Saturday, December 5, 2015

Living With Cancer: Hurry Up and Wait - The New York Times

A hostile letter from a reader made me stop and think about the torments of waiting that cancer patients endure: waiting for a doctor, waiting for radiation, waiting for the delivery of chemotherapy drugs, waiting through interminable infusions or transfusions, waiting for a scan or a biopsy, waiting for the results of a scan or a biopsy, waiting (sometimes starved and unclothed on a gurney in a hall) for surgery. 

The email arrived the day after an essay I had written on cancer language appeared online. Without a salutation, it began, "I hate what I've read by you. Simple as that. Your style is dark and nasty." Let's just say that it did not get any better after that. 

But toward the end my correspondent stated, "last week I needed to have a thoracentesis for a large pleural effusion" after a seven hour wait in an emergency room. "That's a serious systemic issue," she emphasized, especially for someone with metastatic disease and a shut-down lung who is forced "to sit five hours, then lie on a stretcher for two more and finally be transferred to a real bed at 4 a.m." 

From this account, which triggered memories of my own experiences in the ER, I could interpret her fury at me as anger deflected from its primary source: distress at her condition and at having had to wait so long under such frightful circumstances.

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Wednesday, December 2, 2015 The Surprising Failure of Calorie Counts on Menus

Americans remain very overweight. According to the Centers for Disease Control and Prevention, about 38 percent of adults were obese in 2013-14, compared with 32 percent just 10 years ago. This is in spite of huge efforts to get people in the United States to eat more healthily.

Policy makers continue to believe that the problem is people's lack of knowledge that they are wolfing down calorie-rich foods. It is assumed that once Americans know what they are eating, they will eat less, or at least with health in mind. For this reason, many health advocates have called for restaurants to provide people with calorie counts of what they are ordering. Recent mandates mean that by the end of next year, calorie labeling will be required on all menus in chain restaurants and establishments selling food in the United States.

Because many restaurants are already trying menu labeling, we can look at how they have worked, or haven't, and begin to predict how this widespread regulation might function. For instance, researchers looked at data from 66 of the largest chains — those that posted calories and those that didn't — and found that average calories per item were 139 calories lower in restaurants that posted their nutritional information.


Tuesday, December 1, 2015

Blood Pressure, a Reading With a Habit of Straying - The New York Times

Measuring blood pressure seems so straightforward. Stick your arm in a cuff for a few seconds, and there they are: two simple numbers, all the information you need to know whether you are in a healthy range or high enough that you should be taking one of the many cheap generic drugs that can bring down your blood pressure.

But the reality is more confusing, as I discovered recently when I tested mine.

It turns out that blood pressure can jump around a lot — as much as 40 points in one day in my case — which raises the question of which reading to trust.

Ever since I wrote about a woman who was in denial about her high blood pressure until she had a stroke, I have been worried that my blood pressure might creep up without my knowing it. I became interested again when I reported that a large federal study of people at high risk for a heart attack or stroke found that bringing blood pressure well below the current national guidelines — a systolic blood pressure below 120 millimeters of mercury instead of 140, or instead of 150 for people older than 60 — significantly reduced the death rate and the rate of heart attacks, strokes and heart failure. The results were so compelling that guideline committees are expected to revise their recommendations.

A week after that study was published, I decided to check my blood pressure with a home monitor before a coming physical examination. The first night, I was startled to find that my systolic pressure was a scary 137. The next night, it was only 117. The next morning, before I saw my doctor, it was a terrifying 152. At the doctor's office, it was 150. I measured it again that night, and it had plummeted to 110. And my diastolic pressure, the lower number, was a rock-bottom 60 that evening.

It seemed unreal. Did I have hypertension because my pressure had hit 152 in the morning? But if I took a drug to bring it down, what would happen if my pressure was trying to go down to 110 in the evening?

I asked a few experts.

"Short answer is, you are normal," said Dr. David McCarron, a research associate at the University of California, Davis, adding that anyone whose pressure goes down to 120 or, in my case 110/60, does not have hypertension. His advice to patients is to abstain from obsessively monitoring their blood pressure.

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The Heart Disease Conundrum - The New York Times

South Asians today account for more than half of the world's cardiac patients. Heart disease is the leading cause of death in India, Pakistan and Bangladesh, and rates have risen over the past several decades. South Asian immigrants to the United States, like me, develop earlier and more malignant heart disease and have higher death rates than any other major ethnic group in this country.

The reasons for this have not been determined. Traditional cardiac risk models, developed by studying mostly white Americans, don't fully apply to ethnic communities. This is a knowledge gap that must be filled in the coming years. Fortunately, there is a model for doing so: research performed in a small town in Massachusetts over the past seven decades. Known as the Framingham Heart Study, it is perhaps the most influential investigation in the history of modern medicine.

The Framingham Heart Study is a big reason we have achieved a relatively mature understanding of heart disease in the United States — at least for a large segment of our population. It established the traditional risk factors, such as high blood pressure, diabetes and cigarette smoking, for coronary heart disease. Framingham also spearheaded the study of chronic noninfectious diseases in this country, and indeed introduced many doctors to the very idea of preventive medicine.

The impetus for Framingham was clear. In the 1940s, cardiovascular disease was the main cause of mortality in the United States, accounting for nearly half of all deaths. Knowledge of coronary risk factors was spare. As Dr. Thomas Wang and colleagues wrote in the journal Lancet last year, "Prevention and treatment were so poorly understood that most Americans accepted early death from heart disease as unavoidable."

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Bacteria on the Brain - The New Yorker

As the chairman of the neurosurgery department at the University of California at Davis, Paul Muizelaar saw patients on Wednesdays, at a clinic housed in a former cannery in East Sacramento. Among the people waiting to see him on the afternoon of November 10, 2010, was Terri Bradley, a fifty-six-year-old woman on whom he had operated the previous May, to remove a malignant brain tumor the size of a lime. Sitting in his office, Muizelaar reviewed Bradley's file. He read a letter from her oncologist, asserting that Bradley was doing well: a brain scan had found no evidence of the tumor. "I think, This sounds great," Muizelaar, a sixty-eight-year-old Dutchman, recalled. "So I go to her exam room with a big smile on my face, and there she is with her daughter, crying, not able to speak."

Muizelaar hadn't seen Bradley's latest test results. Her condition had suddenly deteriorated, and new scans revealed that her tumor—a deadly type known as glioblastoma multiforme, or GBM—had returned. It had spread from the right side of her brain to the left frontal lobe, acquiring an ominous winged shape that doctors refer to as a butterfly glioma. A second tumor had sprouted in the region of her brain associated with speech. Bradley, partially paralyzed and dependent on a wheelchair, had already undergone chemotherapy and radiation; her doctors believed that more drugs were pointless. "The radiologist said, 'I've never seen anything grow so fast,' " Bradley's daughter Janet recalled. "He said, 'Call hospice.' That scared the hell out of me."

Bradley, a fiercely self-reliant woman who had raised four daughters on her own, refused hospice care. Finally, Janet took her to Muizelaar, who said that he was unable to help. "It's a blessing to most patients not to linger," Muizelaar, who practiced medicine in California under a license reserved for eminent foreign-trained physicians, told me. "Within four weeks, this woman had regrown a massive tumor, plus a second tumor. There was clearly nothing I could do about it."

Yet the conversation did not end there. An hour before Bradley's appointment, Muizelaar had received tantalizing news about a patient on whom he had performed an exceedingly unusual procedure. The previous month, he had operated on Patrick Egan, a fifty-six-year-old real-estate broker, who also suffered from glioblastoma. Egan was a friend of Muizelaar's, and, like Terri Bradley, he had exhausted the standard therapies for the disease. The tumor had spread to his brain stem and was shortly expected to kill him. Muizelaar cut out as much of the tumor as possible. But before he replaced the "bone flap"—the section of skull that is removed to allow access to the brain—he soaked it for an hour in a solution teeming with Enterobacter aerogenes, a common fecal bacterium. Then he reattached it to Egan's skull, using tiny metal plates and screws. Muizelaar hoped that inside Egan's brain an infection was brewing.

Muizelaar had devised the procedure in collaboration with a young neurosurgeon in his department, Rudolph Schrot. But as the consent form crafted by the surgeons, and signed by Egan and his wife, made clear, the procedure had never been tried before, even on a laboratory animal. Nor had it been approved by the Food and Drug Administration. The surgeons had no data to suggest what might constitute a therapeutic dose of Enterobacter, or a safe delivery method. The procedure was heretical in principle: deliberately exposing a patient to bacteria in the operating room violated a basic tenet of modern surgery, the concept known as "maintaining a sterile field," which, along with prophylactic antibiotics, is credited with sharply reducing complications and mortality rates. "The ensuing infection," the form cautioned, "may be totally ineffective in treatment of the tumor" and could cause "vegetative state, coma or death."

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