Saturday, November 14, 2015

NYTimes: You, Only Better

Dave Asprey does not like infomercials. He didn't want our conversation to feel like one, he said, raising both hands in a gesture of innocence, like a magician showing there was nothing up his sleeve. But once he planted the suggestion, it wouldn't go away. There was the register of his voice, oscillating between breathy and enthusiastic, and the complete absence of qualifiers to soften his bold claims. And then there were the wares clustered on the table in front of him. He had laid out cups of his signature product, Bulletproof Coffee, which is made with grass-fed butter and Brain Octane, a trademarked oil extracted from coconuts. Next to the cups lay Bulletproof-branded protein bars in chocolate and vanilla. ''I am not plugging my stuff,'' he said with a semi-embarrassed laugh. ''I'm just talking about how things work.''

And this is how things work for Asprey, according to his claims: By experimenting on his own body, he found a diet to end all diets, one that encourages the consumption of rich foods like avocado, steak and butter and requires little exercise to maintain a healthy weight. In the course of developing this diet — the Bulletproof Diet — Asprey says he lost 100 pounds, boosted his I.Q. more than a dozen points and lowered his biological age in the process.

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Friday, November 13, 2015

Bringing iPhone-style Medical Research to the Android World - The New York Times

Since Apple introduced its ResearchKit software in March, scientists at leading medical schools across the country have written apps to study asthma, Parkinson's disease, autism, epilepsy, melanoma, breast cancer and other ailments. Medical experts are hopeful that using smartphones to gather health data from millions of people, with their consent, can open a window to new insights into diseases, treatments and lifestyle effects.

The Apple move was a breakthrough, but a gap remained. "You can't just do research studies on people who can afford iPhones," said Deborah Estrin, a professor of computer science at Cornell Tech in New York.

Shortly after Apple introduced ResearchKit, Ms. Estrin, who is also a professor of public health at Weill Cornell Medical College, started trying to bring similar capability to the other major smartphone software platform, Google's Android. She coordinated the work on a new initiative, ResearchStack, announced on Thursday.

The new software framework will be similar to ResearchKit, which is open source and designed as modular building blocks. The ResearchStack design work is being led by Cornell Tech; Touch Lab, an Android developer; and Open mHealth, a nonprofit start-up focused on software for sharing health data. ResearchStack is being funded by the Robert Wood Johnson Foundation.

ResearchStack is intended to work smoothly with research projects underway that use Apple's ResearchKit. "Researchers can create a study that is independent of what smartphone is used, and they won't have to start from scratch," said Ms. Estrin, who is also co-founder of Open mHealth.

One of the current projects ResearchStack will soon support is Mole Mapper, an app for a melanoma study developed by the Oregon Health and Science University. The melanoma study involves people taking smartphone pictures of moles at regular intervals to track their growth, with the goal of creating detection algorithms and helping people manage the health of their skin.

The key to successful apps for large-scale studies, Ms. Estrin said, is to develop them for individuals as well as researchers. People, she said, have to control their health data and find it personally useful. That is what will fuel "the growing data-sharing movement," she said, prompting millions of people to "contribute to big-data-derived discovery and understanding" in medicine.

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Thursday, November 12, 2015

LitMed: Literature Arts Medicine Database - NYU

The Literature, Arts and Medicine Database (LitMed) is a collection of literature, fine art, visual art and performing art annotations created as a dynamic, comprehensive resource for scholars, educators, students, patients, and others interested in medical humanities. It was created by faculty of the New York University School of Medicine in 1993. The annotations are written by an invited editorial board of scholars from all over North America.

We define the term "medical humanities" broadly to include an interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theater, film, multimedia and visual arts) and their application to healthcare education and practice. The humanities and arts provide insight into the human condition, suffering, personhood, and our responsibility to each other. They also offer a historical perspective on healthcare. Attention to literature and the arts helps to develop and nurture skills of observation, analysis, empathy, and self-reflection -- skills that are essential for humane healthcare. The social sciences help us to understand how bioscience and medicine take place within cultural and social contexts and how culture interacts with the individual experience of illness and the way healthcare is practiced.

Wednesday, November 11, 2015

CDC assists in heroin, fentanyl investigation in Greater Cincinnati | Local News - WLWT Home

Cincinnati - The heroin problem in Ohio is now getting attention from the Centers for Disease Control and Prevention.

The federal agency has been asked to come here and help find answers to a disturbing new trend that is costing lives – heroin mixed with a prescription pain medication.

State and local health experts said they are hoping what they learn during meetings Tuesday at the Hamilton County Board of Health will help them tackle the heroin crisis.

The CDC has a six-person team on the ground in Ohio, meeting with the Ohio Department of Health, and the Hamilton County Health Department.

Officials said they're focusing on a particular part of the heroin crisis – the number of deaths related to fentanyl.

Authorities said fentanyl is a prescription pain medication that has been showing up in heroin. The big mystery is why it's being mixed with heroin.

"We don't fully understand the fentanyl situation, and that's one of the reasons we wanted their help with this," said Dr. Mary DiOrio, the medical director of the Ohio Department of Health.

ODH asked the CDC to help look into the problem.

"We think that some people don't even know that it's in what they're injecting so we're trying to fully understand what people do and don't know so we can target the messages appropriately so we can protect lives," DiOrio said.

We've seen the deadly consequences of fentanyl in Greater Cincinnati.

Kenneth Gentry is facing charges in the overdose death of an Arlington Heights man earlier this year that was blamed on fentanyl.

Authorities said the fentanyl problem causes only a fraction of the deaths heroin alone causes – but it's a problem that's growing quickly.

Authorities said heroin deaths increased 18 percent in Ohio last year to a total of nearly 2,500. In 2014 there were about 500 deaths linked to fentanyl – an increase of nearly 600 percent from the year before.

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How Doctors Helped Drive the Addiction Crisis - The New York Times

There has been an alarming and steady increase in the mortality rate of middle-aged white Americans since 1999, according to a study published last week. This increase — half a percent annually — contrasts starkly with decreasing death rates in all other age and ethnic groups and with middle-aged people in other developed countries.

So what is killing middle-aged white Americans? Much of the excess death is attributable to suicide and drug and alcohol poisonings. Opioid painkillers like OxyContin prescribed by physicians contribute significantly to these drug overdoses.

Thus, it seems that an opioid overdose epidemic is at the heart of this rise in white middle-age mortality. The rate of death from prescription opioids in the United States increased more than fourfold between 1999 and 2010, dwarfing the combined mortality from heroin and cocaine. In 2013 alone, opioids were involved in 37 percent of all fatal drug overdoses.

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I Am Paying for Your Expensive Medicine - The New York Times

You may not know it, but you could be on the hook to pay at least $124 this year for a drug you probably don't take.

The drug is a new class of cholesterol-lowering agents called PCSK9 inhibitors. Its cost and how we are paying for it illustrate why we all need to care about not only our own health care bills but also those of our neighbors. And it helps focus the debate about drug prices on two questions: What is the value delivered by the drug, and can that be linked to its price? And how should such value-based prices be implemented?

In July, the Food and Drug Administration approved the first of two new PCSK9 inhibitors that lower the bad type of cholesterol, LDL. Studies suggest that they can reduce it by up to 60 percent, compared with a placebo, and reduce it up to 36 percent more than statins and a drug called ezetimibe. However, there are no definitive data on how much these drugs actually reduce heart attacks, strokes and deaths from heart disease. Researchers suggest they might decrease the likelihood of such bad outcomes. For example, one preliminary study found that taking the drug lowered the overall chances that a patient would experience a heart attack or stroke, or hospitalization or death from heart disease, to 1.7 percent from 3.3 percent. The definitive studies will be out in 2017.

Drugs like these can help us lead longer, more productive lives. The problem is that the companies producing these drugs — Amgen, Sanofi and Regeneron — announced that the retail price for a prescription would be more than $14,000 per patient per year. The price is particularly steep given that these drugs may need to be taken for the rest of the patients' lives. How much patients pay directly would depend on their insurance plan.

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Defeating My Anxiety - The New York Times

When the stock market crashed in 2008, my wife and I were 70. And we saw half of our retirement funds disappear. Before the crash, we felt secure in the belief that we had enough money to last as long as we lived; after the crash, we feared that we would not, and I worried about it a great deal. I had a hard time going to sleep and an even harder time going back to sleep after getting up to go to the bathroom in the middle of the night. I came to hate going into that bathroom because I knew my demons resided there and would invade my consciousness immediately.

By the time the stock market began to recover and our savings were again at a comfortable level, I had become conditioned to associate my nightly bathroom trips with "worry time." I would worry about everything: home repairs, trip planning, medical issues and all the vicissitudes of old age, fears of infirmity, dying and seeing my friends and loved ones die.

One night two weeks ago, for the first time in seven years, I realized that the worry demons had not appeared and that I had gone several days without hearing from them. This was a direct result, I believe, of changes that I made to my life over the previous two months. My tools consisted of a tiny amount of the tranquilizer clonazepam and three concurrently undertaken therapies, all new to me: psychological therapy, awareness meditation and religion. I call religion new in the sense that I had pretty much stopped believing in God when I was 20 years old. I call it a therapy because it helped to heal what ailed me.

My call to action began one evening when my blood pressure reached 199. For the previous six months my blood pressure had been jumping around. I had started monitoring it myself with a home machine. For two weeks I would take my blood pressure, meditate, check it again, meditate more, etc. At first, I was able to correlate a finding that proved to me that my blood pressure dropped after meditating, but on this night the numbers went the other way. My blood pressure increased after meditating and I panicked. I checked it repeatedly until it hit 199. I rushed to the bedroom and told my wife that she might have to call 9-1-1. She recommended that I take a Xanax, lie down and try to relax, and for God's sake stop taking my blood pressure. (She has since hidden my machine.)

The next morning we saw our family doctor. He gave me a prescription for clonazepam and said he thought I would be fine. I was more concerned than he was, and I asked if he could recommend a psychologist. Soon I began weekly visits with a clinical psychologist, Dr. Henry Kimmel, in Encino, Calif. I also started meditating regularly for one hour each night, with the aid of a free online service through the Mindful Awareness Research Center at the University of California, Los Angeles. I now had two therapies plus a drug to help arm me against the nighttime attacks in my bathroom.

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Artificial Patients, Real Learning - The New York Times

The patient's blood pressure had reportedly crashed in the ambulance; a gunshot wound had damaged the heart. In the operating room, a medical resident, Dr. Dan Hashimoto, slid a knife into the patient's chest and sliced horizontally, from the sternum across the torso.

He thrust his hand into the gash, grasped the beating heart and squeezed, to the tempo of 100 beats a minute.

Noticing bleeding from the right ventricle, Dr. Hashimoto stopped pumping to sew up the hole. The pulse recovered, and blood pressure climbed.

Concerned there might be more bleeding in the belly, Dr. Hashimoto moved to stop blood flow to the aorta. He struggled a bit to position the clamp.

"Remember your anatomy," the attending physician, Dr. Marc de Moya, advised over Dr. Hashimoto's shoulder.

Moments later, Dr. de Moya pronounced the procedure a success.

Yet no one's life had been saved. Dr. Hashimoto, a third-year-resident at Massachusetts General Hospital, had been practicing what is known as an emergency department thoracotomy on a rubber and plastic dummy that — but for the fact that it did not have a head — felt and acted remarkably like a human body.

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NYTimes: Beware the Beer Belly

A beer belly is a dangerous thing.

A new analysis of data from a large national study has found that carrying fat around the middle of the body greatly raises the risk for heart disease and death, even for those of normal weight.

Doctors usually determine obesity by body mass index, or B.M.I. — calculated from height and weight — but the calculation does not distinguish between fat and lean muscle weight. Measuring waist-to-hip ratio presents a different, and possibly more accurate, picture because it accounts for central obesity, or visceral fat, the fat stored around the internal organs.

Waist-to-hip ratio is waist measurement divided by hip measurement. According to the World Health Organization, a ratio higher than .90 for men or .85 for women defines central obesity.

It has been known for some time that having an "apple" shape increases the risk for disease and death. But the new study found that a man of normal B.M.I. with an abnormally large belly has an 87 percent higher risk for death than a man with the same B.M.I. but a normal waist-to-hip ratio. Pot-bellied women of normal B.M.I. have a 48 percent higher risk than women with normal B.M.I. and normal belly fat.

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NYTimes: Psychiatry’s Mind-Brain Problem

Recently, a psychiatric study on first episodes of psychosis made front-page news. People seemed quite surprised by the finding: that lower doses of psychotropic drugs, when combined with individual psychotherapy, family education and a focus on social adaptation, resulted in decreased symptoms and increased wellness.

But the real surprise — and disappointment — was that this was considered so surprising. The study, by Dr. John M. Kane of Hofstra North Shore-LIJ School of Medicine and his colleagues, simply gave empirical support to the longstanding "biopsychosocial" model of illness, which acknowledges that, in ways not fully understood, biology, psychology and social forces can all affect mental health. This model has long been the basis of treatment for experienced, pragmatically minded clinicians.

Unfortunately, such clinical pragmatism has seriously declined in the United States, as psychiatry has veered toward pharmacology. After the emergence of Prozac and the newer antipsychotic drugs like Risperidone some two decades ago, there was a sustained effort by academic research leaders in American psychiatry to promote these successes, and to fight the stigmatization of the mentally ill by forgoing the complexities of the biopsychosocial model for a simpler, more authoritative claim: Mental illness is a brain disease.

Inherent to this proposition is the implication that psychological and social events somehow are not also brain events. Acknowledgment of any nonexplicitly neural factors is seen as opening the door to those who dismiss mental illness as metaphysical, fake or the result of a moral failing. By these lights, meaningful interventions for those struggling with mental illness must be biochemical or anatomical.

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Tuesday, November 10, 2015

Use of Long-Acting Birth Control Methods Surges Among U.S. Women - The New York Times

The share of American women on birth control who use long-acting reversible methods like intrauterine devices and implants has nearly doubled in recent years, the federal government reported Tuesday.

The share of women on birth control who use the devices rose to 11.6 percent in the period from 2011 to 2013, up from 6 percent in 2006 to 2010, according to the National Center for Health Statistics. The share is still smaller than for the pill (26 percent) or condoms (15 percent), but it is the fastest-growing method. In 2002, just 2.4 percent of women on birth control in the United States used the long-acting methods.

Women's health advocates say long-acting birth control is giving American women more say over when — and with whom — they have children. About half of the 6.6 million pregnancies a year in the United States are unintended, and health experts contend that broader use of long-acting methods could help reduce that number, because the methods work better than other types.

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When to Ignore a Promise to 'Never Put Me in a Home' - The New York Times

Our new patient, 88 years old, had been demented for years. She was admitted to the hospital with a deep, malodorous and infected pressure sore stretching from the top of her right shoulder down to the middle of her spine.

It took us a only few seconds to choose her antibiotics, but a half hour later we were still standing outside the door to her room, caught up in her case.

We wondered which nursing home could have allowed such a thing to happen. But it turned out that she had been admitted from home. We wondered if adult protective services, or maybe even the police, should be called. Then we learned the whole story.

Our patient came from a poor immigrant household without much community support. For years, as she felt herself slipping, she had emphasized over and over again that she never wanted to go into a "home" or be tended by strangers. She wanted to stay at home with her children. Nothing unusual there.

What was unusual was the precision with which her children followed her wishes. As their mother became really confused, then silent, then bedbound, they continued to care for her themselves in the back bedroom.

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3 Things to Know About the Sprint Blood Pressure Trial - The New York Times

New data from a major study called Sprint, released Monday, has shaken some of the basic assumptions about the treatment of high blood pressure. The trial found that lowering systolic blood pressure from currently recommended levels of 140 to 150 to below 120 could prevent heart attacks and strokes and potentially save many lives.

The study is remarkable and has many nuances. Here are three things that you should know about it.

First, the results should not be considered a mandate for people to run out and get treated so their blood pressures are below 120.

The Sprint trial included people 50 and older who had a systolic blood pressure — the higher number — between 130 and 180. Those under 75 needed to have evidence of heart disease, kidney disease or other risk factors. The study excluded people with diabetes or those who had experienced a stroke.

So the results apply only to a fraction of the people already being treated for high blood pressure and a smaller group of others. Over all, about one in 12 Americans would have been considered eligible for the study, or about 17 million adults. Of those already being treated for high blood pressure, one in six would have been eligible. What that also means is that five of six people already being treated for high blood pressure would not have fit into this study — making this evidence less relevant to them.

Another important aspect of the study was that the blood pressure was measured with patients sitting in a quiet area for five minutes, with no doctor present, using an automated machine that took three readings. With this approach blood pressure measurements tend to be lower than in rushed single measurements at the doctor's office.

If you are age 50 or older, with a top blood pressure number between 130 and 180 (measured as in the study), and are either age 75 or older or have a high risk of stroke or heart or kidney disease, then you have a new option to consider.

For the many people treated for blood pressure who would not have qualified for this study, including those with diabetes, it is not clear that they should do anything different. A healthy lifestyle that includes salt in moderation, daily physical activity, adequate sleep and weight control remain the tenets of avoiding high blood pressure.

Second, the potential benefits of lowering blood pressure must be weighed against harms.

The study found potentially lifesaving benefits: There was one bad health event avoided, including heart attack or stroke, for about every 200 people treated per year, and the results suggested one death was avoided for every 300 people treated per year.

The benefit, however, was offset a bit by some increased risk. As expected, treating people with more medications to achieve a lower blood pressure caused some harm. People who were treated more intensively also experienced more fatal or life-threatening events, including very low blood pressure and fainting. A surprise of this study was that intensive treatment could also increase the risk of kidney failure. Over the 3.3 years of follow-up, for every 100 people treated to achieve the lower blood pressure, one more person suffered life-threatening low blood pressure, one more fainted and two more had severe kidney problems.

The study opens a new option for treatment, but it is not a slam dunk that everyone who fits the eligibility criteria of the study ought to be treated. It is a choice that is worthy of thought and reflection.

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Data on Benefits of Lower Blood Pressure Brings Clarity for Doctors and Patients - The New York Times

When the federal government announced in September that it had abruptly halted a large blood pressure study because its results were so compelling, doctors were left in frustrating limbo.

The announcement said researchers had found that driving systolic blood pressure to levels far below what current guidelines recommend — less than 120 instead of 140 or 150 millimeters of mercury — can save lives and prevent heart disease and strokes. But they declined to release any data on the number of lives saved, the number of heart attacks prevented or other critical measures.

"How can anyone do anything different tomorrow with regard to blood pressure control without knowing more about what they found?" asked Dr. Harlan Krumholz, a cardiologist at Yale, echoing the concerns of other specialists.

On Monday, reporting at an American Heart Association meeting in Orlando, Fla., and in a paper published simultaneously in The New England Journal of Medicine, study investigators lifted the veil. Among the 9,361 hypertension patients followed for an average of 3.2 years, there were 26 percent fewer deaths (155 compared with 210) and 38 percent fewer cases of heart failure (62 compared with 100) among patients who achieved the systolic pressure target of 120 than among those who achieved the current 140 target.

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