How to Take Care of the Very Old and Still Preserve Their Independence

By Dena Rifkin, MD

We treated a very old woman in the hospital this week. She was nearly 100, but looked ageless, sitting by the window and watching the world go slowly by her. She had gotten unsteady and short of breath at home and was waiting for us to make things better.

There’s something regal about the very old. As a physician, I tread lightly with them. They are survivors, but fragile. The slightest change or perturbation in their care can lead to all kinds of complications, from disorientation or delirium to falls. In fact, preventing falls and delirium in the elderly is a major focus of geriatric practice and research. Read More

Sleep Apnea Linked to Night Heart Attacks

(HealthDay News) -- A study links night-time heart attacks with the breathing disorder sleep apnea, which makes people gasp for breath every few minutes.

The link is not fully established, but it seems logical, said Dr. Virend Somers, a cardiologist from the Mayo Clinic who is lead author of the report in the July 29 issue of the Journal of the American College of Cardiology.

Most heart attacks occur in the day, generally between 6 a.m. and noon, Somers said. Having one during the night, when the heart should be most at rest, means that something unusual happened, he said. Somers and his colleagues have been working for a decade to show that sleep apnea is to blame.

Their studies have looked at the most common form, obstructive sleep apnea, in which the tube carrying air to the lungs, collapses periodically, blocking the flow. "About 10 years ago, we showed that obstructive sleep apnea has a powerful effect on the sympathetic nervous system, causing an acute increase in adrenaline flow, high blood pressure and lack of oxygen," Somers said.

That study was followed by another showing that sudden death at night is more common for people with sleep apnea. An obvious cause of sudden death is a heart attack, so in this latest study, Somers and his colleagues studied the breathing patterns of 92 people admitted to the hospital after heart attacks.

"For those who had heart attacks at night, the vast majority had undiagnosed sleep apnea," Somers said. "So, perhaps sleep apnea is acting as a trigger for night-time heart attacks."

The "perhaps" is there because it is an observational study, not the kind of carefully controlled study that is the gold standard of medical research. Prospects for such a study, in which people with and without sleep apnea would be followed for months or years to determine their risk of night-time heart attacks, are dim, Somers acknowledged.

Several studies have shown a link between sleep apnea and cardiac problems, said Dr. Allan Pack, director of the sleep center at the University of Pennsylvania. The largest, done several years ago, followed thousands of individuals. "It showed that people with sleep apnea who refused treatment had a three- to fourfold increased risk of cardiac events," Pack said.

What the new study adds is "a relative difference in the timing of cardiac events," he said. In clinical practice, if someone has a heart attack in the night, "you would strongly suspect sleep apnea," Pack said.

If tests detect sleep apnea, there is an effective treatment available that can reduce the risk of future cardiac events, he said. Continuous positive air pressure (CPAP) keeps airways open continuously by pushing air into the lungs through a face mask.

"It might be cumbersome, but it is effective," Pack said.

More information
Learn about the symptoms and treatment of sleep apnea from the American Sleep Apnea Association.

Workshop Helps Parents, Kids Talk About Sex

(HealthDay News) -- Teach parents how to talk about sex with their teen, and they will tackle this tough subject more readily and often, a new study says.

The study, published online July 11 in British Medical Journal, evaluated a workshop-based program called "Talking Parents, Healthy Teens" aimed at parents of 6th- to 10th-graders. In eight weekly, hour-long sessions, the parents use role-playing and other interactive exercises to learned techniques for starting and sustaining conversations on sex in everyday situations. The parents were also instructed on how to listen to their children without interrupting or lecturing, and how to teach decision-making and assertiveness skills to their kids.

The program also recognized diverse views on sex that parent might have. For example, one session covered both abstinence and condom use for teens.

"The great thing was that the parents really learned," lead researcher Dr. Mark A. Schuster, chief of general pediatrics and vice chairman for health policy research at Children's Hospital Boston, said in a news release issued by the hospital. "We'd teach them some skills one week, and they'd come back the next week, bubbling over with excitement that they'd talked with their teen about relationships, love or sex, and this was the best part: Their teen had actually engaged in a real conversation with them, or role-played a topic like how to say no to unwanted sexual advances."

Several surveys done after the program reported the participants said they had more dialogues about sex with their kids than ever before and were also better able to discuss sex openly with their children.

Similar follow-ups with the participant's children agreed. For example, they reported in a survey done one week after the classes concluded that 18 percent of their parents had gone over how to use a condom, compared with 3 percent of the parents in a control group. Nine months after the sessions ended, this gap had grown to 25 percent versus 5 percent.

The researchers held the program sessions during lunch breaks at large private and public companies, a strategy designed to draw more parents to the program through convenience alone.

"Many employers provide programs to help employees lose weight or stop smoking," Schuster said. "We wanted to see if we could apply worksite health promotion principles to help parents address their kids' sexual health. It turned out that employers loved the idea. They are under pressure to create family-friendly workplaces. And they're often providing the health insurance for these kids, so they are concerned about lost productivity when parents are distracted with their kids' sexual health issues."

More information
The U.S. Department of Health & Human Services has more about talking to your child about sex.

My Little Niece’s Surgery: Hospitals Are Stingy With Pain Relief

By Theresa Tamkins

My niece, Zoe, traveled with her mom and dad from Miami to our house last weekend because the 4-year-old was scheduled for craniofacial surgery at a local hospital.

Zoe was born with a couple of problems, including craniosynostosis, a condition in which the sutures of the skull fuse too early and cause the skull to grow abnormally. She needed surgery when she was only 4 days old, again at age 2, and now, at 4. Read More

Are Medical Meetings Environmentally Unfriendly?

(HealthDay News) -- Anyone who has arrived at Chicago O'Hare, Orlando or Dallas airports during one of the dozens of huge medical meetings held every year will no doubt encounter tens of thousands of specialists from all over world thronging the hallways, the Starbucks, the luggage claim area.

Of course, the attendees use jet fuel to get to the meeting and gas to get from the airport to the hotel where, once they're checked in, they'll have the option or reusing or not reusing their towels.

But an expert writing in the June 28 issue of the British Medical Journal argues that medical meetings should be a thing of the past.

The author, Dr. Malcolm Green, a professor emeritus of respiratory medicine at Imperial College London, confesses to having attended such meetings himself throughout an illustrious career going back 30 years.

"This is not a matter of whether, but when," Green said. "The adaptations to climate change over the next few decades will be massive. This will be an inevitable part of that change. Canute was unable to hold back the tide, and we will be unable to hold back the consequences of climate change. The current 'crisis' of oil prices is here to stay and will intensify."

Green makes the point that the relatively cozy meeting of the American Thoracic Society draws more than 15,000 respiratory doctors and scientists each year, some 3,500 of whom are from Europe. The 2006 conference in San Diego, by one estimate, resulted in 100 million person air miles and produced a carbon burden of 10,800 tons.

The American Cardiac Society meeting, with about 45,000 attendees, represents 300 million person air miles. Add to that the American Heart Association last year, which had almost 26,000 attendees, and the American Society of Clinical Oncology's meeting, which drew crowds of 34,000 or more.

Green estimates that the overall impact of travel to and from conferences is at least 6 billion person air miles a year, or 600,000 tons of carbon, equivalent to the sustainable carbon emissions for 500,000 people in India. And this doesn't include the impact from the use of hotels, conference centers and more.

So, Green argues, virtual networks and virtual meetings should be the order of the day.

"Teenagers and others get to know each other and conduct all manner of relationships over the Internet," Green said. "It is just as possible for researchers and doctors to establish professional relationships and exchange information, ideas and discussions. It will require learning new ways of working, indeed, but this should not be unattainable."

And curbing air travel has another advantage not mentioned by Green.

"Close contact is a factor in the spread of respiratory diseases," said Dr. Len Horovitz, a pulmonary specialist at Lenox Hill Hospital in New York City. "[There was] a reduction and delay of the spread of influenza in 2002 due to the curb on flying and the reduction in air travel after 9/11."

However, another doctor countered in the same issue of the journal that giving up all medical conferences will have little effect on global warming, since the majority of international travel is recreational in nature.

James Owen Drife, a professor of obstetrics and gynecology from Leeds General Infirmary in England, wrote that conferences are essential for stimulating global initiatives in the medical community. Cutting back on conferences that duplicate each other is a reasonable option, he acknowledged.

However, "hiding behind our computer screens and pretending that this is helping the planet" isn't the answer, Drife added.

Adding to that point was yet another American expert. "I absolutely agree that we all should do what we can to reduce our carbon footprint, but does somebody really think if physicians stopped traveling to international conferences that all planes would be grounded?" said Dr. Kirby Donnelly, department head of environmental and occupational health at Texas A&M Health Science Center School of Rural Public Health.

"There are a lot of things we can do other than stop flying," he added. "We could do a lot more with conferences and video conferences. But, still, the face-to-face contact is extremely important and the opportunity to make connections."

More information
Calculate your own carbon footprint at carbonfootprint.com.

Saying Good-Bye to Patients

By Dena Rifkin, MD

Next month I’ll be finishing the final year of my fellowship in kidney disease and transitioning into my new role as attending physician, with mainly in-hospital rather than outpatient responsibilities. So I’m saying good-bye to some patients I’ve been seeing in clinic for the past two years.

These patients won’t be left scrambling to find a new doctor. The attending physician who followed them for years before I showed up, and who supervised me, will see them from here on, albeit with another fellow. This pattern repeats itself every two or three years in our clinic. Read More

The Food Allergy Pantry Purge

By Sean Kelley

A few days after my son, Graeme’s, food allergies (to peanuts, corn, soy, wheat, egg whites, and chicken) were confirmed, my wife mentioned his problems to a surgery colleague at the hospital where she is a nurse. “We harvested the organs of a 2-year-old this week. She got into the pantry when no one was looking,” he told her. “Peanut butter.”

I’ve learned from my wife that people in the medical profession don’t often sugarcoat things and the sheer terror we felt hearing that story sent us straight to the pantry for an all out purge. Though it would have been easier to seal it off with bricks than to only remove the items that offend Graeme’s sensitive body, we opted for a surgical strike. Read More

Telemedicine a Cost-Effective Alternative to ER Visits

(HealthDay News) -- Telemedicine is a cost-effective way to replace more than a quarter of all visits to the pediatric emergency department, according to a community-wide study conducted in New York.

Ailments, such as ear infections or sore throats, that virtually always prove manageable by telemedicine made up almost 28 percent of all pediatric ER visits in Rochester, N.Y., during one year, according to investigators from the University of Rochester Medical Center.

Their findings were presented recently at the 2008 Pediatric Academic Societies annual meeting, in Honolulu.

"We learned that more than one in four local patients are using the pediatric emergency department for non-emergencies," lead investigator Dr. Kenneth McConnochie, a professor of pediatrics at the University of Rochester's Golisano Children's Hospital at Strong, said in a prepared statement. "This mismatch of needs and resources is inefficient, costly and impersonal for everyone involved."

McConnochie and his colleagues, who direct a Rochester-based telemedicine program that provides interactive, Internet-based pediatric health-care service to the area, analyzed data for all pediatric visits to the largest emergency department in the city. Based on their experience, they determined at least 12,000 visits were ones they routinely treat with success via telemedicine.

The other visits were either problems that sometimes are treatable through telemedicine, such as asthma attacks; or ones beyond the scope of the technology, such as a serious wound or injury.

"This would've not only freed up emergency resources to people who needed them more, it would have afforded smaller co-pays for parents and more timely, personalized care," McConnochie said.

In related research presented at the meeting, McConnochie suggested that telemedicine could also help insurers and the community by providing better quality care at a lower price -- saving insurers more than $14 per child per year in that local community.

The conclusion was reached by studying two groups of children that were almost identical, but one had access to their doctor's office, the emergency department and telemedicine technology for care, while the second had only the first two options.

"We found that the first group of families, which had access to telemedicine for their children, did in fact access care for illness overall nearly 23 percent more often than the second group," McConnochie said.

But since children with telemedicine access had 24 percent fewer ER visits, which cost about seven times the cost of a doctor office or telemedicine visit, the telemedicine group ultimately still cost insurers less per child over a year.

More information
The Nemours Foundation has more about children's health.

Doctor-Patient Talks Affect Use of Breast Reconstruction Surgery

(HealthDay News) -- A lack of patient-doctor discussion may contribute to socioeconomic, age and race-related disparities in the use of breast reconstruction after mastectomy, says a study by researchers at Brigham and Women's Hospital and the Dana-Farber Cancer Institute in Boston.

The study also found that breast reconstruction was more likely to occur after a surgeon discussed options with a patient, which suggests the need to increase and improve these conversations, the researchers said.

They analyzed data on 626 patients who underwent mastectomy for breast cancer. Of those patients, 253 (40.4 percent) received breast reconstruction, and 249 (39.8 percent) had a documented discussion about the option with a doctor.

About 70 percent of those who had a discussion about breast reconstruction had the procedure. But the researchers found that increasing age and lower levels of education were associated with lower rates of a documented discussion. Hispanic patients, those born outside of the United States, and those whose primary language wasn't English were less likely to undergo reconstruction after discussing it with a doctor.

The study was published in the April issue of the Journal of the American College of Surgeons.

The decision to have breast reconstruction is a complex one that's influenced by access to care, patient preference and a doctor's interaction with the patient, the researchers noted.

"Patient preferences should be respected, but an informative discussion of reconstruction is required to help patients understand and weigh the risks and benefits of this procedure," Dr. Caprice C. Greenberg, Instructor of Surgery in the Center for Surgery and Public Health at Brigham and the Center for Outcomes and Policy Research at Dana Farber, said in a prepared statement. "We learned that physicians need to improve communications with all women undergoing a mastectomy, regardless of age, race or socioeconomic status."

She and her colleagues said doctors should systematically address the issue of breast reconstruction with all patients undergoing mastectomy. Doctor-patient discussions could include interpreters and educational materials to ensure an informative discussion regardless of a patient's primary language, ethnicity or education level.

More information

Roshini Raj, MD, Explains Common Flu Symptoms on the "Today" Show

"Health" contributor Dr. Raj on the "Today" show Feb. 13, discussing tips on fighting the flu
by Ross Weale

In the following segment, Roshini Raj, MD, of Health magazine describes flu symptoms and talks about whether you can still get that shot.



DR. ROSHINI RAJ
Roshini Raj, MD, a Health magazine contributor and part of the magazine's Health Expert Network, is board-certified in gastroenterology and internal medicine with degrees from the New York University School of Medicine and Harvard University. Currently Dr. Raj is an attending physician at NYU Medical Center's Tisch Hospital in New York City. She also serves as an assistant professor at the NYU School of Medicine, and she has a special interest in women's health and cancer screening. She has also published several research articles on colon-cancer screening.

Dr. Raj has discussed health topics on numerous television outlets including NBC's Today show, ABC's Good Morning America, CNN, FOX News, and Discovery Health. She has been quoted in publications such as the New York Times, the Wall Street Journal, Men's Health, Women's Health, and Fitness on the state of health care and other health news of the day. Dr. Raj is often called upon to explain and demystify complicated health topics.

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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 »

One in 4 Teen Girls Has a Sexually Transmitted Disease

(HealthDay News) -- More than 3 million teenaged girls have at least one sexually transmitted disease (STD), a new government study suggests.

The most severely affected are African-American teens. In fact, 48 percent of African-American teenaged girls have an STD, compared with 20 percent of white teenaged girls.

"What we found is alarming," Dr. Sara Forhan, from the U.S. Centers for Disease Control and Prevention, said during a teleconference Tuesday. "One in four female adolescents in the U.S. has at least one of the four most common STDs that affects women."

"These numbers translate into 3.2 million young women nationwide who are infected with an STD," Forhan said. "This means that far too many young women are at risk of the serious health effects of untreated STDs, including infertility and cervical cancer."

These common STDs include human papillomavirus (HPV), chlamydia, herpes simplex virus and trichomoniasis, Forhan said.

Forhan announced the results as part of the CDC's 2008 National STD Prevention Conference, in Chicago.

"These findings are really giving us a lot of pause about how we provide care to adolescent girls who are sexually active," said Dr. Elizabeth Alderman, an adolescent medicine specialist at Children's Hospital at Montefiore in New York City and chairperson of the Executive Committee of the Section of Adolescent Health of the American Academy of Pediatrics. "The numbers are really astonishing."

Forhan noted that most of the burden of STDs falls on young African-American women. "Among African-American teenagers, about one in two were affected compared to one in five white teens," she said.

In terms of the racial disparity, "it's what we've always seen, which is very unfortunate," Alderman said.

In the study, Forhan's team collected data on 838 girls aged 14 to 19 who took part in the 2003-2004 National Health and Nutrition Examination Survey. The study did not include syphilis, gonorrhea or HIV, as earlier studies found very low prevalence of these diseases in this age group.

HPV and chlamydia are the most common STDs found among teenage girls, Forhan said. "Almost one in five overall had a strain of HPV associated with cervical cancer or genital warts," she said.

"We need to be screening adolescent girls who are sexually active and providing them with HPV vaccine," Alderman said. "The recommendations are to screen sexually active girls, but many girls don't disclose to their health-care provider that they are sexually active, even when asked," she said.

As for chlamydia, 4 percent of teenaged girls had this STD, Forhan said. "The majority of chlamydia infections do not have symptoms. If left untreated, it can lead to pelvic inflammatory disease, which leaves these young women at risk for atopic pregnancy, chronic pelvic pain or infertility," she said.

In addition, the study found that 2.9 percent of young women had trichomoniasis, and 2 percent were infected with genital herpes, Forhan said.

According to Forhan, about 50 percent of the teens reported having sex, and the prevalence of STDs in this group was 40 percent. "Even for young women with only one reported lifetime sexual partner, one in five had an STD," she noted.

"If you choose to be sexually active, you need to protect yourself and be screened for these infections," Alderman said. "And all girls between the ages of 11 and 26 should get vaccinated for HPV."

Among women with an STD, 15 percent had more than one infection, Forhan added.
"These data provide a clearest picture to date of the overall burden of STDs in adolescent women in the United States," Forhan said. "The study also underscores the importance of addressing racial disparities in STD rates among young women."

Race itself is not a risk factor for STDs, Forhan said. However, factors such as limited access to health care, poverty, community prevalence of STDs, and misperceptions about individual risk are some of the reasons that STD rates are particularly high among African-Americans, she said.
More information
For more on STDs, visit the U.S. Centers for Disease Control and Prevention.

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.

Depression in Young Doctors Tied to Medication Errors

(HealthDay News) -- Medical residents who are depressed are about six times more likely to make medication errors than those who aren't depressed, says a study that looked a 123 pediatric residents at three children's hospitals in the United States.

Researchers found that 20 percent of the residents were depressed, and 74 percent were burned out. During the study period, the residents made a total of 45 medications errors, and those who were depressed made 6.2 times more medication errors than those who weren't depressed.

There didn't appear to be any link between higher medication error rates and burnout. The study was published online Feb. 7 in the British Medical Journal.

These findings suggest that doctors' mental health may play a more significant role in patient safety than previously suspected, the study authors said. In addition, the high burnout rate among residents in this study -- consistent with other studies -- indicates that methods of training doctors may cause stress that harms residents' health.

The researchers did note that their data was collected before work hour limits were implemented for medical residents in the United States.

More needs to be done to study and improve the mental health and working conditions of doctors, the study authors concluded.

Each year in the United States, as many as 98,000 patients die due to medication errors, and the stress of resident training, including lack of sleep and leisure time, are among the most commonly cited reasons for such errors, according to background information in the study.

While it may seem logical to link medication errors to depression and burnout among doctors, these study findings are not conclusive, researchers from Scotland's University of Aberdeen noted in an accompanying editorial.

Large, prospective trials need to be conducted to pinpoint the factors that cause medication errors, they wrote.

More information
The U.S. Food and Drug Administration has more about medication errors.

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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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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Urine Test Results Can Point to Heart Dangers

(HealthDay News) -- Even a small amount of a protein called albumin in the urine of patients with stable coronary artery disease increases their risk of cardiovascular death, say U.S. researchers.

The findings from this study of almost 3,000 patients, age 50 and older, with stable coronary artery disease (CAD) have implications for assessing and perhaps treating patients with vascular disease.

The study was published in the current issue of the journal Circulation.

Albumin is normal and necessary in blood, but its presence in urine indicates leakage in the kidney filtration system and possible damage to cells that line the kidney's blood vessels, according to background information in the study.

"We found that virtually any degree of albuminuria, even albumin below the level we call microalbuminuria, placed a patient at significantly higher risk of cardiovascular events," lead author Dr. Scott D. Solomon, associate professor of medicine at Harvard Medical School and director of Noninvasive Cardiology at Brigham and Women's Hospital in Boston, said in a prepared statement.

He and his colleagues also found that the hypertension drug trandolapril (an ACE inhibitor) lowered albumin levels in patients' urine.

The findings of this study and previous research by the same team indicate that "we cardiologists need to pay more attention to kidney function in our patients, and we need to look at two aspects -- filtration and albuminuria," Solomon said.

"It is important for cardiologists to understand that these are not patients who will even come to dialysis or even necessarily see a nephrologist," he said. "But they do have mild kidney disease that puts them at increased risk for a cardiovascular event."

More information
The U.S. National Institute of Diabetes and Digestive and Kidney Diseases has more about protein in urine.
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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.

Cardiac Artery Trouble Boosts Family Heart Risk

(HealthDay News) -- The close relatives of people who carry an abnormality in the heart's left main artery should take special care of their own cardiac health, experts say.

Healthy brothers and sisters of someone with such problems are 2.5 times more likely to develop some form of heart disease, compared to the siblings of patients with heart disease not related to that artery, concludes a report in the Oct. 4 issue of the European Heart Journal.

"We first reported a relationship two years ago," said Dr. Heribert Schunkert, head of cardiology at the University of Luebeck, Germany, and lead author of two reports in the journal. "This time, we specifically investigated the possibility of high heritability of the condition. That was the case."

In one report, Schunkert and his colleagues analyzed coronary angiograms from more than 1,800 members of families in which two or more people developed coronary artery disease.

They found that 12 percent had a 50 percent or more narrowing of the left main coronary artery. According to Schunkert, that finding demonstrated that the problem clusters in families and that its cause was probably genetic.

The second study followed almost 1,400 healthy brothers and sisters of people with coronary artery disease for five years.

A left main coronary artery problem was found in 13.9 percent of those who developed heart disease but in only 6.4 percent of those who did not. The risk of developing heart disease was 2.5 times higher for brothers and sisters of someone with a left coronary artery than in those where the patient suffered from some other form of heart disease.

"The clinical implication is that if a person demonstrates a left main coronary artery problem, siblings should know that they have a greatly increased risk of coronary artery disease," Schunkert said.

Those family members might undergo screening to detect left main coronary artery problems, he said, although it is not clear whether the chance of preventing heart disease is high enough to justify the costs and risks of screening.

But the German studies do not necessarily show that problems with the left main coronary artery gives relatives any more reason be concerned, said Dr. Dhananjay Vaidya, an assistant professor of internal medicine at the Johns Hopkins University in Baltimore.

Because a family history of heart disease is a known risk factor for heart trouble, "brothers and sisters of someone with any heart disease should take it seriously," said Vaidya, who is also a member of the team conducting the Sibling Family Heart Study.

The Sibling Family Heart Study has enrolled more than 700 family members of people treated for heart attacks in Baltimore hospitals. Researchers are following them to detect "whether persons present with the same kind of heart disease as their close relatives," Vaidya said.

There is particular reason to worry when the left main coronary artery is affected, since it supplies about two-thirds of the heart's blood flow, Vaidya said. But the German studies showed that this was a relatively rare condition, and the data on its heritability was not conclusive, he said.

It's possible that the Baltimore study may now be changed slightly "to determine if there is something biologically special about left main coronary artery disease," Vaidya said.

More information
The role of family history in the various risk factors for heart disease is explained by the American Heart Association.