jeudi 31 décembre 2015

Child Psychiatrists Suggest New Year’s Resolution: ‘Let’s Parent Ourselves This Year.”

Child Psychiatrists Suggest New Year’s Resolution: ‘Let’s Parent Ourselves This Year.”

The authors propose framing resolutions in an entirely new way. (PROfrankieleon/Flickr)

The authors propose framing resolutions in an entirely new way.
(PROfrankieleon/Flickr)

By Drs. Gene Beresin and Steve Schlozman

There’s this guy Sisyphus.

I feel like he invented the New Year’s resolution.

You know Sisyphus—he’s the guy who works so hard to push that stupid boulder up the hill, only to have it roll down again at the end of his hard work. You’d think he (and we) would have learned after all these years, but there he is, at the bottom of the hill, trying again and again.

It’s a lot like so many of us. “Today,” you may be saying with resolve, “will be different.” “Today I will get that boulder to the top of the hill.” Or: “This year I’ll lose weight. Drink less. Exercise More.” Fill in the blank.

But how many times do we fail in these New Year’s resolutions?

Researchers note that New Year’s resolutions are typically grounded in motivations to change our perceived vices: our addictions, our “bad” behaviors, our so-called “destructive flaws.” We know what’s good for us, we just can’t get it right.

Luckily for us, we do a little better than Sisyphus. It turns out that almost half of us succeed in our goals. We don’t hear about those successes so much but it’s true: we manage to keep about 50 percent of our self-improvement mandates. Of course that means that about 50 percent of the time we lose our momentum before the year is over. Hence, those same darn resolutions return to us each December.

This exercise in at least partial futility begs a fundamental question: Why is “bad” behavior so hard to change? We try to raise our kids to correct misbehavior; why can’t we do it ourselves?

This query is, understandably, the focus of a lot of research. We harbor false or exaggerated predictions. We assume (and we all know the dangers of assumptions) that change will be easier this year, or more predictable this year, or that we’ll somehow have changed enough that the resolution will finally be within our grasp.

Here’s the kicker, though, and it’s an important one: we truly believe that we’ll succeed. We’re not actively lying to ourselves.

Psychologists Janet Polivy and Peter Herman call this a “false-hope syndrome,” an exaggeration of our expectations for change, inevitably followed by the forlorn shutting down of our previously high aspirations.

But there is controversy as well. John Norcross and his associates suggest that the process of making a resolution is perhaps the most important step in behavioral change. Sprinkle this process with some select and admirable behavioral traits — self-efficacy, maintaining a course of action and readiness to change — and we stand a good chance of achieving our goals.

Typically, he notes, we meet these goals through positive reinforcement from others, and avoidance of past behaviors.

Being human is hard, though. Avoiding past behaviors is like learning to swim. It doesn’t really come naturally to anyone, though some of us are quicker to learn than others.

So, how about we look at resolutions in an entirely different way?

What if we take note of our already achieved positive traits, and focus on making them better? This seems a more productive recipe for success than our yearly tendencies towards self-flagellation.

Try these resolutions on for size, and see if they fit:

  • “I will take greater pleasure in my partner, children, parents and friends.”
  • “I will increase my caring of and sensitivity toward others.”
  • “I will further my dedication to social and individual justice.”
  • “I will emphasize my gratitude for the blessings in my life.”
  • “ I will celebrate the times that I make a positive difference in my life and in the lives of others.”
  • “I will spend more time and energy on the things that make me happy.”

We all have positive attitudes and activities that promote our health and well-being, and that foster the same in others. Positive thinking enhances relationships. Optimism promotes resilience. We have within us the capacity for creative thinking and personal fulfillment; these processes are hardwired into one big anti-Sisyphean feedback loop. Positive emotions promote positive thinking, and vice versa.

This is, of course, easier said than done. It can be a trap to resolve that we must simply work harder to think positively. Lots of the time, that approach by itself allows Sisyphus to win.

Look: these are scary times. But perhaps this time around, New Year’s resolutions can emerge from a reflection on the year gone by, and a sincere desire to make things better for ourselves and others.

This year, let’s focus on the brightness within us. Let’s resolve to enhance and build on what is good, fair and admirable.

At the end of the day, we’re much more likely to approach something positive than we are to walk away from something negative. We see this all the time as parents. Let’s parent ourselves this year.

Dr. Gene Beresin is executive director of The MGH Clay Center for Young Healthy Minds and professor of psychiatry at Harvard Medical School. Dr. Steve Schlozman is associate director of The MGH Clay Center for Young Healthy Minds and an assistant professor of psychiatry at Harvard Medical School.

Patient Demand Surges In Opening Year Of Medical Marijuana Dispensaries In Mass.

Patient Demand Surges In Opening Year Of Medical Marijuana Dispensaries In Mass.

In 2015, medical marijuana took root in Massachusetts, with four dispensaries now open in Salem, Brockton, Ayer and Northampton more than two years after voters approved a ballot question on the issue. (Jesse Costa/WBUR)

In 2015, medical marijuana took root in Massachusetts, with four dispensaries now open in Salem, Brockton, Ayer and Northampton more than two years after voters approved a ballot question on the issue. (Jesse Costa/WBUR)

By the numbers, the first year of medical marijuana dispensaries in Massachusetts looks pretty dramatic.

The latest data released by the Department of Public Health shows that 16,510 patients had obtained a certificate from a physician and registered through the state as of Nov. 30.

That’s up from 1,423 in January, a nearly 12-fold increase.

This chart shows the sharp increase in both active and certified medical marijuana patients since October 2014. (Screenshot via DPH)

This chart shows the sharp increase in both active and certified medical marijuana patients since October 2014. (Screenshot via DPH)

A steady stream of men and women waited outside a former factory in Salem on June 24 for the opening of the state’s first dispensary. Some were frustrated at having had to wait more than two years since voters approved a medical marijuana ballot question.

“I’m a law-abiding citizen, two kids, daycare provider, no criminal record,” Salem resident Wendy Atwood said. “So I feel like I’m a good example of someone who can use [marijuana] responsibly.”

Patients purchased 9,576 ounces of marijuana in 65,270 individual transactions between the end of June, when the first dispensary opened in Salem, and the end of November, according to the state. By then, there were four stores open — in Salem, Brockton, Northampton and Ayer. Some dispensaries could not keep up with demand and had to close for days at a time, although problems with state testing rules and delays at testing labs also interrupted the supply of weed.

This chart shows data compiled by the state's Department of Public Health related to providers, users and sales of medical marijuana as of Nov. 30. (Screenshot via DPH)

This chart shows data compiled by the state’s Department of Public Health related to providers, users and sales of medical marijuana as of Nov. 30. (Screenshot via DPH; click to enlarge)

Despite the early figures, inside the industry analysts say 2015 was a year of slow growth. Only about 1 in 10 patients who are expected to buy marijuana to help them treat pain, nausea, seizures and other ailments have signed up so far. A fully mature market, with an expected 150,000-plus patients, is still two to three years away, says Kris Krane, managing partner at 4Front Advisors. He’s working with companies that hope to open more than 20 dispensaries in Massachusetts.

Krane predicts a surge of patients and sales as more dispensaries open. Many people, Krane says, are buying marijuana from illegal sources and risking the $100 fine for possession of one ounce or less, while they wait for a dispensary to open near them.

Two more storefronts, in Brookline and in Lowell, are in the final stages of seeking approvals to open. A total of 17 dispensaries have provisional certificates.

A second round of rolling applications for medical marijuana licenses began in late June. So far, there are 159. No one expects all of those applicants to complete the full application process or get state approval to begin operations.

Outside the dispensaries, there’s a growing vendor network of companies that make fertilizer, lights, software and accessories.

Doug Leighton, managing director at Boston-based Dutchess Capital, has invested tens of millions of dollars in 21 ventures since 2012, and most of them are located outside of Massachusetts. Leighton says it’s becoming clear that the successful investments are in “things that can cross state lines, because there’s a big difference between touching and not touching the plant.”

It’s hard to scale up products that require touching marijuana, Leighton says, because regulations vary from state to state. But the cannabis social network MassRoots, for example, is available anywhere.

While the industry expands, many mainstream medical groups are stepping up their opposition to the idea of marijuana as medicine. In early December, the Massachusetts Medical Society (MMS) began recommending that doctors warn women in their child-bearing years about the potential harms of marijuana.

MMS President Dennis Dimitri acknowledged there is no firm evidence that using marijuana would harm a baby during pregnancy or while nursing, but said “given the special circumstance that we’re talking about here, we think that caution is the right route to take.”

Marijuana plants at In Good Health in Brockton (Jesse Costa/WBUR)

Marijuana plants at In Good Health in Brockton (Jesse Costa/WBUR)

One-hundred and twenty-four physicians had registered with the state so that they can issue marijuana certificates to patients as of November. That’s up from 35 at the beginning of the year, but just a fraction of the estimated 23,000 physicians who see patients in Massachusetts.

Dr. Uma Dhanabalan, a family physician who practices in Natick, urges doctors to learn more about marijuana.

“I’m not telling all doctors to go out there and start making the recommendation” of marijuana, Dhanabalan said, “but I want them to understand that cannabis is an option, and not have patients be alienated when they use it, especially in pain clinics.”

Dhanabalan says the state and country need much clearer standards for providers using cannabis, as well as for labs so patients can be sure they are using marijuana safely.

Look for debate about the pros and cons of medical — and recreational — use of marijuana to explode in the coming year. A proposed ballot question that would make marijuana legal at age 21 will be filed with the state Legislature in January. Gov. Charlie Baker has said he’s opposed. If the Legislature and governor don’t approve the measure by early May, supporters plan to collect the 10,792 signatures needed to place the question on the November ballot.

Related:

mercredi 30 décembre 2015

Top CommonHealth Stories of 2015: From Kale And Sex To Opioids And Suicide

Top CommonHealth Stories of 2015: From Kale And Sex To Opioids And Suicide

This Jan. 1, 2014, file photo shows fireworks lighting up the sky over Boston Harbor to celebrate First Night in Boston, during New Year's celebrations. (Elise Amendola/AP)

This Jan. 1, 2014, file photo shows fireworks lighting up the sky over Boston Harbor to celebrate First Night in Boston, during New Year’s celebrations. (Elise Amendola/AP)

In the Radio Boston segment above, Dr. Neel Shah looks back at the year in medicine and highlights several important trends, among them:

  • Obamacare is now here to stay, but health costs — particulaly out-of-pocket costs — continue to rise; Obamacare affected how health care is paid for, but curbing costs requires reform of how health care is delivered.
  • Health care is moving — slowly — toward more transparent consumer information about prices, and hospitals are taking more responsibility for the costs of care.
  • Tracking apps are transforming not just fitness but health care and disease management.

All important. Now, let’s also look back at 2015 through the CommonHealth lens. Of course, we must resist the siren song of easy metrics; if click counts were everything, we’d write about nothing but trendy vegetables and sexual organs. But just in case you missed them, these were our highest click counts of the last year:

Now to get serious, as serious as drug overdoses and suicide.

In this September photo, Joey, who had recently started using methadone to try and kick his heroin addiction, visits his parents grave at Woodlawn Cemetery in Everett. (Jesse Costa/WBUR)

In this September photo, Joey, who had recently started using methadone to try and kick his heroin addiction, visits his parents grave at Woodlawn Cemetery in Everett. (Jesse Costa/WBUR)

Opioids

There’s been a lot of (well-deserved) journalistic self-congratulation around Boston lately, so let’s limit ours to this: At a recent public forum, the dean of Harvard Medical School introduced WBUR’s Martha Bebinger as “a treasure,” and we concur with his diagnosis.

Along with her continuing coverage of health care, Martha has focused particularly this year on medical marijuana and, with WBUR’s Deborah Becker, on the opioid crisis. Three of her many memorable stories:

Suicide

WBUR’s Lynn Jolicoeur performed an important public service this year with her series, “Suicide: A Crisis In The Shadows,” and CommonHealth was honored to help bring the painful topic a bit further out of the shadows.

The opening segment — ‘The Biggest Barrier’ To Preventing Suicide: Not Talking About It — was shared about 30,000 times on Facebook within the first week or so. Lynn received messages from all over the country, from people who were glad to see the issue of suicide reported on, wanted to share their own stories of how suicide had affected them, or wanted to suggest angles to cover.

The full series is here, including a piece on researchers’ efforts to understand suicide better and a profile of a bereaved husband who speaks out widely about suicide.

The Checkup

The Checkup

It was fun while it lasted. CommonHealth’s podcast, “The Checkup,” survived for a second season, including enticing episodes with names like “Muffin-Top” and “Sexual Reality Check.” Then it died a dignified death, but I suppose it will live on in perpetuity on iTunes. (Old podcasts don’t die, they just float down slowly to the bottom of the list, right?)

Sugar, Anxiety And Dyslexia

Rachel and I picked a few of our own favorite stories from the year. Rachel’s:

Smart Good People, Big Hard Things

And I’ve decided I’d like my beat to be “smart good people who do big hard things,” like solving scientific puzzles and restoring blind children’s vision. So these are mine:

A study finds that a year's supply of Gleevec , a leukemia drug, (generic name imatinib), costs about $159 a year to make, but the yearly price tag is $106,322 in the US and $31,867 in the UK. (Photo: Wikimedia Commons)

A study finds that a year’s supply of Gleevec , a leukemia drug, (generic name imatinib), costs about $159 a year to make, but the yearly price tag is $106,322 in the US and $31,867 in the UK. (Photo: Wikimedia Commons)

Rising Drug Prices And Ringing Ears

Regular NPR listeners and long-time Boston Globe readers will recognize Richard Knox as a byline to watch for, including these recent hits:

Honored Regulars And Guests

There are still just a few spaces left for our Jan. 26 launch event for “Narrating Medicine,” a platform for first-person writing by people from across the health-care spectrum. Among our invited speakers are some of the distinguished Dr.-prefaced bylines you’ve seen here: Drs. Annie Brewster, Michael Misialek, Gene Beresin, Steve Schlozman, David Scales, and more. A sampling of their work this year:

For all the power of an M.D. or a Ph.D., perhaps the highest credential of all is the long-term experience of living with and managing a condition, as witness:

Thank You

And finally, thank you for reading and sharing and responding. Special thanks to readers who filled out our feedback survey, which yielded some wonderfully helpful insights. (More fitness and nutrition! More mental health! More science and medical research! Quite enough patient and doctor stories, thank you.) We’re aiming for some big changes in 2016, including a much more mobile-friendly redesign, while preserving the core CommonHealth voices. Please stay tuned.

Wishing you a wonderful 2016. For next year’s reading agenda, here’s a hot-off-the-airwaves book recommendation from Neel Shah: When Breath Becomes Air, by Paul Kalanithi, a philosophical surgeon diagnosed with fatal cancer.

mardi 29 décembre 2015

Lost In Translation: How Foreign-Speaking Patients Suffer Without Medical Interpreters

Lost In Translation: How Foreign-Speaking Patients Suffer Without Medical Interpreters

Hospitals take different approaches to support people with low English-speaking ability. In this 2004 photo, medical interpreter Carmen Diaz interprets for Spanish-speaking patient at Temple University Hospital in Philadelphia. (Bradley C. Bower/AP)

Hospitals take different approaches to support people with low English-speaking ability. In this 2004 photo, medical interpreter Carmen Diaz interprets for Spanish-speaking patient at Temple University Hospital in Philadelphia. (Bradley C. Bower/AP)

By Dr. David Scales

When I met Mr. Y., he was sitting up in bed, sweating and breathing quickly. An elderly, Russian-speaking man, he was admitted to the cardiology ward at a large hospital where I was working. His blood pressure was dangerously high and he struggled to breathe. His fear was instantly apparent in his wide blue eyes. Panting, he told us that he had liver pain, pointing to just below the ribs on his right side.

It’s unusual for patients to complain about liver pain. In broken English Mr. Y explained that it began after starting new blood pressure medications a few months ago. But his chest X-ray told a different story. His lungs were drowning in fluid — the likely reason why he was so out of breath — and that couldn’t have been caused by the medications he was so worried about. Having already perused his laboratory results, his condition seemed like a straightforward case of heart failure, but I quickly realized admitting Mr. Y would be linguistically and culturally complex.

I needed to understand what made him so short of breath, and why he thought his medications caused the problem. But no in-person interpreter was available for another hour and a half. The telephone interpreting service at this hospital was designed to be accessible — the interpreter can be paged from any hospital telephone and should call back. Yet, no one had called back after my two attempts. I imagined they were busy interpreting for other patients. In the meantime, Mr. Y continued to pant and sweat, leaning forward in bed to help his breathing.

Reluctantly, I asked his adult daughter if she would interpret for me. She agreed, but was clearly reticent; her hesitance and discomfort apparent as she stumbled over questions about her father’s recent urinary and bowel habits. While I speak no Russian, I became suspicious of misunderstandings when she interpreted my question about previous “heart failure” as “infarkt,” which sounds like a medical term for a heart attack.

I know of studies showing patients suffer when clinicians do not use interpreters or use untrained, informal interpreters like family members. I learned this during medical interpreter training and in my own experience volunteering as an Arabic interpreter with Iraqi refugees in New Haven and Syrian refugees in Jordan. As was the case with Mr. Y’s daughter, family members may struggle to interpret accurately when family or cultural expectations are upset by medically routine, but personally embarrassing questions.

As a trained interpreter myself, it is painful and frustrating when good interpreter services are not available. But it isn’t just a dearth of interpreters — it’s also a lack of time that presents challenges to providing good care to non-English speakers. If I had a leisurely day I could have waited or returned, but on an adrenaline-fueled day on call, waiting for the interpreter was not possible. I had to balance my limited time with Mr. Y against preparing for the three other patients I expected to be admitted at any minute. Worried this would be my only chance to hear his story, I put my interpreter training aside.

Long waits for in-person interpreters, an unreliable telephone interpreting system and the pressure of three other sick patients waiting to be admitted put both my resident and me in the uncomfortable position of just “getting by.” I had enough information to treat his illness but not enough time to understand how he connected his liver pain to his new medications.

Interpreters are easier to obtain with better technology. One analysis points out that physicians tend not to use interpreters much in the system I was using. It’s where the patient speaks to the interpreter over the phone then passes the phone to the physician for interpretation. Advancements in technology to two handsets and video phones now bring the telephone interpreter into the room with my patients and me. Some studies show these technological improvements have increased the use of interpreters by physicians. In one small study, placing a dual-handset phone at every patient’s bedside led to a four-fold increase in the use of telephone interpreter services without a decline in demand for in-person services.

In my case, better technology would have helped. But the busy day with high patient numbers also contributed to my rush. On any given day, I divide my time between different patients, prioritizing to care for the sickest among them. On admitting days, I have more patients who tend to be sicker, raising the stakes as I divide my time. Non-English-speaking patients force what feels like an “unfair” reprioritization — regardless of how sick they are a non-English speaking patient often requires significantly more of my time.

In a setting with such competing demands on time, I wonder if our hospitals are really set up to support high-quality of care for people with low English-speaking ability?

I have a colleague who recently relocated to a New Hampshire hospital, and recounted a particularly egregious example. An outside company determined that a doctor there should be able to see 1.8 patients per hour, meaning 24 patients a day. Even the basics of good care — talking to the patient, examining them, discussing the plan with them, coordinating care with nurses and specialists, writing notes, having a discussion with a family member — will take much longer than the allotted 33 minutes per patient. Add interpreting to the list, which often doubles the time it takes to see a patient, and its no wonder patients with limited English proficiency receive worse care.

At the small community hospital where I am usually based, I typically have a handful of patients. Rather than admit a wave of sick patients every fourth day, we admit a small number each day. As a result, I can usually find enough time to meet the linguistic needs of all my patients.

This is no accident. The administration of my community hospital has designed the hospital to cater to those of different cultures. Patient loads tend to be lower to allow more time, and there are portable videophones available on each floor and in the emergency room, making it easy to speak to the many patients who are Portuguese, or Haitian Creole-speaking immigrants. This helps explain how, despite being one of the smallest hospitals in the state, we have some of the highest numbers of interpretation sessions in Massachusetts (at least when the study was done in 2008). Our hospital recently received an award for treating high proportions of underserved patients. Perhaps there should be awards for institutions that go the extra mile (and provide commensurate funds) to free up nurses’ and doctors’ time to provide patient-centered care.

Of course, patient-centered care is expensive, as my hospital also has some of the highest cost-per-patient ratios in the state (and recently one of the largest budget deficits, too). Allowing doctors and nurses to see fewer patients and hiring interpreters is costly, putting an additional strain on hospital budgets even as they face the usual shortfalls.

Still, there are low-cost steps every hospital can take to make physicians more likely to access interpreters. One study found five key factors, including institutional commitment, investing in relatively inexpensive remote interpreter technologies like video phones, training clinicians in how to access interpreters, and supporting and certifying bilingual staff to function as interpreters.

We gave Mr Y. medications to help him urinate out extra fluid and also drained the fluid around his lungs. He started to breathe more easily. The following day, my resident was able to obtain an in-person interpreter. We found out that Mr. Y thought his new blood pressure medications were damaging his liver so he only took them intermittently. We reassured him that his liver tests were normal, explained his new symptoms of heart failure and emphasized the importance of his new medications in keeping fluid out of his lungs and helping him breathe.

A care transition team with a Russian-speaking pharmacist planned to follow him for 30 days outside the hospital. Ultimately, with a clearer understanding of his perspective and a good care plan for discharge, we were all able to breathe a little easier.

lundi 28 décembre 2015

Play Through The Pain? Audition Season Means Injury Risk For Young Musicians

Play Through The Pain? Audition Season Means Injury Risk For Young Musicians

The Emerson String Quartet performs in 2004. Imagine a quartet without its instruments and it becomes more clear how unnatural their positions are, says neurologist Dr. Michael Charness. (AP Photo/Jennifer Szymaszek)

The Emerson String Quartet performs in 2004. Imagine a quartet without its instruments and it becomes more clear how unnatural their positions are, says neurologist Dr. Michael Charness. (Jennifer Szymaszek/AP)

By Ian Coss

Caitlin Cawley was only 15 when she developed tendinitis in both elbows. The condition is commonly known as “tennis elbow,” but Cawley wasn’t practicing her serve. She was studying classical percussion at a pre-college program for aspiring musicians.

She ignored the early signs until the prickling sensation grew to stabbing pain throughout her forearms so excruciating she had to stop playing. It took three months of rest for the inflammation in her tendons to subside, and she has had multiple flare-ups since then.

Now 21 and a senior at Boston University’s School of Music, Cawley is preparing to audition for graduate programs. So while most college applicants can breathe a sigh of relief after their Jan. 1 deadline, she and other music students are headed back to the practice rooms. Cawley currently averages six hours of independent practice a day, not including ensemble rehearsals. In her words: “Right now I’m doing as much work as I’ve ever done for music.”

Boston University senior Caitlin Cawley practices on the marimba (Photo: Ian Coss/WBUR)

Boston University senior Caitlin Cawley practices on the marimba. (Ian Coss for WBUR)

That diligence also means risk of injury. For Cawley and other young musicians, the question of this season is: How much practice can my body take before perfection turns to pain?

Their odds are not good. In the mid-2000s, a Chicago-based physician began surveying the incoming music students at a midwestern university, and after four years, the trend in the data was clear: Almost 80 percent of freshman “reported a history of playing-related pain.”

For players of string, keyboard and brass instruments the percentage was even higher. For percussionists like Cawley: 100 percent.

Dr. Michael Charness, who directs the Performing Arts Clinic at Brigham and Women’s Hospital, has treated thousands of musicians who play everything from bagpipes and sitars to violas and trombones.

He describes the crux of the problem: “If you look at a string quartet, it’s the most natural looking sight, but if you simply remove the instruments from their hands and pose them on stage, it’s nothing that we were ever really designed to do for any long period of time.”

The arms are elevated, wrist extended, head tilted — all while performing rapid repetitive motions (a two-minute movement from Handel’s “Messiah” includes 740 strokes of the violin bow). It’s a recipe for repetitive stress injuries, and the same could be said of any instrument when played intensively.

High-pressure events such as auditions and recitals bring heightened risk, Charness says; they push musicians to put in eight or 10 hours a day and repeat the same passage over and over to get it right — “things that most athletes know not to do.” He often sees those same musicians in his clinic once the pressure has passed.

Performing Patients

Every Saturday, there is a line of musicians at the Brigham and Women’s clinic carrying instrument cases of all shapes and sizes. Dan Snydacker, a harpsichordist who travels from Connecticut for treatment, describes the waiting area as tense — somber even: “We all share this sense of potential loss.”

About half of the musicians that Charness sees suffer from overuse injuries to the soft tissue, such as tendinitis. The doctor watches each one play, looking for tension in the shoulders or an unnecessary twist in the wrist — subtle habits that can lead to strain.

Slightly less common are nerve injuries — often in the wrist and elbow, where nerves can become compressed or entrapped in the joints. In many cases the condition is totally painless, only affecting the musician’s coordination.

The most rare and debilitating musical malady is focal dystonia, a neurological condition that is rooted in the brain but impacts a specific part of the body — fingers for pianists and sometimes the lips for players of wind instruments. The condition is not well understood even though it affects almost 2 percent of professional musicians — including the celebrated pianist Leon Fleisher and possibly the 19th century composer Robert Schumann.

Snydacker, the harpsichordist, knew something was wrong when he started missing notes on the keyboard. Then he noticed that his fingers were curling under his palm involuntarily when he tried to play. The dystonia was interfering with the motor routines he had developed over years of playing, and he now receives regular botox injections that relax the overactive muscles in his hand. Total recovery is unlikely; Snydacker is just hoping that he can still play the harpsichord for his grandchildren.

Dr. Michael Charness, who directs the Performing Arts Clinic at Brigham and Women's Hospital. He's also Chief of Staff at the VA Boston Healthcare System and Professor of Neurology at Harvard and B.U. (Courtesy)

Dr. Michael Charness, who directs the Performing Arts Clinic at Brigham and Women’s. He’s also Chief of Staff at the VA Boston Healthcare System and Professor of Neurology at Harvard and BU. (Courtesy)

Charness is a keyboard player himself, and he started treating musicians after suffering his own injury — an entrapped nerve in his elbow. He was a medical student at the time, but none of his neurology professors could explain what was wrong. His hands seemed perfectly fine, but on the piano keyboard they had suddenly lost their precision.

Once Charness did find treatment, other musicians he knew suddenly started “coming out of their closets” and approaching him about their own injuries. This was in the mid-1980s, and there was no clinic for performing artists, so Charness saw them in a back room of the lab where he worked. Within two years, he says, he was treating principal orchestra players from around the country, including almost one-quarter of the local San Francisco Symphony — all by word of mouth, all in secret.

The stigma and secrecy surrounding injury make perfect sense from the musicians’ standpoint: Orchestras don’t want injured players any more than a baseball team does. Even musicians with steady employment might keep health issues secret from their colleagues and conductor, afraid of facing additional scrutiny. So Charness is careful to guard the confidentiality of his patients, knowing that this secrecy makes it even harder for them to get help.

Practicing Wellness

A lot has changed in performing arts medicine since Charness first ran his back-room medical practice. The issue gained widespread attention in 1987 when a study by the International Conference of Symphony and Orchestra Musicians found that 76 percent of their members had experienced a playing injury that seriously affected their performance.

Charness opened his clinic in Boston two years later, and it is now one of several in the country that specifically treat musicians.

But in the classical music world, old habits die hard. Music camps still ask kids to play for seven hours a day and many teachers are more attuned to expression and tone than they are to mechanics and posture.

The stigma of injury persists as well. Cawley recalls hearing at age 16: “If you tell people that you’re injured, you won’t work, people won’t hire you.” And while none of her teachers today would ever tell her to “play through the pain,” the competitive culture of the music industry pushes some musicians to do just that.

Cawley must navigate this contradictory terrain carefully. During a recent practice session, she was working on a Bach cello suite arranged for marimba, an instrument whose tuned wooden bars are laid out like the keys on a piano, extending nine feet from end to end. The notes came in a constant stream and Cawley, just over five feet tall, stayed on the balls of her feet as she moved to follow the melody.

“The thing about Bach,” she says, “you can’t miss.” If the mallet falls an inch to the left, everyone will know. But as determined as she was to get the notes right, she was equally determined not to push her body too hard. Another injury now could upend everything that she was practicing for.

Cawley’s first graduate school audition is just a few weeks away, but she knows her limits and won’t push them. Every practice session starts with 30 minutes of stretching and warm-ups and she won’t go more than 90 minutes without taking a break. If she can’t work more with her hands, Cawley will practice by studying the scores — a technique she developed after her first bout of tendinitis when she couldn’t play more than 15 minutes a day.

Most of these practice strategies were not taught in conservatories when Snydacker studied music in the 1970s. He recalls: “Like everyone of my generation I practiced until I couldn’t practice any more. I practiced too much.” He played through the tension and through the discomfort — things musicians today know not to do. Charness has worked over his career to spread this knowledge, and gives tips for injury prevention on the clinic’s website.

But even with all the best practices and caution in the world, the fear of injury remains.

Cawley has seen the surgical scars on the arms of her peers who suffered from nerve entrapment, and heard the stories of opportunities lost or careers ended by health problems. As she took a break from practicing, Cawley reflected on the tenuous nature of her chosen profession: “It’s hard to think that your body is so connected to your livelihood. Most people, when their body gets injured in some way, can still feed their family. If you’re an orchestra player, you only have one skill in this world. And if that goes away, you’re kind of screwed. It’s a weird thing to have to contend with.”

As soon as we finished talking, it was back to practicing. Auditions are approaching, the day was getting on, and she was still shy of her six-hour target.

Ian Coss is a Ph.D. student in ethnomusicology at Boston University who has done music reporting for The World and Afropop Worldwide. He writes at iancoss.com

In 2015, The Opioid Crisis Continued To Ravage Massachusetts

In 2015, The Opioid Crisis Continued To Ravage Massachusetts

Massachusetts’ opioid crisis continued to be a major story of 2015.

Early in the year, the state released staggering statistics showing that close to four people die in Massachusetts every day from opioid overdoses. Just last week, Gov. Baker became emotional when speaking during the screening of a new HBO movie, set on Cape Cod, about the nation’s heroin problem.

WBUR’s Martha Bebinger joined Deborah Becker on Morning Edition to discuss the issue.

vendredi 25 décembre 2015

Opinion: ‘Lactivism’ Has Trump-Like Appeal For Breastfeeding Backlash, But Science Is Off

Opinion: ‘Lactivism’ Has Trump-Like Appeal For Breastfeeding Backlash, But Science Is Off

(Grahford/Flickr)

(Grahford/Flickr)

By Melissa Bartick, M.D.

Judging from the hype around Courtney Jung’s new book “Lactivism,” breastfeeding backlash is alive and kicking.  In fact, if Donald Trump suddenly jumped into the breastfeeding fray, he might sound a bit like Jung: In her world, breastfeeding advocates are nearly always “lactivists,” self-righteous extremists preying on innocent mothers in the name of science and good parenting.

Jung, a professor in the Department of Political Science at University of Toronto. conjures a villain (or villains) everyone can rally against, as evidenced in the book’s subtitle: “How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy.”

If only some of the glowing book reviews mentioned Jung’s sloppy reading of the scientific literature, her absurd claims about the breastfeeding industrial complex and her misplaced theories of breastfeeding class warfare.

Let’s be clear: There is no place for shaming any mother about how she feeds her infant. There are indeed people out there who deserve our ire, who shame and pressure women instead of listening and educating. But Jung lumps nearly all breastfeeding advocates into this camp, stoking hatred of an entire group where only some are guilty.

Perhaps the book is popular for the same reason Trump is popular. It taps into mothers’ collective anxiety, anger and fears over a highly emotional topic, and then hold up twin “culprits”: breastfeeding zealots and bad science. The only problem is, the actual zealots are few (though offensive), and the science is not as Jung states.

Here are some facts: Breastfeeding mothers still get harassed in public and at work, and formula feeding mothers are subject to shame as well. For decades, formula feeding has been the norm in this country, and for much of our society it’s still the norm. CDC data show low-income women and African-American women have lower breastfeeding rates than middle class white women.

Not everyone can breastfeed and not everyone wants to breastfeed, but data show 68 percent of women who want to exclusively breastfeed do not meet their own goals.

To be fair, Jung does a few things right. For instance, a 2007 report from the Agency for Health Research and Quality (AHRQ) found that exclusively breastfeeding for three months cuts the risk of ear infections in half. To her credit, Jung highlights the same data from a different perspective, illustrating that six babies would need to be exclusively breastfed for three months to prevent one ear infection. And, also to her credit, she highlights fairly recent data showing little if any link between breastfeeding and lower risk of asthma, eczema and type 1 diabetes.

But overall, Jung’s grasp on the medical research is poor. Scientific papers are peer reviewed by other researchers who are experts in the same field and must pass rigorous standards before publication. Jung is not a medical researcher. While I don’t know if Jung’s book was reviewed by any medical authority, as a reviewer myself I can say it never would have made it past the first stage of the peer review process. It was reviewed by editors whose goal is to sell books.

She misstates so much of the medical literature, one wonders if she did more than just skim through these papers. Here are a few examples of inaccuracies:

• The rate of HIV transmission from mothers to their 6-month-old infants via breast milk is 4 percent among those exclusively breastfed, according to a study in The Lancet; Jung wrongly puts that number at 22 percent.

• Jung cites my 2010 paper showing that suboptimal breastfeeding rates in the U.S. cost our economy $13 billion and cause 911 excess deaths, but she claims it was based on data only on countries “without access to clean water.” In fact, our data was based on an AHRQ report of only developed countries, including the U.S and European countries.

• Infant diarrhea is actually cut by more than half by exclusive breastfeeding in developed countries such as the Netherlands, not just in “Afghanistan,” as Jung claims.

• The milk of mothers of preterm infants is different from that of term infants, contrary to what Jung writes.

• Jung cherry-picks the evidence on SIDS, omitting the seminal 2011 meta-analysis showing marked reduction of SIDS associated with breastfeeding, and fails to mention that numerous countries, including Canada and the U.K., include breastfeeding in their national SIDS prevention strategies.

• Jung does not discuss the significant effects that breastfeeding has on the health of the mother. Women who don’t breastfeed or who wean early, have higher risks of high blood pressure, heart attackstype 2 diabetesbreast cancer and  pre-menopausal ovarian cancer.

lactivism

Breastfeeding helps women themselves, and it’s another reason why I believe society should be supporting women to breastfeed longer. It’s really not about moral righteousness or good or bad parenting.

Jung paints breastfeeding as the stylish choice of the middle class, and assumes middle class women and lactivists scoff at the feeding “choices” of lower-income and African-American women.

In fact, Jung seems to be unaware that there is much work going on in this country to close what breastfeeding advocates see as a tragic injustice and inequity. Large government-sponsored initiatives are targeting predominantly African-American and low-income areas to improve hospital and community support contributing to low breastfeeding rates. WIC initiatives have markedly improved breastfeeding rates among low-income women and women of color, and non-profits such as the WK Kellogg Foundation and the U.S. Breastfeeding Committee, on whose Board I served for the past six years, has been committed to raising breastfeeding rates in communities of color. And it’s been working.

We deeply understand that breastfeeding is not a viable “choice” at all for so many women. The low breastfeeding rates among these populations represents a complex, multifaceted social problem, much bigger than any individual mother.

Jung describes a working mother who gets harassed for pumping at the factory. What mothers like this need is support from bosses and coworkers. This is what breastfeeding advocates mean when we talk about “civic obligation,” a term Jung misunderstands as depriving women of feeding choice. “Civic obligation” does not mean forcing women to breastfeed. And that is the fundamental flaw of Jung’s book.

The vast majority of breastfeeding advocates want to support women, and empower them, not force them to breastfeed. They educate, not pressure. Sadly, an unfortunate encounter with a true zealot can color one’s perceptions of the rest of the field of compassionate advocates.

About those breastfeeding extremists, I offer myself as Exhibit A in Jung’s book. She spends pages tearing apart a 2007 essay I wrote on combating formula proponents’ use of the word “choice.” Taking my essay out of context, she implies to readers that breastfeeding advocates do not think mothers should be given a choice in how they feed their infants. Here she describes me as an “ardent lactivist,” although in that very essay, I caution against “lactivism.” Jung couldn’t have gotten me more wrong: I have never engaged in any of the judgmental pressuring tactics to women I meet typical of the lactivists Jung describes.

In fact, I recently wrote a blog post asking breastfeeding advocates to stop using the word “lactivist” and all it stands for. I work with scores of breastfeeding advocates in numerous organizations, and the overwhelming majority of them understand that mothers are just doing the best they can for their circumstances. As with me, Jung misjudges most breastfeeding advocates, mistaking fair-minded people for zealots, stoking hatred where none is warranted.

Repeatedly, Jung tells us how she endured those thousands of hours of breastfeeding, all for little health benefit to her kids, telling us breastfeeding comes at “considerable personal (financial) cost.” Never mind that formula feeding costs thousands of dollars a year, and preparing and washing bottles also takes time, and may not provide as much emotional satisfaction to mother or infant. That is not in Jung’s calculus.

Also noticeably absent in Jung’s calculus are the continuing exploitative marketing practices in the United States and abroad of the multibillion-dollar formula industry, whose products have enormous profit margins, and who make false and confusing marketing claims.

Instead Jung “exposes” the breastfeeding industry, especially pumps, which is tiny by comparison. In 2013, U.S. formula sales totaled $4.8 billion and $14.8 billion globally, whereas Medela, the world’s leading breast pump manufacturer, had 2014 global revenue of $630 million.

In the U.S., lactation consultants cannot even get reliably reimbursed by insurance companies and low-income women have no reliable access to professional breastfeeding help.

A book on the “bad” policies of breastfeeding is bound to resonate for some. But Jung’s review of the science is sloppy and irresponsible, and her few good arguments are subsumed by more absurd points. And to top it all off, Jung writes from Canada, where she benefits from paid maternity leave and national health care, only sets our American struggle back further.

Melissa Bartick, M.D, MSc, is an assistant professor of medicine at Cambridge Health Alliance and Harvard Medical School.

jeudi 24 décembre 2015

Space Going Fast: Launch Event For Our New Feature, ‘Narrating Medicine’

Space Going Fast: Launch Event For Our New Feature, ‘Narrating Medicine’

(Dan Hodgett/Flickr Creative Commons)

(Dan Hodgett/Flickr Creative Commons)

Sure, you may be feeling partied out around now, but in a month, the holiday hyper-cheer will have faded from memory and you’ll be ready to interact with people again, right?

So here’s an invitation to a special CommonHealth event at WBUR: The launch of our new feature, Narrating Medicine, a platform for first-person writing from across the health-care spectrum. Interested? You might want to decide quickly, and register here; more than half the 100 seats are already gone. Here’s the official invitation text:

‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾‾

You may be the next Oliver Sacks. You may be a health-care provider or caregiver who needs to share some hard-won wisdom with the public. Or who just needs some catharsis to fight burn-out.

Whatever your reasons for wanting to write, you’re invited to the official launch of Narrating Medicine, Jan. 26, 7-9 p.m., at WBUR, 890 Commonwealth Ave. Light refreshments will be served.

HOUR 1: BRIEF TALKS

CommonHealth co-hosts Carey Goldberg and Rachel Zimmerman introduce Narrating Medicine and explain how it will work. CommonHealth, which averages close to a million clicks a month, will provide editing and audience, including for possible on-air versions of some stories. Writers will share their stories and retain copyright.

We’ll hear from local luminaries who have already ventured into this territory:

Dr. Annie Brewster
Drs. Gene Beresin and Steve Schlozman
Dr. Elissa Ely
Dr. Elizabeth Gaufberg
Dr. Suzanne Koven
Dr. David Scales

And we’ll hear from a legal expert on the first question many writers have: What about HIPAA?

HOUR 2: WORKSHOPS

Pitchfest: Got a story you think you might want to write up? Share a two-minute “pitch” and see what reaction you get.

Bookswap: Got good books on medicine and/or writing that you’ve already read? Bring them in and swap them.

Brainstorm: What next? WBUR will host quarterly meetings. Should we hold a Moth-like storytelling event? Should we think about a book-length collection?

Network: Hobnob, find a writing partner or constructive critic. Sign up for the Facebook group or suggest another online meeting place.

Hope you can make it! We’ll update this post if it sells out (except it can’t “sell” out because it’s free.) If you’re interested but can’t make this particular event, please drop an email to goldberg.carey@gmail.com with “Narrating Medicine” in the subject line, and we’ll keep you in the loop.

mercredi 23 décembre 2015

Child Psychiatrist: Why ‘Star Wars’ Is Good For Kids — And Nostalgic Parents

Child Psychiatrist: Why ‘Star Wars’ Is Good For Kids — And Nostalgic Parents

Carrie Fisher, left, and Mark Hamill star as Princess Leia and Luke Skywalker in the original 1977 “Star Wars,” later renamed “Star Wars: Episode IV – A New Hope.” (Vernon Area Public Library/Flickr)

Carrie Fisher, left, and Mark Hamill star as Princess Leia and Luke Skywalker in the original 1977 “Star Wars,” later renamed “Star Wars: Episode IV – A New Hope.” (Vernon Area Public Library/Flickr)

By Dr. Steve Schlozman

Like lots of people, I can remember the first time I saw “Star Wars.”

It was my first summer at sleep-away camp; I was 11 years old, and suffering from homesickness bad as a fever. I think I had about three weeks to go in an eight-week session that was hardly, in retrospect, torture. Still, when you’re 11, there are some things that never stop being terrifying. For instance, walking across the cold Minnesota dirt to the morning group shower was a daily tribulation. I was ready to go home.

Then, inexplicably, the camp director announced one morning during breakfast that the normal activities of the day would be cancelled. There would be no canoeing, fishing or riflery. He had a special treat, he told us, and we were to clear our trays and head out to the parking lot, where a bunch of school buses would be waiting to take us on a surprise field trip.

The parking lot was, to me, a lot like a landing pad. Five weeks earlier we had all been deposited there by these same buses, and since that time, while it had not been entirely off-limits, its hallowed ground was rarely frequented — lest we risk revisiting the fact that we would not be talking to our parents except through written letters for the next two months. (“Dear Mom and Dad. How are you? Today I caught a fish and cooked it. It tried to bite my finger off.”)

We boarded those buses, and drove through the small town that harbored our camp, pulling into the parking lot of the only movie theater in town. It was a small town, so the theater itself was not that big; it couldn’t possibly accommodate all of the gangly legs and arms that emerged from the three big yellow buses, so we were divided into waves. I was in Wave 1 — I entered the theater near the front of the pack, while many of my fellow campers were left to while away the time at a local park until the next movie began.

And the movie we were to see was, of course, “Star Wars.”

Remember that this was during what some have called the golden age of summer camps. By definition, there was no contact with the outside world. We had no access to phones, or Internet, or even newspapers. There was certainly no television. I had no idea what “Star Wars” was all about; I hadn’t even heard of it. For me, it was enough to be sitting in the air-conditioning. But then, those words started scrolling across the screen:

“A long time ago, in a galaxy far, far away…”

And I’ll be damned if that movie wasn’t about a boy who willingly travels far away from his own home.

We burst out of the theater at the end of the movie ready to take on whatever foes blocked our inextricable march toward justice. Sure, Darth Vader worried me a little, but I knew Luke could handle him. And I, after all, had been exiled just like Luke; that meant that I could handle Darth Vader as well. Han Solo was the “bad guy” we all knew would turn good in less than an hour, and each of us wanted a Wookiee for a friend. In fact, I think we wanted a Wookiee even more than we wanted a light saber.

(And yes, it’s hard for the shrink in me to ignore the symbolism of that long, powerful sword that emerges ready to fight with energy and cool noises. To this day, the concept of a light saber gives me the same sense of power that I experienced at camp whenever we boys chose to extinguish a fire by urinating on it.)

All of these memories…it has to be driving some of the current “Star Wars” fervor. Just look at the numbers. This year’s iteration of the film shattered just about every movie record ever set. It grossed the most money ever for a December opening. It had the single largest opening Friday profits in movie history. People skipped school and work to see the film. Even President Obama hurried out of his last press conference of 2015 by saying, “OK, everybody, I gotta get to ‘Star Wars.’ ”

So yeah, let’s chalk up much of the excitement around this film to parent and child nostalgia. Parents today saw this film’s genesis in droves when they were kids, and the movie has therefore become part of the cultural landscape. Few movie franchises have so thoroughly pierced our everyday lives.

But all this hype begs an important and perhaps untoward question:

“Star Wars,” as a story? It’s nothing special. (Please don’t egg my house!)

“Star Wars” is pretty standard stuff: good guys and bad guys, evil empires and noble rebels. There’s even a princess. It’s like Carl Jung got in a car accident with a John Ford western. How many American archetypes can fit into a single motion picture? A lot, it turns out. In fact, these archetypes are the very reason we celebrate “Star Wars” in the first place.

I’ve noted elsewhere that “Star Wars” can be a bit clunky. But, I also know that the film refuses to bow to my stodgier impulses. (And don’t worry. I’m going to resist the perhaps expected psychological discussion of Darth Vader being Luke’s father.)

“Star Wars” is fundamentally about nostalgia. It speaks to our collective longing for a world where the boundaries are clear and and our ideals remain unquestioned. The Empire is bad and the Rebels are good. Even the surprises are pleasantly predictable. We adults know that the world is not really this straightforward, but that doesn’t matter when you have your kids next to you and a large (and overpriced) popcorn to share.

And nostalgia, remember, is a good thing. In fact, multiple studies have stressed the benefits of nostalgic indulgence. Nostalgia allows our own histories and memories to rework themselves into something grander and even optimistically stalwart. Nostalgia creates connection, courage and a sense of a brightened future.

Ironically, this is a far cry from the original conceptualization of nostalgia as a disease. Now, we recognize nostalgia as a legitimate source of hope, or even, perhaps, inspiration. I mean, look at the title of first “Star Wars” film back in 1977: “A New Hope.”

These kinds of explanations inevitably yield clichés, but it’s also the very nature of these explanations that allow clichés to ring true. We’ve had almost nonstop news lately about terrorists and nasty politicians and seemingly unsolvable social chasms. How great is it, then, to have a movie in which these lines are never gray? That has to feel good to our kids. After all, they’re worried about the adults around them. We can’t seem to stop fighting with each other, and we aren’t even sure who’s on our side.

In “Star Wars,” there is no ambiguity. (OK, so there’s a little ambiguity, but no spoilers here!) This kind of straightforwardness is refreshing, even if we need to remind ourselves that the movies have an uncanny ability to make things impressively clear while the outside world remains murky and undecided.

And, here’s the epilogue to my own experience: after I saw “Star Wars” that day in 1977, I forgot all about my homesickness. I had The Force. That was more than enough to get me through the rest of those open showers.

Dr. Steve Schlozman is an assistant professor of psychiatry at Harvard Medical School and associate director at The Clay Center for Young Healthy Minds at Massachusetts General Hospital.

Related:

Sweeping Harvard Study Finds Skin-To-Skin ‘Kangaroo Care’ Helps Preemies Thrive

Sweeping Harvard Study Finds Skin-To-Skin ‘Kangaroo Care’ Helps Preemies Thrive

If a premature baby is medically stable, a study finds the practice of holding the tiny child might well do some good. (BradleyOlin/Flickr)

If a premature baby is medically stable, a study finds”kangaroo care” — including prolonged skin-to-skin contact — might well do some good. (BradleyOlin/Flickr)

You want to hold your baby. It’s surely one of the deepest of human instincts. But if your newborn is among the nearly 10 percent who arrive prematurely in America each year, you may need to wait — until the days of tubes and high-tech monitors in the incubator have passed.

Now, a new study, apparently the most sweeping yet, offers added evidence that if a premature baby is medically stable, the age-old practice of holding the tiny child — skin to skin, heartbeat to heartbeat — might well do some good. A survey of more than 100 previous studies, it found that overall, the skin-to-skin cradling widely known as “kangaroo mother care” may cut a premature, low-birth-weight baby’s risk of death by 36 percent.

The findings may rightly spur parents to advocate for holding their preemies once they’re medically stable enough, says the study’s senior author, Dr. Grace Chan of Boston Children’s Hospital and the Harvard Chan School of Public Health.

“With this degree of evidence, it doesn’t hurt to ask,” she says. High-tech medical interventions “are necessary for many conditions,” she says. “At the same time, for your preterm, low-birth-weight baby who’s otherwise stable, this is the best thing for the baby.”

Kangaroo care is considered most useful in low-income areas where high-level-care hospitals — and incubators — are few. But Dr. Chan says it seems to offer benefits across all settings. The new study, in the journal Pediatrics, quantifies those benefits, finding both the 36 percent drop in risk of death and a 47 percent drop in infection or sepsis. It looked at newborns who weighed less than 2 kilograms, or 4.4 pounds.

My own son weighed just about that when he was born two months early, back in 2004. And I remember the joy of the brief periods when we were allowed to extract him from his incubator home for a few minutes and hold him close. Judging by that Boston hospital experience, I asked Dr. Chan, kangaroo care is fairly widely accepted, right?

“Surprisingly, the acceptance of kangaroo care really varies,” she says, “based on multiple factors, including leadership and policies at the institutions and the health care providers who are on service at that time.”

“Some providers who strongly believe in kangaroo mother care and skin-to-skin care would highly encourage it. And when you have champions for kangaroo mother care, the adoption rate is much higher. To date, we don’t have a specific policy or set of guidelines for kangaroo mother care in the U.S. or globally. If a health provider team believes keeping the baby safe in an incubator is more beneficial, then that is probably where the baby will be. There’s not a standard of care yet.”

“I imagine it can be a hard clinical decision,” I said.

“I think it is,” Dr. Chan replies. “There hasn’t been a lot of data. Some people can argue that there hasn’t been a ‘gold-standard’ randomized controlled clinical trial that compares tertiary-level care — with a high-risk baby either ventilated or on non-invasive ventilation in an incubator — versus on the mother, skin to skin. Most of the studies that we looked at in our meta-analysis are from settings with limited resources, perhaps just an incubator or a bassinet.”

Still, she added, the World Health Organization has included kangaroo mother care in its preterm guidelines for all babies under 2 kilograms. And the practice has also been gaining ground because there are few other effective interventions for preterm newborn babies. Malawi and Ethiopia also now include kangaroo care in their national guidelines.

So will it take off still further in the United States? Barriers remain, Dr. Chan says, in a system that leans toward the high-tech, and some wonder, “Really? Could skin-to-skin really be as beneficial as a nice incubator that provides humidity and temperature regulation?”

We don’t exactly know the mechanism behind the benefits of kangaroo care, Dr. Chan adds. It appears that it helps babies regulate their body temperature better. Also, mothers become likelier to breastfeed, so their babies get better at fighting infections, and parents can monitor their babies’ breathing and overall well-being better.

For all the kangaroo fathers out there, my first question for Dr. Chan was whether a kangaroo caregiver had to be a mother.

That question has come up repeatedly, she says, but studies have mainly focused on mothers. There has been talk of doing research that would compare mothers with other caregivers, but for now, “we would assume the father or other caregiver would have the same attachment and relationship with the baby,” Dr. Chan says. And in terms of the warmth and attention they provide, “physiologically, it’s probably all the same.”

Readers, have you given kangaroo care, or wanted to? How was it?

lundi 21 décembre 2015

Harvard Experts On Eating Disorders Call For Workplace Ban On Dangerously Thin Models

Harvard Experts On Eating Disorders Call For Workplace Ban On Dangerously Thin Models

A model during Paris Fashion Week 2015, before French lawmakers passed a ban on too-thin models. (Thibault Camus/AP)

A model during Paris Fashion Week 2015, before French lawmakers passed a ban on too-thin models. (Thibault Camus/AP)

In April, the country that’s arguably most serious about fashion got serious about fighting starvation among its models.

Consider some headlines:

Quartz: “In France, you can now be jailed for employing extremely thin models”

• Reuters: “France bans super-skinny models in anorexia clampdown”

CBS: “In France you can be too thin”

French lawmakers passed a measure that’s expected to require models to have a body mass index of at least 18 — that translates to 120 pounds if you’re 5-foot-9 and 130 pounds if you’re 5-foot-11. It proposes punishments of up to six months in prison and hefty fines for agents who violate it. Israel had passed a ban on ultra-thin models as of 2013.

Now, two Harvard experts on eating disorders are calling for similar measures in the United States. In an editorial in the American Journal of Public Health, they argue that the Occupational Safety and Health Administration (OSHA), which regulates workplace safety, should set rules that bar hiring models below a healthy body mass index for runway work or photo shoots.

I spoke with Prof. S. Bryn Austin, the paper’s senior author and director of the Harvard Chan School of Public Health’s Strategic Training Initiative for the Prevention of Eating Disorders. Our conversation, lightly edited:

What exactly are you calling for? 

What we’re calling for is new attention and government intervention from OSHA, to take seriously the risks that are being forced on models in the professional fashion industry. Many of them are girls — they’re teenagers and some young women — and of course we know there are some boys and young men. The majority of models start working as children, some in their very early teens, and they’re very vulnerable to the pressures that adults working in the industry place on them.

One of the pressures we are very concerned about is the expectation that they be extremely thin — thin beyond what anyone would consider healthy and certainly beyond what any physician would consider healthy. They’re really putting pressure on these young women and girls and sometimes boys to risk starvation — self-starvation in a way — to achieve the standards to be able to work in the industry.

Do you want OSHA to consider the French model? Or what are the specifics you’re calling for?

We’re specifically asking OSHA to take a look at this problem, and we’re recommending that one way that OSHA could intervene would be to impose limits on how low somebody’s weight could be to be able to work in the industry. The point is not to punish the models themselves — we know they don’t need any more punishment, they’re already working under horrendous conditions. The purpose of these regulations would be to prevent agents, their employers, from forcing them to keep their weight so low, to lose weight in order to get jobs.

We gave 18 as an example of what a BMI limit might be. We already know 18 is a very low BMI, and where doctors start to get concerned about somebody’s health. The World Health Organization considers a BMI of 16, which is just a little lower than that, to be medically dangerous, on its face. And then when you’re working with children, the metric changes a little bit but the idea is the same.

So you’re calling for workplace regulation — is that because attempts to do this in a more voluntary way have failed?

There have been efforts over the years, and the fashion industry in the United States and some other places have come up with voluntary guidelines. But what we haven’t seen is any real change in these pressures on models. The degree of extreme thinness really looks the same. The risks that the models are forced to take in order to keep their jobs really is the same. And you often don’t see voluntary measures getting too far if the government isn’t willing to step in and take an issue seriously. You usually need those coupled together. Certainly, the government takes very seriously workplace hazards in factories in farm work, in a number of other settings where the government has set limits on what employers can do to workers, what they can expose workers to, but they have not stepped in with the fashion industry, and they need to.

You can imagine some ripple effects — the fashion industry tends to promote extreme thinness to the whole population.

Yes, the ripple effects will be enormous. Certainly, we are first and foremost concerned about the health and safety of models working in the industry, because they are grossly abused and exploited and we have to say no. We have to stop this. Many of them are children. We have to stand up and protect these models who are working professionally in the industry.

But we also know the fashion industry projects out to the world the most unrealistic standards of female beauty — and more and more, we’re seeing unrealistic standards of male beauty, through the ways they force models to distort their bodies to get jobs. Then they project these images — sometimes with an overlay of Photoshopping, digital manipulation — that are fed to all of us. And what we’re most worried about is the images projected to girls and young women, which we know from decades of research from psychology is harmful and distorts and disturbs and undermines body image and self esteem.

So you’re saying extreme thinness endangers the models, both from their need to starve themselves and the risk of eating disorders, and then the risk of eating disorders ripples out to the rest of the population.

Yes, the fashion industry for too long has been allowed to create a toxic work environment for professional models and then a toxic social environment, a toxic media environment for all the rest of us, especially for the millions of young people growing up in this country. Every day, they’re bombarded by these images that are dangerous. We need to tell the fashion industry, ‘No! It’s time to stop, you have to take care of your workers and you need to be projecting healthy images out to the world.’

Is this the launch of something else, like a campaign?

I would say the paper is meant to launch advocacy and new serious attention on the part of our federal government but also the state governments where the fashion industry is most based, so that would be New York State in the United States.

A bill was introduced in Congress this summer to try to get better regulation of child models in particular, through amending the Fair Labor Standards Act at the federal level. And in New York State, there’s been some continuing advocacy also to protect child models and to expand that to adult models. Two years ago New York passed a similar law to what’s in Congress to protect models, and it became law. It appears that law has reduced the agents and casting directors employing children in large numbers, in order to avoid regulation. It appears they’ve been tending to employ older people, meaning like 18 and 19, but we need to go further to have more health protections. It’s not that we want the 18-year-olds exploited instead of 16-year-olds, we want none of them exploited.

When you say employers, you mean mostly agents?

Yes, that’s what part of the argument really focuses on. One of the reasons the industry has been able to get away with this is they falsely claim models are independent contractors and not employees. There are a lot of regulation and protections for people classified as employees, however, when it comes to independent contractors, there’s not nearly so many protection. OSHA needs to recognize and speak up and make clear that models are employees; they meet the definition of employees and they need to be treated with all the respect and protections that employees deserve.

Was there any particular case that prompted this work?

It’s really the continuing lack of movement. There have certainly been court cases where models have gotten together or individually have tried tried to sue. And interestingly, in those cases, judges have ruled that models are employees and not independent contractors. This is where we need the federal government to step in. And the New York State government should be stepping in here too, because clearly that’s the main center point of the industry in the United States.

Because if France already passed this ban, if you could get New York, that would be the heart of the fashion industry?

Absolutely. No designer, no agent, is going to be able to compete on a global scale if they can’t participate in the New York Fashion Week and the Paris Fashion Week. If we have the regulation in place to protect models in New York and in Paris, that will make a massive change in the fashion industry and what they’re allowed to get away with.

Readers? Reactions? 

vendredi 18 décembre 2015

From Cancer Drugs To Gut Bugs: 10 Medical Trends To Watch In 2016

From Cancer Drugs To Gut Bugs: 10 Medical Trends To Watch In 2016

Former President Jimmy Carter, whose latest brain scans show no sign of the melanoma he was diagnosed with, is a high-profile example of recent advances in treating cancer. (David Goldman/AP)

Former President Jimmy Carter, whose latest brain scans show no sign of the melanoma he was diagnosed with, is a high-profile example of recent advances in treating cancer. (David Goldman/AP) 

By Dr. Michael Misialek
Guest contributor

2016 is the year of the monkey, according to the Chinese calendar, but from my corner of the medical world — as a pathologist who tries to stay current on the medical big picture — it’s looking more like the year of the crab (cancer, that is).

Looking through my microscope, I expect the most striking medical advances next year in the field of cancer treatment. More broadly, here’s what I expect in the year to come, starting with scientific and technological progress and then getting into the health care system.

1. Cancer: Immunotherapy And More

Immunotherapy for cancer exploded in 2015. What is immunotherapy? It’s the technique by which the power of the immune system is harnessed to attack cancer. It’s already used in many cancer treatments, but it tends to be a second-line approach or reserved for advanced disease. In 2016, we’ll see more immunotherapy treatments approved and they will likely become the first-line choice in many cancers.

We can also expect to see more cell-mediated therapies — engineering a patient’s own immune cells to attack cancer — added to the cancer armamentarium. And expect to hear more about epigenetics — using the cancer cell’s genetic programming to push it back toward normalcy.

Recently, the American Association for Cancer Research convened an international immunotherapy conference, which completely sold out. One of the biggest stories to emerge was how chemotherapy resistance can be overcome using engineered proteins. Resistance is an all-too-common problem that dampens the hopes of precision medicine. These proteins, which are smaller than antibodies, will bring immunotherapy to new levels in 2016.

New drug combinations, combining traditional chemotherapy with immunotherapy, will also blossom in 2016. Such approaches are already showing promise in lung cancer, prostate cancer and melanoma. And we can expect new vaccines against cancer to emerge in 2016.

2. Related: ‘Basket Studies,’ A New Approach to Clinical Trials

Traditional drug trials test a drug against a known cancer type. With the precision medicine revolution upon us, it has become evident that many cancers, regardless of type, often share the same genetic mutations. 2015 saw the first trials of using a drug in an off-label manner to target common mutations across cancers of many different organs. Such “basket trials,” I think, will explode in popularity in 2016 in an effort to bring greater patient access to drugs. This new clinical trial paradigm will become commonplace in 2016. Already the American Society of Clinical Oncology is sponsoring its first-ever basket trial, partnering with five drug companies. Expect preliminary results in 2016.

3. Leveraging Our Gut Microbes

The bacteria in the gut have long been known to play a role in the immune system and metabolism. Now, new research is showing that many diseases may be caused in part by gut microbes, and I expect the coming year to bring a flurry of new uses for these microbes.

One of the fasting-growing applications is the use of fecal transplants to treat the deadly Clostridium difficile infection. Other diseases such as inflammatory bowel disease, irritable bowel syndrome, autoimmune diseases and allergic disease will likely see bacteria-based treatment advances in 2016.

Recently, gut microbes have even been shown to reduce the side effects of chemotherapy. Perhaps most exciting are the ways in which these bacteria are detected. Traditional methods of bacterial culture will become replaced by genetic sequencing of bacterial DNA. Such powerful information is already showing early promise in helping to stem transmission of drug-resistant bacteria within and between hospitals, a major cause of illness and death.

A microbiologist points out an isolated E. coli growth on an agar plate. E. coli is a gut microbe that plays a major role in health and disease. (Elaine Thompson/AP)

A microbiologist points out an isolated E. coli growth on an agar plate. E. coli is a gut microbe that plays a major role in health and disease. (Elaine Thompson/AP)

4. Closer To 3D-Printing Organs

2015 has brought success in the 3D printing of human tissues. Such advances will continue into 2016. Even though the holy grail of 3D-printing human organs remains years away, it is a future that now appears to be within reach. Such an accomplishment will address the current problems of organ transplantation — long waiting lists, limited organ availability and rejection. 3D printing of organs will eliminate these obstacles, as organs will be printed on demand, and from a patient’s own tissues.

2015 has seen the 3D printing of ribs, prosthetic limbs and other body parts. There has already been success in blood vessel printing, a crucial step toward building an organ. We can also expect more headlines in 2016 in the field of regenerative medicine. Cancer treatment and research may benefit if tumors can be routinely 3D printed. This field still faces regulatory challenges, and will need time and significant investment for the technology to advance, but 2016 should already bring more steps ahead.

5. Taking The Microscope Inside The Body

In vivo microscopy is a new microscopic technique in which images are obtained from endoscopes — a device on a long tube inserted into the patient’s body — in real time. The traditional way in which biopsy tissue is examined requires tissue to be removed from the body, processed in a lab and made into a glass slide, a process typically taking about 24 hours. A diagnosis is then made long after a patient has left the office or operating room. In vivo microscopy offers a number of advantages such as:

• A diagnosis can be made instantly on tissues that cannot be easily removed.
• An entire organ can be screened for microscopic disease without having to remove any tissue.
• More effective traditional biopsies can be obtained through precise targeting.
• A real-time assessment of the effects of treatment can be accomplished.

I believe In Vitro Microscopy promises to revolutionize the way we pathologists examine tissues and render diagnoses. And I expect this technology to take off like a rocket in 2016.

6. Lab On A Chip: Miniaturizing The Lab

A NASA test of an early "lab on a chip" in 2006. (Wikimedia Commons)

A NASA test of an early “lab on a chip” in 2006 (Wikimedia Commons)

Recent advances have revolutionized lab testing technology. Miniaturizing the complex and grand scale of lab testing down to a microchip will allow health care providers in 2016 to do more, with smaller samples, and more cheaply. One such company, Theranos, has already gained FDA clearance for herpes testing this year. Theranos is controversial, but more such tests will inevitably follow in 2016 if this new technology holds up to peer review. I expect 2016 to see an explosion in this minimally invasive lab testing technology. The traditional site of care will further shift outside the lab, clinic or hospital to the consumer.

7. Related: Mobile Diagnostics

Consumers can expect to see a rise in wearable health tracking technology in 2016, and providers can expect an explosion of mobile diagnostics.

“Point-of-care” handheld mobile devices will expand access to care throughout the United States and the world. Whether in remote areas of rural America, or the jungles and deserts of the Third World, this next generation of diagnostics may transform access to care in 2016. Smartphones can be easily retrofitted to microscopes and other types of analyzers.

Now for the health care system:

8.The Rise Of The Health Care Consumer

Driven by rising health care costs and higher deductibles, consumers are expecting more from health care. They are asked to pay more and also choose more. This rise of consumerism is already shaking up health care as hospitals and health systems scramble to meet the needs of more educated and demanding customers. I expect 2016 to see even more competition in the market.

Consumers are opting for the most affordable choices, often neglecting care in the process. In 2016, I expect to see care increasingly facilitated through smartphones and apps. Also more high deductible plans, a continued proliferation of “minute clinics,” more virtual health care visits and online health tools.

9. Value-Based Health Care: Bundles And Population Health

Health care value can be defined as outcomes relative to cost. 2016 will likely see “coordinated care” efforts take off in an attempt to provide high quality care at lower costs both for individuals and entire populations. I expect improved access to care and patient-centered care to make headlines in 2016, including concerted efforts to improve quality of care across the care continuum while lowering costs, eliminating waste and redundancy and controlling utilization.

“Bundled care” means a flat fee is given to providers for the care of a condition across the entire care continuum. 2016 will likely see more bundles for top users, such as cancer care, the elderly, Alzheimer’s, end of life, specialty drugs, behavioral health and social work.

For America’s seniors, this summer brought cause for optimism just as Medicare marked its 50th anniversary: A landmark study found spending and hospitalizations decreased for Medicare beneficiaries aged 65 and older from 1999 to 2013. Expect more such initiatives in 2016 as the market moves from a fee-for-service model to one of value.

10. Insurer Megamergers Change The Landscape

This summer Aetna announced it would buy Humana. In a similar move, Anthem said it plans to buy Cigna. These blockbuster insurance deals will bring the number of large insurers from five to three (UnitedHealth Group remains). This will mean less choice for consumers, particularly for seniors looking toward Medicare Advantage plans. Though the mergers will take time to complete, pass court approval and address anti-trust concerns, expect more such mergers in 2016. Accordingly, we can expect higher premiums.

Readers, expectations of your own? Hopes or fears?

Dr. Michael Misialek is associate chair of pathology at Newton-Wellesley Hospital and assistant clinical professor of pathology at Tufts University School of Medicine.