Monday, June 13, 2011

Health - Well: Digital Dalliance: Easy to Do and Easy to Get Caught

Health - Well: Digital Dalliance: Easy to Do and Easy to Get Caught

Well: Digital Dalliance: Easy to Do and Easy to Get Caught

Posted: 13 Jun 2011 12:34 PM PDT

18 and Under: A Graduation That May Carry Unnecessary Risk

Posted: 13 Jun 2011 11:50 AM PDT

Right before I moved from Boston to New York City, I went to see one of my patients graduate from high school. I was in an elegiac mood — leaving the city, saying goodbye to friends — and I teared up as I watched her from the balcony. It felt right that her time as my pediatric patient was ending not with my moving away, but with her marching proudly into the future.

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Ken Orvidas

In adult medicine, patients don’t graduate. You don’t provide adult primary care with an eye toward the day that your patients outgrow you and pass triumphantly on to the next doctor. Pediatrics, on the other hand, is about growth and change. The goal is to help a healthy child grow into a healthy adolescent — and then the pediatrician says goodbye, and the patient moves on.

But we have a lot to learn about helping families make that transition. Studies show that the zone at the end of the pediatric period is fraught with uncertainties and risks, especially for children with chronic illnesses and disabilities. We often fumble the handoff to adult primary care, and the consequences can be serious.

Dr. Debra Lotstein, assistant professor of pediatrics at the University of California, Los Angeles, studies this transition in adolescents and young adults with chronic medical conditions — problems which can range from asthma and diabetes to developmental conditions like autism to complex and rare syndromes. As they move out of the pediatrician’s office, Dr. Lotstein and her colleagues have found, transition planning is often limited, and gaps in care occur for as many as two-thirds of these young adults.

“A large number of them either have no care as adults or just very minimal care that really is much more haphazard and not nearly as comprehensive as the care they had when they were children,” she said.

Even young adults without major medical problems often go without regular health care after leaving their pediatricians. One cause is poor access to insurance, as young adults age out of their childhood coverage, public or private. The transition years are a high-risk period in this regard. A report released in May by the Commonwealth Fund found that in 2009, a third of the 19- to 29-year-olds in this country had no coverage, though it predicted improvement with the Affordable Care Act, the health care law enacted in March 2010.

There are few distinct medical dividing lines between pediatric care and adult medicine. Pregnancy has been one traditional marker; get pregnant and you move on to the women’s clinic (other reproductive health needs are often met by pediatricians, including adolescent medicine specialists).

Indeed, in recent years pediatricians have had to do some catch-up learning about a number of conditions that we used to think of as belonging more to adult medicine — hyperlipidemia and Type 2 diabetes, for instance, or high blood pressure. This is in part a result of the growing population of obese teenagers, along with a fuller awareness of the importance of finding and treating early stages of adult chronic diseases.

Conversely, adult specialists have increasingly needed to learn how to handle adults with a range of problems once limited to pediatric practices.

When I was doing my residency during the 1980s, we took care of adolescents with cystic fibrosis, knowing that many were unlikely to live past their 20s — it was a pediatric disease, and the experts were pediatricians. Not that long ago, there were relatively few grown-up survivors of complex congenital heart disease, for example, or childhood cancer, or congenital H.I.V. infection.

But life expectancy for all these patients has lengthened significantly, necessitating a deliberate effort to create adult centers with adult expertise in these diseases — places to catch young patients as they exit pediatric care. And cystic fibrosis is often cited as a particular success story, with those adult centers functioning well for the patients who now live for many decades past leaving pediatric care.

Dr. Mary R. Ciccarelli, associate professor of clinical medicine and pediatrics at Indiana University School of Medicine, directs a program called the Center for Youth and Adults with Conditions of Childhood. “In the past, what we’ve done is feel successful because youth have survived to 18,” she said of children with these complex medical problems. These days, success should mean that an 18-year-old with such a condition is not only surviving, but also learning the skills to manage all the different health care pieces going forward — “a much taller order.”

Dr. Renata Arrington Sanders, assistant professor of pediatrics and adolescent medicine at Johns Hopkins University, has developed tools for pediatric providers to assess certain checkpoints of maturity that young patients need to function as adults in the health care system — knowing your medical history, knowing how to obtain and transfer your records, knowing how to get and refill prescriptions, how to contact an insurance company.

The goal is to get doctors, and parents, thinking along these lines early in a child’s adolescence. “People think, ‘I don’t need to do this till 18,’ ” she said. “Eighteen is probably too late.”

There is no established ritual for leaving your childhood doctor, whatever I may have imagined as my patient marched across her high school stage. But helping a family make that transition successfully may be one of the most important services a pediatrician can provide. As the valedictorian’s cliché goes, commencement is supposed to represent a beginning, not an ending.

Social Media Join Toolkit for Hunters of Disease

Posted: 13 Jun 2011 09:34 AM PDT

On a chilly February night in Los Angeles, attendees at the DomainFest Global Conference crushed together in a tent at the Playboy Mansion for cocktails and dancing. Two days later, Nico Zeifang, a 28-year-old Internet entrepreneur from Germany, woke up with chest pains, chills and a soaring fever. Four colleagues shared his symptoms, Mr. Zeifang soon learned.

So he did what any young techie would: He logged on to Facebook and posted a status update. “Domainerflu count,” it said. “Who else caught the disease at D.F.G.?”

Within hours, 24 conference attendees from around the world added themselves to Mr. Zeifang’s Facebook list; within a week, the number climbed to 80. Many of them “friended” him to get information and to compare notes on their fevers and phlegmy coughs. Almost everyone, it seemed, had a theory about the source of the infection. Many suspected the artificial fog that permeated the tent.

Los Angeles County health authorities and the federal Centers for Disease Control and Prevention stepped in to investigate a few days later. By that time, victims from across the globe already had arrived at their own diagnosis — legionellosis — and had posted their own Wikipedia entry on the outbreak.

Social media — Facebook, Google, Twitter, location-based services like Foursquare and more — are changing the way epidemiologists discover and track the spread of disease. At one time these guardians of public health swooped onto the scene of an outbreak armed with diagnostic kits and a code of silence. Officials spent weeks interviewing victims privately, gathering test results and data, rarely even acknowledging in public that an investigation was under way. The results might not be announced for weeks or months.

Now technology is democratizing the disease-hunting process, upsetting the old equilibrium by connecting people through channels effectively outside government control. While the online chatter can be unproductive or even dangerous — spreading fear along with misinformation about causes and cures — a growing cadre of epidemiologists sees social media as a boon. Future hunts for pathogens may rely as heavily on Twitter streams and odd clusters of search queries as on blood tests and personal histories.

The C.D.C. officer assigned to the Los Angeles case did not show up at Mr. Zeifang’s doorstep with a black bag. Instead, she joined his Facebook page, read up on everyone’s symptoms, recommended certain diagnostic tests and referred the victims to the agency’s online questionnaire. The agency still will not discuss the Los Angeles case or what may have caused the outbreak, the origin of which is unknown, but officials acknowledge the need to modernize.

“We can’t turn the clock back,” said Dr. Taha Kass-Hout, deputy director for information science at the C.D.C. “Given that the next SARS probably can travel at the speed of an airliner from continent to continent in a matter of hours, it just makes perfect sense to adapt the speed and flexibility of social networking to disease surveillance.”

John Brownstein, an assistant professor of pediatrics at Harvard Medical School, is a leader among self-described “computational epidemiologists,” who use unconventional data sources to help predict disease outbreaks. “Tapping into people’s communications about health events can tell you a lot,” Dr. Brownstein said. “Wherever people are having discussions, whether it’s Facebook, Twitter, chat rooms or blogs, you can process that information using modern tools and extract key elements.”

In 2006, frustrated by the difficulty of getting data from government sources, Dr. Brownstein and Clark Freifeld, a software developer, designed HealthMap, a Web site that tries to pinpoint global outbreaks in real time. HealthMap scours the Web for disease reports from local news articles, witness accounts, blogs, Twitter and official reports from the C.D.C. and World Health Organization, and renders them as little red pins on a map. With a related mobile app, Outbreaks Near Me, users rely on global positioning to help them steer clear of infectious hazards; they also can report new ones from their smartphones. If an amateur report is verified by Dr. Brownstein’s team, it appears on the Web site’s map as a colored point.

More than 100,000 people have downloaded the mobile app. And while Dr. Brownstein acknowledged the potential for false alarms, he said that this experiment in crowdsourced epidemiology was promising: Erroneous reports submitted by amateurs have been surprisingly few. “We’ve done a lot of investigations of the data, and the positive reports far outweigh the negative,” he said.

In the last few years, scientists have managed to identify regional spikes in seasonal flu a week or more in advance of the C.D.C. by sifting through online search queries and Twitter feeds for flu-related terms. Dr. Brownstein is now collaborating with the C.D.C. and Google to develop methods for online tracking of dengue fever. The first, Google Dengue Trends, started in May.

Essay: He Looked at Gays With Judgmental Eyes

Posted: 13 Jun 2011 12:37 PM PDT

For millions of us he was the perfect physician, even if he never existed.

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ABC

Every week from 1969 to 1976, viewers would tune to ABC in time to catch that signature opening: a tall man in a gray suit, medical bag in hand, striding to his Detroit-made sedan and driving into the night for another house call.

Seconds later, an oxygen mask was lifted from an unseen patient comforted by the reassuring smile of Marcus Welby, M.D. — the general practitioner, played by Robert Young (at right) of “Father Knows Best” fame, who embodied the fast-fading era of the warm, compassionate, all-knowing family doctor.

But even if Dr. Welby was a throwback, he could not avoid the roiling social currents of the time. As I had occasion to recall during medical-school commencement season this spring, he once set off a noisy campus uproar here at the University of Michigan.

It began with an episode on Feb. 20, 1973, titled “The Other Martin Loring.” In it Welby treated a middle-aged man who suffered from obesity, diabetes, alcoholism, depression and impotence. Loring’s wife confessed that she wished “the problem was another woman,” and his mother revealed that Loring’s father was distant and unavailable.

From this information, Dr. Welby deduced that Loring was struggling with “homosexual tendencies,” and tidily wrapped up another week’s show by assuring his patient that he could win his battle against such aberrant urges and someday be “normal.”

For a program that prided itself on its up-to-the-minute medical information (the American Academy of Family Physicians vetted every script for medical verisimilitude), the Loring episode seemed strangely unaware of the intense national debate going on just then over homosexuality. That awareness was raised in a hurry: The Gay Activist Alliance staged a sit-in at ABC’s New York offices, and on the day of the broadcast, activists picketed the Los Angeles County Medical Association and called Marcus Welby a “quack.”

Both efforts inspired a few newspaper articles but little sympathy from Main Street America. Still, the tide was moving rapidly; that same year the American Psychiatric Association formally voted to amend the Diagnostic and Statistical Manual of Mental Disorders to remove any mention of homosexuality as a “disease.”

Oddly, in October 1974, “Marcus Welby, M.D.” made another foray into sexuality with an episode about a male teacher who raped a teenage boy. This sparked an angry response from gay advocates objecting to the suggestion that all pedophiles were gay. Seventeen affiliate stations refused to broadcast the episode. Several journalists, including John J. O’Connor, the television critic for The New York Times, questioned the activists’ motives and accused them of censorship.

In the midst of all this, the dean of the University of Michigan Medical School, Dr. John A. Gronvall, announced that its 1973 commencement speaker would be Robert Young. The news quickly spread beyond Ann Arbor and was widely reported across the nation.

In those heady days of youthful dissent, several medical students protested having their diplomas blessed by an actor, especially one who played a paternalistic doctor with judgmental views of human sexuality. But the decision also represented an overstepping of established boundaries. Traditionally, a medical school’s graduating class chooses its own commencement speaker without faculty interference.

The class’s first choice had been Senator Edward M. Kennedy, who was too busy trying to pass a comprehensive health care bill to accept the honor. Second choice was Dr. Benjamin Spock, the pediatrician and Vietnam war critic, whom a faculty committee rejected on the spurious basis that he was “a poor speaker.”

One of the student protesters, David Morens, who is now senior adviser to the director of the National Institute of Allergy and Infectious Diseases, enlisted some classmates to stage a countercommencement featuring Dr. Spock. In a recent telephone interview, Dr. Morens recalled that the event was “a relic of the times we lived in — we were young, activist, and wanted to create a better world.”

Dr. Spock accepted the challenge in return for travel expenses. He wrote Dr. Morens on April 3 that the faculty committee’s “remark about having an extremely poor speaking ability did it.”

The commencement and countercommencement proceeded without serious repercussions. On the evening of June 7, Dr. Spock admonished his audience “that it is a shame, an outrage, that only the wealthy can have health care in this country.” The following afternoon, Robert Young cheerfully reminded the graduates to pay attention to their patients’ emotional needs. Credentials aside, both were right.

Dr. Howard Markel, a professor of the history of medicine at the University of Michigan, is the author of “An Anatomy of Addiction,” to be published next month.

A Defect That May Lead to a Masterpiece

Posted: 13 Jun 2011 12:36 PM PDT

In learning to draw or paint, it helps to have a sense of composition, color and originality.

And depth perception? Maybe not so much, neuroscientists are now suggesting. Instead, so-called stereo blindness — in which the eyes are out of alignment so the brain cannot fuse the images from each one — may actually be an asset.

Looking at the world through one eye at a time automatically “flattens the scene,” said Margaret S. Livingstone, an expert on vision and the brain at Harvard Medical School who helped carry out a study on stereo vision.

That appears to give people with stereo blindness a natural advantage in translating the richly three-dimensional world onto a flat two-dimensional canvas, she said. They use monocular depth cues like motion, relative size, shadows and overlapping figures to stimulate a 3-D world.

For one experiment in the study, published in the journal Psychological Science, the researchers measured stereoscopic ability in 403 students from two art schools known for an emphasis on representational rendering and in 190 non-art majors at a university with similar tuition.

All students donned red and green glasses, the kind used to view 3-D movies, and stared at a background of colored dots that were manipulated by a computer to flicker randomly. Those with stereo vision were able to focus their eyes to see a square floating in front of or behind the computer screen, just as they might see the blade of a sword pop out of a 3-D screen. Those who were stereo blind just saw noise. The artists as a group performed more poorly than the controls.

In a second experiment, the researchers obtained portraits of 121 famous artists and 127 members of Congress from the National Gallery of Art and the photographic archives of the Smithsonian American Art Museum. The subjects’ eyes were cropped from the photos and shown to observers who measured eye alignment using reflected light, not knowing anyone’s identity.

The eyes of the established artists were more often misaligned, Dr. Livingstone said.

Dr. Livingstone and her colleagues first suspected a connection between artistic talent and stereo blindness when they examined 36 self-portraits by Rembrandt and found that his right eye was noticeably deviated in 35 of them. (That finding was published in The New England Journal of Medicine in 2004.) They wondered how widespread the phenomenon might be.

The idea that some artists have a fundamental visual defect seems counterintuitive, said a co-author of both studies, Bevil R. Conway, a stereo-blind artist who teaches neuroscience at Wellesley College.

“But I always found it easy to draw,” he said, “not because of dexterity, but because when I looked at a scene the relative size and spatial relationships of objects seemed obvious and related immediately to their representation on a flat sheet of paper.”

An expert not involved in the new research, Susan R. Barry, a professor of neuroscience at Mount Holyoke College, said she thought the authors were “on to something.”

Dr. Barry is the author of “Fixing My Gaze” (Basic Books, 2009), an account of how she regained stereo vision at age 50 using vision therapy. “I have received hundreds of e-mails from people who are stereo blind, and it seems a disproportionate number are artists. Not being able to see in stereo might bias some people toward art.”

Ten percent of people develop various degrees of stereo blindness in early childhood because of visual defects that do not allow both eyes to line up, Dr. Barry said. Some have weak stereo that comes and goes with fatigue, while others completely lack what she calls the “palpable volumes of space” that come with stereo. Stereo-blind people learn to navigate by using monocular cues and never know what they are missing.

Most artists’ eyes are aligned, of course, so stereo blindness is not a condition for artistic success. And many people with no stereo vision show no artistic talent.

“You can’t make yourself a great artist by poking out one eye,” Dr. Conway said.

But if you have normal stereo vision, he continued, you can appreciate the monocular cues used by artists if you sit perfectly still in front of a painting, close one eye and wait.

“Stereo vision, which tells you the canvas is flat, will be suppressed,” he said. “The image will pop out at you. It can be quite a surprise.”

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$4.3 Billion Pledged at Vaccine Fund-Raiser

Posted: 13 Jun 2011 12:16 PM PDT

Public and private donors have pledged $4.3 billion toward vaccinating children against a variety of diseases, according to the GAVI Alliance, which held its first fund-raising conference for vaccines in London on Monday.

That exceeds the $3.7 billion that the alliance — created 11 years ago as the Global Alliance for Vaccines and Immunization to help poor countries pay for vaccines — had hoped to raise. Some is matching money contingent on other pledges. 

The target is to immunize more than 250 million children by 2015. Vaccines, medical experts say, save more lives than any public health measure other than clean water and sewage.

When GAVI was created, experts estimated that three million children a year were dying of vaccine-preventable diseases; that number has now dropped to two million.

Fifty countries have already applied for the funds, some of which will buy newer, more expensive vaccines against rotavirus, meningitis, pneumococcal disease, hepatitis B and yellow fever; the alliance also hopes to eventually add vaccines against cervical cancer, rubella, typhoid, Japanese encephalitis and other diseases.

Exactly how much the money will buy will be cannot be calculated because vaccine makers have been steadily lowering their prices as political pressure on them increases and as low-cost competitors, mostly from India, enter the field.

“Vaccines are absolutely brilliant value for money,” Andrew Mitchell, Britain’s secretary of state for international development, said at the news conference where the pledges were announced. “For the price of a cup of coffee, it’s possible to vaccinate a child against five killer diseases.”

Bill Gates, who helped create GAVI and whose foundation has given it more than $1.5 billion, said the new money meant “we will be upping our sights” on how fast new vaccines can be made and how many children can be reached. “Eighty percent coverage is not nearly enough,” he said, referring to how many of the world’s children get the three most common vaccines, against diphtheria, whooping cough and tetanus.

The United States, which has given more than $650 million in the past, pledged another $450 million, pending Congressional approval. The British government, a sponsor of the pledging conference, gave $266 million, roughly doubling its previous donation. Australia, Norway and Sweden also doubled theirs, Mr. Mitchell said. Japan and Brazil pledged for the first time, as did some foundations and companies, like Anglo-American, the South African mining giant.

The financially strapped British government had recently re-examined all 43 agencies to which it donates foreign aid, Mr. Mitchell said. It froze or cut donations to some, but concluded that GAVI was one of the most cost-effective.

Vital Signs: Patterns: Prenatal Vitamins May Ward Off Autism

Posted: 13 Jun 2011 10:56 AM PDT

Scientists have identified an unexpected factor that may play a significant role in the development of autism: prenatal vitamins.

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A new study reports that mothers of children with autism and autism spectrum disorders were significantly less likely than mothers of children without autism to have taken prenatal vitamins three months before conception and in the first month of pregnancy. The finding, published in the July issue of the journal Epidemiology, suggests that taking vitamins in this period may help prevent these disorders, reducing the risk by some 40 percent.

Researchers recruited children through a California project, the Childhood Autism Risks From Genetics and Environment Study, or Charge, enrolling 288 children with autism and 144 with autism spectrum disorders, and compared them with 278 children who were developing normally. Blood was drawn for genomic analysis, and mothers were asked about their consumption of vitamins before and during pregnancy.

In mothers and children with gene variants that affect folate metabolism, not taking prenatal vitamins before conception was associated with an up to sevenfold increase in the risk of autism, the researchers found. Prenatal vitamins are rich in folate.

“Taking prenatal vitamin supplements even before conception is a concrete step concerned parents can take,” said Dr. Irva Hertz-Picciotto, the study’s senior author and principal investigator of the Charge study.

Vital Signs: Disparities: Health Risks Seen for Single Mothers

Posted: 13 Jun 2011 09:32 AM PDT

Middle-aged women who were single when they had their first child are in worse health than similar women who were married when first giving birth, suggesting that the stress of being a single parent has long-term health consequences, a new study has found.

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The report, published June 2 in American Sociological Review, is one of the first to assess the health of single mothers. Researchers analyzed data on 3,400 women taken from the 1979 National Longitudinal Survey of Youth, which tracks the health of a nationally representative sample of people who were ages 14 to 22 when the survey started.

The mothers were asked at age 40 to rate their health with a type of self-assessment considered a highly accurate indicator of health and future mortality.

Both black and white women who had children outside of marriage ranked their health as worse than women who had their first children while married. That was not the case, however, for Hispanic single mothers, who are more likely to have children in long relationships that closely resemble marriage, the authors said.

The findings are of concern because unmarried women account for almost 40 percent of births in the United States, up from 10 percent in 1960, said Kristi Williams, an associate professor of sociology at the Ohio State University and the paper’s lead author.

Vital Signs: Risks: Better Odds for Surviving Complex Surgery

Posted: 13 Jun 2011 09:39 AM PDT

The odds that a Medicare patient will die after undergoing one of eight high-risk operations have fallen sharply, an analysis of medical records has found.

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Fewer hospitals are performing these procedures, and the hospitals that do them are high-volume facilities that tend to have more experience caring for high-risk patients, the researchers found. But that trend does not fully account for the decline in deaths.

Patients who had surgery to repair abdominal aortic aneurysms experienced the steepest decline in mortality in the analysis. Their death rate fell to 2.8 percent in 2007-8 from 4.4 percent in 1999-2000 — a 36 percent drop, due mostly to new medical technology, the researchers said.

Death rates also fell among patients after operations to treat cancers of the esophagus, pancreas, lung and bladder, and among those who had had coronary artery bypass grafting, aortic valve replacement and carotid endarterectomy, according to the study, published this month in The New England Journal of Medicine.

The declines in mortality translate into about 2,000 fewer deaths each year, said Dr. John D. Birkmeyer, director of the Center for Healthcare Outcomes and Policy at University of Michigan and the paper’s senior author. Much of the improvement stems from a new emphasis on patient safety, Dr. Birkmeyer added.

Recipes for Health: Farm-Fresh Favas

Posted: 13 Jun 2011 11:09 AM PDT

Farmers’ markets are filling up with one of my favorite vegetables: fava beans. Grassy and sweet, fresh favas are high in protein and a good source of vitamin C, vitamin A and potassium.

Recipes for Health

Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat.

Not everyone is enthusiastic about them. They require double peeling, a job you might find tedious. But it goes more quickly than you’d think, especially if you have some company around to help, glasses of rosé in hand. Don’t believe those who tell you that young favas in particular don’t require double peeling; the light green skins that surround the beautiful darker bean have nothing going for them -- they’re bitter and fibrous.

When the beans are really young, you can eat them uncooked as a snack. I learned this from Lulu Peyraud, the proprietress of the famous French winery Domaine Tempier. She would serve tender shelled favas as an aperitif with chilled wine, red or rosé, setting them out on plates for guests to skin and snack on before dinner.

A warning: Fava beans are toxic to individuals with favism, a genetic disorder. Be cautious when trying fava beans for the first time.

To skin favas, bring a medium pot of salted water to a boil. Fill a bowl with ice water. Drop the shelled fava beans into the water, and boil them for five minutes. Drain, and transfer immediately to the cold water. Allow the beans to cool for several minutes, then, holding several beans in one hand, slip off their skins by pinching the eye of the skin and squeezing gently. Place the shelled favas in a bowl.

Fava Bean Puree

You find variations on this fava bean puree in Southern Italy, the Middle East and Morocco. This one, from Apulia, is the simplest. The puree should have the texture of hummus.

4 pounds fava beans, shelled

Salt to taste (about 1 teaspoon)

1 garlic clove, mashed in a mortar and pestle with 1/4 teaspoon salt

1/3 to 1/2 cup extra virgin olive oil

Imported black olives for garnish

1. Bring a large pot of salted water to a boil. Fill a large bowl with ice water. Drop the shelled fava beans in the water, and boil five minutes (if the beans are small or medium sized) to eight minutes (if the beans are large). Transfer the beans immediately to the cold water. Do not drain the water in the pot. Allow the beans to cool for several minutes, then drain and slip off their skins.

2. Place the skinned fava beans, salt and the mashed garlic in a food processor fitted with the steel blade. Turn on the machine, and with the machine running, add the olive oil in a slow stream. Process until you achieve a smooth puree. If necessary, add enough of the cooking water to give the puree a soft, hummus-like consistency. Scrape down the sides of the bowl, taste and adjust seasoning.

3. Mound the puree onto an earthenware platter or in a wide bowl. Garnish with olives, and serve with crostini or warm triangles of pita bread.

Yield: Eight servings.

Advance preparation: This will keep for three or four days in the refrigerator.

Nutritional information per serving: 242 calories; 1 gram saturated fat; 1 gram polyunsaturated fat; 7 grams monounsaturated fats; 0 milligrams cholesterol; 27 grams carbohydrates; 12 grams dietary fiber; 79 grams sodium (does not include salt to taste); 12 grams protein

Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Personal Health: Marching Through Life With Parkinson’s

Posted: 13 Jun 2011 11:20 AM PDT

Dr. Karen Jaffe, an obstetrician-gynecologist in Cleveland, was only 48 when she learned she had Parkinson’s disease. Four years later, she continues to maintain a full-time medical and surgical practice, even performing ritual circumcisions.

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Patient Voices: Parkinson’s Disease

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“I’m doing everything I can to stay healthy,” she told me in an interview. “My medications and exercises control my tremor, so doing surgery is not a problem.”

For patients with Parkinson’s disease, like Dr. Jaffe, there still is no cure. But researchers have begun to make progress in identifying causes of the disease, and a new study promises to help identify better treatments.

Until then, many patients are getting by on grit and determination. In speaking recently with several of them, two common threads emerged: an initial unwillingness to believe or reveal the diagnosis, followed by acceptance and a determination to pursue whatever it takes to remain as healthy and functional as possible.

In addition to taking medication designed to replace the brain chemical, dopamine, that is diminished in this neurological disease, each person I spoke with is dedicated to regular, often vigorous physical activity that can minimize the disabilities caused by Parkinson’s.

One, David Wolf, 51, of Buffalo, has even taken up fencing, saying (in jest, I hope), “There’s nothing like running someone through with a sword to make your day.” Another, Rena Bulkin, 68, of Manhattan, goes to a gym several times a week to do aerobics, stretching and range-of-motion and balance exercises. “If I don’t work out, my symptoms are much worse,” she said.

Dr. Jaffe dances the tango and whacks a heavy punching bag to reduce her symptoms and enhance function. “The punching bag helps my arms and relieves my frustrations,” she said. “It feels so good to hit the thing.”

She also rides an exercise bike at low resistance and high speed — 80 to 90 revolutions a minute — an activity that was shown in studies at the Cleveland Clinic to significantly reduce arm tremor.

The Parkinson’s patients also emphasized the importance of having a physician who is both expert in the disease and willing to work with patients to find treatments that produce the most benefits with the fewest side effects.

Theirs is a lesson worth learning by the growing numbers of people with Parkinson’s and their caregivers. The sooner one comes to terms with the diagnosis and starts treatment, the less rapidly the disease is likely to worsen.

More Than a Movement Disorder

Parkinson’s disease is a slowly progressive neurodegenerative condition involving a significant loss of dopamine, a neurotransmitter produced in a section of the brain called the substantia nigra that helps to control movement and emotional responses.

While manifestations of the disease can vary widely from person to person, the most common physical symptoms include tremor, or shakiness or trembling in the hands, arms, legs, jaw and face; rigidity of the muscles; slowness of movement or difficulty starting to move; and problems with balance and coordination.

Other symptoms may include fatigue, depression, anxiety, irritability, restlessness, tingling, memory problems, slowed thinking, changes in body temperature, sweating and constipation.

Although the disease usually does not produce recognizable symptoms until the seventh decade or beyond, it sometimes affects much younger people like Dr. Jaffe, Mr. Wolf and the actor Michael J. Fox, 50. Although Dr. Jaffe said she can no longer play the piano — “My left hand can’t keep up with my right hand, and I wasn’t very good in the first place” — she was able to knit a number of cotton wraps that were sold to raise money for the Michael J. Fox Foundation for Parkinson’s Research.

The foundation, in partnership with industry, is sponsoring an international study of biological markers that can help monitor progression of the disease. Results of the study, called the Parkinson’s Progression Markers Initiative, are expected to facilitate the testing of new drugs that may slow or stop the disease in its tracks.

Dr. Kenneth Marek, a neurologist at Yale University and principal investigator for the biomarkers study, said in an interview, “We need a way to keep track of whether a medicine is working or not.” Because the disease progresses very slowly in some patients and rapidly in others, different treatments are likely to be more effective in some patients than in others.

He said, “A roadblock in developing new drugs has been the inability to predict what will happen over time.”

Dr. Jaffe and her husband are both participating in this study (he as a control subject). Two other participants, Marty Bullock, 68, of Stillwater, Okla., and his wife, Gay Lyn, plan to drive 560 miles every three months to Houston for the next five years, to be prodded and poked to give blood, urine and spinal fluid samples for analysis.

“After my diagnosis, I looked for a research program to participate in,” said Mr. Bullock. “It’s my understanding that Parkinson’s disease doesn’t get any better, so I wanted to see if perhaps I can help benefit someone else in the future.”

Advances in Research

Some progress has already been made in unraveling the genetic underpinnings of the disease. By identifying specific gene changes that cause Parkinson’s disease or increase the risk of developing it, it should be possible to develop therapies that modify the effects of these genes, according to Todd Sherer, a neuroscientist who is chief executive of the Michael J. Fox Foundation.

Specific gene abnormalities already have been isolated in families with an unusual number of cases. These changes have been found occasionally in people without a family history of the disease, too, Dr. Sherer said.

In March, Dr. Andrew Feigin of North Shore University Hospital in Manhasset, N.Y., and collaborators described recent success in treating advanced Parkinson’s disease with gene therapy. Their randomized, double-blind study, published online in The Lancet Neurology, showed for the first time that injecting a certain gene directly into the brain is safe and can significantly improve motor function in patients who no longer benefit from drug treatment.

Gene therapy for Parkinson’s, which is carried into the brain by modified viruses, is still in its infancy and hardly ready for clinical use. As Dr. Michael Hutchinson of New York University School of Medicine noted in an editorial accompanying the Lancet report, “Several questions remain. How long will the effect last? Will untoward long-term effects arise after the introduction of viruses into the brain? Does the technique offer any advantages over deep brain stimulation, for which clinical improvements seem twice as large?”

Still, the new study represents progress, most important for a disease that currently knows no cure.

Really?: The Claim: A Sunscreen Chemical Can Have Toxic Side Effects

Posted: 13 Jun 2011 09:07 AM PDT

THE FACTS

Christoph Niemann

Related

Sunscreen is supposed to protect skin. But some people suspect that a chemical in sunscreen, absorbed through the skin, may be even more hazardous than the sun’s rays.

The concerns stem from a small body of research indicating that oxybenzone, which blocks ultraviolet light, may mimic the effects of estrogen in the body and promote the growth of cancer cells. One study found that rats eating high doses of the chemical experienced side effects like abnormal uterine growth.

But in March, researchers at Memorial Sloan-Kettering Cancer Center in New York published an independent report examining all the evidence on the subject and concluded that the alarming findings from early animal studies relied on unrealistic dosages. In rat study, for instance, the animals were fed levels of oxybenzone that would never be achieved in humans through normal exposure to sunscreen.

The researchers also reviewed the data on oxybenzone tested on humans. Men and women do seem to absorb small levels through normal sunscreen use, but there was no evidence that it set off hormonal changes. Nor did the researchers find evidence of toxicity. While the idea of a compound in sunscreen being absorbed through the skin may sound alarming, the report’s authors pointed out that this commonly occurs with skin care products.

For those who have reservations, some sunscreens are now made without oxybenzone, though they may not offer the same ultraviolet protection.

THE BOTTOM LINE

Exposure to oxybenzone, through normal sunscreen use, is safe, studies find.

The New Old Age: Full-Time Caregiving

Posted: 13 Jun 2011 09:08 AM PDT

To Curb Malpractice Costs, Judges Jump In Early

Posted: 13 Jun 2011 06:48 AM PDT

In Justice Douglas E. McKeon’s fluorescent-lighted chambers in the Bronx, a new way of handling medical malpractice suits was on full, and sometimes gruesome, display. Around a polished wood table, lawyers haggled over the price for a lost nose ($300,000) and the missing tip of a finger ($50,000).

The discussion was like some kind of malpractice bazaar, with lawyers blurting out terrible facts and big numbers.

“Our offer of $500,000 is more than we’ve ever had on a dead baby case,” said Margaret Sherman, a lawyer for the New York City Health and Hospitals Corporation, which runs 11 public hospitals.

The patients were not there, but the lawyers and Justice McKeon — who has better-than-average medical knowledge — were. Cajoling, flattering and arguing, Justice McKeon, of State Supreme Court, worked to bring about settlements long before the cases moved toward trials.

The approach, known as judge-directed negotiation, is seen by the Obama administration as offering states a way to curb liability expenses that have sharply increased health care costs nationally. Getting judges involved earlier, more often and much more actively in pushing for settlements, is its crucial ingredient — evident in the recent session watched by this reporter, one of many that are usually not attended by the public.

New York officials say the program bypasses years of court battles, limiting legal costs while providing injured patients with compensation that is likely to be less than a jury would award but can be paid out years earlier, without lengthy appeals.

Under a $3 million federal grant, the city courts are now expanding the program beyond the Bronx, where it started in cases against city hospitals, to courts in Brooklyn and Manhattan, as well as to cases against private hospitals. It is to begin in Buffalo courts in the fall.

“We would hope that other states across the country would look at this as a model they might want to replicate,” said James B. Battles, the official overseeing the grant at the federal Agency for Healthcare Research and Quality. By some estimates, the program could save more than $1 billion annually if state courts adopted it nationally, Dr. Battles said. The city’s public hospitals say the program, along with other changes, like sharply increased attention to safety, has helped save $66 million in malpractice costs a year. During the recent session in Justice McKeon’s chambers, the lawyers seemed more relaxed than they would be with patients watching. After he agreed to take $1.5 million for a child with cerebral palsy, a plaintiffs’ lawyer, Louis G. Solimano, seemed disappointed. “I didn’t get a grand slam,” he said.

Malpractice costs have been at the center of the debate about health care expenses for decades, with some states enacting legislation to limit awards. But the lawsuits have been difficult for judges to control, partly because the cases can go on with little judicial involvement for years, pushing up legal expenses and solidifying positions.

Michelle M. Mello, a Harvard professor of law and public health who is evaluating the New York experiment, said the program represented a major cultural change in malpractice cases. “Ordinarily when the parties come to a settlement conference, it’s late in the game,” she said. “It’s often a pro forma exercise rather than an attempt to grapple with the tricky issues in the case.”

Under the New York program, cases are assigned from their earliest stages to a judge with training in medical issues who holds frequent settlement conferences, often after months, rather than years. A nurse with legal training helps the judge. Lawyers are required to have the authority to settle. Justice McKeon, who started the approach when handling cases against public hospitals in the Bronx, said settlement became more difficult the longer a case lingered. State court officials say statistics indicate he settles about 20 percent more cases than other judges.

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