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Monthly Archives: December 2013

What Does It Take to Make a Decision?

The Washington Post reported yesterday that “a psychologist who examined one of the defendants on trial at Guantanamo Bay in connection with the September 11th terrorist attacks concluded that the high-value detainee was incompetent, raising questions about his fitness to stand trial.”  Cases like these raise the question of how exactly psychologists and psychiatrists determine whether a person is competent to make a decision.  The issue also comes up in medical care.  For instance, can a patient suffering from severe mental illness be forced to take medications to treat his condition even if he refuses to do so?

Mental health professionals use 4 criteria to decide if a person is competent to make decisions about his medical care.  The first is whether the person can clearly communicate a choice about his health care.  The second criterion is that the person can understand relevant information about his health condition.  The third requirement is that the person is capable of using information, such as what his physician says, to reach an accurate perception of reality.  Lastly, a person must be able to reason among the choices in medical treatment with which he is presented.

To systematize the evaluation of decision-making capacity, physicians often use a validated instrument called the MacArthur Competence Assessment Tool for Treatment (MacCAT-T).  It generates numerical scores using the 4 previously described decision-making criteria. 

In the past, it was commonly presumed that people with psychiatric disorders like depression lacked the ability to make reasonable decisions about their health. What these patients wanted was not taken into account when doctors made choices about their care.  As Paul Appelbaum writes,  “During a century and a half of widespread institutional care of mentally ill in the United States, the power of physicians to prescribe most forms of treatment for committed patients went unchallenged.  Generations of patients were thus routinely subjected to bleeding, purging, cold baths, whirling chairs and lobotomies.”  In recent decades, however, research has revealed that the presence of a psychiatric disorder does not necessarily mean a person is incapable of making reasonable decisions about their medical care.  For instance, using the MacCAT-T to measure decision-making capacity, one study found that only 20-25% patients hospitalized for depression had impairment with regard to at least one element of decision-making competence.  In addition, a number of important legal cases have established that patients with psychiatric disorders must be granted a much greater amount of autonomy in their decision-making than was previously recognized.  

The work of psychiatrist Paul Appelbaum has played an important role in shaping medicine’s approach to assessing decision-making capacity.  Appelbaum has an interesting New York Times article on the medical and legal history of the issue linked here.

 
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Posted by on December 28, 2013 in Uncategorized

 

Getting Dizzy With It

At this moment, you may be feeling a bit dizzy.  Perhaps you went overboard on the egg nog.  It tasted so good at the time, but now. . .  Or maybe you’re drained from last-minute shopping sprees and working to make small talk with relatives you see only once a year.  In this post, I will briefly address a difference type of dizziness that can be quite distressing, yet is easy to treat.

For people with Benign Positional Paroxysmal Vertigo (BPPV), just slightly changing the position of their head causes the world to rapidly spin around them.  Although the vertigo usually lasts for less than a minute, the sensation can be quite uncomfortable and frightening.  It occurs most often in people over 60 years old and is more common in women.

The diagnosis of BPPV is made by having the patient perform a simple test called the Dix-Hallpike maneuver.  It consists of the patient turning her head to one side, then lying back rapidly until she is flat on her back.  If BPPV is present, the patient’s eyes will dart back-and-forth sideways (horizontal nystagmus) and the vertigo will recur.  From a physician’s perspective, it is satisfying to have a free, non-invasive test deliver such a certain diagnosis.

Image

The treatment of BPPV is similarly low-tech, but effective.  In the Epley Maneuver, the practitioner repeatedly positions the patient’s head until the symptoms go away.

Epley

All this works because BPPV is caused by the presence of calcium crystals in a part of the inner ear called the semicircular canals.  The semicircular canals work as a kind of motion sensor, giving our brain information about the movement of our head.  The calcium crystals disrupt this motion-sensing function, throwing us off balance.  The Epley Maneuver works by moving the crystals out of the semicircular canal, where they can no longer cause mischief.

Click here for a YouTube video demonstrating how to do the Epley Maneuver.

 
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Posted by on December 26, 2013 in Uncategorized

 

All About Blood Pressure

Blood pressure is not one of the most interesting and sexy subjects in health science. In contrast to the latest findings about the brain, learning more about hypertension is unlikely to evoke wonder or yield new insights into the meaning of human life and the universe.  Moreover, treating high blood pressure probably won’t make an immediate difference in how a person feels.  In fact, the vast majority of people with high blood pressure (otherwise known as hypertension) do not have any symptoms from the condition.  This is why it has been called the silent killer. 

On the other hand, hypertension is common.  By one estimate, 90% of people who live to age 80 will have developed high blood pressure.  Left untreated, it can lead to heart attacks and strokes, as well as kidney and heart failure.  Hypertension is usually easy to treat with medications that are inexpensive and well tolerated.  In my work with hospice, I sometimes see people dying of these conditions at an early age because their hypertension was never addressed and treated. 

So what exactly is blood pressure? It is the pressure in our arteries, those vessels that bring blood to all the cells in our body.  Blood pressure is recorded as 2 numbers, for example 120/80.  The top number is called the systolic blood pressure and is the pressure in the arteries when the heart contracts (systole).  The bottom number, termed the diastolic blood pressure, is the pressure when the heart relaxes (diastole). 

According to the most recent guidelines, hypertension for people less than 60 years old is defined as having an average blood pressure greater than 140/90.  For people, greater than age 60, the new blood pressure goal is having an average less than 150/90.  Keeping an individual’s average blood pressure less than these levels markedly lowers his or her risk of having heart attacks, strokes, kidney and heart failure.

How do you know if you have high blood pressure?  Since hypertension usually doesn’t cause any symptoms, you have to check your reading to be aware of its presence.  This can be done at your doctor or dentist’s office, using a cuff commonly found at pharmacies, or by buying an easy to use home blood pressure machine.  When assessing your blood pressure, it is important to remember that it is the average readings you see that count.  So don’t get worried about a few stray high numbers.  But if you have blood pressure readings that are persistently in the hypertensive range, it is important to see your physician for a discussion.

Some lifestyle measures for preventing and treating hypertension are a low salt diet, regular aerobic exercise, stress management, maintaining a healthy weight, abstaining from heated discussions about Duck Dynasty on Facebook, and avoidance of Dallas Cowboy television viewing.

 
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Posted by on December 23, 2013 in Uncategorized

 

The Bugs in our Gut

Over the past year, a number of interesting studies have shed light on the hitherto unknown functions of the bacteria that live in our gut.  Researchers at UCLA found that women who regularly consumed beneficial bacteria through yogurt showed altered brain function, both while in a resting state and in response to an emotion-recognition task.  Commenting on the study published in Gastroenterology, lead author Dr. Kirsten Tillisch noted that “our findings indicate that some of the contents of yogurt may actually change the way our brain responds to the environment. When we consider the implications of this work, the old sayings ‘you are what you eat’ and ‘gut feelings’ take on new meaning.”  An article linked here provides further insight into the study and its significance.

Researchers have known that the brain sends signals to the gut, which is why stress and other emotions can contribute to gastrointestinal symptoms. This study shows what has been suspected but until now had been proved only in animal studies: that signals travel the opposite way as well.

“Time and time again, we hear from patients that they never felt depressed or anxious until they started experiencing problems with their gut,” Tillisch said. “Our study shows that the gut–brain connection is a two-way street.”

The small study involved 36 women between the ages of 18 and 55. Researchers divided the women into three groups: one group ate a specific yogurt containing a mix of several probiotics — bacteria thought to have a positive effect on the intestines — twice a day for four weeks; another group consumed a dairy product that looked and tasted like the yogurt but contained no probiotics; and a third group ate no product at all.

Functional magnetic resonance imaging (fMRI) scans conducted both before and after the four-week study period looked at the women’s brains in a state of rest and in response to an emotion-recognition task in which they viewed a series of pictures of people with angry or frightened faces and matched them to other faces showing the same emotions. This task, designed to measure the engagement of affective and cognitive brain regions in response to a visual stimulus, was chosen because previous research in animals had linked changes in gut flora to changes in affective behaviors.

The researchers found that, compared with the women who didn’t consume the probiotic yogurt, those who did showed a decrease in activity in both the insula — which processes and integrates internal body sensations, like those from the gut — and the somatosensory cortex during the emotional reactivity task.

Further, in response to the task, these women had a decrease in the engagement of a widespread network in the brain that includes emotion-, cognition- and sensory-related areas. The women in the other two groups showed a stable or increased activity in this network.

During the resting brain scan, the women consuming probiotics showed greater connectivity between a key brainstem region known as the periaqueductal grey and cognition-associated areas of the prefrontal cortex. The women who ate no product at all, on the other hand, showed greater connectivity of the periaqueductal grey to emotion- and sensation-related regions, while the group consuming the non-probiotic dairy product showed results in between.

The researchers were surprised to find that the brain effects could be seen in many areas, including those involved in sensory processing and not merely those associated with emotion, Tillisch said.

The knowledge that signals are sent from the intestine to the brain and that they can be modulated by a dietary change is likely to lead to an expansion of research aimed at finding new strategies to prevent or treat digestive, mental and neurological disorders.

So how do we change the bacteria in our gut?  A recent study published in Nature showed that changing the food you eat rapidly changes the composition of your gut bacteria.  In the study, researchers had nine volunteers go on two extreme diets for five days each.  In the first diet, volunteers ate eggs and bacon for breakfast, ribs and briskets for lunch, and an assortment of pork meat and cheeses for dinners.  Then after a break, the nine volunteers ate a diet that consisted almost entirely of plants. They had granola cereal for breakfast, and for lunch and dinner a combination of jasmine rice, cooked onions, tomatoes, squash, garlic, peas, lentils, bananas and mangoes.

Researchers analyzed the volunteers’ microbiomes before, during and after each diet.  Lead researcher Lawrence David noted that “the relative abundance of various bacteria species looked like it shifted within a day after the food hit the gut.”  After the volunteers had spent about three days on each diet, the genes which the bacteria expressed began to change.  The bacteria found in people’s guts after they ate an animal-rich diet have previously been associated with higher levels of inflammation in the body.  An NPR article on the study is linked here.

Overall, studies like these show that what we eat affects our health in ways that we have not previously appreciated.

 
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Posted by on December 19, 2013 in Uncategorized

 

How Do Antidepressants Work?

I remember feeling puzzled when I first learned how antidepressants worked in medical school.  This much made sense to me: Chemicals called neurotransmitters enable neurons (nerve cells) to communicate with each other.  Some important and commonly known neurotransmitters are serotonin, norepinephrine, and dopamine.  The space between neurons is called a synapse.  When a neurotransmitter such as serotonin or norepinephrine is released and travels between neurons, some of it gets reabsorbed into the neuron that released it.  Antidepressants block serotonin, norepinephrine, and other neurotransmitters from being reabsorbed into neurons.  This allows for a greater amount of neurotransmitter to remain in the space between neurons. 

But what puzzled me as I learned about antidepressants is why having a greater amount of neurotransmitter in the space between neurons should translate into treating depression.  Recently, Scientific American published an article addressing this very question.  In it, Alan Gelenberg, a depression and psychiatric researcher at Pennsylvania State University, remarks that “there’s really no evidence that depression is a serotonin-deficiency syndrome.  It’s like saying that a headache is an aspirin-deficiency syndrome.”  Here he is saying that just because aspirin can relief a headache, this does not mean that headaches are caused by a low level of aspirin in our body.  Analogously, just because medications that raise serotonin levels in our synapses help treat depression, this does not mean that depression is due to a low level of serotonin our synapses.

The article notes that

research headed up by neuroscientists David Gurwitz and Noam Shomron of Tel Aviv University in Israel supports recent thinking that rather than a shortage of serotonin, a lack of synaptogenesis (the growth of new synapses, or nerve contacts) and neurogenesis (the generation and migration of new neurons) could cause depression. In this model lower serotonin levels would merely result when cells stopped making new connections among neurons or the brain stopped making new neurons. So, directly treating the cause of this diminished neuronal activity could prove to be a more effective therapy for depression than simply relying on drugs to increase serotonin levels.

 

Evidence for this line of thought came when their team found that cells in culture exposed to a 21-day course of the common SSRI paroxetine (Paxil is one of the brand names) expressed significantly more of the gene for an integrin protein called ITGB3 (integrin beta-3). Integrins are known to play a role in cell adhesion and connectivity and therefore are essential for synaptogenesis. The scientists think SSRIs might promote synaptogenesis and neurogenesis by turning on genes that make ITGB3 as well as other proteins that are involved in these processes. . . Of the 14 genes that showed increased activity in the paroxetine-treated cells, the gene that expresses ITGB3 showed the greatest increase in activity.

These results were published in the October 15 issue of Translational Psychiatry.  Conceiving of depression as an impairment in the generation of neurons and the connections between them makes sense of the symptoms present in severe depression.  If the neurological processes required for learning and engaging the world are not functioning, then it stands to reason that a person will have a decreased ability to concentrate, reason, retain information, and take pleasure in life.  Time will tell if this new paradigm for understanding depression will generate more effective therapies for this often debilitating condition.

The Scientific American article is linked here.

 
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Posted by on December 15, 2013 in Uncategorized

 

Inheriting Trauma

Could a trauma that you experienced be passed on to your children or grandchildren?  Could your anxieties be related to something that happened to your parents or grandparents?  A fascinating new study published in Nature Neuroscience suggests that information, such as our responses to life experiences, can be passed on.  

A Washington Post article reports that In an experiment, researchers

taught male mice to fear the smell of cherry blossoms by associating the scent with mild foot shocks. Two weeks later, they bred with females. The resulting pups were raised to adulthood having never been exposed to the smell.  

 

Yet when the critters caught a whiff of it for the first time, they suddenly became anxious and fearful. They were even born with more cherry-blossom-detecting neurons in their noses and more brain space devoted to cherry-blossom-smelling.

 

The memory transmission extended out another generation when these male mice bred, and similar results were found.

 

Neuroscientists at Emory University found that genetic markers, thought to be wiped clean before birth, were used to transmit a single traumatic experience across generations, leaving behind traces in the behavior and anatomy of future pups.

 

The Post article reports that this study 

adds to a growing pile of evidence suggesting that characteristics outside of the strict genetic code may also be acquired from our parents through epigenetic inheritance. Epigenetics studies how molecules act as DNA markers that influence how the genome is read. We pick up these epigenetic markers during our lives and in various locations on our body as we develop and interact with our environment.

 

Through a process dubbed “reprogramming,” these epigenetic markers were thought to be erased in the earliest stages of development in mammals. But recent research — this study included — has shown that some of these markers may survive to the next generation.

 

Until recently, the scientific consensus was that life experiences could not be passed on to offspring.  

“When I was in school, this was against Darwin — it was ridiculed,” said University of Pennsylvania neuroscientist Christopher Pierce, who was not involved in the study but previously discovered an epigenetic inheritance related to cocaine. Male rats whose fathers were exposed to cocaine chose to ingest less of the drug than those rats whose fathers never took cocaine.

The Washington Post article goes on to ask whether we as humans have also inherited generations of fears and experiences.  

Quite possibly, say scientists. Studies on humans suggest that children and grandchildren may have felt the epigenetic impact of such traumatic events such as famine, the Holocaust and the Sept. 11, 2001, terrorist attacks.

 

Read the Washington Post article here and the Nature Neuroscience article here.

 

 
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Posted by on December 9, 2013 in Uncategorized

 

Hospital

Here’s a review I wrote for the Journal of Palliative Medicine on a book by Julie Salamon called Hospital: Man, Woman, Birth, Death, Infinity, plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids.

The discipline of palliative care emerged from careful observation and consideration of modern health care.  Pioneers such as Dame Cicely Saunders and Balfour Mount studied how people were being treated at the end of their lives and asked if there was a better way.  In this tradition, palliative care practitioners continue to monitor and try to make sense of how contemporary technological, economic, social, and political forces are shaping modern medicine.  For anyone performing this reflective task, Julie Salamon’s Hospital may be an illuminating resource.  The book is a journalist’s account of a year spent in Brooklyn’s Maimonides Medical Center with unrestricted access to the hospital and its personnel.  Searching for the universe in a grain of sand, Salamon hopes the story of this large urban hospital will help tell the larger story of American medicine at the beginning of the twenty-first century.

The story that emerges is one of ever increasing industrialization.  While Maimonides’ staff clearly strives to do what is best for their patients, the institution’s driving ethos is efficiency and financial success.  As the hospital’s chief of surgery explains to Salamon, “It’s all about patient turnover.  The more you can get in and out, the more times that cash register rings.  It sounds like business and it is business. . . We’re not kicking them out.  But if you get them out two days later, for every discharge you lose, you’re losing ten thousands bucks.”  Like a factory mass producing a standardized product, the care at Maimonides relies upon treatment protocols  derived from evidence-based medicine that applies to the everyman of population studies rather than the individual patients of the real world.  In its growing emphasis on medical specialization, the hospital incorporates the basic industrial principle of division of labor.  Finally, just as the industrial revolution saw the rise of a managerial class to organize and maximize production, so Maimonides has an administrative superstructure headed by its chief executive officer Pamela Brier, a business-savy MBA.

The industrialization of American medicine exemplified in Salamon’s portrayal of Maimonides has clear merits.  To remain financially solvent enough to carry out their mission of patient care, hospitals must pay close attention to efficiency and the bottom line.  Treatment protocols derived from evidence-based medicine promote consistency and quality of care.  And with the logarithmic growth of medical knowledge, more and more specialization is necessary to effectively bring scientific developments to bear on patient treatment.

But as Salamon’s book shows, medicine’s industrial shift comes at considerable cost.  It is the cost of the alientation that pervades the pages of Hospital.  At Maimonides, physicians and patients often feel estranged from the healing physician-patient relationship that has traditionally been the heart of medicine.  As one physician tells Salamon, “The past few decades, patients have been saying, ‘I feel I’m just a machine, a widget on the assembly line.’  But lots of doctors are now beginning to experience that, because of the medical industrial complex that treats doctors as another widget.  It’s all interchangeable parts, and the chief virtue becomes efficiency rather than caring compassion.  Lots of physicians are feeling a sense of emptiness, alienation:  ‘Is this why I went into this? Is this what it’s about?. . . Is there more than just thinking about how many colons I can put a scope up per day and how many polyps I can remove and how fast I can be and how few complications I can get?”

The character of Davey Gregorius shows how medical industrialization has shaped the next generation of physicians’ views of their profession.  Gregorius is a first-year resident in emergency medicine at Maimonides who harbors no quixotic aims for his career after finishing his training.  He plans on a job in an emergency department in the Colorado mountains, where he can work two to three shifts a week to finance a life of plentiful skiing and fishing.

Gregorius spends the majority of his time during emergency department shifts in front of a glowing computer screen monitoring patient test results and documenting his work.  Rather than learning about patients’ conditions through listening to their stories and physically examining them, most of Gregorius’ diagnostic information comes through a battery of labs and imaging tests he has ordered.  We see here how modern medicine’s ever-growing diagnostic technology sometimes alienates patients and physicians from each other.  We also see how much time the modern American physician spends breaking down her care for patients into artificial units of value that a third-party payer has devised to determine compensation.  But none of this seems to bother Davey Gregorius.  He does not romantically long for a bygone era in which medicine was a deeply meaningful, even noble profession.  Gregorius instead pragmatically views being a doctor as interesting shift-work that provides adequate compensation to pursue his true passions.  

In contrast, Allan Astrow is determined to preserve the idea of medicine as a deeply moral enterprise.  Astrow in an oncologist whose formative years as a physician were spent in the 1980s and 1990s treating AIDS-related malignancies in a Greenwich Village hospital. Over against the idea of health care as a commodity, he believes that medicine is a covenant between the practitioner whom society has entrusted with the power of healing and the sick person who is in a uniquely dependent, vulnerable, and anxious state.  Astrow has come to Maimonides to take over as associate director of its medical oncology department.  It is an administrative position in which he’ll have to concern himself with efficiency and the bottom line, something seemingly ill-suited for this idealistic man.  But as an outspoken critic of medicine’s industrialization, Astrow feels a duty to get involved in the muck of the system to try to improve it.  It is an admirable, but deceptively perilous endeavor.  Will a position where success is often measured in financial terms distract Astrow from his commitment to medicine’s higher calling?  Will the system change him more than he is able to change it?

His dilemma is akin to one that palliative care faces as it searches for its place in twenty-first century American medicine.  Should the field see itself as comfortably fitting into the industrial division of patient care into component tasks?  Is our place at the end of the health care conveyer belt, taking over patient care at the end of life from hospitalists who were handed the care baton from internists upon hospital admission?

Or should palliative care consider itself a protest against medicine’s industrial trend?  After all, as medicine becomes more and more specialized, palliative care self-consciously takes a holistic approach to patient care.  As futuristic medical technology becomes today’s reality, palliative care’s special procedure is effective interpersonal communication.  As medical research promises scientific certainty and miracle cures, palliative care embraces the art and limits of medicine.

Ultimately, of course, palliative care must continue to seek integration into America’s modern health care system.  Doing so is necessary for the field to have its greatest possible impact.  But palliative care must also intentionally and rigorously guard against attempts to downplay or alter its core commitments in the name of medicine’s infinite quest for maximal efficiency.  For these core commitments are what gave birth to the field and remain its most valuable contribution to medicine.

 

 
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Posted by on December 6, 2013 in Uncategorized

 
 
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