Sunday, November 30, 2008
As a boy, long before I took any of my pre-medical courses, I experienced the brutal reality of SIDS. Our neighbor found her six-month-old son – my friend Michelle's younger brother – dead in his crib. I was seven-years-old at the time and, despite my parents’ best efforts to explain what had happened, I was severely shaken. How could a healthy baby just die in his sleep, without any warning? Could that happen to me? Or my brother? I remember Michelle’s mother, a single parent, was puffy-eyed for months afterwards. Over the subsequent years, her house fell into disrepair and eventually, she and Michelle moved away. Since then, I have often wondered whether either of them ever recovered. And, I’ve followed each development in the SIDS mystery with interest. Babies have gone “Back to Sleep,” pollutants (including cigarette smoke and “stale air”) have been implicated, and so have excessive swaddling and hidden infections. Heart rate and breathing (apnea) monitors have been recommended and their utility subsequently disputed. Pacifiers and fans are in; mom and dad's bed is out. And still, in this country, over 2,000 infants die of SIDS each year.
Now, scientists are buzzing about the recent article in Science. “The exciting thing,” says Dartmouth physiologist Eugenie Nattie, “is that the mice are dying, spontaneously.” Watching mice die spontaneously may not seem all that exciting to you, but when you’re dealing with a devastating condition like SIDS, you can’t blame a physiologist for her morbid enthusiasm. The new evidence comes from an Italian experiment that found that mice who died spontaneously had out-of-whack serotonin levels. Serotonin is a mood-related brain hormone, one that can already be modulated by numerous pharmaceuticals (including prescription drugs such as anti-depressants and recreational ones such as ecstasy.) The Italian researchers, who set out to establish a model of the serotonin-feedback mechanism by injecting genetically modified serotonin receptors into mice, found, accidentally, that mice with decreased serotonin levels were at risk for sudden death – usually in conjunction with sudden and extreme drops in temperature or heart rate. The nature of this type of sudden death – in otherwise healthy mice – is very similar to what is believe to happen in human victims of SIDS. These results support previous human autopsy findings from 2006, which found fewer brainstem serotonin receptors in children who died from SIDS. Taken together, these studies provide a working model for how SIDS kills: infants with abnormal serotonin regulating systems are unable to effectively compensate for metabolic abnormalities (likely related to carbon dioxide levels) that occur during sleep.
The Italian team's unexpected findings can be added to a long list of serendipitous medical discoveries. Throughout human history, the science of medicine has advanced haphazardly. As Ben Gordon writes in The Alarming History of Medicine, “The history of medicine is largely the substitution of ignorance by fallacies.” And when truth has emerged, it has often been by chance. Antony Leeuwenhoek, a 17th-century Dutch draper, discovered the existence of microbes, “animalcules” he called them, after being inspired to examine his own semen under a homemade microscope. One of the greatest discoveries of the early 20th century, an antibiotic called penicillin, came about because microbiologist Alexander Fleming happened to go on a two-week vacation to the country. While Fleming was on holiday, his bacteria-filled Petri dishes became overgrown with a mold, pencillium notatum. When he returned, he observed that the areas around the mold were devoid of bacteria, and this gave him an extraordinary idea.
In the case of SIDS, it's not yet clear how the fortuitous new findings will alter prevention efforts. Ultimately, they may lead to the development of a genetic test to identify babies at high risk of SIDS. In the meantime, current recommendations (including pacifiers, circulating air, and “Back to Sleep”) are still very relevant. One thing, though, is for sure, this study should provide a touch of solace to the families of SIDS victims. I hope that Michelle’s mom, wherever she is, is one of those who can take heart. I hope she realizes that science seems to have found an explanation for what happened to her son – an explanation based on a genetic disorder. I hope that if she harbored any maternal guilt over all these years, if she suffered from any second-guessing and wondering… I hope she can now let those things go.
Saturday, October 18, 2008
A day later, I treated Matt*, a 42-year-old father of three, who was completely healthy until he suddenly lost the ability to formulate speech. By the time I saw him, his speech had returned and he was ready to blow off the entire incident – he’d smoked marijuana just before his symptoms set in and figured he’d tripped out. I noticed that the right side of his face looked a little asymmetric and that his smile seemed somewhat crooked. I asked his wife about this, but she was nonplussed – he’d looked like that for as long as she’d known him. I talked Matt into getting a CT scan, and was shocked by the images – he had a large egg-sized mass in his left brain. “I’ve got another ugly one,” I told our neurosurgeon and he agreed. “Hard to say what type that is, but the prognosis is not good.” When I walked in to tell Matt the awful news, I saw his kindergarten-aged daughter, with shiny black hair and overalls, and I almost lost my composure. This girl was not much older than my own daughter and I was about to tell her father that he had a large brain tumor. At my request, the young girl left the room with her mother, skipping contentedly, oblivious to the fact that her life was about to drastically change. Matt took the news stoically and asked all the appropriate questions. It wasn't until I showed him the images from the CT scan on a hallway monitor that he began to tear up and shake. An hour later, as we were discharging him, Matt asked me if I thought there was anything specific that could have caused this. "Well, probably not," I replied, "but let me ask you this, do you spend much time on your cell phone?" "Yes," he said, "all day long."
Now, as a physician and part-time medical researcher, I am well aware of the danger of extrapolating large-scale causality from the circumstances of one or two patients. Intellectually, I knew that just because Stan and Matt were both heavy cell phone users, and both developed brain cancer at an early age, did not mean that cell phone use causes cancer. But, it seemed like too much of a coincidence not to at least investigate the question.
For over a decade, researchers have searched for just this sort of connection: the chance to say that brain cancer can be caused by exposure to increased levels of electromagnetic radiation (EMR) from cellular phones. It is well known that high levels of electromagnetic radiation can cause severe symptoms such as blindness, burns, and even death. Lower levels of EMR are associated with headaches, auditory and sleeping disturbances, and short-term memory loss. EMR has also been implicated in cellular and DNA changes that may be precursors to cancer. And while multiple studies have failed to find a connection between cell phone use and brain cancer, research continues, and at least one respected oncologist has sounded the alarm.
Last June, Ronald B. Herberman, head of the prestigious University of Pittsburgh Cancer Institute, sent a memo to 3,000 faculty and staff warning them of a risk of cancer from the low levels of EMR emitted by cellular phones. Citing early and unpublished data, Herberman called for across-the-board caution with cell phone use, especially in children. According to a recent article in The Economist, it is thought that Herberman was basing his recommendations on the preliminary findings of the multi-national "Interphone study". This investigation, involving 13 countries, 14,000 subjects and spanning 2000-2006, has yet to formally release its overall findings. To date, however, nine of the thirteen individual national research groups have published their work - without evidence of a cell phone-cancer link. On the other hand, an outside researcher from Sweden (Lennart Hardell), who grouped the analysis of the Interphone study with nine other studies found an increased risk of cancer in people using their cell phones for more than an hour a day for ten years or more.
Having read a bit about the potential methodological weaknesses of the Interphone study (and similar studies), I am skeptical about whether these results are meaningful. Interphone's design suffers from an excess of bias. Bias, which might be healthy in some circumstances (such as parenthood), is not good for research projects. Interphone identified patients with the outcome of interest (brain cancer) and quizzed them, after the fact, about cell phone use. This group was compared to another group of healthy, cancer-free patients who also answered questions about cell phone use. It turns out that the cancer-free patients selected had a much higher cell phone use (nearly twice that) of comparables in the general public. This flaw is called selection bias and in the case of Interphone would be expected to (artificially) deflate the observed cancer risk of cell phone users. A second Interphone bias, common to many retrospective (backwards looking) trials is recall bias. One might expect that subjects diagnosed with brain cancer would be more likely to over-report previous cell phone use. Finally, there is a generalization bias; many study participants were asked about cell phone use in the 1990s - at a time when most phones were analogue rather than digital and therefore resulted in different types of EMR exposure (analogue phones usually have higher wattage than digital). Any results in these patients could not be reliably applied to the current population of over 3 billion digital cell phone users.
So it makes one wonder, what exactly does Dr. Herberman know that we don't? If he is right about the potential health risks of cell phone usage, especially long-term cell phone usage, we may have a big ol' brain cancer epidemic on our hands in a few years. If he is wrong, this scare will join a long list of other associations, such as immunizations and autism, that never panned out. In the meantime, I am hedging my bets. I will limit my own cell phone use to less than an hour a day and keep my mobile as far away as possible from my daughter's developing brain. And I will hope that by the time she asks, or perhaps demands, a phone of her own, quality research will have settled the question.
*Names and indentifying information altered to protect patient privacy
Thursday, June 12, 2008
A newly released study has found that 75% of ED patients do not understand their discharge instructions. This does not surprise me one bit. Here's five reasons why:
1) Diagnosis and treatment of a medical condition usually involves new and often confusing terminology and explanation
2) Emergency physicians concentrate their time and energy on the sicker patients and
may not have the time to fully explain their instructions to those patients well enough to go home
3) Nurses will often give different (and even conflicting) instructions from those the doctor gives
4) Written instructions may be either: A) handwritten in chicken scrawl or B) printed but voluminous and generic
5) A certain percentage of patients do not have any intention of reading or following their discharge instructions
ER Patients Don't Understand Doc's Orders
More Than Three in Four Patients Don't Understand What They're Told in the ER
By SAMI BEG, M.D.
More than three in four emergency room patients do not fully understand the instructions that doctors give them after their visits, new research suggests.
Even worse, not only do the patients not understand the care instructions from their doctors, but the vast majority are also unaware that they have not fully understood what the doctor has told them.
The findings were published Monday in the journal Annals of Emergency Medicine.
"It is critical that emergency patients understand their diagnosis, their care and, perhaps most important, their discharge instructions," Dr. Kirsten Engel, one of the study's authors, at Northwestern University said in a news release issued Monday by the American College of Emergency Physicians.
"It is disturbing that so many patients do not understand their post-emergency department care, and that they do not even recognize where the gaps in understanding are."
Other experts agreed that these numbers, while high, are not surprising.
"This report confirms what I have long suspected," said Dr. Richard O'Brien, spokesman at the American College of Emergency Physicians. "Our nation's emergency departments are overburdened and overcrowded, and one of the consequences is a significant amount of difficulty communicating effectively with our patients.
"It is like trying to teach in an overcrowded classroom, with many distractions," O'Brien said. "The message will sometimes get lost."
But other experts said the study, which looked at 138 patients and two caretakers, could have resulted in such high numbers because it may have been too narrow or not comprehensive enough.
"Things like the kind of instructions patients were given and how complicated the patient problems were will play a role," said Dr. Alfred Sacchetti, chief of emergency services at Our Lady of Lourdes Medical Center in Camden, N.J. "For example, some instructions are simply overly complete, making it impossible for anyone to understand them."
Time and Training a Factor
The amount of time a doctor gets to spend with patients in a busy emergency department is a big factor in communication.
"The most important factor in having patients understand their instructions is time," said Dr. Jawad Arshad, senior staff physician in the department of emergency medicine at Henry Ford West Bloomfield Hospital in Michigan.
But because an emergency department doctor has to take care of emergencies, time is not always available after he or she takes care of the urgent need of one patient.
"Unfortunately, due to clinical burden, there are times when physicians literally go from room to room giving discharge diagnosis and instructions, and leave before the patient has had any time to digest the information given," Arshad said.
But there are ways to improve the system, Arshad added. "For example, at the Henry Ford Health System here, physicians go through periodic mandatory courses on active health care issues such as patient communication," he said.
In this course, health providers are taught a method of communication known as teach-back. In this approach, the health care provider will tell the patient what they should do to care for themselves, and then they ask the patient to repeat back the instructions that they are given.
By following this simple process, patients are better able to understand their diagnosis, treatment and follow up instructions, Arshad said.
Other experts said patients would do well to bear in mind the same kind of approach themselves.
"One of the easiest things a patient can do to make sure he or she is well informed is try to repeat to the nurse or doctor in their own words their understanding of what is being discussed, and ask, 'Have I got that right?'" O'Brien said.
But even though some patients may be assertive enough to take the reins in their health care, others may slip through the cracks, which means that health providers must work together to identify and educate these patients before they leave the emergency department.
"Nurses are essential," O'Brien said. "Emergency department nurses are there for critical care and critical communications as well."
Others agree that even if a doctor does not have time to spend with a patient, a nurse or technician reviewing detailed instructions with a patient fills the gap.
"Nurses sign off that the patients verbalized back to them that they understand their instructions before they leave the department," Camden's Sacchetti said. "If the patient has any questions, doctors can always go back."
And though being in the emergency department can be very scary for patients, they should not be afraid to ask questions.
"It is always helpful when patients have a list of questions written down instead of relying on memory," Arshad said. "Family members can be helpful in asking pertinent questions as well, and later can help a patient in remembering details of treatment and follow up.
"Medicine is half science and half art. Only by working together as a team can we really empower our patients."
Dr. Sami Bég is the associate medical director of U.S. Preventive Medicine
Copyright © 2008 ABC News Internet Ventures
Saturday, May 24, 2008
The problem with Google Health, as I see it, is that at least in its infancy it relies on patient driven (rather than provider-driven) coordination of medical records. One of the four bulleted selling-points on the Google Health welcome page urges patients to "Keep your doctors up-to-date about your health." As I am sure most providers would agree, this is a fabulous idea. Working in the ED, I am tremendously appreciative of patients who bring and show me an updated list of medications they are taking. Nonetheless, I find that even the most fastidious of patients hand me lists that contain duplications, miss-spellings or omissions. This is understandable; just as I excuse myself for not recalling which index funds I hold in my retirement account, I don't expect patients without medical backgrounds to keep completely accurate records of a laundry list of medications. So, the idea that patients be the caretakers of their own medical information, while laudable, will turn out to be unreliable. With Google Health, patients enter only the medical information they want to, and although Google promises to safeguard personal health information, there are sure to be privacy concerns. A better model, I think, (and I am clearly biased here) is an integrated health system with a universal IT system. In this (provider-driven) system, patients can review all of their medical information and are encouraged to alert their doctors to changes or inaccuracies. Ideally, this sort of system would offer incentives to patients who are actively involved with their medical record and help to keep them up-to-date. This sort of EMR hold tremendous potential for providers and patients. Google Health, on the other hand, will appeal to a small segment of tech-savvy and health-conscious patients and probably make money doing so. This result offers little in the way of improving our national health, and if anything may add to the divide between the have and have-not's. It's probably too early to pass judgement, but I don't anticipate becoming part of the Google Health community.
*Graetz et al. Care coordination across clinicians and health information technology: connecting the medical home with the rest of the village.
Answers from the previous post's trivia, with accompanying links found through my good friend Google:
A) A girl born with two faces (TRUE
B) A parasite twin (a fetus growing inside of another fetus) (TRUE)http://www.medicalnewstoday.com/articles/107814.php
C) A girl born with a cyclops eye (TRUE) http://cache.bordom.net/images/fad8f423bb1eeed8cd10ab83dd10372d.jpg
D) A boy with a true human tail (TRUE)http://www.talkorigins.org/faqs/comdesc/images/tail.jpg
E) A true hermaphrodite with both ovarian and testicular tissue (TRUE)http://www.healthyplace.com/Communities/Gender/intersexuals/about_me.htm
Friday, May 2, 2008
In May 2003, a South African woman carried a healthy baby girl to term on and in her liver. When my wife Angela brought home this tale of miraculous reproduction from her anatomy class a few weeks ago, I was dubious. A healthy baby, growing in the liver? That sounded impossible. How did it get there? How could it survive? It turned out, however, that as usual my wife was right. Apparently this baby, back when it was nothing more than a fertilized egg, fell off the path to the uterus, floated through the abdomen, and implanted on the liver. It turns out that the path from ovary to uterus via the fallopian tube is not as tightly sealed as you might expect, and occasionally eggs lose their way. Normally, these eggs, without the rich blood supply of the uterus, wither and get reabsorbed. But, in this situation, and in a dozen or so other previously reported cases, the egg found a happy, well-vascularized (albeit alternative) home. The resulting pregnancy was extremely high-risk; without the protection of the muscular walls of the uterus, even minor trauma could have threatened the fetus. And, if the fetus or placenta had obstructed the blood or bile vessels of the liver, the mother's life would have been in danger. But, in this case, both mom and baby were fortunate; there were no serious complications, and the anomalous location of the baby was not discovered until a c-section was performed during labor. In a country with routine prenatal care, this miraculous liver pregnancy would almost certainly have suffered a different fate. Consider, a recent case report in the journal Obstetrics and Gynecology describing the "Diagnosis and Management of Hepatic Ectopic Pregnancy." (Obstetrics & Gynecology 2007;109:544-546) In this case, a woman with abdominal pain, a positive pregnancy test and an empty uterus on Ultrasound, went through a battery of tests and procedures until a MRI identified an 11-week ectopic pregnancy with fetal cardiac activity located in the maternal liver. This pregnancy, due to it's high risk nature, was successfully terminated with fetal injections of methotrexate and potassium chloride (under ultrasound guidance) and subsequent maternal intramuscular injection of methotrexate. I am sure there are some right-to-lifers out there who would argue that since this mother's life was not in imminent danger, the fetus should have been protected. The healthy liver baby from South Africa does give this argument some semblance of credence. Western medicine is efficient and saves lives, but its application does preclude some of nature's miraculous anomalies.
Medical Anomaly Trivia:
Which of the following are actual, reported, medical anomalies;
A) A girl born with two faces
B) A parasite twin (a fetus growing inside of another fetus)
C) A girl born with a cyclops eye
D) A boy with a true human tail
E) A true hermaphrodite with both ovarian and testicular tissue
Answers next week...
Thursday, March 13, 2008
The voting was very close and all of the reviews were scored highly. But, a choice had to be made, and here are the winners:
Many of us are drawn to the time tested TV medical drama formula used by the likes of ER or Grey's Anatomy. A victim is rushed to the hospital after some heinous crime or outrageous mishap. Doctors speak in declarative, jargon filled sentences in their urgent attempts to save John or Jane Doe. Family members and friends trickle into the hospital to color in the life that the victim was leading before landing in the emergency room. We are shocked by the nature of the injury, fascinated by the medical procedure, and begin to feel emotionally invested in the victim. But there is a problem with this formula: is often over-scripted, sensationalized, and/or fake. Dr. Ballard's autobiographical account of his dealings with one of his most memorable patients, on the other hand, is painfully real. In this short, very readable book, Ballard brings the emergency department to life. We learn the real reason why Doe is such a common surname on hospital charts, we effortlessly begin to attach meaning to medical terms, and we develop an appreciation for how the doctor's mind works in making diagnoses under severe time pressure to the robotic two-minute drill of their daily rounds. Yet in telling the story of Jeffrey Mains, an innocent victim to a shooting rampage, Ballard's compelling narrative follows his patient outside of the hospital to show how difficult it can be to regain some sense of normalcy after such trauma. He deftly uses Jeffrey's experience to underscore broader societal problems including gun control and the failure to exchange psychiatric information across state borders that indirectly abet senseless violence such as the recent killings at the Northern Illinois University. If there is a weak point to this book, however, some readers might find it difficult to invest emotionally in Jeffrey, in part because the author at times seemed to have trouble establishing a connection himself. Ironically, the perpetrator of the attack, Joseph Ferguson (and the shocking, though briefly described personal circumstances that led to his terrible crime), represented perhaps the book's most unforgettable stranger. Should Ballard ever choose to revise or expand this book, it might be worthwhile not only to generate more reader sympathy for the challenges of the healing process (perhaps by taking additional steps to humanize Mains or introducing other patients facing similar challenges), but also to delve more deeply into Ferguson's story, which provides the launching point for much of the author's social commentary on violence. Overall though, The Bullet's Yaw is an important, authoritative, and thoughtful work that is engaging enough to captivate the Grey's Anatomy audience and substantive enough to resonate with health care and policy practitioners.
Thought provoking; delivers an unexpected and impactful message
Owen S. Good (San Jose, Calif.)
Dr. Ballard's compact and engaging narrative comes through as a highly thought-provoking conversation with a brilliant dinner guest. This book's purpose and argument concerns violence and its prevention, and specifically firearms violence, which he correctly notes is an extremely toxic debate in the United States. Ballard's book earns the right to discuss it by laying a very human presentation of the challenging and harrowing details faced by an urban hospital trauma unit, details most Americans know nothing of and may never encounter even once. Ballard then trains his lens specifically on Jeffrey Mains, a badly wounded victim of a psychotic's gun rampage. Mains' cruel and unnecessary injuries and the physical and emotional challenge of his recovery are delivered first as a medical procedural, and later fleshed out in personal terms. But after laying both foundations, then Ballard states his conscience: That firearms violence is, like deaths from automobile accidents in the 1960s, "a neglected disease" in that both, in their era, pose seemingly intractable problems to trauma response physicians nationwide. In the 1960s, a combination of accident prevention and trauma medicine innovation -- both of which Ballard reports completely and cogently, with a personal association with the principals involved -- combined to reduce traffic fatalities by two thirds. Today, such a meaningful public health approach to gun violence is long overdue. Ballard, whose opinion is both personal and relevant, proposes a reasonable plan of accident prevention, as applied to firearms purchasing and ownership. One senses that it is offered in hopes that the blind risks we seem to accept today will become shockingly clear, and seem as primitive and unacceptable as the dangerous conditions a motorist faced 40 years ago.
To see all the reviews, go to:
Thursday, January 17, 2008
A scrawny young man visited my Emergency Department several years ago complaining of thousands of tiny bugs crawling over and under his skin.* This sensation had been progressing for weeks and had driven him to a frenzy of nervous activity. He was covered with excoriated sores and streaks of scarlet - inflicted, I was sure, by his fingernails. I inspected him from head to toe but did not see any evidence of insect or parasite, but he was not deterred. He handed me a smudged envelope and asked me to (carefully) look inside. I pulled out a half dozen pieces of scotch tape, each of which had trapped a number of black-brown specks. These specks were the bugs, he declared, and he dared me to prove otherwise by looking at them under magnification. Although I was quite sure that he was wrong, I humored him, and took a real close look under a magnifying glass. And while I didn't see any signs of movement or of anatomic structure, I was perplexed as to the source of these small dark specks. They seemed too slim to be dirt and too irregular to be sand. After several minutes of debate, during which my patient demanded answers and I challenged his theory but failed to offer an alternative explanation, I noticed something. His fingernails were crusted, outside and under the tip of the nail, with a black-brown substance that looked like..."Are you a painter?" I asked him. Well, yes, of course he was and while I was pleased to have solved the mystery, my patient remained dubious. Nonetheless, I prescribed him a medication for itching and referred him to psychiatry with the presumed diagnosis of "delusional parasitosis."
I recalled this odd patient encounter yesterday as I was reading an article about a strange medical condition called Morgellons. This week, the CDC announced a $338,000 grant to Kaiser Permanente to study this "unexplained dermopathy," that some believe is caused by infection or toxic exposure but others believe is nothing more than a new name for the psychiatric condition known for seventy-five years as delusional parasitosis. In 2001-2002, biologist Mary Leitao took her two-year-old son to numerous doctors looking for an explanation for a strange skin condition: the sensation of bugs crawling and biting the skin associated with cutaneous sores that, upon close inspection, contained bundles of fine, multi-colored fibers. The doctors were either baffled, disinterested or skeptical and out of her frustration. Leitao found the inspiration to name her son's condition. She lifted the name Morgellons from a line in Thomas Browne's A Letter to a Friend (1690) that describes a "distemper of children...called the morgellons, wherein they critically break out with harsh hairs on their backs."
*The medical term for this sensation is "formication"
The key distinction between Morgellons and delusional parasitosis appears to rest with these bundles of fine fibers. What are they? Skeptics believe that they are textile threads from clothing scratched and rubbed into sores, but Leitao and thousands of others are convinced that there is some other source. Lyme disease has been fingered as a possible culprit, as have pesticides. Personally, I would have a much easier time writing off the Morgellons concept if it weren't for two aspects of the condition that don't fit cleanly into the realm of psychiatry: the hundreds of affected children and the geographic clustering of disease. I have seen plenty of adults, most of them psychotic or high on methamphetamine, who believing themselves infested, have scratched and clawed their skin raw. The patient I described above is a textbook example. But not children, and especially not young children like Andrew Leitao. And, there's the matter of clustering. Of the over 11,000 families that have registered with the Morgellons Research Foundation, 26% are in California and there appear to be disease clusters in Southern California, Texas and Florida. I have no doubt that some of these (self-diagnosed) Morgellonians are battling scabies, drug abuse or psychiatric illness, but I am not so sure they all are. And, I do hope that someday soon scientific research can define precisely what it is that is bugging these people.