-old woman went to a surgeon wanting to have a prophylactic double mastectomy, citing an extensive history of cancer in her family. However, she was not willing to undergo any work-up, and her medical team noted several inconsistencies in her story. When they searched online, it turned out she had set up multiple Facebook accounts soliciting donations for malignancies she never had. One page showed her with her head shaved, as if she had already undergonechemotherapy. The surgeons immediately decided to halt her care.

I was once taking care of a frail, older patient who came to the hospital feeling very short of breath. It wasn't immediately clear why, but her breathing was getting worse. To look for accidental ingestions, I sent for a drug screen and, to my great surprise, it came back positive for cocaine. It didn't make sense to me, given her age and the person lying before me, and I was concerned she had been the victim of some sort of abuse. She told me she had no idea why there was cocaine in her system.

When I walked out of the room, a nurse called me over to her computer. There, on MugShots.com, was a younger version of my patient's face, with details about how she had been detained for cocaine possession more than three decades earlier. I looked away from the screen, feeling like I had violated my patient's privacy. I resumed our medical exam, without bringing up the finding on the Internet, and her subsequent hospital course was uneventful.

I am tempted to prescribe that physicians should never look online for information about their patients, though I think the practice will become only more common, given doctors' — and all of our — growing dependence on technology. The more important question health care providers need to ask themselves is why we would like to.

To me, the only legitimate reason to search for a patient's online footprint is if there is a safety issue. If, for example, a patient appears to be manic orpsychotic, it might be useful to investigate whether certain claims the patient makes are true. Or, if a doctor suspects a pediatric patient is being abused, it might make sense to look for evidence online. Physicians have also investigated patients on the web if they were concerned about suicide risk, or needed to contact the family of an unresponsive patient. In my state, Massachusetts, doctors can also use a specialized database to track every pharmacy a patient took controlled drugs from — an especially useful tool when drug abuse is suspected. But if the only reason a doctor searches online is to gather personal information that patients don't want to share with their physicians, then it is absolutely the wrong thing to do.

Recently, one of my primary care patients was back in clinic, with some worrisome news. In spite of increasing the dose of his medication, his panic attacks were getting worse. He had told me that as he saw his business success grow, so did his stress, and the frequency of his panic attacks.

I stepped out of the clinic to speak with my supervising physician. I related the patient's history, telling him about the growing success of the patient's business.

"What sort of business?" he asked. When I told him that I had forgotten to ask, he quickly flipped the window on the computer before us from an electronic medical record to Google and typed in the patient's name.

But before he pressed return, he paused.

This was unusual — most doctors I know don't pause. Then, with the cursor blinking before us, he pressed the backspace key, keeping it pinned until there were no more letters for the cursor to gobble up. And he proceeded to do what has worked for physicians for eons. He sat down next to the patient and asked.

Haider Javed Warraich is a resident in internal medicine and Katherine Swan Ginsburg Fellow in Humanism at the Beth Israel Deaconess Medical Center in Boston and author of the novel "Auras of the Jinn."


Growing up unvaccinated: A healthy lifestyle couldn’t prevent many childhood illnesses.

I am the '70s child of a health nut. I wasn't vaccinated. I was brought up on an incredibly healthy diet: no sugar till I was 1, breastfed for over a year, organic homegrown vegetables, raw milk, no MSG, no additives, no aspartame. My mother used homeopathy, aromatherapy, osteopathy; we took daily supplements of vitamin C, echinacea, cod liver oil.

I had an outdoor lifestyle; I grew up next to a farm in England's Lake District, walked everywhere, did sports and danced twice a week, drank plenty of water. I wasn't even allowed pop; even my fresh juice was watered down to protect my teeth, and I would've killed for white, shop-bought bread in my lunchbox once in a while and biscuits instead of fruit, like all the other kids.

We ate (organic local) meat maybe once or twice a week, and my mother and father cooked everything from scratch—I have yet to taste a Findus crispy pancake, and oven chips ("fries," to Americans) were reserved for those nights when Mum and Dad had friends over and we got a "treat."

As healthy as my lifestyle seemed, I contracted measles, mumps, rubella, a type of viral meningitis, scarlatina, whooping cough, yearly tonsillitis, and chickenpox. In my 20s I got precancerous HPV and spent six months of my life wondering how I was going to tell my two children under the age of 7 that Mummy might have cancer before it was safely removed.

So the anti-vaccine advocates' fears of having the "natural immunity sterilized out of us" just doesn't cut it for me. How could I, with my idyllic childhood and my amazing health food, get so freaking ill all the time?

More ...

Sunday, January 5, 2014

Why Everyone Seems to Have Cancer - NYTimes.com

Every New Year when the government publishes its Report to the Nation on the Status of Cancer, it is followed by a familiar lament. We are losing the war against cancer.

Half a century ago, the story goes, a person was far more likely to die from heart disease. Now cancer is on the verge of overtaking it as the No. 1 cause of death.

Troubling as this sounds, the comparison is unfair. Cancer is, by far, the harder problem — a condition deeply ingrained in the nature of evolution and multicellular life. Given that obstacle, cancer researchers are fighting and even winning smaller battles: reducing the death toll from childhood cancers and preventing — and sometimes curing — cancers that strike people in their prime. But when it comes to diseases of the elderly, there can be no decisive victory. This is, in the end, a zero-sum game.

The rhetoric about the war on cancer implies that with enough money and determination, science might reduce cancer mortality as dramatically as it has with other leading killers — one more notch in medicine's belt. But what, then, would we die from? Heart disease and cancer are primarily diseases of aging. Fewer people succumbing to one means more people living long enough to die from the other.

The newest cancer report, which came out in mid-December, put the best possible face on things. If one accounts for the advancing age of the population — with the graying of the baby boomers, death itself is on the rise — cancer mortality has actually been decreasing bit by bit in recent decades. But the decline has been modest compared with other threats.

graph from the Centers for Disease Control and Prevention tells the story. There are two lines representing the age-adjusted mortality rate from heart disease and from cancer. In 1958 when the diagram begins, the line for heart disease is decisively on top. But it plunges by 68 percent while cancer declines so slowly — by only about 10 percent — that the slope appears far less significant.

Measuring from 1990, when tobacco had finished the worst of its damage and cancer deaths were peaking, the difference is somewhat less pronounced: a decline of 44 percent for heart disease and 20 percent for cancer. But as the collision course continues, cancer seems insistent on becoming the one left standing — death's final resort. (The wild card in the equation is death from complications ofAlzheimer's disease, which has been advancing year after year.)

Though not exactly consoling, the fact that we have reached this standoff is a kind of success. A century ago average life expectancy at birth was in the low to mid-50s. Now it is almost 79, and if you make it to 65 you're likely to live into your mid-80s. The median age of cancer death is 72. We live long enough for it to get us.

The diseases that once killed earlier in life — bubonic plaguesmallpoxinfluenza, tuberculosis — were easier obstacles. For each there was a single infectious agent, a precise cause that could be confronted. Even AIDS is being managed more and more as a chronic condition.

Progress against heart disease has been slower. But the toll has been steadily reduced, or pushed further into the future, with diet, exercise and medicines that help control blood pressure andcholesterol. When difficulties do arise they can often be treated as mechanical problems — clogged piping, worn-out valves — for which there may be a temporary fix.

Because of these interventions, people between 55 and 84 are increasingly more likely to die from cancer than from heart disease. For those who live beyond that age, the tables reverse, with heart disease gaining the upper hand. But year by year, as more failing hearts can be repaired or replaced, cancer has been slowly closing the gap.

For the oldest among us, the two killers are fighting to a draw. But there are reasons to believe that cancer will remain the most resistant. It is not so much a disease as a phenomenon, the result of a basic evolutionary compromise. As a body lives and grows, its cells are constantly dividing, copying their DNA — this vast genetic library — and bequeathing it to the daughter cells. They in turn pass it to their own progeny: copies of copies of copies. Along the way, errors inevitably occur. Some are caused by carcinogens but most are random misprints.

Over the eons, cells have developed complex mechanisms that identify and correct many of the glitches. But the process is not perfect, nor can it ever be. Mutations are the engine of evolution. Without them we never would have evolved. The trade-off is that every so often a certain combination will give an individual cell too much power. It begins to evolve independently of the rest of the body. Like a new species thriving in an ecosystem, it grows into a cancerous tumor. For that there can be no easy fix.

These microscopic rebellions have been happening for at least half a billion years, since the advent of complex multicellular life — collectives of cells that must work together, holding back, as best each can, the natural tendency to proliferate. Those that do not — the cancer cells — are doing, in a Darwinian sense, what they are supposed to do: mutating, evolving and increasing in fitness compared with their neighbors, the better behaved cells of the body. And these are left at a competitive disadvantage, shackled by a compulsion to obey the rules.

As people age their cells amass more potentially cancerous mutations. Given a long enough life, cancer will eventually kill you — unless you die first of something else. That would be true even in a world free from carcinogens and equipped with the most powerful medical technology.

Faced with this inevitability, there have been encouraging reductions in the death toll from childhood cancer, with mortality falling by more than half since 1975. For older people, some early-stage cancers — those that have not learned to colonize other parts of the body — can be cured with a combination of chemicals, radiation therapy and surgery. Others can be held in check for years, sometimes indefinitely. But the most virulent cancers have evolved such wily subterfuges (a survival instinct of their own) that they usually prevail. Progress is often measured in a few extra months of life.

OVER all, the most encouraging gains are coming from prevention. Worldwide, some 15 to 20 percent of cancers are believed to be caused by infectious agents. With improvements in refrigeration and public sanitation, stomach cancer, which is linked to Helicobacter pylori bacteria, has been significantly reduced, especially in more developed parts of the world. Vaccines against human papilloma virus have the potential of nearly eliminating cervical cancer.

Where antismoking campaigns are successful, lung cancer, which has accounted for almost 30 percent of cancer deaths in the United States, is steadily diminishing. More progress can be made with improvements in screening and by reducing the incidence of obesity, a metabolic imbalance that, along with diabetes, gives cancer an edge.

Surprisingly, only a small percentage of cancers have been traced to the thousands of synthetic chemicals that industry has added to the environment. As regulations are further tightened, cancer rates are being reduced a little more.

Most of the progress has been in richer countries. With enough political will the effort can be taken to poorer parts of the world. In the United States, racial disparities in cancer rates must be addressed. But there is a long way to go. For most cancers the only identifiable cause is entropy, the random genetic mutations that are an inevitable part of multicellular life.

Advances in the science will continue. For some cancers, new immune system therapies that bolster the body's own defenses have shown glints of promise. Genomic scans determining a cancer's precise genetic signature, nano robots that repair and reverse cellular damage — there are always new possibilities to explore.

Maybe someday some of us will live to be 200. But barring an elixir for immortality, a body will come to a point where it has outwitted every peril life has thrown at it. And for each added year, more mutations will have accumulated. If the heart holds out, then waiting at the end will be cancer.

George Johnson is a former reporter and editor at The New York Times and the author of "The Cancer Chronicles."