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From helping people lose weight in a healthy way, to teaching the world about life-threatening diseases, to poop and neti pots, Dr. Oz has never been dull. Relive the unforgettable »

Health-Care Costs Go Up, and Stay Up, for Abused Women

(HealthDay News) -- Women who are physically or psychologically abused by their partners spend more each year on health care, even years after the abuse stops, a new report says.

The long-term study of more than 3,300 women in the Pacific Northwest revealed that women in ongoing abusive relationships spent about 42 percent more a year on physical and mental health-care services than did women not in abusive relationships.

Even those who had not been subjected to abuse in at least five years spent 19 percent a year more for health care than those who had never suffered abuse from an intimate partner, according to findings by a team from Ohio State University, the Group Health Cooperative, and the University of Washington in Seattle.

"Along with all the physical and emotional pain it causes, domestic violence also comes with a substantial financial price," Amy Bonomi, an associate professor of human development and family science at Ohio State and a co-author of the study, said in a news release from the university.

In relationships involving psychological abuse, such as verbal threats, stifling control by a partner and other such tactics, women spent 33 percent more on health care than their non-abused peers, even though the incidents had occurred not at the time of the survey but within the previous five years.

Abuse victims sought care from specialists, prescription services and radiology far more than other women, the report found

The findings were published online in the journal Health Services Research.

The study, which included data from 1992 to 2002, found that physically and psychologically abused women sought help from mental health services at least twice as often as women who were not abused, Bonomi said.

"This lends support to the idea that mental health providers should always ask women about their abuse history when they first come in for treatment," she said.

More information
The Rural Assistance Center has more about domestic violence.

Why Cigarettes Should Cost $10 a Pack

By Scott Mowbray

Istockphoto/Health
As the U.S. government throws tax money on the banking bonfire, you have to wonder how many billion-dollar notes are left in the Washington ATM machine for health-care reform. If an income-tax hike isn’t in the cards for 95% of Americans, there will surely be a revenue hunt elsewhere.
The last time a president was looking for major health-reform dollars, it was Bill Clinton, and he targeted tobacco. The reform didn’t happen, but federal, state, and municipal taxes on cigarettes soared from about 52 cents a pack in 1994 to $2.22 per pack in 2007.
Despite that rise, tobacco tax revenue falls far short of the health-care bill associated with tobacco-related disease. Read More

Will We Soon Be Storing Our Medical History on Facebook-Like Pages?

That’s what some big companies believe. I’m not so sure
by Scott Mowbray

Count me skeptical about the Microsoft and Google forays into personal medical information storage. The idea is good: We travel through life throwing off data about our health, which scatters like dust into doctor’s computers, hospital computers, HMO computers, and pharmacy computers. That data should be organized into a personal profile and accessible—like a password-protected Facebook page—but right now the computers don’t talk to each other.

Worst case, a doctor has to make an urgent treatment decision without knowing some very recent, possibly live-saving medical history (see “My Patient Can’t Tell Me Where It Hurts”). In the future, the data optimists say, all the important information will be available through a secure link, and the patient grants access (or, if he’s unconscious, has presumably worked it out ahead of time). Continue reading »

Calcium Scans Help Predict Coronary Risk

(HealthDay News) -- Scanning the heart arteries for calcium deposits can help predict future cardiac problems, a new study shows, but experts aren't sure that adding such scans to routine checkups would be worth the cost.

"It has been shown to be predictive" of potential heart trouble, said Dr. Diane Bild, deputy director of the division of prevention and population sciences at the U.S. National Heart, Lung, and Blood Institute, which funded the study. "Whether it is actually beneficial to the people who are screened has not been shown."

A calcium scan using computed tomography (CT) costs $300 to $600. These scans look for calcification -- hardening of the arteries caused by high blood fats and calcium deposits that can eventually cause blood vessel blockage. The scan is a potential competitor for much less expensive tests for coronary risk, such as blood cholesterol and blood pressure readings.

The new study involved more than 6,700 American men and women across a number of racial and ethnic groups -- white, black, Chinese, Hispanic -- who were followed for an average of 3.8 years. It found that the risk of a coronary event was nearly 10 times higher for those with the highest calcium deposit scores than for those with the lowest.

"This study was launched in 1999, a time when there was a lot of interest in whether this new test could predict coronary artery disease," Bild said. "A lot of studies have been done in predominantly white populations. This was one of our efforts to include minority groups."

The study does show that calcium scanning "modestly improves predictions over traditional risk factors," she said. "Several pieces of information are needed in order to understand whether this is clinically useful."

The findings are published in the March 27 issue of the New England Journal of Medicine.

The cost of such scans could be reduced, according to a statement from study lead author Dr. Robert Detrano, professor of radiological sciences at the University of California, Irvine, who is traveling in China. Scans have been done for just $30 in China, Detrano noted.

"It is mostly an issue of cost," said Dr. William S. Weintraub, chief of cardiology at the Christiana Health Care System, the largest health-care system in Delaware, who wrote an accompanying editorial in the journal. "It does add to our discrimination, but it costs a couple of hundred dollars and we're not sure how you use it."

Reducing the cost would make the test more usable, and "more epidemiological studies showing its value in risk prediction would be of great value," Weintraub said.

"But I'd be uncomfortable now with the idea of recommending this for everybody, or even defining a middle ground where we are unsure how we treat people so they get this first," he said.

A calcium scan also carries some risk, since it exposes a person to radiation, Bild noted. "It would be worth it if the benefit outweighed that risk," she said. "We don't clearly have both sides of that equation established."

More information
For more on coronary calcium scans, visit the U.S. Heart, Lung, and Blood Institute.

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Anxiety Helps Elderly Women Live Longer

(HealthDay News) -- Higher anxiety levels may help elderly women live longer, but may harm older men, U.S. research shows.

A team at the Cleveland Clinic and Case Western Reserve University followed 1,000 seniors in three Florida retirement communities for up to 15 years.

They found that women with higher levels of anxiety at the start of the study lived longer than others. Year-to-year changes in anxiety levels didn't appear to affect women's survival, either.

In contrast to women, men with higher anxiety levels at the start of the study were more likely to die earlier, the researchers said.

"Our research indicates that anxiety may have a protective effect on women, possibly causing them to seek medical attention more frequently than men," Dr. Jianping Zhang, of the department of psychiatry and psychology at the Cleveland Clinic, said in a prepared statement. "In contrast, increasing anxiety over time is more detrimental to men. Additional research is needed to better understand the mechanisms and effects of anxiety in men and women."

The study is noteworthy due to the large amount of data collected over a long period of time, noted co-researcher Dr. Leo Pozuelo, who is also in the department of psychiatry and psychology at the Cleveland Clinic.

"Baseline higher anxiety could have led the female study participants to be more active and health-conscious," Pozuelo said in a prepared statement. "We are not certain of the absolute connection between anxiety and mortality, but this data set shows there may be a gender difference."

The study was to be presented Thursday at the annual meeting of the American Psychosomatic Society.

More information
The American Academy of Family Physicians has more about anxiety.

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Health Tip: When Caregiving Becomes Too Stressful

(HealthDay News) - Caring for a loved one who needs extensive help can be physically and emotionally draining. To continue providing loving care, it's important to monitor your own well-being, too.

Here are some warning signs of caregiver stress, courtesy of the American Academy of Family Physicians:

• Feeling unusually angry or resentful toward the person you care for, yourself or your family.


• Withdrawing from social activities.


• Anxiety.


• Sleeping too much or having difficulty sleeping.


• Feeling irritable.


• Being sick frequently.

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ADHD Drugs Won't Raise Risk of Substance Abuse

(HealthDay News) -- Parents of children who are prescribed psychostimulants for attention deficit-hyperactivity disorder (ADHD) might have one less thing to worry about now that a new study concludes these kids are no more likely than their peers to abuse drugs and alcohol as young adults.

The report, which was funded by the National Institutes of Health, is published in the March issue of the American Journal of Psychiatry.

"The results should reassure clinicians who might be hesitant to treat ADHD because of concerns about future substance abuse," said study co-author Michael C. Monuteaux, assistant director of research at the pediatric psychopharmacology program at Massachusetts General Hospital.

Past research looking for a link between ADHD medications and substance abuse has produced conflicting conclusions.

"Some previous studies showed an increased risk of substance abuse associated with stimulant treatment, and other studies showed both no association and also a protective effect from treatments," Monuteaux said. "But those studies had some methodological limitations, and not all of them followed their samples well into late adolescence and early adulthood."

The Massachusetts General Hospital investigators designed their study to overcome the shortcomings of previous studies. They followed their research subjects up to a median age of about 22, included an assessment for psychiatric problems such as conduct disorder that are associated with substance abuse, and applied rigorous methods to accurately analyze data.

The research study team interviewed 112 young men (ranging in age from 16 to 27) a decade after they had been diagnosed with ADHD about their use of alcohol, tobacco and a variety of psychoactive drugs. Seventy-three percent of the subjects had been treated with stimulants at some time, and 22 percent were currently taking the stimulant medications.

The study found no relationship between having ever received stimulant treatment and the risk of future alcohol or other substance abuse. The age at which stimulant treatment began and how long it continued also had no impact on substance use.

"This study is a continuing effort to explicate the factors that mediate risk. It is methodologically sound and suggests that, as always, things are more complicated than we want them to be. The study demonstrates that the use psychostimulants for ADHD children do not increase the risk for substance abuse in adulthood, but it also suggests there is no protective effect, said Dr. Jon A. Shaw, director of the Division of Child and Adolescent Psychiatry and Behavioral Science at the University of Miami.

Symptoms of ADHD include impulsiveness, hyperactivity and inattention. According to a study published last fall in the Archives of Pediatrics & Adolescent Medicine, almost 9 percent of American children have ADHD, but only 32 percent of them are getting the medication they need.

"There is sufficient evidence that parents should be reassured that the use of psychostimulant medication for the treatment of ADHD in children and adolescents does not increase the risk for substance abuse in later life and remains the most effective treatment for this condition," Shaw said.

More information
For more on ADHD, visit the National Institute for Mental Health.

Gene Variations Help Regulate Response to Stress

(HealthDay News) -- Certain variations in a gene that helps regulate stress response offer protection against depression in adults who suffered abuse when they were children, a new study says.

Adults who were abused as children and didn't have the protective variations of the CRHR1 gene had twice the symptoms of moderate to severe depression, compared to those with the variations.

The researchers interviewed more than 400 adults and tested their DNA. About one-third of them had the protective variations in the gene that produces CRHR1, a receptor for the stress hormone corticotropin-releasing hormone (CRH).

Extreme stress in childhood, brought on by factors such as abuse, can hyper-activate the hormone system that regulates stress response, leading to an increased risk of depression in adulthood, the researchers said.

"Our results suggest that genetic differences in CRH-mediated neurotransmission may change the developmental effects that childhood abuse can have on the stress hormone system -- developmental effects that can raise the risk of depression in adults," Dr. Kerry J. Ressler, of Emory University, said in a prepared statement.

"We know that childhood abuse and early life stress are among the strongest contributors to adult depression, and this study brings to light the importance of preventing them," Ressler said. "But when these tragic events do occur, studies like this one ultimately can help us learn how we might be able to better intervene against the pathology that often follows."

The study, funded by the U.S. National Institute of Mental Health (NIMH), is published in the current issue of the journal Archives of General Psychiatry.

NIMH Director Dr. Thomas R. Insel said in a prepared statement: "People's biological variations set the stage for how they respond to different environmental factors, like stress, that can lead to depression. Knowing what those variations are eventually could help clinicians individualize care for their patients by predicting who may be at risk or suggesting more precise avenues for treatment."

More information
Mental Health America has more about depression.

Born to Be Obese?

(HealthDay News) -- The brain circuitry that controls appetite might be wired differently in some people, and that could predispose them to obesity, California researchers suggest.

The study was conducted in rats, not humans, and yet it could ultimately lead to novel obesity treatments, said Philip Smith, director of the Office of Obesity Research at the National Institute of Diabetes and Digestive and Kidney Diseases.

"It is not just about drugs that modify short-term appetite," he said, "there may be drugs that stimulate development of the appropriate neural pathways. So, it is an exciting, but very early, time in this field."

The study was published in the February issue of Cell Metabolism.

Sebastien Bouret, an assistant professor of neuroscience at the University of Southern California, and his colleagues examined neural circuits emanating from the appetite, hunger and body-weight control center of the brain -- the so-called arcuate nucleus of the hypothalamus (ARH) -- in a series of rats bred to be either prone to, or resistant to, obesity.

The team found fewer neural connections projecting from the ARH in obesity-prone animals than in their leaner counterparts. Surprisingly, Bouret said, this deficiency developed very early in life, before the animals became obese, and appeared to extend into adulthood.

"Somehow, these animals are programmed to become obese," Bouret said. "The obesity is hard-wired into the brain."

When the researchers then looked at why the brains of obese rats differed from their normal-weight counterparts, they found that the neurons from obesity-prone animals were less responsive to leptin, a hormone that controls the development of these circuits, and which also signals the body's energy status and controls metabolic rate.

"This paper presumes to say, these animals must be leptin-resistant, and that is why the pathways are not developing," said Smith.

But that doesn't mean they are doomed to a life of severe obesity, said Dr. Barbara Kahn, chief of the Division of Endocrinology, Diabetes and Metabolism at Beth Israel Deaconess Medical Center, in Boston. How they live their lives also matters.

"It is important not to 'blame' the obese person or imply that he/she is responsible for being obese," Kahn noted. "Having said that, reasonable, healthy caloric restriction and a safe and sustainable program of physical activity can help limit weight gain and often bring about some degree of weight loss. In addition, healthy eating and regular exercise can reduce the complications of obesity such as type 2 diabetes and cardiovascular disease."

At the same time, she added, not everyone can wear a size 4.

"There is a certain aspect of genetics that sets somebody in a certain range of possible body weights, and then how that person lives his or her life will determine whether they are at the bottom or top of the range," she explained.

Human obesity has both genetic and environmental roots. The rats used in this study, like most humans, developed obesity when fed a high-energy diet. On a normal diet, they were heavier than normal rats, but not yet obese.

"This is quite an exciting paper," said Smith, "because it links more closely to human behavior than most rodent models we have seen."

The findings also suggest a possible therapeutic approach to combating human obesity. If drugs could be designed to influence the formation of neural circuits during development and targeted to at-risk pregnancies, Smith said, "there is a good likelihood we could have successful interventions that improve the health of the mother, and which have a major impact on disease risk for the infant, during pregnancy."

A related study from Boston University researchers in the same journal found that bulking up muscle mass can lead to a general metabolic improvement in obese individuals. "Interventions designed to increase skeletal muscle mass in at-risk human populations may prove to be critical weapons in the fight against obesity and obesity-related comorbidities, including diabetes, heart disease, stroke, hypertension and cancer," an accompanying editorial stated.

More information
For more on obesity, visit the National Institute of Diabetes and Digestive and Kidney Diseases.

Genetics May Determine Antidepressants' Effectiveness

(HealthDay News) -- Genetic variations that predict patient response to the two common antidepressant drugs citalopram (brand name Celexa) and venlafaxine (Effexor) have been identified by German researchers.

The team at the Max Planck Institute of Psychiatry in Munich found that 11 variants in the gene for a protective transporter protein called P-gp, which removes drugs and other substances from the brain, compromise the effectiveness of these two drugs.

In the first part of the study, the researchers knocked out genes for P-gp in mice and gave them antidepressants. They found that brain concentrations of citalopram and venlafaxine were regulated by P-gp, indicating that the antidepressants were "substrates" of the transporter protein.

Next, the team analyzed 443 people on antidepressants for genetic variants that correlated with reduced efficacy of the two antidepressants.

"To our knowledge, our results provide for the first time evidence that genetic variants in the (gene for P-gp) account for differences in the clinical efficacy of antidepressants, most likely by influencing their access to the brain," the researchers wrote.

The findings, published in the Jan. 24 issue of the journal Neuron, suggest that genetic testing could help predict how individual patients would react to specific antidepressants, the researchers said.

They added that genetic tests may also help predict the effectiveness of any drugs used to treat neurological diseases.

"The general conclusion to be drawn is that any drug treatment administered to treat CNS (central nervous system) diseases should be analyzed for its P-gp substrate status, which can be determined by using knockout mice. From a clinical point of view, the findings warrant that patients receiving a drug that is a P-gp substrate for the treatment of brain diseases are genotyped to exclude the possibility that a patient receives a drug that fails to enter the CNS to an extent required for efficacy," the study authors wrote.

Future development of antidepressants should take into account whether new drugs are transported by P-gp, and clinical trials of antidepressant drugs need to factor in the P-gp genetic status of participants, the researchers recommended.

More information
The U.S. National Institute of Mental Health has more about depression.

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Terriers Join Fight Against a Killer Disease in Humans

(HealthDay News) -- A feisty breed of terrier could stop scientists from barking up the wrong tree as they research a deadly lung disease in humans.

The illness, called idiopathic pulmonary fibrosis (IPF), affects 128,000 Americans, is typically fatal within three years of diagnosis, and kills more than 40,000 people in the United States annually -- a death toll equivalent to that of breast cancer.

A fatal condition that looks remarkably like IPF also strikes the diminutive West Highland White terrier ("Westie"), however. And recently, medical scientists from the human and veterinarian worlds met for the first time to share information and pool resources against a mysterious killer.

"People may be a little startled at first to learn about this idea -- 'You're kidding me, you actually think there's promise in studying this dog to help my Dad with this disease?' And the answer is -- 'Yes'," said Mark Shreve, chief operating officer of the patient advocacy group Coalition for Pulmonary Fibrosis, based in San Jose, Calif.

Because the Westie is so tightly bred, and because the illness progresses faster in dogs than humans, it is conceivable that dog-based research might yield valuable clues to the genetics or environmental factors that trigger pulmonary fibrosis in both species, experts explained.

"And if it transpires that it is the same disease, then obviously the options are limitless as to how we can look at information from dogs and use it to understand the disease in humans and vice versa," said Dr. Brendan Corcoran, director of the Hospital for Small Animals at the University of Edinburgh, Scotland, and a pioneer in researching pulmonary fibrosis in Westies.

According to Shreve, most people find it hard to believe that a disease like IPF even exists amid the wonders of modern medicine.

"We are dealing here with one of the few diseases left on the planet for which there are no proven causes and no treatments," he said.

Idiopathic pulmonary fibrosis occurs spontaneously, although certain factors -- such as smoking or exposure to airborne toxins -- do raise risks for the illness. "IPF is a progressive scarring process in the lungs that gradually robs a person of the ability to breathe," Shreve explained.

Some sort of signaling seems to go awry at the cellular level, he said, converting normal, expansive lung tissue into stiff, fibrotic scar tissue.

"Once it starts in patients with IPF, your body just never sends a signal to stop that scar tissue from being produced," Shreve said. "This scar tissue is obviously not lung tissue that is able to process oxygen."

There have so far been very few promising leads in discovering the root causes of IPF, said Dr. Jesse Roman, one of the country's leading researchers in the disease and a professor of medicine at Emory University in Atlanta.

"Studies do suggest very specific [cellular] pathways, and there's a number of molecules that everybody is tuned into," he said. "But how you block them and how they relate to what happens in humans, that's less clear."

So, scientists are turning to creative new ways of looking at IPF.

Cross-talk between scientists worldwide led to the first-ever summit on the disease that included both veterinary and human medical researchers. The meeting was held in October on the campus of Purdue University in West Lafayette, Ind., and was attended by Corcoran, Roman and others. It was sponsored by the Westie Foundation of America and the American Kennel Club (AKC) Canine Health Foundation.

Westies, which grow to just under a foot in length, are described by the AKC as "courageous and self-reliant, but friendly."

"They're a very popular pet because of their size and their nature," Corcoran said.

However, pulmonary fibrosis does pop up in the breed with regularity, first revealing itself as excessive panting and shortness of breath. The illness also tends to develop in the terriers' late middle-age (about eight or nine years), mimicking its typical onset in humans at about age 50 to 60.

Westies inevitably succumb to the lung fibrosis about a year and a half after their diagnosis, Corcoran said.

Still, "there's still the contentious issue of whether this is the same disease as occurs in humans," he said. The exact prevalence of the disease among Westies is also unclear, he added. That means the first aim of Westies-centered research will be epidemiological -- studying disease prevalence and gathering a core of dogs and their owners that researchers might follow going forward.

Getting postmortem samples of canine lung tissue will also be crucial to a better understanding of the causes of the disease, Corcoran said. But that has its own challenges, he added.

"Getting owners to volunteer their dogs for necropsy is always problematic," he said. In fact, it's often "harder in many instances to get lung pathology samples from dogs than it is from humans," Corcoran said.

"However, one of our plans is to try and build up a group of concerned owners who will volunteer to donate their dog when that day arrives. We've been having some discussions on that already with our colleagues in America," Corcoran said. "Hopefully, the more publicity that we get with this condition, the more we may get owners coming forward and volunteering their dogs for research."

Corcoran and the other experts said that a cure for IPF is definitely not around the corner -- the disease has been as tenacious in keeping its secrets as, well, a terrier.

But Westies may be just the foe in the fight against IPF requires. Corcoran pointed out that the dogs' tight breeding means genetic research could yield important clues. And their shorter lifespan -- a seventh of that of humans -- means scientists can watch the disease in "fast-forward," which might also speed research.

Westies are also free of certain confounding factors, such as smoking, that often muddle human research. "The dogs might turn out to have a very pure form of the disease that allows you to investigate the disease itself and not worry about other factors," Corcoran noted.

Given all of this, "why wouldn't you look at a Westie and research how the disease progresses?" said patient-advocate Shreve.

"We think it's a very creative approach to trying to help out humans," he said, "and our patients don't really have the patience to hang around waiting for a miracle.

More information
To learn much more about IPF, visit the Coalition for Pulmonary Fibrosis.

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Realistic Expectations Help Ward Off Holiday Depression

(HealthDay News) -- For many people, heightened expectations, financial and social stress, and memories of lost loved ones can cause tension, anxiety and sadness.

All of that can lead to seasonal blues during the holidays, says an expert at Cedars-Sinai Medical Center.

For example, people who expect difficult relationships to improve just because it's Christmas are likely to be disappointed.

"In terms of relationships, nothing magical 'just happens' during the holidays," Dr. Mark H. Rapaport, chair of the department of psychiatry and behavioral neurosciences at Cedars-Sinai, said in a prepared statement.

"If you don't get along with your in-laws during the year, you're probably not going to get along with them during the holiday season, either. Understanding that before you go to visit them can improve how you'll handle your feelings while you're there," he said.

Planning ahead can help people cope with many sources of holiday-related stress and anxiety.
"If you plan ahead and focus on what you really enjoy about the season, you can spend more time 'living in the moment,' which is the key to getting the most out of each holiday experience," Rapaport said.

He offered some tips for coping with the holidays:

• Have realistic expectations about interactions with family and friends.
• Make a list and prioritize activities that you feel are most important.
• Limit your drinking. Too much alcohol can lead to bad behavior, hangovers, and remorse which, in turn, can lead to depression.
• Share holiday responsibilities such as shopping, cooking, party planning, and activities.
• Get regular exercise. Walking for just 30 minutes three times a week can give you a big boost.
• Keep your holiday spending under control.
• Eat well, get enough rest, and make time for yourself.
• Spend time with caring and supportive people and reach out to those who may benefit from your support.
• Don't worry too much about details. Live in the moment as much as possible and look for meaningful moments throughout the season.

More information
Mental Health America has more about holiday depression and stress.

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Health Tip: What's Plantar Fasciitis?

(HealthDay News) - Plantar fasciitis is a common condition -- caused by overuse -- and characterized by often severe pain in the heel.

The American Academy of Orthopaedic Surgeons offers additional information about the condition, including its risk factors:

• Women and people who are overweight are more likely than others to develop plantar fasciitis.
• Frequent running or walking for exercise may increase your risk of developing the condition.
• People with flat feet or very high arches are at greater risk.
• Standing or walking on hard surfaces for long periods also may increase your risk.
• The injury usually doesn't hurt during exercise, but pain begins to develop afterward.
• Pain may be most severe when waking up in the morning, or after rest.
• Plantar fasciitis requires treatment to prevent it from becoming chronic.

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Cancer Patients Gain From Reporting Symptoms Online

(HealthDay News) -- Having cancer patients report to doctors on their symptoms and side effects online may improve their care, a new study finds.

Even the sickest cancer patients are willing and capable of reporting their symptoms online, says a team from Memorial Sloan-Kettering Cancer Center in New York City.

"Cancer care has become increasingly complex, causing office visits to become more compressed. This makes it challenging for the clinician to comprehensively assess each patient's symptoms in that brief window of time," study author Dr. Ethan Basch, a medical oncologist, said in a prepared statement.

"Because cancer therapies can be highly toxic, early detection of symptoms and timely treatment is vital. What is exciting to us about online self-reporting is that patients can alert clinicians to crucial symptoms in real time," Basch said.

The study included 107 lung cancer patients receiving outpatient chemotherapy who had access to a secure Internet patient reporting system developed by Basch and his colleagues. The patients were able to access the Symptom Tracking and Reporting (STAR) site using computers in waiting room kiosks and at home to report cancer symptoms and chemotherapy-related side effects.

The patients were followed for up to 16 months and 40 visits. All of the patients used the waiting room kiosks at some or all of their office visits, and an average of 78 percent logged onto the system at any given office visit. Patients were more likely to use STAR if they had prior computer experience.

The study found that 98 percent of patients found STAR easy to use, 90 percent said it was useful, and 77 percent believed it improved the quality of their discussions with clinicians.
The study appears in the Dec. 1 issue of the Journal of Clinical Oncology.

More information
The U.S. National Cancer Institute has more about coping with cancer.

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Health Tip: Female Infertility

(HealthDay News) - About 7.3 million females in the United States aged 15 to 44 had difficulty becoming pregnant or carrying a baby to term in 2002, according to the U.S. Centers for Disease Control and Prevention.




The U.S. Department of Health and Human Services lists these factors that may contribute to female infertility:

• Age.
• Stress.
• Unhealthy diet.
• Being overweight or obese, or significantly underweight.
• Strenuous exercise.
• Smoking or drinking alcohol.
• Sexually transmitted disease.
• Health conditions that affect hormone production.

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Prostate Cancer Treatments Often Compound Existing Health Problems

(HealthDay News) -- More than a third of prostate cancer patients may receive treatments that are inappropriate because of problems they are already having with urinary, bowel or sexual function, a new study suggests.

These mismatches might occur, because patients don't give enough information to their doctor or because their doctor favors a particular type of treatment, according to the report in the Nov. 26 online edition of Cancer.

"We found an awful lot of patients whose treatment seemed to be contraindicated by urinary, bowel or sexual problems they had before they got treated," said lead researcher Dr. James Talcott, from the Center for Outcomes Research at Massachusetts General Hospital Cancer Center in Boston. "That's pretty good evidence that information wasn't transmitted or didn't factor in with the treatment decision."

Unlike other cancers, there are several treatment options for prostate cancer. The treatment that is best for an individual patient is based on several factors, including stage at which the cancer is diagnosed, age of the patient, and existing problems with urinary, bowel or sexual function that the patient has.

Treatments include external radiation therapy; brachytherapy, in which tiny radioactive particles are implanted into the prostate gland, and the surgical removal of the prostate gland.
Although these treatments are effective, each has a different set of side effects. External radiation can lead to bowel dysfunction, brachytherapy can cause urinary problems, and surgery can damage nerves involved in sexual function.

Treating patients who already have problems in these areas with a procedure that could exacerbate their problem is usually not recommended.

For example, treatment designed to preserve normal functions, such as nerve-sparing, prostate-removal surgery, is not appropriate for patients who have already lost sexual function, Talcott said.

To find the extent of treatment mismatches, Talcott's team collected data on 438 prostate cancer patients. Patients were asked to complete questionnaires that included questions about urinary incontinence and other urinary problems, and bowel and sexual dysfunction.

The researchers found that 89 percent of the patients had some level of urinary, bowel or sexual problem before starting treatment. Among these patients, 34 percent of those with one serious symptom had a mismatched treatment, as did 37 percent who had a less serious symptom. Moreover, 40 percent of those who had several symptoms also received contraindicated therapy.

In addition, among patients with significant dysfunction in all three areas for whom no treatment would be recommended, only 5 percent chose watchful waiting. In this strategy, patients are not treated but are followed closely.

These mismatches appear to occur because doctors and patients don't communicate well. Patients are often reluctant to talk about urinary, bowel and sexual problems, Talcott said. "And, sometimes patients override their doctor's recommendation," he added.

Talcott also thinks that physicians can be wedded to a particular treatment at the exclusion of others. "Surgeons believe in surgery, and radiation oncologists believe in radiation," he said. "That may be part of the problem."

To counterbalance physician bias, patients should get another opinion, Talcott said. "Patients should always get a second consult," he said. "It's a good idea to talk with a surgeon, a radiation oncologist and possible a medical oncologist."

One expert thinks that patients need to make an informed decision about which treatment is best.

"The kind of doctor that you see often predetermines the treatment you receive," said Dr. Durado Brooks, director of prostate and colorectal cancer at the American Cancer Society. "Urologists are much more likely to have a surgical solution, and those who see a radiation oncologist are more likely to have radiation."

Patients need to be well-informed about their condition and the possible treatments and their side effects, Brooks said. "Patients need to arm themselves with as much information as possible about what their treatment options are, and what some of the contraindications of particular treatments are," he said.

Men also need to know what all the treatment options are, Brooks said. "Men need to be aware that, in some cases, depending on their overall medical condition and the stage of their cancer, that it is, at times, appropriate not to have any active treatment," he said. "Watchful waiting is a legitimate option in a significant proportion of men."

"In addition, doctors need to work with their patient to choose the best treatment option, Brooks said.

"If one takes the time to have a discussion, educate the patient and not rush them into a decision, then you may be able to allow them to get past their emotional response and make a more educated, logic-based response," Brooks said.

Brooks noted that because there are so many treatment options in prostate cancer, patients may insist on a particular treatment even though it's not the best choice for them.

"Where treatments are contraindicated in other places in medicine, doctors don't provide a treatment for a patient just because that's what they say they want," Brooks said. "You explain that that treatment is simply the wrong treatment for you, and therefore, we are not going to take that approach."

More information
For more on prostate cancer, visit the American Cancer Society.

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Precancerous Lesions Raise Cervical Cancer Risk

(HealthDay News) -- Women who have had advanced precancerous lesions of the cervix are still at risk for invasive cancers up to 25 years later, Swedish researchers report.

Currently, the American Cancer Society recommends that women who have had precancerous lesions called severe dysplasia/carcinoma in situ (CIS) continue getting Pap tests for 10 years after treatment. But, based on this study, these guidelines may need to be changed, said Debbie Saslow, the society's director of breast and gynecologic cancer, who was not involved with the research.

Saslow added, however, that even though these women continue to be at risk for developing cervical or vaginal cancer, the risk is low. "Women who have been treated for advanced precancer do need to remain vigilant," she said.

"This paper is going in my file for when we update our guidelines in the next two years," Saslow added. "We will see if we want to stick with 10 years or go to a much wider interval."

The study was led by Dr. Bjorn Strander, a senior consultant with the Department of Obstetrics and Gynecology at Sahlgren's Academy at the University of Gothenburg. The researchers collected data on 132,493 women who had a diagnosis of severe dysplasia/CIS between 1958 and 2002. The statistics came from the National Swedish Cancer Register.

The researchers found 881 women had developed cervical cancer, and 111 had developed vaginal cancer more than one year after the initial diagnosis. This was almost seven times higher than expected, the researchers said.

Women with a diagnosis of severe dysplasia/CIS were more than twice as likely to develop cancer compared with the general female population. The women were also twice as likely to develop invasive cervical cancer after diagnosis of CIS if that diagnosis was made between 1991 and 2000, compared with the same diagnosis made from 1958 to 1970. This increased risk might be due to changes in treatment over that period, particularly because fewer hysterectomies are being done as part of treatment for CIS, the study authors said.

Strander's team also found a particularly high risk for women over age 50, and this risk continued to increase with age. "The risk after treatment hardly decreases at all after treatment and is still sustained after more than 25 years," he said.

"While well-screened women after 50 to 60 years of age are very well protected from cervical cancer and have little, if any, further use of screening, this does not apply to women who have been treated for grade 3 CIS," Strander said. "They need, and should have, long-term follow-up, perhaps lifelong," he said.

The results are published in the Oct. 26 edition of the British Medical Journal.

More information
For more on cervical cancer, visit the American Cancer Society.
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Doctor-Patient Bond Frays After Medical Mistake

(HealthDay News) -- Serious medical errors don't just affect the health of the patient, they can quickly destroy the patient's relationship with his or her doctor, too, experts say.

Too often, a health care mistake causes shame and fear in the physician responsible, leading to stilted, unsatisfying conversations with -- or avoidance of -- the affected patient, say the authors of an article in the Oct. 25 New England Journal of Medicine.

All of this can quickly move patient and doctor into an adversarial or litigious position.

But that's not always necessary, said one of the article's co-authors.

"Trust is an enormously important part of medicine -- if people aren't straight with you, you do not trust them," said Dr. Tom DelBanco, a professor of general medicine and primary care at Harvard Medical School.

"So, being upfront and honest, indicating that you want to do something about what happened, makes all the difference in the world," said Delbanco, who co-wrote the article with Harvard colleague Dr. Sigall Bell.

In many cases, doctors who frankly admitted their mistake and told patients how they would safeguard against future errors avoided litigation by doing so, Delbanco said. Those doctors also maintained strong, long-lasting bonds with the patient and the patient's family.

According to Delbanco, several patients interviewed for the article (and a related film) said that, " 'We don't expect you to be perfect, everybody makes mistakes. We just want you to be honest when it happens. We can deal with that.' "

In fact, "There are now some malpractice [insurance] companies that teach doctors to be honest and open," Delbanco noted. "There is slowly growing evidence that it may actually prevent lawsuits."

Medical errors have gotten a lot more attention recently, ever since the U.S. Institute of Medicine issued its 1999 report, To Err is Human. That report estimated that the deaths of more than 100,000 Americans each year are tied to some form of medical mistake.

In the wake of such errors, doctors often feel shame and guilt, as well as fear linked to the looming threat of lawsuits. For legal reasons, "I think that doctors are very confused about what they can and cannot say" to patients after an error comes to light, Delbanco said. That includes the use of simple words such as "mistake," "error," or even "I'm sorry."

"It depends on their institutions' views, it depends on the lawyers that they may or may not talk to," Delbanco said. "Very often, they are not only confused, but depressed, because they feel like they cannot say what they really feel like saying."

People who care deeply for a patient affected by a medical mistake often shoulder their own level of guilt after the incident. "Family members, in particular, can feel extraordinary guilt," Delbanco said, and often berate themselves, thinking, " 'If I had done this, this wouldn't have happened,' 'If I had been there, I would have prevented it,' 'If only I had been more forceful, the doctor wouldn't have done this.' "

Such was the case for those close to a young man with sickle cell anemia, mentioned in the NEJM article. The unnamed patient received morphine while in the hospital -- despite a well-documented allergy to the painkiller. He slipped into kidney failure and coma soon after, and his sister said she felt as if she "failed her family in terms of 'I should have been there.' That's a guilt that everyone shares."

Doctors who acknowledge that a mistake has happened, and outline steps to prevent such mistakes going forward, can ease a lot of distress for themselves and the patient, experts say.

But, in many cases, physicians have "a lack of confidence in their communication skills -- they just aren't sure how to have these conversations," said Dr. Thomas Gallagher, associate professor of medicine at the University of Washington School of Medicine, in Seattle.

Gallagher said Delbanco's and Bell's article echoes the findings of studies he has led, which revealed profound differences in the ways doctors and patients communicated after a serious medical error.

But he also believes the landscape around medical errors is changing. Already, about 30 states have enacted so-called "I'm sorry" laws, which, to a certain degree, make a doctor's apology for an error inadmissible in a court of law.

That should help ease patient-doctor conversations. But Gallagher said many of these laws still "provide very little protection for clinicians. They allow you to say 'I'm sorry,' but they don't allow you to make any expression that a mistake happened or to admit liability."

And, he said, it's not entirely clear that admitting to mistakes always wards off a lawsuit. "It's not a magic bullet," Gallagher said. "There will clearly be some cases where disclosure is what precipitates a lawsuit."

So, work remains to be done in finding strategies that allow patients and doctors to remain close even after a mistake occurs.

For his part, Delbanco said he is currently screening his film for third-year students at Harvard Medical School -- at the request of the school's dean -- to help them become better physicians. "Traditionally, there's been little coaching in this area," he said. "That's changing."

His advice to patients: If a serious medical error occurs, "be very aggressive in asking for communication. Patients should not be afraid of opening their mouths." And if that communication is not forthcoming, "Ask why and with whom can they speak?" he said.

And a hasty "I'm sorry" from a physician may not always be adequate, Delbanco added.

"Apology only means something when you show what you are going to do for that person -- and for the next person," he said. "Otherwise, they are just words."

More information
There's more on preventing medical errors at the U.S. Agency for Healthcare Research and Quality.

Best Breast-Cancer Care Eludes Older Women

(HealthDay News) -- As women live longer lives, the number of breast cancer cases among older patients is rising, too.

Yet many older women are being under-diagnosed and under-treated for the disease, studies show. Often, age -- rather than health status -- is the deciding factor in determining how to care for the 80-and-older set.

"I think that the biggest problem to this point has been physicians' and patients' attitudes toward treatments," said Dr. David A. Litvak, a general surgeon and surgical oncologist for the Permanente Medical Group in Southern California.

Patients, on one hand, often have misconceptions about what the treatment involves. "They think it's going to be too disruptive to their daily lives," Litvak said. On the other hand, a lot of physicians have biases about treating anyone over 80, he added. Their thinking is, "How much time could they possibly have left?" As a result, many doctors assume a "leave-them-alone sort of attitude," he said.

Litvak led a study examining the medical records of 354 women, 70 and older, who were diagnosed with breast cancer at a community hospital in Michigan between 1992 and 2002. The study was published recently in the Archives of Surgery.

In all, 46 percent of the women had breast cancer that doctors could detect during a physical examination. Even though 72 percent of the women had mammograms, those tests were given mainly to verify the physical exams.

Seventy percent of the women were diagnosed when their cancer was in the early stages. But 36 of the women overall, and 56 percent of those 80 and older, were never closely evaluated to see whether the cancer had spread to their lymph nodes.

The study also revealed lapses in treatment. About half of the women had breast-conserving surgery, but fewer than expected received chemotherapy, radiation and hormonal therapy after surgery, and the rates of treatment were lowest among the oldest women.

The findings add to a growing body of medical literature examining the under-treatment of older breast cancer patients.

Dr. Rebecca Silliman, a professor of medicine and public health at Boston University and chief of the geriatric section at Boston Medical Center, noted that she and others have been reporting on this gap in care for many years. As a co-author of a recent article in the journal Cancer, she and her colleagues have even linked under-treatment to a higher risk of breast cancer recurrence in older women.

"What is really needed is better evidence for treatment efficacy in this age group, plus more accurate strategies for identifying those at risk of bad outcomes and matching treatment intensity to risk," she said. "This isn't being done as well as we would hope."

Dr. Arti Hurria, director of the aging and cancer research program at City of Hope in Duarte, Calif., is leading an effort to develop a geriatric assessment tool to improve the ability to predict how an older breast cancer patient will tolerate certain treatments and what the benefits of treatment will be.

"We've developed a geriatric assessment that's feasible to do within daily practice, and now we're looking to see how does the assessment predict how an individual will do if they receive a certain treatment, or if they don't," she said.

The tool is simple enough that most patients can provide the information themselves and complete the survey in less than 30 minutes, Hurria said. It asks about a patient's activity level, medical problems, social support, nutritional status, and psychological state, among other things.

The assessment seeks to gather information about a woman's life expectancy, tolerance to treatment and access to support systems that may be necessary to get through therapy, Hurria said.

For example, she explained, "If they don't have social support, can we get a visiting nurse in? If they are feeling depressed and anxious, should we be getting some physiological support as part of the treatment plan?"

Litvak supports geriatric assessments as a way to get past age discrimination. "We should be changing our way of treating older patients and not have absolute cutoffs for age," he said.

More information
Read the American Geriatrics Society's position statement on breast cancer screening for older women.