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The Instincts to Trust Are Usually the Patient’s

January 6th, 2009

From nytimes.com
Not long ago, I took care of an elderly man with congestive heart failure. A few days into his stay in the hospital, he told me he was not going to make it out alive. “I am going to die here,” he whispered, as if letting me in on a secret.

I tried to reassure him: on the scale of disease I normally treat, his case was relatively mild. But then he became sicker.

His bloated legs dripped fluid, soaking his bed sheets and puddling on the tile floor. His blood pressure dropped. He became delirious. I was perplexed by the precipitous downturn. What did my patient know that I did not?

After several days of keeping round-the-clock vigil in the intensive care unit, his wife of nearly 50 years could no longer bear his suffering and requested hospice care. A few hours before he died, groggy from morphine, he managed to summon a few moments of lucidity. Gripping his wife’s hand, he said to her, “You’re doing the right thing.”

Every day in medicine there are examples of patients who know they are about to die, even if no one else does. They often have a feeling of impending doom before a catastrophic event like a heart attack or a fatal infection, and though doctors don’t know how to explain it, most of us take it seriously.

When we talk about instinct in medicine, we usually talk about expert clinicians grasping diagnoses in ways that seem to defy analytical explanation. These doctors appear to know almost intuitively which data to focus on and which to ignore. Of course, their decision-making is based on experience and deductive reasoning (and perhaps on evidence, too), yet it seems almost mystical.

I will never forget the time in medical school when we presented a baffling case to the chief of medicine. He made a diagnosis of primary pulmonary hypertension within seconds, on the basis (he claimed) of the loudness of the second heart sound, an incredible feat of observation and logical synthesis.

This sort of diagnostic intuition is becoming rare in the current era of technological medicine. Patients today often receive a battery of tests even before a physician examines them. The results, usually expressed in numbers that give a misleading impression of absolute precision, tend to lull doctors into a sort of laziness that has atrophied instinct.

On the other hand, doctors’ prognostic instincts have always been poor. In my work as a critical care cardiologist, I am often asked to predict how long someone is going to live. I know how useful such projections can be to patients and their families, but I rarely, if ever, venture a guess because they are so often inaccurate. (I am usually too optimistic.)

So it amazes and baffles me when patients have a sixth sense about their own deaths. Last year, my team cared for a woman who told us calmly on morning rounds that she had a feeling she was going to die that day.

A few hours later she complained of belly pain, and when a tube was inserted through her nose and into her stomach, old digested blood — “coffee ground” secretions — came up. Her blood count plummeted, and within a few hours she had spiraled into shock and multiple organ failure, even before we could get a CAT scan to see what was going on. It was totally unexpected, one of the most rapid noncardiac deaths I have ever witnessed.

I don’t know how my patient was seemingly able to predict her own demise. Perhaps high levels of circulating adrenaline caused a reaction similar to a panic attack; I don’t know. But I have learned over time to take such intuitions very seriously.

Sometimes, morbid instincts derive from other sources. In 2007, The New England Journal of Medicine had the story of a cat named Oscar who lives in a nursing home in Providence, R.I., and seems to have an uncanny sense for when elderly residents are about to die.

He goes to their rooms, curls up beside them — even those residents for whom he has previously shown little interest — and purrs. Staff members at the facility have learned that this is a telltale sign of impending death, having witnessed this behavior in the deaths of at least 25 patients. “This is a cat that knows death,” one doctor said. “His instincts that a patient is about to die are often more acute than the instincts of medical professionals.”

No doubt there are more such animals. But I have learned that the best instincts in medicine derive from the patients themselves. Their intuitions about their own health may be denigrated by doctors. But we must learn to pay attention to them. As my patients have taught me, they often hold the vital clue.

Sandeep Jauhar is a cardiologist on Long Island and the author of the recent memoir “Intern: A Doctor’s Initiation.”

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A New Cigarette Hazard: ‘Third-Hand Smoke’

January 5th, 2009

From .nytimes.com
often open a window or turn on a fan to clear the air for their children, but experts now have identified a related threat to children’s health that isn’t as easy to get rid of: third-hand smoke.

That’s the term being used to describe the invisible yet toxic brew of gases and particles clinging to smokers’ hair and clothing, not to mention cushions and carpeting, that lingers long after second-hand smoke has cleared from a room. The residue includes heavy metals, carcinogens and even radioactive materials that young children can get on their hands and ingest, especially if they’re crawling or playing on the floor.

Doctors from MassGeneral Hospital for Children in Boston coined the term “third-hand smoke” to describe these chemicals in a new study that focused on the risks they pose to infants and children. The study was published in this month’s issue of the journal Pediatrics.

“Everyone knows that second-hand smoke is bad, but they don’t know about this,” said Dr. Jonathan P. Winickoff, the lead author of the study and an assistant professor of pediatrics at Harvard Medical School.

“When their kids are out of the house, they might smoke. Or they smoke in the car. Or they strap the kid in the car seat in the back and crack the window and smoke, and they think it’s okay because the second-hand smoke isn’t getting to their kids,” Dr. Winickoff continued. “We needed a term to describe these tobacco toxins that aren’t visible.”

Third-hand smoke is what one smells when a smoker gets in an elevator after going outside for a cigarette, he said, or in a hotel room where people were smoking. “Your nose isn’t lying,” he said. “The stuff is so toxic that your brain is telling you: ’Get away.’”

The study reported on attitudes toward smoking in 1,500 households across the United States. It found that the vast majority of both smokers and nonsmokers were aware that second-hand smoke is harmful to children. Some 95 percent of nonsmokers and 84 percent of smokers agreed with the statement that “inhaling smoke from a parent’s cigarette can harm the health of infants and children.”

But far fewer of those surveyed were aware of the risks of third-hand smoke. Since the term is so new, the researchers asked people if they agreed with the statement that “breathing air in a room today where people smoked yesterday can harm the health of infants and children.” Only 65 percent of nonsmokers and 43 percent of smokers agreed with that statement, which researchers interpreted as acknowledgement of the risks of third-hand smoke.

The belief that second-hand smoke harms children’s health was not independently associated with strict smoking bans in homes and cars, the researchers found. On the other hand, the belief that third-hand smoke was harmful greatly increased the likelihood the respondent also would enforce a strict smoking ban at home, Dr. Winickoff said.

“That tells us we’re onto an important new health message here,” he said. “What we heard in focus group after focus group was, ‘I turn on the fan and the smoke disappears.’ It made us realize how many people think about second-hand smoke — they’re telling us they know it’s bad but they’ve figured out a way to do it.”

The data was collected in a national random-digit-dial telephone survey done between September and November 2005. The sample was weighted by race and gender, based on census information.

Dr. Philip Landrigan, a pediatrician who heads the Children’s Environmental Health Center at Mount Sinai School of Medicine in New York, said the phrase third-hand smoke is a brand-new term that has implications for behavior.

“The central message here is that simply closing the kitchen door to take a smoke is not protecting the kids from the effects of that smoke,” he said. “There are carcinogens in this third-hand smoke, and they are a cancer risk for anybody of any age who comes into contact with them.”

Among the substances in third-hand smoke are hydrogen cyanide, used in chemical weapons; butane, which is used in lighter fluid; toluene, found in paint thinners; arsenic; lead; carbon monoxide; and even polonium-210, the highly radioactive carcinogen that was used to murder former Russian spy Alexander V. Litvinenko in 2006. Eleven of the compounds are highly carcinogenic.

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Posted in Children & Pregnancy, Nicotine / Smoking | No Comments »

Rising Blood Sugar May Harm the Aging Brain

January 3rd, 2009

And exercise might help offset the effect, study suggests

From healthday.com
Scientists have unmasked what appears to be a major mechanism contributing to normal, age-related cognitive decline.

Happily, it’s a mechanism that is amenable to change: rising blood glucose levels, which means that exercise might be the antidote.

Researchers reporting in the December issue of Annals of Neurology showed that rising blood sugar levels, a normal part of aging, affect a part of the hippocampus, a part of the brain critical to learning and memory.

“This would suggest that anything to improve regulation of blood glucose would potentially be a way to ameliorate age-related memory decline,” said senior study author Dr. Scott Small, an associate professor of neurology at the Taub Institute for Research on Alzheimer’s Disease and the Aging Brain at Columbia University Medical Center in New York City.

The findings may also help explain why people who exercise don’t have as many cognitive problems as they age: Exercise helps stabilize blood glucose levels.

“We had previously shown that physical exercise strengthens a part of the brain involved with aging but, at the time, we didn’t know why physical exercise would have this selective benefit,” Small said. “Now we have a proposed mechanism. We think it’s because subjects who exercised had better glucose handling.”

It’s well known that damage to the hippocampus is evident with Alzheimer’s disease, and there has been some suggestion that this region of the brain is also affected by normal aging.

The researchers used MRI to record the functioning of the hippocampus in 240 healthy older people (average age almost 80). Sixty of the participants had type 2 diabetes, while 74 had brain “infarcts” — some damage to brain tissue. Diabetes and infarcts were each linked with separate areas of the hippocampus, indicating that different mechanisms are at work in each disorder.

The findings were confirmed in animal tests.

“The paper identifies an etiology [cause] for normal age-related memory decline,” Small explained. “Elevations in blood glucose levels differentially target the dentate gyrus part of the hippocampus implicated in aging and, as we age, we develop a slight but gradually worsening difficulty in handling blood sugar levels.”

That difficulty coincides with the beginning of loss of cognitive function, Small added.

“In my opinion, that’s an interesting hypothesis and needs to be studied — that exercise helps improve cognitive functioning through that mechanism, but I think there are other mechanisms as well,” said Bryan Freilich, a clinical neuropsychologist at Montefiore Medical Center in New York City.

Mark Mapstone, an associate professor of neurology at the University of Rochester Medical Center in New York, said: “If these findings are replicated and confirmed, I think the implications could be very important, specifically, that maintaining optimal blood sugar levels throughout aging is a feasible way to [slow or prevent] cognitive decline. It goes beyond diabetes to look at people who don’t have diabetes. The implication is even if you don’t have a clinical condition of diabetes, that you can still do something about cognitive aging.”

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Posted in Brain Health, Aging, Health & Exercise | No Comments »

KONDRACKE: Targeting obesity

January 2nd, 2009

From washingtontimes.com
President-elect Barack Obama has plenty of serious problems on his agenda, but here’s another worthy one:a war on obesity.

The reason is: Fatness is killing Americans by the millions. It’s driving up health costs and damaging the national economy. It’s also aesthetically displeasing.

And Mr. Obama is singularly positioned to lead the charge against excess flab: He’s lean, he exercises and he can set a great example for getting the nation fit again.

He’s also smart enough to figure out how to do it — which is probably to mention the obesity problem in his health-care reform speeches and assign his yet-to-be-named surgeon general to mount a campaign of exhortation and scolding.

If it were up to me, being fat would be made as socially unacceptable as smoking. (And, before you send me an irate e-mail, as a formerly overweight person, I admit to some prejudice here.)

We can’t put fat people outside in the cold, I suppose, but the fact is that incidence of smoking has dropped from 42 percent in 1965 to below 20 percent, reducing cases of lung cancer along the way.

I like what Southwest Airlines does — charge double for people who can’t fit into one seat. I would also favor higher health insurance premiums for fat people and for taxes on fast foods with high fat and sugar content.

New York Gov. David Paterson has talked about fostering social pressure on people to lose weight, but Mr. Obama probably would prefer a kinder and gentler approach.

After showing interest in the problem — and repeating it often enough to show he’s serious — Mr. Obama can advance the cause by continuing to let photographers show him working out, playing basketball and hunking it up on the beach.

The Washington Post reported last week that, whatever else he has to do, Mr. Obama works out 90 minutes a day. Pictures of him on the beach while vacationing in Hawaii show the results.

Why bother to take on this cause? Because no less than 66.3 percent of U.S. adults are overweight, according to the federal Centers for Disease Control, and nearly 20 percent of children.

More than a third of adults — more than 72 million — are obese, fatter than fat. That percentage has doubled since 1980. The figure for children has tripled. According to the Almanac of Chronic Disease, unless something is done, by 2015, three-quarters of U.S. adults will be overweight and 41 percent, obese.

What’s fat? What’s obese? Officially, such questions are measured by body mass index (BMI). For an adult 5 feet, 9 inches tall, weighing more than 169 pounds (BMI 25) is overweight and 203 pounds (BMI 30) is obese.

Mr. Obama, at 6-1 and 180 pounds, has a BMI of 23.7 — perfect. And First Lady-elect Michelle Obama, at 6 feet and 175, has an identical BMI.

(You can easily find out your own at the National Institutes of Health Web site, nhlbisupport.com.bmi/bmicalc.htm For what it’s worth, mine was 27.4. Now it’s 24.3. It is possible to lose 20 pounds.)

The reason a president should tackle the issue of obesity is this: it kills and it costs.

Incidence of Type 2 diabetes — which can lead to blindness, loss of limbs and even mental impairment — has doubled over the past three decades, on track with obesity.

There has also been an upsurge in incidence of high blood pressure, coronary heart disease, strokes and gall bladder ailments.

According to the nonprofit Partnership to Fight Chronic Disease, the doubling of obesity accounts for nearly 30 percent of the rise in health care spending since 1987.

If the prevalence of obesity was the same as it was in 1987, the group said, health-care spending per capita would be 10 percent less than it is, saving $200 billion.

The burden of obesity on society is felt in Medicaid and Medicare spending and in everyone’s insurance premiums.

It would be impolite, I know, to walk up to a fat person and say: “You know, you are costing me money,” as you might complain without compunction to someone smoking.

But it’s a fact. Insurance companies are afraid of lawsuits alleging discrimination, so many of them offer premium discounts for people who enter fitness programs, but they don’t charge extra based on weight.

That means everyone else pays higher premiums to insure the overweight and pay for treatment of their diseases.

At a recent gathering of corporate CEOs sponsored by the Wall Street Journal, the top health-care issue the group thought Mr. Obama should address was obesity and its costly burden.

News reports indicate that some employers refuse to hire fat people, fearing their insurance costs will balloon.

Some of these workers are being unfairly discriminated against, based on genetics or hormonal imbalance, but certainly not most.

Trimming down America probably is going to be harder during a deep recession than at other times. There’s a socioeconomic correlation to obesity - it’s more prevalent among poor people than wealthier folk.

Making things even tougher, depressing circumstances undoubtedly cause people to seek comfort in food and being fat probably increases depression, creating a vicious cycle.

So it will be difficult right now for Mr. Obama to get people to eat less and exercise more. But it can be done and it’s definitely worth the try.

Morton Kondracke is a nationally syndicated columnist.

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Posted in Health & Exercise, Obesity, Obesity | No Comments »

Traumatic Brain Injuries Linked to Long-Term Health Issues for Iraq Vets

January 1st, 2009

Government report notes problems include dementia, aggression, depression

From healthday.com
A new report provides evidence linking traumatic brain injury sustained by troops in combat in Iraq and Afghanistan to a variety of long-term health problems including dementia, aggression, depression and symptoms similar to those seen in Parkinson’s disease.

But the Institute of Medicine committee charged with developing the report also pointed to a troubling lack of scientific data on such injuries, which are fairly recent in the history of warfare.

“The real bottom line significant finding is that there’s not a good human literature on the kinds of neurotrauma seen in Iraq and Afghanistan caused by blasts,” said Dr. George W. Rutherford, vice chair of the department of epidemiology and biostatistics at the University of California, San Francisco, School of Medicine. “The human literature is really about people who’ve had [brain injury] from car crashes or falling down stairs and, in the military, from shrapnel or gunshots. We’re all worried that blast neurotrauma hasn’t really made it into the human literature.”

This makes it difficult, if not impossible, to anticipate and hopefully mitigate the long-term consequences of such injuries, added Rutherford, who chaired the committee that wrote the report.

“They focused on blast-induced neurotrauma, a blast injury that leaves the head without any external marks of even being knocked about,” explained Keith Young, vice chair for research at Texas A&M Health Science Center College of Medicine and Neuroimaging and Genetics Core Leader for the VA Center of Excellence for Research on Returning War Veterans. “The blast is so close and so large, it seems to be shaking the brain. My guess is that this causes micro-bleeds,” Young said.

The current U.S. conflicts in Afghanistan and Iraq, which have been ongoing since Oct. 7, 2001 and March 2003, respectively, differ vastly from previous combat deployments in terms of injuries sustained. They differ even from injuries seen in the 1991 war, with more deaths, multiple traumas and more traumatic brain injuries (TBI).

Blast injuries are considered the “signature” wound of the Iraq war and are largely a result of newer, more powerful explosive devices.

“One cause of the high rates of TBI is relatively simple: survival,” Young said. “The reason more people are surviving is better on-the-scene treatment and medivacing to facilities within minutes rather than hours.”

According to the Department of Defense (DOD), more than 5,500 soldiers had suffered TBIs as of January 2008, accounting for about 22 percent of all casualties, as compared with only 12 percent to 14 percent of all combat casualties during the Vietnam War.

In an effort to detail the long-term consequences of TBI, the committee looked at almost 2,000 studies on the subject.

The committee found evidence of a causal relationship between penetrating TBI and unprovoked seizures as well as death, and between severe or moderate TBI with unprovoked seizures.

There was “sufficient” evidence of an association between TBI and decline in neurocognitive function, long-term unemployment and problems with social relationships; Alzheimer’s-like dementia, endocrine dysfunction, depression, aggressive behavior, memory problems and early death.

There was “limited/suggestive” evidence of an association between moderate or severe TBI and diabetes or psychosis; and between mild TBI and visual problems, dementia, post-traumatic stress disorder and suicide.

“Inadequate/insufficient” evidence existed on the relationship between moderate or severe TBI and brain tumors; mild TBI and employment and social functioning problems, bipolar disorder or attempted suicide; TBI and multiple sclerosis or amyotrophic lateral sclerosis (Lou Gehrig’s disease).

The committee put forth a number of recommendations.

“Three of the recommendations are really directed towards the DOD and the VA about how to keep track of this stuff so people in the future can put registries together,” Rutherford said. “Once you know that, you can start answering questions, are five of these five times as bad as one, what’s the long-term risk of any bad outcome.”

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Posted in Traumatic Brain Injury | No Comments »

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