Noelle Swan

Archive for the ‘Healthcare’ Category

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Testing, Testing…HIV: Taking the Stigma Out of AIDS Testing

In Healthcare on August 10, 2012 at 1:52 pm

This article first was published by Spare Change News on August 10, 2012.

“College-educated black women who live in the suburbs and date lawyers don’t get HIV and AIDS. This just doesn’t apply to you,” Kimberly Wilson remembers her doctor saying back in 2004.

That was the first time she asked her physician for an HIV-test.

Four years, seven bouts of shingles and five requests for an HIV-test later, Wilson was admitted to Boston Medical Center. She had stopped in hoping to get some prescription cough syrup. Emergency room doctors ordered a chest X-ray.

“The technician who took the X-ray of my lungs thought the machine was broken, because the lung was so black, ” Wilson recalls.

The machine had not malfunctioned; Wilson’s lungs were coated with thrush, a yeast infection common among patients with compromised immune systems. Soon, she was diagnosed with Pneumocystis carinii pneumonia (PCP), an opportunistic infection commonly associated with HIV.

Four years after she first requested an HIV-test, Wilson learned that she was HIV-positive. Today, she manages her condition through a myriad of medications and describes her health as excellent. But she believes that an earlier diagnosis could have eliminated years of pain and suffering.

Since her diagnosis, she has become a self-described poster child for HIV-testing, working as a peer advocate for AIDS Action, routinely sharing her story with the media and serving as a delegate at a recent international conference on AIDS and HIV in Washington, D.C.

“I think everybody should get an HIV-test,” she says. “It should be part of your physical. It should be a part of your whole entire care.”

Recent Massachusetts legislation targeting consent requirements for HIV-testing aims to normalize the process and potentially improve testing rates.

Until last month, state law required that patients interested in receiving an HIV-test had to sign a form giving written informed consent. The new law allows patients to provide consent verbally in a move that doctors, advocates and policymakers hope will normalize the process.

According to the Centers for Disease Control, over 1 million Americans are living with an HIV-positive status. However, as of 2006, one in five of those patients were unaware of their condition. In response to this data, the CDC issued new guidelines for the management and care of HIV, calling on states to streamline the testing process.

Many physicians and advocacy organizations in Massachusetts, such as the AIDS Action Committee, have petitioned the state Legislature to remove the requirement for written informed consent, which they consider to be an unnecessary hurdle for testing.

“Many states early on had this [requirement for written consent] because of the discrimination and stigma surrounding HIV, but also because in early years it was a death sentence,” explains Rebecca Haag, President and CEO of AIDS Action Committee in Massachusetts.

In recent years, HIV treatment protocols have improved dramatically. Many patients with an HIV-positive diagnosis are able to successfully control their condition with medication and do not develop AIDS. Wilson’s story illustrates how effective treatment can be, once the diagnosis has been confirmed.

“HIV testing has been encumbered for about 25 years, since we first developed the tests in 1984,” says Stephen Boswell, President and CEO of Fenway Health in Boston and former HIV policy advisor to the Clinton Administration.

“Over the years, [written consent] has been felt by many clinicians to be more and more of an impediment to people’s willingness to be tested,” Boswell says. “Not only did it continue to stigmatize the patients but made the testing process more complicated.”

By removing the formality of written informed consent, legislators and physicians hope that HIV-testing can become part of routine conversation between patients and their doctors.

“Patients will still be informed of what the test means, they will not be tested without their knowledge and they have the right to opt out or opt in of getting tested, but it won’t add paperwork to that process,” says Rep. Carl Sciortino (D) of Medford.

Once an HIV-positive diagnosis has been confirmed, strict laws govern how that information can be shared with other providers.

“If a patient has an HIV-positive result, their test results cannot be shared with anybody else without their written informed consent; and I think that’s for good reasons,” explains Sciortino.

Boswell recognizes the need to protect patients’ privacy. However, he worries those strict requirements for sharing information could compromise patient care.

“For example, if my patient is seen at an ER, I could not relay any HIV testing information without first obtaining the written informed consent from the patient who might be unconscious,” he explains.

Boswell says that while he and his colleagues are celebrating the removal of one impediment to care, they are left struggling to understand what is required of them in terms of sharing information in the age of electronic records.

“Most of the institutions are struggling to figure out how to comply. If we have to get written informed consent every time we ask another clinician for assistance, it would dramatically complicate the process of providing care to patients who are HIV-positive.”

In the final days of the 2012 legislative session, Sciortino sought to address this issue by adding language into the health care payment reform law that allows patients to extend overall consent to information sharing. The health care payment reform law placed heavy emphasis on the use of electronic medial records to streamline healthcare. However, Sciortino’s language did not make it into the final wording of the bill signed by Governor Patrick earlier this week.

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Delaware kids suffer from more food allergies than peers nationwide

In Healthcare on July 19, 2012 at 12:26 pm

This article first was published by DFM News on July 10, 2012.

Less than an hour after her daughter’s first taste of peanut butter, Kirsten Cataldi found herself racing down the local drugstore’s child medication aisle with her swollen two-year-old on her hip, while speed-dialing her pediatrician on her cell phone. With the doctor on the phone, she tore open a box of Benadryl and measured out what would be the first of four doses required to dissipate the hives that had covered her toddler’s body. A trip to the doctor’s office the next day confirmed that Cataldi’s daughter, we’ll call her Sarah, was allergic to peanuts… and tree nuts, and coconut, and sesame. The doctor advised Cataldi that with such a severe initial reaction, additional exposure could send Sarah into anaphylaxis, a severe and potentially life-threatening allergic reaction that can include a drop in blood pressure, swelling of the throat, and inability to breathe.

Another mother, Aleasa Word watched her 13-month-old daughter, Kennedy, go into anaphylactic shock in her arms the first time she fed her cow’s milk. Soon, she was diagnosed with eleven life-threatening allergies. She has since outgrown several of them, though in some cases new allergies have popped up in their stead. When she outgrew her allergy to shrimp, Word’s seafood-loving family celebrated with a fish fry. “She literally ate two crumbs of tilapia and she almost died in my dining room.” Several weeks later, she had a reaction to fish being cooked in a restaurant. Even airborne, microscopic fish protein could send her immune system into overdrive.

Once considered rare conditions, food allergies now affect nearly one in ten children living in Delaware, a rate that surpasses the national average by nearly 20 percent, according to a Northwestern University study examining the geographic distribution of food allergies published this month in the medical journal Clinical Pediatrics.

This finding came as something of a side effect of the major focus of the study that has been widely publicized in the national press; children living in urban areas are more likely to suffer from food allergies than those living in suburban and rural environments. As Dr. Ruchi Gupta, lead author of the study explains, “We saw a stepwise decrease from urban centers to metro cities to urban outskirts to suburban areas to small towns, to rural.” In the process of charting prevalence against population density, Gupta and her fellow researchers at Northwestern also mapped out the prevalence by state naming Nevada, Florida, Georgia, Alaska, Maryland, Delaware, New Jersey, and Washington, D.C. as the 8 states with the highest prevalence rates, all with rates greater than or equal to 9.5 percent.

For many of these states, the findings are not necessarily mutually exclusive, says Ruchi Gupta, a practicing pediatrician, associate professor of pediatrics at Northwestern, and lead author of the study. “We found a huge disparity in the presence of food allergies in urban and rural environments,” says Gupta. Rates in urban centers were over 50 percent higher than in rural areas. For states like Nevada and Maryland, high rates in densely populated Las Vegas and Baltimore could push up averages for the entire state. Similarly, high rates found in Wilmington could have influenced Delaware’s overall rank. Despite being the second smallest state in the union, 2010 census data ranks Delaware as the eighth most densely populated state (including Washington, D.C. and Puerto Rico).

For the Cataldis, the Words, and other families living with the threat of food allergies everyday, this correlation holds little comfort. “Food allergies invade every aspect of your life,” says Cataldi. She packs a special cupcake for birthday parties and orders special Halloween candy that has not been manufactured on the same equipment as nuts. For now, Sarah attends a peanut-free daycare, but Cataldi worries about when she enters elementary school.

Linda C. Wolfe, director of School Support Services for the Delaware Department of Education says that Delaware public schools offer a higher level of care than in many states, because every public school in the state has a registered nurse on the premises. She adds that school nurses are trained to treat food allergies, including administering epinephrine, a hormone that naturally occurs in the body and is administered by injection to halt anaphylaxis. She adds that school nurses collaborate with the child, parents, and teachers to accommodate the child’s individual allergy plan. “In other schools, when you come to school parents are relying on a layperson to oversee the care of their child, whereas in Delaware, families have this nurse in place.”

Word has collaborated with school nurses all over the state through the Food Allergy and Asthma Multicultural Society of Delaware (FAMSOD), which she founded after scrambling to learn everything she could about advocating for and protecting her daughter. “[The nurses] are doing a fabulous job but they are stretched beyond belief.” She adds that she was not surprised to see Delaware ranked among the states with the highest prevalence. “I believe we need to do some environmental studies that are food allergy specific to try to identify why these children are having this.”

Gupta has been asking the question “why” for the past seven years in her research at Northwestern. However, as is often the case in medicine, studies can lead to more questions than answers. What about urban environments makes children more susceptible to food allergies? Do rural children’s immune systems become more robust because of their routine exposure to dirt, plants, and animals, as suggested by the hygiene hypothesis? Or perhaps air pollution from traffic, which also tends to correlate to population density, plays some role in creating hypersensitive immune systems.

Before researchers can tease out the “why” they must first have a firm hold on the extent of the problem. Gupta cautions that this is just one study and the implications for Delaware were not the major focus. Gupta suggests that Delaware researchers examine data on hospitalizations and emergency room visits. “If this is not something that is on the state’s radar already, it should be raising some questions,” says Gupta.

Currently, Delaware-specific data does not seem to be readily available. According to a Delaware Division of Public Health spokesperson, the DPH does not have any current work or expertise relating to food allergies. Wolfe says that the Department of Public Education does not currently track any chronic illnesses within the school system. Neither does Christiana Hospital, according to its senior manager of media and government relations.

People familiar with the study, and those who live with allergies, take this situation very seriously. Now the question that is left hanging: Will the state and the schools take it with equal seriousness?

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Black Women’s Health Study Aims To Improve the Lives of African American Women for Generations to Come

In Healthcare on June 1, 2012 at 10:50 am

This article first was published in the Spring 2012 edition of the Association for Women In Science Magazine.

In 1995, when Lynn Rosenberg, Sc.D., Julie Palmer, and Lucille Adams-Campbell, Ph.D. began the Black Women’s Health Study (BWHS), the medical and epidemiological community already widely understood that African American women disproportionately suffer from a variety of medical conditions. In addition to being more likely to die from breast cancer, black women are three times as likely to develop uterine fibroids, Rosenberg explained. Lupus, scarcoidosis, preterm birth, diabetes, hypertension, and obesity are all more prevalent in the African American community, added Palmer. However, no one has been able to definitively address why this is the case.

Black Women and Breast Cancer

While African American women develop breast cancer at a lower rate than their white counterparts, it has become the most commonly diagnosed cancer among black women, and they seem to die from it more than any other race does. What could be causing this deadly disparity?

Researchers for the BWHS at Boston University’s Sloan Epidemiology Center think they just might have unraveled the answer and with it, a potential solution. B.U. Epidemiology Professor Julie R. Palmer, Sc.D., is a co-principal investigator for the BWHS. Palmer has devoted the better part of the past 20 years to understanding the causes of breast cancer among African American women. She explains that breast cancer comes in two varieties, estrogen-receptor positive, ER+, and estrogen-receptor negative, ER-. While the former can be treated with hormonal therapy, the latter and more deadly type requires intensive chemotherapy. This more aggressive ER- breast cancer is twice as common in black women as it is in white women. “That’s part of the reason why black women are more likely to die from breast cancer,” Palmer explains. The question remains, why is this deadlier variation more common in black women?

Among the 59,000 African American women enrolled in the BWHS, 1800 breast cancers have been diagnosed so far. Of those 1800 cases, investigators have been able to confirm and examine some 350 ER- cases.

Knowing that reproductive factors play a major role in the incidence of ER+ breast cancer, Palmer wondered if there might be a similar correlation between ER- breast cancer and reproductive history. She examined the reproductive histories of the 350 ER- women as reported in various questionnaires. In addition to categorizing women in the study by type of breast cancer, she and her fellow researchers looked at the women’s age at their first pregnancies, number of births, and history of breastfeeding. Comparison of all this data showed that women who had more than two children had about a 50% higher risk of ER- breast cancer than women who did not have any babies. However, further analysis indicated that this increased risk for ER- breast cancer did not occur in women who breastfed their children (1).

This revelation could have enormous implications for the breast health of black women if born out to be true in follow-up studies. “Breastfeeding might be a really important factor that is modifiable and that could be used to prevent breast cancer,” says Palmer. Currently, breastfeeding rates tend to be lower among African American mothers, which could explain why they are disproportionately developing—and dying from—ER- breast cancers. If further research corroborates this hypothesis, then a simple behavioral shift could have a dramatic impact on the long- term health of thousands of black mothers.

This Potentially Groundbreaking Finding Begs the Question: Why Has It Taken Us So Long To Find This Out? “Thirty or forty years ago, all the studies were of men,” said Rosenberg. “After that, all of the studies were of white men and women.” She saw black women’s health as a frontier in health care, one that had been overlooked with dire consequences.

With such little data available about this population, Rosenberg, Palmer, and Adams-Campbell decided to create a longitudinal cohort study in order to explore as many diseases as possible. The medical community had a lot of catching up to do in understanding how to best treat women of color.

It would be impossible to consider a large-scale study focusing specifically on an African American population without taking into consideration the infamous Tuskegee syphilis experiment. From 1932-1972, the U.S. Public Health Service, in conjunction with the Tuskegee Institute in Tuskegee, Alabama, studied 600 African American sharecroppers. Some 400 participants had syphilis, and in an effort to understand the progression of the disease, researchers monitored their suffering for forty years without offering any diagnosis or treatment. Outrage over this study led to stricter ethical standards for medical studies.

Rosenberg said that designing the study required some careful thinking about Tuskegee. Plans for communication with the study participants were carefully laid out. African American women were solicited to serve on an advisory board, including a physician who had investigated the history of medical research among African Americans in this country. Soon afterwards, two participants joined the advisory board.

One study participant, Jo-Anna Rorie, also a professor and a researcher at Boston University, but in a different department of the Black Women’s Health Study, said that she had run into fears stemming from the Tuskegee syphilis experiment in her own research. “Tuskegee is embedded in the memory of all communities of color.” As a participant in this study, she said that she had been impressed by the level of communication between the researchers and the participants and considered the BWHS to be a model for how information should be disseminated. As an individual study subject, she has taken some of the information included in the BWHS quarterly newsletters to heart. When a BWHS newsletter arrived in her mailbox suggesting that a stressful neighborhood could contribute to health problems, she started thinking about moving.

Black Women and Hypertension, Diabetes

For a variety of reasons, many African American women, regardless of income, tend to live in racially segregated urban neighborhoods. “We found that there was an effect over and above people’s individual behaviors, and we hypothesized that it may be the stress of living in an area where there’s more danger [that contributes to health disparities],” Palmer said. Add in the all-too-common coupling of a lack of fresh produce and an excess of fast food found in many low-income neighborhoods, and you have a recipe for diabetes.

“This cohort tends to be a middle class cohort, but we still live in low-income, sort of fringy kinds of neighborhoods,” said Rorie. “And that, in and of itself, might be causing a certain amount of stress that causes our blood pressures to go up.” Rorie, a successful researcher and professor with two master’s degrees and a nearly complete Ph.D., lives in Dorchester, Massachusetts, a largely working-class neighborhood of Boston with a reputation of high crime rates. As a controlled hypertensive at risk for pre-diabetes, she wondered if a change of scenery might be the needed prescription.

Another BWHS researcher, Patricia Coogan, Sc.D., a senior epidemiologist at Sloan Epidemiology Center, recently published in Circulation, a journal of the American Heart Association, further evidence that Rorie’s decision to move might be the right one (2). In a study of a subset of the BWHS cohort (those living in Los Angeles), she analyzed air pollution data and found a correlation between the common traffic pollutant, nitrous oxide, and incidence of diabetes and hypertension in black women. “It is well documented that African Americans tend to live in more highly polluted areas, and the incidence of diabetes and hypertension is much higher, twice as high in African American women [than in] white women,” said Coogan. She has secured funding from the National Institute of Environmental Health Science to look at this in the entire BWHS cohort.

Women in Epidemiology

Over the course of her career, Rosenberg has watched the field of epidemiology evolve and push the boundaries. When she applied for the doctoral program at the Harvard School of Public Health (HSPH), most people accepted into the program were male, medical doctors. She became one of the first women and biostatisticians to earn a doctorate in epidemiology at HSPH. Ten years later, Julie Palmer graduated from the same program along with two other women in a class of nine. Palmer said that today, the breakdown is closer to 50 percent female.

While Palmer suspected that in much of the field the professional demands on women made raising a family difficult, she found the leadership at Sloan (including Rosenberg and two male directors) fostered an environment compatible with motherhood. “I was fortunate to work in this group. The culture of this place is that family comes first and that you work when you’re at work and you don’t when you’re with your family,” she says. “Yes I would put in a 40-hour week, but I had all the rest of the time for family.”

However, BWHS is not just about women. “One thing that we’ve tried to do in this study, in addition to studying African American women, is to mentor African American scientists. It’s a long process moving up in the sciences, and it requires a lot of mentoring.” Palmer said that they had taken six to eight doctoral students from Boston University and Harvard under their wings. In addition, they mentored two junior faculty members and one postdoctoral researcher.

The Way Forward

In addition to making up for lost time and conducting research that should have been done long ago, the BWHS is pushing to bring knowledge of black women’s health into the 21st century.

In hopes of adding to the genetic data available for African Americans – currently most genetic data is from Europeans and Asians – Palmer has managed to secure DNA samples from more than 27,000 participants. Like all information gathered throughout the study, the samples were collected by mail. Participants used a relatively new technique to preserve their saliva samples; they swished with mouthwash and spit into a cup. The alcohol in the mouthwash acted as a preservative until the sample arrived at Sloan. Palmer plans to analyze the DNA samples in conjunction with data for incidence of breast and colon cancers, lupus, uterine fibroids, and sarcoidosis. Understanding genetic predispositions for these diseases could lead to additional treatments.

The daughters of BWHS participants are currently an untapped resource. Rosenberg said participants were surveyed to see whether they would consider having their daughters included in the study. “The response was not overwhelming,” she said. Palmer added that while it would be helpful to study a younger generation, current funding limits will not afford any expansion of the cohort. Because the study has many aims, funding must come from a variety of grants. Rosenberg and Palmer are trying to think creatively about how to push the study forward, always juggling the need to secure funding, design new studies, analyze data, and publish outcomes while hoping that women like Rorie, their daughters, and granddaughters will be better off.

Since forming the BWHS, Rosenberg, Palmer, and their fellow researchers have published over 100 articles in peer-reviewed journals examining the underlying causes heightened prevalence of a variety of health problems among African American women. With each paper, researchers shed additional light on a vastly understudied population. Palmer’s hypothesis that breastfeeding could reduce risk for estrogen-receptor negative breast cancer is one example of the potential benefits of widening this understanding. Coogan’s purported link between air pollution and diabetes and hypertension could be used to influence emissions policy and urban planning should the findings be confirmed. However, as with all scientific research, individual studies only reveal so much. Additional studies and independent research are needed to corroborate or disprove each finding.

References

1. Palmer, Julie R., et al. (September 2011). Parity and lactation in relation to estrogen receptor negative breast cancer in Afri- can American women. Cancer Epidemiol Biomarkers Prev 20(9): 1883-91. Available at http://www.ncbi.nlm.nih.gov/ pubmed/21846820

2. Coogan, Patricia F., et al. (January 2012). Air pollution and in- cidence of hypertension and diabetes in African American women living in Los Angeles. Circulation 125:767-772. Available at http://circ.ahajournals.org/content/early/2012/01/04/CIRCU- LATIONAHA.111.052753.abstract

 

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Contaminated Drinking Water Linked to Mental Illness

In Healthcare on January 23, 2012 at 12:40 pm

This article was first published on New England Post on January 23, 2012.

Move over family history and traumatic experience, here comes another piece in the mental illness puzzle.

A recent Boston University study suggests that exposure to a common drinking water contaminant in the womb and during early childhood could lead to heightened risk for bipolar and post traumatic stress disorders.

From the late 1960s to the early 1980s, Mass. public works and water departments lay over 600 miles of pipe lined with vinyl that had been applied with tetrachloroetylene (PCE), a common dry cleaning solvent. At the time, it was assumed that the PCE would evaporate during a 48-hour drying period. They thought wrong.

Over a decade after water began coursing through the pipes, it became clear that PCE remained in the liner and subsequently leached into the water. In 1992, the EPA listed PCE as a drinking water contaminant and set a maximum contaminant level of 5 parts per billion in 1992. Today towns monitor for PCE and are required by law to notify residents should levels spike above EPA limits.

The 1970s residents of Massachusetts received no such warning. Bottled water and home filters had not gained popularity yet. Everyone, including pregnant women and young children drank directly from the tap

Boston University epidemiology professor Ann Ashengrau has studied the health effects of PCE in drinking water for over 20 years exploring cancer risks, reproductive affects and most recently, neurotoxic effects. Her latest findings appearing in the current issue of the peer-reviewed journal Environmental Health addressed anecdotal evidence suggesting that PCE exposure might be connected to prevalence of mental illness.

Aschengrau’s team asked participants if a doctor had ever told them that they had bipolar disorder, depression, schitzophrenia, or post traumatic stress disorder (PTSD). All 1,500 study participants were born between 1969 and 1983 in either Barnstable, Bourne, Falmouth, Mashpee, Sandwich, Chatham, or Provincetown—towns now known to have had at least one mile of contaminated pipe sourcing drinking water. Each of these participants was likely exposed during prime development, both in utero and in early childhood.

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Aschengrau explained her results in an interview. While exposure carried no additional risk for depression, the results indicated a doubled risk for bipolar disorder and a 1.5 fold increased risk for PTSD. The incidence of PTSD sheds as much light on PTSD as it does PCE exposure. “This is really entering relatively uncharted territory. I don’t think that the mechanism for this are clearly understood,” Aschengrau said. “For PTSD you still have to have that trauma for the disorder. But maybe this makes you more susceptible to it.”

The implications of this study go beyond the shores of Cape Cod. “Even though this study focuses on an historical exposure, there still are people that are being exposed to PCE in other ways,” Aschengrau said. In New York City, airborne PCE was found in five apartment buildings attached to dry cleaners in a study conducted by the New York State Health Department in 2005. In Ravenswood, West Virginia, PCE has migrated into the ground water, prompting the EPA to declare the site a superfund. It can evaporate off dry cleaned clothes and is used in many consumer products, including some spot removers, brake cleaners, and water repellents.

While this study adds to the growing body of information about the health effects of PCE, Aschengrau says that more needs to be done to corroborate the findings and hopes that others will conduct similar studies in different places and settings.

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Weighing New Prescription for Doctor/Patient Communication

In Healthcare on December 20, 2011 at 7:52 pm

This article first was published by New England Post on December 20, 2011.

Every day countless people see their primary care physician for sick visits, routine physicals, and to follow up on chronic conditions. On average, patients spend 8-15 minutes face-to-face with their doctors. Doctors have checklists that they need to push through in addition to any concerns that the patients may have. Appointments fly by and patients often feel they have just spun out of a revolving door.

What if after appointments patients could go online and review the their primary care physicians’ notes? What if they could share them with their family and caregivers?

Researchers at the Beth Israel Deaconess Medical Center (BIDMC) in Boston have done just that. For one year, patients were granted access to the doctors’ note section of the hospital’s existing online patient portal—a secure website where patients can access lab results and medication lists. Study authors released a preliminary report of the trial today in the Annals of Internal Medicine detailing physicians’ and patients’ expectations for the program.

Jan Walker, R.N., M.B.A.

“Knowledge is power. If patients understand more and have more knowledge about what the doctor is thinking, they’ll be more empowered to make better decisions,” said Jan Walker, RN, MBA, member of the research team at BIDMC and Harvard Medical School and the study’s lead author.

By law, patients are entitled to these notes and can obtain them from hospital records offices by jumping through a few bureaucratic hoops and possibly paying a fee. Unsurprisingly, few seek hard copies of their records.

Participating patients at BIDMC, as well as at participating hospitals in rural Pennsylvania and suburban Washington overwhelmingly embraced the idea with 90% of patients reporting that the notes would put them more in control of their health. Half of them said they thought they would take their medication better if they understood more about why they were taking it.

Tom L. Delbanco, M.D.

Michael Meltsner, a 74-year-old patient of the study’s senior author, Tom L. Delbanco, M.D. said in an interview that he enthusiastically agreed to participate in the study. “It’s not as if we didn’t have an open relationship before,” he said of his interactions with Delbanco. He added that the notes not only reminded him about what was said during his appointment but prompted additional follow up questions. “It’s as if I was being presented with a potential checklist so I could write him back in an email,” he said.

Walker hopes that the notes can improve communication between family members and caregivers as well. “If you’re an elderly patient and your adult children are in another city, this is a way to share information about your health,” she said.

As a licensed marriage and family therapist, Meltsner said that he sees tremendous potential in this possibility as well. “Healthcare is often a family event as well as an individual event. An appointment doesn’t involve the family.” As a husband and father, he found that sharing his own notes with his family prompted additional questions for his doctor and ultimately a better understanding of his health.

Most patients and many doctors see this added layer of communication between doctor and patient as a step forward. However, some doctors expressed reservations and worried that harmful effects would outweigh any benefits.

Doctors participating in the survey process of the study but not in the actual trial expressed concerns around confusing, upsetting, and frightening patients. Some said that they would not be comfortable taking candid notes if they knew that their patients could read them.

Meltsner brushed away these concerns and said that he is prepared to read whatever his doctor writes about him. “All too often, the professional has an image of the patient as someone who is going to dissolve if they’re told something difficult,” he said.

Instead, he says that notes come in especially handy in such situations. “When something tense or difficult comes up in a doctor appointment the patient often has selective amnesia, having something to refer back to is extremely valuable.”

Walker pointed to anecdotal evidence that difficult news delivered in written form can be a vital reinforcement. She said that one patient reported that she had been able to ignore her doctors annual urging to lose weight, but when she saw the word “obese” in black and white, something hit home. Many patients tune out their doctors recommendations to lose weight, quit smoking, lower their cholesterol. Perhaps doctors’ notes hold the key to put the physical symptoms into the context of habitual choices.

An additional concern raised by many non-participating doctors was how to address issues of mental health and substance abuse.

“When you talk to mental health professionals, the waters part,” said Delbanco. “Half think the idea is nuts, the other half like it.” He added that his personal philosophy is, if a doctor thinks his patient has mental health or substance abuse issues, the patient should be the first person to know.

Delbanco does not deny that some people could become upset by what they read. “Think about it like a new medicine. We think it’s going to be good for the vast number of people and it’s going to hurt a few people. We also have to learn how and when to use it and so do patients.”

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Study Links Food Container Toxins to Emotional and Behavioral Problems in Young Girls; Researchers from Harvard and BU Weigh-in on the Issue

In Healthcare on October 26, 2011 at 3:13 pm

This article first was published by New England Post on October 26, 2011.

Beth Santoro of Billerica thought she did all the right things during her pregnancy. “I didn’t eat cold cuts for the listeria. I didn’t have caffeine. I avoided quite a few things,” said the stay at home mom and former preschool teacher.

According to a recent study published by the journal Pediatrics, Santoro may have unknowingly exposed her unborn daughter to bisphenol-A, or BPA, a chemical found in a variety of plastics. BPA became a household term in 2008 when the compound made the news with reports that it could be leaching into the contents of water bottles. The new study suggests that other types of containers deliver BPA into the body as well. The report links aggression, depression, and anxiety in very young girls to their exposure in utero.

“We’re primarily exposed through the diet because BPA is used for a lot of food contact material and processes,” said Joseph Braun, an environmental health researcher at Harvard School of Public Health and a co-author of the study.  The chemical can be found in food storage containers and in the tin cans’ linings used to prevent spoilage. He said that pregnant women should consider reducing consumption of canned or packaged foods.

“In my head I’ve always said, ‘It’s water bottles,’ ” said Santoro. “That’s what they were drilling into your head.” She was careful not to use old water bottles and to look for the BPA-free label. She said she was shocked to learn she had likely been exposing her unborn baby to BPA.

Santoro said she would have done things differently if she had had that information a year ago. “I would have probably bought the big jar of applesauce instead of the little prepackaged ones.” She said she looks back to all the yogurt, hummus, and applesauce she ate out of plastic containers.

However, Santoro said she does not generally eat many canned goods. “I do a lot of frozen vegetables rather than canned vegetables,” she said.

For many families, canned vegetables and beans represent a large portion of their diet. Braun recognizes that canned goods represent an affordable way to incorporate healthy food into the family diet. “So don’t get rid of those and start eating French fries and milk shakes.”

David Ozonoff, an environmental health professor at Boston University School of Public Health, said in a telephone interview that low-income families frequently are exposed to greater levels of pollutants. Ozonoff knew of no income-specific data relating to BPA, but he said it is highly probable that children in low-income families are exposed to higher levels of BPA both in utero and in early life.

Both Braun and Ozonoff pointed to cash register receipts as an unexpected yet significant source of BPA exposure. Braun suggested that the BPA can be absorbed through the skin when handling receipts. “They get thrown in landfills and get into the water and the environment, ” Ozonoff added.

Joseph Braun

Scientists have long suspected that BPA disrupts the body’s endocrine system, according to Ozonoff. “When the fetus is developing, especially the nervous system, there is a delicate choreography from one cell to another. In order to do this in a coordinated way, they have to talk to each other. One of the main ways they talk to each other is through chemical signaling—that’s the endocrine system,” he said.

He offered this example. “Imagine you go with friends to a crowded bar, and you’re sitting at a table trying to talk about something, but the band is playing. You’re not going to hear anything.” Endocrine disruptors create static-like noise that can lead to distortion and miscommunication and affect development, he said.

Braun said the study found that prenatal BPA exposure appeared to affect the development of “executive functioning” in the brain. “So when you sit down and you know you have to write a story, you have steps in your head, and you are able to plan how to carry them out,” he explained. “People with good executive function can manage those steps and know the order they should take. People with poor executive function can’t manage those types of tasks from start to finish.”

David Ozonoff

Some of the effects of BPA cited by Braun and his colleagues resemble the symptoms of Attention Deficit Hyperactivity Disorder, or ADHD. “Children with ADHD have difficulty in executive function. They are hyperactive, and they don’t know how to react in situations,” he said. He added, that the majority of the children in the BPA study had not been diagnosed with ADHD.

Braun’s study followed children from the womb through their third birthdays. The researchers have continued to track their development and are in the process of completing their fifth-year assessments. Braun expects to publish those findings in the next 18 months.

Ozonoff finds good reason to trust the results of this study. He was not affiliated with this research but is familiar with the work of the scientists collaborating on the study. “These are really good, experienced scientists who really know what they are doing and how to interpret the data.”

Ozonoff believes policymakers and regulators should not wait for additional research but should ban BPA now. He adds, “If it turns out it’s okay, we can always let it back in the environment.”

Is the Current Healthcare System Driving the Nation to Economic Collapse?

In Healthcare on September 23, 2011 at 2:26 pm

This article was first published by New England Post on September 23, 2011.

“Healthcare costs are destroying our American prosperity and even beginning to destroy the American dream,” Dr. Atul Gawande told the Harvard Institute for Learning in Retirement, Wednesday in a lecture entitled “The Battle for the Soul of Medicine.”

Gawunde is a surgeon at Brigham and Women’s Hospital, associate professor at Harvard School of Public Health, and regular contributor to The New Yorker. He is the author of three books including The Checklist Manifesto in which he prescribes a 19-item checklist for surgical teams to address before each surgery. He has been presenting his “Battle for the Soul of Medicine” lecture around the country for a year warning of impending economic medical collapse if healthcare costs are not reigned in within the decade.

These concerns are nothing new to Boston area medical and public health professionals. Dr. Alan Sager, Boston University professor of public health and management and director of BU’s Health Reform Program has been weighing these problems for a decade and testified before Congress about such matters.

In a telephone interview following Gawunde’s lecture, Sager confirms Gawunde’s concerns. “We’re already there,” he said. “There are huge signs of that already,” and cited individual state struggles to cover ever rising Medicare costs.

Gawunde, however, remained optimistic.

“The answer is right in front of us. We can rediscover our American ability to solve problems,” he said and offered his checklists as one solution.

Gawunde advocated medical culture that looks beyond providing individuals the best training and hospitals the best technology to a system where individual doctors work in concert. “We’ve trained all of our physicians to be cowboys when we need pit crews,” Gawunde said. It used to be that individual doctors could “do it all,” he explained.

But medicine has changed.

“We now understand there are 13,600 different ways that the human body can fail. There are 6000 drugs that I can legally prescribe and 4,000 medical and surgical procedures to choose from,” Gawunde said. Where doctors once prescribed an aspirin, they now might recommend a knee replacement. A knee replacement requires a lot more doctors than an aspirin and those doctors need to work together he said, then added “cowboys aren’t even cowboys anymore. They drive in teams and have specific protocols that they follow…checklists.” ”

However, even cowboys and pit crews need a leader, someone to coordinate efforts and reduce redundancy.

Sager said he sees primary care physicians as the key to unlocking the healthcare crisis. A shortage of primary care doctors means that full time physicians care for 1500 to 4000 patients, he said. He said an increase of 300,000, full-time equivalent primary care doctors would bring the doctor to patient ratio down to 1 doctor for 1000 patients. He predicted this would improve the overall quality of primary and secondary care and reduce reliance on expensive hospitals for routine care.

Dr. Gregg Meyer, primary care physician and vice president of quality and safety at Mass General Hospital agreed in a telephone interview that there is much to be gained from an investment in primary care doctors.

“I think there is strong evidence to say that if we invested more in primary care and we did it in the right way, that we could make a dent in health care costs,” said Meyer. However, primary care is not an attractive field to medical students, he qualified. He added that primary care doctors are often overworked and underpaid.

American cultural norms contribute to excessive medical costs, as well. Dr. Karen Thomas, cardiologist at Beth Israel Deaconess Medical Center and Mount Auburn Hospital said in a telephone interview that she often felt trapped as a physician by cultural expectations.

“Americans think they should be able to live forever and they should be able to spend millions and millions of dollars to do so at no personal cost to themselves,” says Thomas. “We just don’t have $50,000 to be putting a preventative device in a 90 year old.” Still families want their loved ones to receive every medical advantage possible, and Medicare will readily pay for it.

Sager suggested that physicians benefit from over providing. More tests mean more visits and more visits mean more fees. “Financial incentives to over-serve and fear of being sued come together as two mighty rivers and lead to a flood of over-care.”

Thomas admitted to ordering tests that she knew were probably not necessary in order to avoid a potential lawsuit. Meyer said that this is a problem throughout the United States and should be a major subject in the national healthcare dialogue.

Gawunde called the identification of these problems as the first step. His checklists are one idea for addressing the problem of errors. As Doctors Sager, Meyer, and Thomas pointed out, problems abound in the current medical system. Only time will tell how these problems will be addressed.