Should You Stay or Should You Go?

Picture this familiar scene. A critically injured person is wheeled into the emergency room by paramedics. Concerned, shocked and occasionally hysterical family members rush to the patient’s side. An army of doctors, nurses and techs begin emergency resuscitation efforts, inserting breathing tubes, CPR, starting IV’s, drawing blood, administering drugs and other fluids.  One of these health care professionals, nodding toward the family and screaming “Get them out of here!”

We’ve all see it… either in real life or on TV.

Cutting to the next scene, the family is escorted into a stark family crisis room. While healthcare staff work desperately to resuscitate the patient, a social worker updates the family on their progress. If the patient dies, staff  make him as presentable as possible, and then invite the family in to say good-byes. The social worker supports the family during this difficult time, and the code team return to their care of other patients.

For decades, this approach seemed to work well. The common wisdom was that if we did let the family in during the code, they’d either get in the way or become so distraught that we’d have more patients on our hands. Furthermore, we felt we were doing the family a greater service by letting them see their loved one only after we’d removed tubes and lines, even though the calm scene we produced was in total contradiction to actual events.

But recently, this traditional approach has been questioned. It turns out that many family members want to be present during resuscitation efforts, rather than hidden away in a side room.

And even though health care professionals are still divided on whether families should be present, most agree the issue must be addressed.

Now, research is starting to question whether family members be allowed to remain in the room as these potentially lifesaving efforts begin?

A two-year study led by a researcher Jane Leske PhD, has shown that family members – parents, spouses, fiancées and adult children – of trauma patients, can benefit by being present during critical moments of care.

“Those who do choose to do it really want to be there,” says Leske, professor of nursing at the University of Wisconsin-Milwaukee. “They want to watch everything and get information. It lowers their anxiety and stress to see that everything possible is being done. Seeing is believing.”

However, family presence during resuscitation is controversial and underutilized. Indeed, many health care professionals and hospitals argue against it, concerned that the procedures may be too traumatic for family witnesses, or that family members may become emotionally out of control and interfere with care.

Leske conducted this study in collaboration with medical staff at a facility where families have the option of staying and observing resuscitation efforts. It compared outcomes for family members of patients, ages 18-93, with critical injuries from gunshot wounds or motor vehicle accidents at a Southeast Wisconsin Level 1 trauma center.  The center had offered family presence during resuscitation for more than two years by the time Leske’s study began.

The study focused on 140 family members over age 18, divided in two roughly equal groups – those who opted to remain with the victim during resuscitation; and those who chose not to, or were not able to reach the emergency department in time. Researchers interviewed family members within 72 hours after admission to the surgical intensive care unit, to discuss the family’s coping resources, communication and anxiety levels.

She and her research team found a number of benefits to having family members present, and no drawbacks.

They concluded that while families can benefit from being present during resuscitation, it’s also important that the hospital have policies and procedures in place on when and how to allow the option. For example, family presence during resuscitation should not be permitted when family members are intoxicated, extremely agitated or emotionally unstable.

Other researchers agree. A large French study published last month in the New England Journal of Medicine concluded that relatives who did not witness CPR had post-traumatic stress disorder (PTSD)–related symptoms of anxiety and depression more frequently than those who did witness CPR. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, or the level of emotional stress in the medical team and did not result in medico-legal claims.

What are your thoughts on this?  Would you want to stay…or walk away.  Let us know.

Bullseye! Lyme Disease Without the Rash

With the weather finally starting to warm up, if you’re anything like me, you probably can’t wait to get outdoors and get active. However, and with apologies for being a Debbie Downer, we want to remind you that warmer weather also means that ticks become more active and are more likely to bite you, your kids and your pets. Just being outside in the garden could put you at risk of tick-borne diseases such as Lyme.

Should you contract Lyme disease, quick diagnosis and treatment are essential to avoiding long term complications. However, the diagnostic process may be delayed if the skin rash caused by Lyme disease does not have the typical bull’s-eye appearance.

A Research Letter just published in the CDC journal Emerging Infectious Diseases, shows that Lyme disease has been identified in patients with skin lesions that more closely resemble the classic signs of conditions such as contact dermatitis, lupus, insect or spider bites.

Based on these findings they urge doctors to consider Lyme disease when presented with patients complaining of such lesions, particularly when they have been in an area where Lyme disease is endemic.

The research team led by Steven E, Schutzer, MD, Professor of Medicine at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School, studied 14 patients.

An advanced diagnostic technique, based upon polymerase chain reaction (PCR) testing was used to identify Borrelia burgdorferi, the bacterium that causes Lyme disease. Unlike existing methods, the new technique is able to detect evidence of B. burgdorferi early, even in cases where the bacterium is still at low levels in the bloodstream, and sooner than traditional antibody tests, which may require several weeks before becoming positive. It also is able to distinguish between new infections and prior exposure to B. burgdorferi.

Of the patients analyzed, ten were found to have strong microbiologic evidence of Lyme disease, despite the fact that they had presented with skin lesions that differed markedly from the classic bull’s-eye pattern. In fact, not all patients with Lyme disease will even have a rash.

Based on this finding, Schutzer says, “Doctors who see a rash in a patient who has been in an area where Lyme disease frequently occurs should be alert to the fact that the Lyme disease rash does not have to look like a bull’s-eye, ring-within-a ring. The rash may look different. Doctors should search carefully both for other signs that might suggest Lyme disease, such as flu-like symptoms, and equally for signs that may point towards other conditions. Early diagnosis of most diseases gives the best chance for a cure. This is especially true for Lyme disease.”

So, this summer, make sure your doctor isn’t in a rush to take any rash decisions about ruling out a diagnosis of Lyme Disease.

Put on the red light

We’ve all been there, some of us more often than others. You know what I’m talking about. That mid-afternoon moment where we find ourselves crashing at our computers. Or nodding off into our notebooks.

And it’s not just our productivity that’s affected.  It turns out that acute or chronic sleep deprivation and the resulting fatigue is one of the leading causes of workplace incidents and related injuries. Most performance failures, including car accidents, occur in the mid-afternoon hours known as the “post-lunch dip.”  Typically this occurs sometime between 2-4 p.m., or about 16-18 hours after the previous night’s bedtime.

Now a new study from the Lighting Research Center [who knew there was such a thing?]  at Rensselaer Polytechnic Institute – the nation’s oldest technological university – suggests that there may be a way to alleviate afternoon accidents.  Their research shows that exposure to certain wavelengths and levels of light have the potential to increase alertness during the post-lunch dip. These results pave the way for a non-pharmacological intervention to increase alertness during the daytime.

Mariana Figueiro, LRC Light and Health Program director, has previously conducted studies that show that light has the potential to increase alertness at night. Exposure to strong levels of white light at night increases performance, elevates core body temperature, and increases heart rate.

In most studies to date, the alerting effects of light have been linked to its ability to suppress the circadian rhythm regulating hormone – melatonin, the levels of which are typically lower during the daytime, and higher at night. However, results from a previous study by Figueiro demonstrated that acute melatonin suppression is not needed for light to affect alertness during the nighttime. While both short-wavelength (blue) and long-wavelength (red) lights increased measures of alertness, only short-wavelength light suppressed melatonin.

Based on this finding the researchers hypothesized that if light can impact alertness via pathways other than melatonin suppression, then certain wavelengths and levels of light might also increase alertness during the middle of the afternoon.

During the study, participants experienced two experimental lighting conditions in addition to darkness. Long-wavelength “red” light and short-wavelength “blue” light were delivered to the corneas of each participant by arrays of light emitting diodes (LEDs) placed in light boxes. Participant alertness was measured by electroencephalogram (EEG) and subjective sleepiness (KSS scale).

The team found that, compared to remaining in darkness, exposure to red light in the middle of the afternoon significantly improves alertness.

Co-author Levent  Sahin, a doctoral student  at the Lighting Research Center, was interested in this study from a transportation safety perspective, and what the results could mean to the transportation industry. “Safety is a prerequisite and one of the most important quality indicators in the transportation industry,” said Sahin. “Our recent findings provided the scientifically valid underpinnings in approaching fatigue related safety problems in 24 hour transportation operations.”

Those of us who remember the lyrics of the 1978 Police hit Roxanne – “You don’t have to put on the red light,” may need to rethink…

Even though the present results don’t fully explain the underlying mechanisms of light-induced changes in alertness it seems we could all benefit from a little red light on our desks.

The Skinny on Breakthrough Myelin Sheath Disorders

In patients with multiple sclerosis, cerebral palsy, and other rare genetic disorders known as leukodystrophies, the myelin sheath – the fatty covering that acts as an insulator around nerve fiber is progressively destroyed. Without this vital insulation, brain impulses to the rest of the body are lost leading to debilitating symptoms such as loss of muscle tone, movement, gait, speech, vision, hearing, ability to eat, and behavioral changes.

So we were very excited to learn that researchers at Case Western Reserve School of Medicine have discovered a technique that can directly convert skin cells to the type of brain cells destroyed in myelin disorders.

This amazing new technique involves converting fibroblasts – an abundant structural cell present in the skin and most organs – into oligodendrocytes, the type of cell responsible for myelinating the neurons of the brain.

“Its ‘cellular alchemy,’” explains Paul Tesar, PhD, assistant professor of genetics and genome sciences at Case Western Reserve School of Medicine “We are taking a readily accessible and abundant cell and completely switching its identity to become a highly valuable cell for therapy.”

In a process termed “cellular reprogramming,” researchers manipulated the levels of three naturally occurring proteins to induce fibroblast cells to become precursors to oligodendrocytes (called oligodendrocyte progenitor cells, or OPCs).  Tesar’s team, rapidly generated billions of these induced OPCs (iOPCs). They also showed that iOPCs could regenerate new myelin coatings around nerves after being transplanted to mice – a result that offers hope the technique might be used to treat human myelin disorders.

When oligodendrocytes are damaged or become dysfunctional in myelinating diseases, the insulating myelin coating that normally coats nerves is lost. A cure requires the myelin coating to be regenerated by replacement oligodendrocytes.  Until now, OPCs and oligodendrocytes could only be obtained from fetal tissue or pluripotent stem cells. These techniques have been valuable, but with limitations.

“The myelin repair field has been hampered by an inability to rapidly generate safe and effective sources of functional oligodendrocytes,” explained co-author and myelin expert Robert Miller, PhD. “The new technique may overcome all of these issues by providing a rapid and streamlined way to directly generate functional myelin producing cells.”

This initial study used mouse cells. The critical next step is to demonstrate feasibility and safety using human cells in a lab setting. If successful, the technique could have widespread therapeutic application to human myelin disorders.

These are exciting times. The progression of stem cell biology is providing therapeutic opportunities that a decade ago would not have been thought possible. As always SRxA’s Word on Health, will bring you further developments on this story as soon as they’re released.

Puzzling how to get Lady Gaga out of your head?

You know how it goes. You hear a song on the radio, or TV and it gets stuck in your mind. Once there, it takes root and will (almost) never leave.

Among some of the worst offenders in my experience are songs such as:

•  “Single Ladies” – Beyoncé
•  “Bad Romance” – Lady Gaga
• “Poker Face” – Lady Gaga
• …just about anything by – Lady Gaga
•  “Call Me Maybe” – Carly Rae Jepsen
• “We Are Never Ever Getting Back Together” – Taylor Swift

Did you know there’s even a term for these songs that won’t go away?  Earworms…yes really !

If you’ve already got “Call Me Maybe” stuck in your head, or you’re thinking “if you liked it, then you shoulda put a ring on it” purely as a result of reading the above, I apologize!

But while I may have been the one to have exposed your impressionable mind to such repetitive refrains, the real culprit is the Zeigarnik Effect – the  terrific-but-occasionally-traumatic tendency we have to keep thinking about tasks we’ve left incomplete.  As humans we like to finish what we’ve started.  So even when our conscious minds move on to a new thing, our unconscious minds remain preoccupied with our unfinished business, leading to dissonance.

According to music psychologist Ira Hyman, who recently published a paper on earworm science (who knew?!?)  songs function much like puzzles in our brains.  Music is catchy because its patterns and rhythms engage our minds like a crossword puzzle would.  And the music of Ms’s Carly Rae, Beyoncé, Rihanna, and Gaga, apparently fall into that cognitive sweet spot of attention and inattention, making them especially “sticky.”

Music is different from puzzles, though, in one significant way: while puzzles can be solved, songs have no obvious solution. So they stay. And stay. And stay. Haunting and taunting and put-a-ring-ing in our ears.

But…big drum roll… scientists may have found a way to stop them.  Hyman and his colleagues figured that if earworms function like puzzles, they might be vanquished by puzzles, too. Their researcher concluded that cognitive subterfuge is the best way to rid the mind of sticky songs. In other words, if you want to get rid of an earworm, you just have to fool your brain into solving another, non-musical puzzle.

The best way to do that? Give your brain an actual puzzle to concentrate on. Do a crossword. Tackle an anagram. Trick your mind out of its need to finish what it started by giving it something else – something simple, but not too simple – to focus on.

Solving anagrams might not always be the best way to spend your time, sure. But it’s a small price to pay.

And, even though  – this is crazy – it’s much, much better than having “Call Me Maybe” stuck in your head all day!

Pharma Under Fire for Fair Balance Failings

Uh oh! Seems like the Pharma industry is in trouble again.

Research published in the Journal of General Internal Medicine suggests that family physicians receive “little or no information” about adverse effects associated with medicines in the majority of drug promotions made by sales representatives.

In the study, 255 family doctors from urban practices in the US [Sacrameto], France [Tolouse] and Canada [Montreal and Vancouver] answered questionnaires following visits from sales representatives.  The primary outcome measure was “minimally adequate safety information” (mention of at least one indication, serious adverse event, common adverse event, and contraindication, and no unqualified safety claims or unapproved indications).

The findings showed that sales representatives did not provide any information about common or serious side effects, or identify the patients who should not be using the drug, in 59% of the promotions. In Canada, no potential side effects were mentioned for 66% of promoted products, according to the results.

The researchers also indicated that although 57% of the promoted drugs carried boxed warnings from the FDA or Health Canada, serious adverse events were only discussed in about 6% of the sales pitches.

Félicitations to the French reps who provided information on harm for 61% of the promotions, compared to only 34% in Canada and 39% in the US.

Despite this lack of “fair balance” overall, the doctors considered the quality of the scientific information to be good or excellent for 54% of the promotions and indicated that they would be willing to prescribe the drugs 64% of the time.

“Laws in all three countries require sales representatives to provide information on harm as well as benefits,” says lead author Barbara Mintzes, Assistant Professor at the University of British Colombia. “But no one is monitoring these visits and there are next to no sanctions for misleading or inaccurate promotion.”

Despite widespread belief by physicians to the contrary, the information provided by pharmaceutical sales representatives has been shown to influence prescribing. Greater exposure to promotion is associated with higher prescribing volume and costs.  And while regulations in all three countries require sales representatives to provide information on the risks as well as the benefits of their drugs, there are differences.  It’s interesting, to correlate the above results with the fact that that France has the strictest information standards, whereas Canada relies on industry self-regulation.

However, across all three countries, the results of this study would appear to question if current approaches are adequate to protect patient health.

The Pharma Industry should take note.  Time to clean up your act before the Government and Regulatory Authorities do it for you.

Praying for Boston

No words tonight, only prayers. For the victims, for the families, for Boston, for sport, for the first responders and for humanity.

Our thoughts are with you.

Lift Weights to Lower Blood Sugar?

SRxA’s Word on Health was interested to read that researchers in the Life Sciences Institute at the University of Michigan have overturned a long-held belief that whitening of skeletal muscle in diabetes is harmful.  Instead, they found that the white muscle that increases with resistance training, age and diabetes actually helps to keep blood sugar in check.

The insights identified in the study may point the way to potential drug targets for obesity and metabolic disease.

“We wanted to figure out the relationship between muscle types and body metabolism, how the muscles were made, and also what kind of influence they have on diseases like type 2 diabetes,” said Jiandie Lin, Life Sciences Institute faculty member.

Much like poultry has light and dark meat, mammals have a range of muscles: red, white and those in between. Red muscle, which gets its color in part from mitochondria, prevails in people who engage in endurance training, such as marathon runners. White muscle dominates in the bodies of weightlifters and sprinters – people who require short, intense bursts of energy.

When you exercise, nerves signal your muscles to contract, and the muscle needs energy. In response to a signal to lift a heavy weight, white muscles use glycogen to generate adenosine triphosphate (ATP) – energy the cells can use to complete the task. While this process can produce a lot of power for a short time, the glycogen fuel soon depletes.

However, if the brain tells the muscle to run a slow and steady long-distance race, the mitochondria in red muscles primarily use fat oxidation instead of glycogen breakdown to generate ATP. The supply of energy lasts much longer but doesn’t provide the burst of strength that comes from glycolysis.

People with diabetes see whitening of the mix of muscle.

“For a long time, the red-to-white shift was thought to make muscle less responsive to insulin, a hormone that lowers blood sugar,” Lin said. “But this idea is far from proven. You lose red muscle when you age or develop diabetes, but is that really the culprit?”

To find out, the team set out to find a protein that drives the formation of white muscle. They identified a list of candidate proteins that were prevalent in white muscle but not in red.

Further studies led the team to focus on a protein called BAF60c, a sort of “zip code” mechanism that tells the cells when and how to express certain genes. The Lin team made a transgenic mouse model to increase BAF60c only in the skeletal muscle. One of the first things they noticed was that mice with more BAF60c had muscles that looked paler.

“That was a good hint that we were going in the white-muscle direction,” said lead author Zhuo-xian Meng, a research fellow in Lin’s lab.

They used electron microscopy to see the abundance of mitochondria within the muscle, and confirmed that muscle from BAF60c transgenic mice had less mitochondria than the normal controls.

“We saw predicted changes in molecular markers, but the ultimate test would be seeing how the mouse could run,” Lin said.

If the BAF60c mice could run powerfully for short distances but tired quickly, the scientists would be able to confirm that the BAF60c pathway was a key part of the creation of white muscle.

Using mouse treadmills, they compared the endurance of BAF60c mice to a control group of normal mice, and found that the BAF60c transgenic mice could only run about 60% of the time that the control group could before tiring.

“White muscle uses glycogen, and the transgenic mice depleted their muscles’ supplies of glycogen very quickly,” Lin said.

After some follow-up experiments to figure out exactly which molecules were controlled by BAF60c, Lin and his team were confident that they had identified major players responsible for promoting white muscle formation.

Now that they knew how to make more white muscle in animals, they wanted to determine whether white muscle was a deleterious or an adaptive characteristic of diabetes.

The team induced obesity in mice by feeding them a “Super Size Me” mouse diet. On a high-fat diet, a mouse will double its body weight in two to three months. They found that obese mice with BAF60c transgene were much better at controlling blood glucose.

“The results are a bit of a surprise to many people,” Lin said. “It really points to the complexity in thinking about muscle metabolism and diabetes.”

In humans, resistance training promotes the growth of white muscle and helps in lowering blood glucose. If future studies in humans determine that the BAF60c pathway is indeed the way in which cells form white muscle and in turn optimize metabolic function, the finding could lead to researching the pathway as a drug target.

“We know that this molecular pathway also works in human cells. The real challenge is to find a way to target these factors,” Lin said.

Until we know for sure SRxA’s Word on Health recommends a healthy mix of running and weight training.

Bye-Bye Backside

Anyone who’s ever been a hospital patient knows that hospital gowns come in three sizes: short, shorter….and don’t bend over! They probably also know that hospital gowns are like health insurance – you can never have enough coverage!

But now the days of the drafty backside may be coming to a close, and hospital gowns may no longer be the perennial the butt of jokes.

A new patient gown that resembles a wrap-around robe that completely closes in the back and front, is being rolled out on several inpatient floors at Henry Ford Hospital in Detroit. It is among the first inventions to be made public by the Henry Ford Innovation Institute in collaboration with the College for Creative Studies.

The traditional back slit hospital gown has been completely designed and in its place is a stylish gown that blends style for the patient with clinical function for the health care team.

Features of the he newly designed gown include:

• Completely closed in the back, creating more privacy for patients
• Made of a thicker, cotton/polyester blend material, which keeps patients warmer
• Double-breasted in the front, using three snaps, instead of ties, to close the gown
• Intuitive in design, with different colored snaps and stitching along the left and right sides of the gown, making it easy for patients to put on
• Accessible for IVs and other medical lines.

Since its introduction, health care teams at Henry Ford say the gown offers them uncompromised clinical access to the patient without the need to undress the patient.

“Our No. 1 goal was to close the backside of the gown with our design,” says Michael Forbes, a product designer at the Henry Ford Innovation Institute and graduate of the College for Creative Studies . “A simple change can have a large impact on the patients’ stay at a hospital. By creating a hospital gown that is safe, stylish and comfortable, we’ve made the patient feel more at home, like they’re wearing their own garments.”

The gown, which began with a drawing two years ago has been tested by patients like Ismail Khalil, M.D., a vascular surgeon from Lebanon who traveled to Henry Ford Hospital for a liver transplant.  Dr. Khalil has the unique perspective as both a physician and now a patient on the design of the new hospital gown versus the traditional hospital gown.

“The new gown is the ultimate in simplicity and sophistication,” he says. “The old gown was uncomfortable with the ties in the back; I did not like it. I’d much rather walk down the hall in the new gown; it fits well and you feel decent. It looks good too. What more could you want?”

The new gown can also be size adjusted using snaps on either side of the gown, allowing for it to fit more patients with a single design.  Currently it comes in navy and light blue, to coincide with the Henry Ford Hospital colors but could easily be modified for other hospitals.

The cost to manufacture and purchase the new gown is very comparable to existing gowns, and laundering is exactly the same too. The goal, says Forbes, is to license the design to an existing gown manufacturer, which would then produce and sell the gown nationally.

A move which can’t come soon enough for  those looking for a little less Southern exposure!

Cutting Costs by Cutting Pills

According to some disturbing data released yesterday by the CDC, many US adults aren’t following doctor’s orders. And it’s not just the very young or very old, who, it could be claimed,  don’t know any better.

It turns out that adults under the retirement age are twice as likely to skip their prescribed medications in order to save money to save money.

And although spending on drugs is expected to increase an average of 6.6% a year from 2015 through 202, 20% of adults regardless of age, have asked their doctors for a lower cost treatment.

Americans spent $45 billion out-of-pocket on retail prescription drugs in 2011. But, “if you’re not insured or you face high co-payments, you’re going to stretch your prescriptions,” says Steve Morgan, an associate professor at the University of British Columbia’s School of Population and Public Health in Vancouver. “Even among insured populations, there is this invincibility mindset among the very young. Older people are more likely to adhere to chronic therapies over a longer period of time than younger.”

The study also found that 13% of those ages 18 – 64 reported not taking their medications as prescribed to reduce costs compared with 5.8% of those 65 and older.

Strategies that alter the way adults take their medications include skipping doses and consuming less than the prescribed amount. About 11% of those aged 18 – 64 also delayed filling a prescription compared with 4.4% of those 65 and older.

Uninsured adults were more likely to have tried to stretch their medications than those with Medicaid or private insurance.

But are such savings worth it? Failing to take medication as prescribed may actually increase costs to the U.S. health system, particularly if medication non-adherence results in increased hospitalizations, or complications of chronic diseases.

Anytime a patient chooses not to take drugs as prescribed, the pharmaceutical industry pharma loses sales. A recent study estimated that pharma loses $564 billion globally to non-adherence to drugs. Not surprisingly then, the industry is experimenting with reminders, to increase adherence. Nevertheless, a nudge from a text or a talking pill container might not inspire patients who are penny pinching.

I’d love to stay and chat, but I need to run to the pharmacy to refill my blood pressure meds that I ran out of several days ago!