Saturday, May 7, 2016

A global quantification of “normal” sleep schedules using smartphone data | Science Advances

The influence of the circadian clock on sleep scheduling has been studied extensively in the laboratory; however, the effects of society on sleep remain largely unquantified. We show how a smartphone app that we have developed, ENTRAIN, accurately collects data on sleep habits around the world. Through mathematical modeling and statistics, we find that social pressures weaken and/or conceal biological drives in the evening, leading individuals to delay their bedtime and shorten their sleep. A country's average bedtime, but not average wake time, predicts sleep duration. We further show that mathematical models based on controlled laboratory experiments predict qualitative trends in sunrise, sunset, and light level; however, these effects are attenuated in the real world around bedtime. Additionally, we find that women schedule more sleep than men and that users reporting that they are typically exposed to outdoor light go to sleep earlier and sleep more than those reporting indoor light. Finally, we find that age is the primary determinant of sleep timing, and that age plays an important role in the variability of population-level sleep habits. This work better defines and personalizes "normal" sleep, produces hypotheses for future testing in the laboratory, and suggests important ways to counteract the global sleep crisis.

Friday, May 6, 2016

Palliative care improves quality of life, but patients link it with death - Health - CBC News

Canadians with advanced cancer and their caregivers tend to link "palliative care" with impending death, and education is needed to help people realize the quality of life benefits such early care brings, doctors say.

Palliative care is designed to improve the quality of life for patients with a serious illness and their families.

The definition has changed over time. Originally, in the 1960s, it was defined as end-of-life care, mainly for people with cancer.

The definition is now much broader. International agencies such as the World Health Organization now encourage palliative care to be applied "early in the course of illness, in conjunction with other therapies that are intended to prolong life."

Several studies show early palliative care for people with advanced cancer also improves satisfaction with treatment and mitigates depression.

To look at perceptions of early palliative care, researchers at the Princess Margaret Cancer Centre in Toronto assigned people with common types of cancer, such as lung, gastrointestinal, colon and breast, to receive early referral for palliative care or standard cancer treatment.

Oncologists estimated all 48 patients had an estimated survival of six to 24 months when the trial began. A total of 23 caregivers were also interviewed.

Initially, patients in both groups linked palliative care to imminent death. One patient in the intervention group said, "It means death to me. It does. The end."

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Results of the 2015 Medical School Enrollment Survey - Association of American Medical Colleges

This report examines first-year medical school enrollment over the past decade and projects first-year enrollment through 2025. The goal is to inform the academic medicine community, researchers, and policymakers about trends and issues related to U.S. medical school enrollment.The report is based on the 12th annual AAMC Survey of Medical School Enrollment Plans. Each fall, the survey is sent to deans at all MD-granting U.S. medical schools with preliminary accreditation or higher. This most recent survey was conducted between September 2015 and January 2016.

Key findings include:

• Medical school enrollment has grown 25 percent since 2002–2003, and 30 percent growth should be achieved by 2017–2018.

In 2006, in response to concerns of a likely future physician shortage, the AAMC recommended a 30 percent increase in first-year medical school enrollment by the 2015–2016 academic year (over 2002–2003 levels).
Using the baseline of the 2002–2003 first-year enrollment of 16,488 students, a 30 percent increase corresponds to an increase of 4,946 students. The survey results indicate that the 30 percent goal will likely be attained by 2017–2018. Enrollment growth could be accelerated if any of the seven applicant or candidate schools in the Liaison Committee on Medical Education (LCME) pipeline attains preliminary accreditation.

• Schools are increasingly concerned about the availability of graduate medical education opportunities for their incoming students.

Medical schools reported concern about enrollment growth outpacing growth in graduate medical education (GME). Half of medical schools reported concerns about their own incoming students' ability to find residency positions of their choice after medical school, up from 35 percent in 2012. Concern about GME availability at the state and national levels declined somewhat since 2013, yet it still remained high.

• There has been a large increase in the percentage of schools experiencing competition for clinical training sites from DO-granting schools and other health care professional programs.

In 2015, 85 percent of respondents expressed concern about the number of clinical training sites and the supply of qualified primary care preceptors. Seventy-two percent expressed concern about the supply of qualified specialty preceptors. There has been a large increase in the percentage of schools experiencing competition from DO-granting schools and other health care professional programs, from about a quarter of schools in 2009 to more than half of schools in 2015. Forty-four percent of respondents reported feeling pressure to pay for clinical training slots, though the majority of schools currently do not pay for clinical training.

• Schools are dedicated to increasing diversity in their student body and increasing student interest in caring for underserved populations.

Most respondents (84 percent) indicated that they had (or were planning to have within two years) specific admission programs or policies designed to recruit a diverse student body interested in caring for underserved populations. The majority of respondents had established or expected programs/policies geared toward minorities underrepresented in medicine, students from disadvantaged backgrounds, and students from rural and underserved communities. Schools reported a variety of approaches, with a focus on outreach at high schools and local four-year universities and admission strategies such as holistic review.

• Enrollment increases at DO-granting schools continue to accelerate. First-year enrollment at DO-granting schools in 2020–2021 is expected to reach 8,468, a 185 percent increase from 2,968 students in 2002–2003. Combined first-year enrollment at existing MD-granting and DO-granting medical schools is projected to reach 30,186 by 2020–2021, an increase of 55 percent compared with 2002–2003.

Wednesday, May 4, 2016

The Power of Writing for Cancer Patients - Penn Medicine News Blog

"To what shall I claim definition?

My life which is no longer the same,

The disease which ravishes me,

Or the hope the trial brings?

The strong and vibrant man of yore has changed."

Jack Ivey wrote those words – part of a longer poem (see below) – following a discussion in Writing a Life, a writers workshop for cancer patients receiving outpatient treatment at the Hospital of the University of Pennsylvania. "I introduced myself [to the group] as a survivor. Another person said she was 'shlepping through' with difficult. Further around the circle, another saw herself as a matador in a fight," he said. "All of this prompted me to write 'To what shall I claim definition.' It just flowed from there."

Writing a Life, created by members of Patient and Family Services at Penn's Abramson Cancer Center, marks a first collaboration between the ACC and the University of Pennsylvania. The monthly sessions are held on campus at the Kelly Writers House, a beautiful Victorian house built in 1851. "It's perfect for this group… so relaxing," said Sandy Blackburn MSW, patient navigator.

Although Ivey has kept a journal since high school ("If I write things down, they make more sense.") – and has written several novels since his cancer diagnosis in 2007 – he never connected writing with helping him cope with the disease. But studies show that writing about a traumatic or stressful situation often has a beneficial impact. According to an article in the American Journal of Public Health, studies "have demonstrated that emotional writing can influence frequency of physician visits, immune function, stress hormones, blood pressure." Expressive writing has also been shown to "improve control over pain, depressed mood and pain severity."

Deborah Burnham, PhD, associate undergraduate chair in the University's department of English, leads the monthly sessions. She starts each session with a poem that she hopes will resonate with the group's personal experiences. A group discussion follows and then the participants separate to work on their individual pieces. "I'd never written a line of poetry in my life," Ivey said. "But it just flowed out."

But the group's positive effects go beyond writing. Being with others who have undergone treatment for cancer "is probably one of the biggest draws," Ivey said. "This group helped me grab hold of [the disease] and deal with it. It's so nice to be in a place where other people understand what you're going through. "

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Researchers: Medical errors now third leading cause of death in United States - The Washington Post

Nightmare stories of nurses giving potent drugs meant for one patient to another and surgeons removing the wrong body parts have dominated recent headlines about medical care. Lest you assume those cases are the exceptions, a new study by patient safety researchers provides some context.

Their analysis, published in the BMJ on Tuesday, shows that "medical errors" in hospitals and other health care facilities are incredibly common and may now be the third leading cause of death in the United States -- claiming 251,000 lives every year, more than respiratory disease, accidents, stroke and Alzheimer's.

Martin Makary, a professor of surgery at the Johns Hopkins University School of Medicine who led the research, said in an interview that the category includes everything from bad doctors to more systemic issues such as communication breakdowns when patients are handed off from one department to another.

"It boils down to people dying from the care that they receive rather than the disease for which they are seeking care," Makary said.

The issue of patient safety has been a hot topic in recent years, but it wasn't always that way. In 1999, an Institute of Medicine (IOM) report calling preventable medical errors an "epidemic" shocked the medical establishment and led to significant debate about what could be done.

The IOM, based on one study, estimated deaths because of medical errors as high as 98,000 a year. Makary's research involves a more comprehensive analysis of four large studies, including ones by the Health and Human Services Department's Office of the Inspector General and the Agency for Healthcare Research and Quality that took place between 2000 to 2008. His calculation of 251,000 deaths equates to nearly 700 deaths a day -- about 9.5 percent of all deaths annually in the United States.

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Tuesday, May 3, 2016

F.D.A. Again Reviews Mandatory Training for Painkiller Prescribers - The New York Times

A pain management specialist, Dr. Nathaniel Katz, was stunned in 2012 when the Food and Drug Administration rejected a recommendation from an expert panel that had urged mandatory training for doctors who prescribed powerful painkillers like OxyContin.

That panel had concluded that the training might help stem the epidemic of overdose deaths involving prescription narcotics, or opioids. At first, Dr. Katz, who had been on the panel, thought that drug makers had pressured the F.D.A. to kill the proposal. Then an agency official told him that another group had fought the recommendation: the American Medical Association, the nation's largest doctors organization.

"I was shocked," said Dr. Katz, the president of Analgesic Solutions, a company in Natick, Mass. "You go to medical school to help public health and here we have an area where you have 15,000 people a year dying."

Now, as the White House, the Centers for Disease Control and Prevention and other federal and state agencies scramble to find solutions to the vexing opioid problem, the role of doctors is coming back to center stage. The Obama administration recently announced that it supported mandatory training for prescribers of opioids.

On Tuesday, a new F.D.A. panel of outside experts will meet to review once again whether such training should be required. The hearing will almost certainly touch off an intense debate inside the medical community and focus attention on medical groups like the A.M.A., which have resisted governmental mandates affecting how doctors practice for both ideological and practical reasons. The panel is expected to make its final recommendation on Wednesday. An F.D.A. spokeswoman said the agency now supported mandatory training.

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After ‘The Biggest Loser,’ Their Bodies Fought to Regain Weight - The New York Times

Danny Cahill stood, slightly dazed, in a blizzard of confetti as the audience screamed and his family ran on stage. He had won Season 8 of NBC's reality television show "The Biggest Loser," shedding more weight than anyone ever had on the program — an astonishing 239 pounds in seven months.

When he got on the scale for all to see that evening, Dec. 8, 2009, he weighed just 191 pounds, down from 430. Dressed in a T-shirt and knee-length shorts, he was lean, athletic and as handsome as a model.

"I've got my life back," he declared. "I mean, I feel like a million bucks."

Mr. Cahill left the show's stage in Hollywood and flew directly to New York to start a triumphal tour of the talk shows, chatting with Jay Leno, Regis Philbin and Joy Behar. As he heard from fans all over the world, his elation knew no bounds.

But in the years since, more than 100 pounds have crept back onto his 5-foot-11 frame despite his best efforts. In fact, most of that season's 16 contestants have regained much if not all the weight they lost so arduously.

Some are even heavier now.

Yet their experiences, while a bitter personal disappointment, have been a gift to science. A study of Season 8's contestants has yielded surprising new discoveries about the physiology of obesity that help explain why so many people struggle unsuccessfully to keep off the weight they lose.

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The Cure For Fear | New Republic

Karin Klaver woke in the darkness and searched the nightstand for her iPhone. It was 2 a.m. Her husband slept quietly beside her. They had arrived in Johannesburg early that morning on the red-eye from Amsterdam and spent the day window shopping and people watching in the city. "This is nice," Klaver had thought to herself as she and her husband relaxed on the outdoor terrace of a shopping mall.

That evening, they retired to a bed-and-breakfast with garden rooms and enthusiastic online reviews. The couple were on their way to Port Elizabeth, where they own a house and spend several weeks each year. But this was the first time they had stayed overnight in South Africa's biggest city.

In the blackness of the room, Klaver sensed a presence at her bedside. A man was standing there with a gun in his hand, and he raised it to her head. Terrified, Klaver rolled onto her stomach. If she was to be shot, she thought to herself, better to be shot in the back. Her movement woke her husband, and the intruder demanded their cash and valuables. Then he slipped away into the night, leaving them unharmed but shaken.

Back in Holland, Klaver, 56, struggled to resume her normal life. What had once been comfortable and familiar now felt like an iron maiden. "Everything would remind me of what happened in Johannesburg," she said. She was nervous around unfamiliar men, and her house became a racket of threatening noises. The wind rustling in the curtains could keep her awake for hours. Nothing could dispel the dread that had overwhelmed her in that hotel room, when she was sure that she would die. "It was always there," she recalled recently. "It felt like a balloon inside."

Klaver found it difficult to talk about her anxiety, even with her husband. Thinking back to the robbery left her feeling even more isolated and vulnerable. "The first seconds, you feel so very, very lonely," she said. She resisted the idea of psychotherapy, with its long sessions devoted to reliving and processing the trauma.

A year and a half later, in 2013, Klaver read an item in the newspaper about Merel Kindt, a professor of clinical psychology at the University of Amsterdam. Kindt had developed a revolutionary treatment that could "neutralize" fear memories with a single pill. This treatment was a scientific breakthrough, building on decades of psychological research. It was also deceptively simple. "It was quick and dirty, and that's what I like," Klaver said. She wrote an email to Kindt introducing herself, and Kindt invited her to the university for a screening.

In the lab, one of Kindt's assistants asked Klaver a series of questions. What did she remember about the robbery? How did she feel when she remembered it? Kindt reviewed Klaver's answers and recognized the intrusive memories, avoidance behaviors, and other hallmarks of post-traumatic stress disorder. Klaver would indeed be a good candidate for the treatment, Kindt decided.

Three weeks later, Kindt, a striking woman with sharp features, crisp blue eyes, and stylishly tousled blonde hair, ushered Klaver into a small, plain room with a table and two chairs. Klaver, who has shoulder-length silver hair, wore black to the session. Normally, a patient who had suffered a traumatic experience might expect a therapist to proceed slowly and gently, offering comfort and support. Instead, Kindt dived straight in, pushing Klaver to relive the night of the robbery and focus on the source of her fear. "There is no escape," Kindt told her, as Klaver wept into her hands. "Nobody can help you." After 15 minutes, Klaver seemed shattered by her memories, and Kindt abruptly stopped the interrogation. She gave Klaver a round, white pill, which she swallowed with a sip of water. "I was totally broken," Klaver said.

Klaver went to bed early that night and slept for twelve hours. When she woke the next morning, she found that her memory was transformed. She recalled the details of what had happened in that bedroom in Johannesburg: She could still see the man's dirty cap, oversized jeans, and cheap plastic shoes. Yet she was able for the first time to think about the experience without anxiety or panic. "It felt like there was not that much weight on my shoulders," she said.

A pill of propranolol, which doctors have prescribed for decades to treat heart disease. Now it may be put to a very different use.

When she returned to see Kindt a week later, she wore white, as though to telegraph her mood reversal. "It's really gone," Klaver said. "It is quite special, isn't it?" Kindt smiled and leaned forward in her chair. "Yes," she agreed. "Very special."

Kindt, 48, has devoted her career to understanding human fear and memory. She has built her own laboratory, published in the most prestigious scientific journals, and developed a simple treatment she hopes might one day help millions of people who suffer from PTSD, phobias, and other anxiety disorders. In her clinic, she has seen it work in hundreds of cases, and yet she still marvels every time she sees a patient disencumbered of fear and trauma after such a short procedure. In those moments, she told me recently, her work doesn't feel like science or medicine at all. "It still feels," she said, "a bit like magic."

The sober-minded scientific community shares Kindt's awe. "'Cure' is a word not often encountered in psychiatry," Roger Pitman, a psychiatrist at Harvard Medical School, wrote in December in the journal Biological Psychiatry, in response to a study in which Kindt had successfully treated a group of people who were afraid of spiders. But a cure is exactly what Kindt appears to have found.

Not all fear needs to be cured, of course. A healthy amount of fear is essential to survival. When we encounter danger, the brain activates the sympathetic nervous system. Adrenaline floods our veins, our hearts race, and our fight-or-flight responsekicks into gear. The more quickly we can recognize a threat, the better our ability to avoid it in the future. In this way, our fears are lessons we have drawn from our experiences in the world. "Fear is a very adaptive emotion," Kindt said. "Because of fear, we anticipate and plan."

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Monday, May 2, 2016

Review: Jenny Diski’s ‘In Gratitude,’ an Uphill Life on and Off Cancer Road - The New York Times

When the essayist and novelist Jenny Diski, who died last week at 68, learned she had inoperable lung cancer, her first impulse was to make a "Breaking Bad" joke. She turned to her husband and said, in front of her doctor, "We'd better get cooking the meth."

Ms. Diski's second impulse was to fear she was a cliché. In her new memoir, "In Gratitude," she thinks: Oncologists must be subjected to that stupid meth joke every day. "I was mortified at the thought that before I'd properly started out on the cancer road," Ms. Diski writes, "I'd committed my first platitude."

Platitudes are hard to come by in Ms. Diski's many books (novels, travelogues, memoirs, short stories), which are mordant and talon-sharp. Her essays in The London Review of Books, where much of the material in this book originally appeared, were among the reading life's dependable pleasures. But cancer threatened to box her in as a writer. By now it's a cliché, when writing a cancer memoir, even to make a show of fighting the genre's clichés.

Ms. Diski was up-to-date on her cancer lit, having read recent books by Oliver Sacks, Clive James and the art critic Tom Lubbock. Their excellence she found distressing. "There are no novel responses possible," she writes. "Absolutely none that I could think of. Responses to the diagnosis; the treatment and its side effects; the development of cancer symptoms; the pain and discomfort; the dying; the death."

With "In Gratitude," she has written a different kind of cancer memoir, and an almost entirely platitude-free one, simply by writing a typically sui-generis Jenny Diski book. Which is to say, a book that pushes in five or six directions at once.

In part, it's about her treatment and her onrushing frailties, and this material is plain-spoken, harrowing and invariably moving. It's also the story of her youth and young adulthood, when she suffered from depression and withdrawal and was in and out of psychiatric hospitals, "rattling from bin to bin," as she puts it. It's about her feckless parents, who more or less abandoned her.

It's about her tangled relationship with the Nobel Prize-winning novelist Doris Lessing, a rhinoceros of a personality, with whom she lived for four years while a teenager. And finally it is about disease as performance, literary and otherwise. There was a "show going on the road," she declares, "in which I was to star."

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A recurring joke in "In Gratitude" is how prepared Ms. Diski was to play the role of cancer patient. She's already an anti-socialite. Her lifelong favorite places are bed and sofa. She lives, she thinks, like one of those secondary characters in Victorian literature who constantly retire to the fainting couch. She tells her doctor, "I have the metabolism of a sloth."

He tells her, "This is different." He is right. It turns out that Ms. Diski has two particularly unpleasant diseases, lung cancer and pulmonary fibrosis. Either can make you feel you are suffocating. Together they are pulverizing. "I don't do things by halves," the author comments.

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