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Probiotics' Benefits May Be More Than a Gut Feeling
By Sumathi Reddy : WSJ : November 26, 2012
Probiotics, believed to help with digestion, are increasingly being studied to treat wide-ranging conditions, from colic to cholesterol and the common cold.
One of the fastest-growing dietary supplements, probiotics are now prominent on drug and big-box store shelves. They are live microorganisms—or "good" bacteria—that when consumed in capsules or yogurt are said to confer a health benefit. So far, however, there is little scientific proof of their effectiveness—many studies of probiotics have involved less-than-rigorous research standards.
As further data become available, some researchers believe probiotics may evolve into prescription drugs, as doctors focus on specific bacteria strains to target patients' particular conditions. At the moment, however, many experts say probiotics are misunderstood.
"Consumers have shown to be willing to spend the money, just in case [probiotics] work," says Michael Fischbach, an assistant professor of bioengineering and therapeutic sciences at the University of California, San Francisco. "What we all have to be careful about is to not view them as a panacea and to make sure that we don't raise our expectations too high."
U.S. sales of probiotic supplements totaled nearly $770 million last year, up some 22% from the previous year, according to Euromonitor International, a market research firm.
The strongest clinical studies have suggested some probiotics may be beneficial for certain gastrointestinal problems, allergies and vaginal infections. Many doctors recommend probiotics when patients are taking antibiotics. Probiotics are widely considered safe except for people with an impaired immune system, though experts recommend talking to a doctor first.
For other ailments, hundreds of probiotic studies are currently under way, experts say. In a report last month in the British Journal of Nutrition, researchers at the University of Medicine and Dentistry of New Jersey-School of Health Related Professions said a combination of two probiotics may reduce the symptoms and recovery time for the common cold. Other studies have shown similar results, especially with children.
Researchers this month presented evidence at a meeting of the American Heart Association showing that two daily doses of a probiotic lowered bad cholesterol by nearly 12% and reduced total and saturated cholesterol esters which contribute to the hardening of arteries. The study was funded by Micropharma Ltd., a Canadian probiotic research and production company.
Some studies have federal backing. UCSF is exploring possible effects of probiotics on infants and early markers of asthma, as well as on colic. Harvard Medical School researchers are studying what good bacteria might do for the immune system to see if the response to flu vaccine in elderly people can be improved.
The body contains trillions of bacteria, both good and bad. Most live in the gut but they also colonize other areas. Good bacteria help digest food, produce vitamins and protect from infections, among other things.
The Flora Inside
Probiotics are 'good' bacteria believed to confer health benefits.
· Products ranging from yogurt to household cleaners contain probiotics.
· Sales of probiotic supplements totaled $770 million last year, up 22% from 2010.
· For supplements, experts suggest sticking to well-known brands like Culturelle, VSL#3, Align and Florastor.
· Different probiotic strains can affect the body differently. Strains should be listed on a product label.
· Probiotics are largely unregulated but they can't make claims to cure or prevent a disease.
The community of bacteria, the body's intestinal flora, begins at birth, says Esi Lamousé-Smith, an instructor in medicine at Boston Children's Hospital and Harvard Medical School. By age 3 these bacteria, sometimes referred to as our gut or intestinal microbiome, are more or less set, she says. Each person's microbiome is distinct and doesn't change significantly with age unless a person becomes ill, takes an antibiotic or makes major changes in diet.
A probiotic, which adds good bacteria only for the time it is being taken, seems to influence other bacteria already present. For example, it might stimulate other bacteria to turn on or off certain genes. These genes, in turn, might be involved in various functions, such as immune regulation or nutrient metabolism.
"I am wholeheartedly a believer" in probiotics, says Maureen Fitzgerald, a Germantown, Wis., resident who blogs about parenting issues.
As a former teacher, Ms. Fitzgerald was exposed to many germs and says she was looking for something to "beef up" her immune system. Once she started regularly taking probiotics she says she wasn't "getting as many of the colds and the bugs that are around." About five years ago, Ms. Fitzgerald's then 3-year-old son began taking a children's probiotic that cleared up digestion problems he was having. After that, Ms. Fitzgerald says she was hooked on the supplements. She raved about probiotics on her blog and has since received free samples, which she reviews.
There are many different strains of probiotics and each may affect the body differently. The dosage—or number of colony-forming units—in a probiotic is also important.Lactobacilli and bifidobacteria are the two most widely studied types of probiotics. Lactobacillus rhamnosus, widely known as LGG, may treat viral and antibiotic-induced diarrhea, and certain allergies, like childhood eczema. A strain of Lactobacillus reuteri has been shown to help with colic. Bifidobacterium animalis, found in some brands of yogurt, is said to improve digestion.
Experts say taking a probiotic supplement with many bacterial strains isn't necessarily better. The key is ensuring each strain in a product is active and has been clinically proven to work at a certain dosage, they say. Tests done by ConsumerLab.com have shown that the number of living organisms in probiotics doesn't always reflect the label. Of 12 products tested this year, two delivered fewer organisms than listed.
Probiotics aren't required to obtain Food and Drug Administration approval before being marketed. "Right now they're considered a food product or dietary supplement, not a drug," says Gerard Mullin, an associate professor at Johns Hopkins University School of Medicine and author of "The Inside Tract."
There aren't any FDA approved health claims for probiotics, says Diane Hoffmann, a law professor at the University of Maryland Carey School of Law, who oversaw a study on the federal regulation of probiotics. But companies can make broader statements, called "structure function" claims. It is the difference between saying a product reduces the risk of heart disease versus supports a healthy heart. Because the difference isn't discernible to many consumers, there is little incentive in the industry to pursue costlier and more resource-intensive health claims.
"Consumers just need to know that claims are not necessarily preapproved and they may not be well substantiated," says Ms. Hoffmann.
In the short term, experts recommend sticking with the strains of probiotics that have a lot of science behind them, like Lactobacillus GG, and brands that have proven to be safe and truthful in labeling.
Dr. Mullin, of Johns Hopkins, says the future may lie in concocting specific probiotics for people based upon their individual needs and microbiomes.
By Sumathi Reddy : WSJ : November 26, 2012
Probiotics, believed to help with digestion, are increasingly being studied to treat wide-ranging conditions, from colic to cholesterol and the common cold.
One of the fastest-growing dietary supplements, probiotics are now prominent on drug and big-box store shelves. They are live microorganisms—or "good" bacteria—that when consumed in capsules or yogurt are said to confer a health benefit. So far, however, there is little scientific proof of their effectiveness—many studies of probiotics have involved less-than-rigorous research standards.
As further data become available, some researchers believe probiotics may evolve into prescription drugs, as doctors focus on specific bacteria strains to target patients' particular conditions. At the moment, however, many experts say probiotics are misunderstood.
"Consumers have shown to be willing to spend the money, just in case [probiotics] work," says Michael Fischbach, an assistant professor of bioengineering and therapeutic sciences at the University of California, San Francisco. "What we all have to be careful about is to not view them as a panacea and to make sure that we don't raise our expectations too high."
U.S. sales of probiotic supplements totaled nearly $770 million last year, up some 22% from the previous year, according to Euromonitor International, a market research firm.
The strongest clinical studies have suggested some probiotics may be beneficial for certain gastrointestinal problems, allergies and vaginal infections. Many doctors recommend probiotics when patients are taking antibiotics. Probiotics are widely considered safe except for people with an impaired immune system, though experts recommend talking to a doctor first.
For other ailments, hundreds of probiotic studies are currently under way, experts say. In a report last month in the British Journal of Nutrition, researchers at the University of Medicine and Dentistry of New Jersey-School of Health Related Professions said a combination of two probiotics may reduce the symptoms and recovery time for the common cold. Other studies have shown similar results, especially with children.
Researchers this month presented evidence at a meeting of the American Heart Association showing that two daily doses of a probiotic lowered bad cholesterol by nearly 12% and reduced total and saturated cholesterol esters which contribute to the hardening of arteries. The study was funded by Micropharma Ltd., a Canadian probiotic research and production company.
Some studies have federal backing. UCSF is exploring possible effects of probiotics on infants and early markers of asthma, as well as on colic. Harvard Medical School researchers are studying what good bacteria might do for the immune system to see if the response to flu vaccine in elderly people can be improved.
The body contains trillions of bacteria, both good and bad. Most live in the gut but they also colonize other areas. Good bacteria help digest food, produce vitamins and protect from infections, among other things.
The Flora Inside
Probiotics are 'good' bacteria believed to confer health benefits.
· Products ranging from yogurt to household cleaners contain probiotics.
· Sales of probiotic supplements totaled $770 million last year, up 22% from 2010.
· For supplements, experts suggest sticking to well-known brands like Culturelle, VSL#3, Align and Florastor.
· Different probiotic strains can affect the body differently. Strains should be listed on a product label.
· Probiotics are largely unregulated but they can't make claims to cure or prevent a disease.
The community of bacteria, the body's intestinal flora, begins at birth, says Esi Lamousé-Smith, an instructor in medicine at Boston Children's Hospital and Harvard Medical School. By age 3 these bacteria, sometimes referred to as our gut or intestinal microbiome, are more or less set, she says. Each person's microbiome is distinct and doesn't change significantly with age unless a person becomes ill, takes an antibiotic or makes major changes in diet.
A probiotic, which adds good bacteria only for the time it is being taken, seems to influence other bacteria already present. For example, it might stimulate other bacteria to turn on or off certain genes. These genes, in turn, might be involved in various functions, such as immune regulation or nutrient metabolism.
"I am wholeheartedly a believer" in probiotics, says Maureen Fitzgerald, a Germantown, Wis., resident who blogs about parenting issues.
As a former teacher, Ms. Fitzgerald was exposed to many germs and says she was looking for something to "beef up" her immune system. Once she started regularly taking probiotics she says she wasn't "getting as many of the colds and the bugs that are around." About five years ago, Ms. Fitzgerald's then 3-year-old son began taking a children's probiotic that cleared up digestion problems he was having. After that, Ms. Fitzgerald says she was hooked on the supplements. She raved about probiotics on her blog and has since received free samples, which she reviews.
There are many different strains of probiotics and each may affect the body differently. The dosage—or number of colony-forming units—in a probiotic is also important.Lactobacilli and bifidobacteria are the two most widely studied types of probiotics. Lactobacillus rhamnosus, widely known as LGG, may treat viral and antibiotic-induced diarrhea, and certain allergies, like childhood eczema. A strain of Lactobacillus reuteri has been shown to help with colic. Bifidobacterium animalis, found in some brands of yogurt, is said to improve digestion.
Experts say taking a probiotic supplement with many bacterial strains isn't necessarily better. The key is ensuring each strain in a product is active and has been clinically proven to work at a certain dosage, they say. Tests done by ConsumerLab.com have shown that the number of living organisms in probiotics doesn't always reflect the label. Of 12 products tested this year, two delivered fewer organisms than listed.
Probiotics aren't required to obtain Food and Drug Administration approval before being marketed. "Right now they're considered a food product or dietary supplement, not a drug," says Gerard Mullin, an associate professor at Johns Hopkins University School of Medicine and author of "The Inside Tract."
There aren't any FDA approved health claims for probiotics, says Diane Hoffmann, a law professor at the University of Maryland Carey School of Law, who oversaw a study on the federal regulation of probiotics. But companies can make broader statements, called "structure function" claims. It is the difference between saying a product reduces the risk of heart disease versus supports a healthy heart. Because the difference isn't discernible to many consumers, there is little incentive in the industry to pursue costlier and more resource-intensive health claims.
"Consumers just need to know that claims are not necessarily preapproved and they may not be well substantiated," says Ms. Hoffmann.
In the short term, experts recommend sticking with the strains of probiotics that have a lot of science behind them, like Lactobacillus GG, and brands that have proven to be safe and truthful in labeling.
Dr. Mullin, of Johns Hopkins, says the future may lie in concocting specific probiotics for people based upon their individual needs and microbiomes.
A Medical Tell-All Can Be Found in Urine
What your urine can tell you
By Jane E. Brody : NY Times : January 2, 2012
I happen to love asparagus and eat it often. But an acquaintance once told me she carefully avoids this wholesome vegetable simply because it makes her urine smell bad.
I was tempted to ask her who is likely to know or care, except perhaps a stranger in a public restroom. Surely there are worse offenses.
As one of the four routes by which substances normally exit the body (the others being feces, breath and sweat), urine has a uniquely valuable role in medicine: It holds clues not just to what people eat and drink, but also to how well their bodies are functioning. The search for these telltale signs is why doctors routinely request urine samples from patients, whether they seem healthy or are obviously sick.
The color, clarity and other physical characteristics of urine, as well as substances dissolved in it, can provide clues to a wide range of problems, including infections, inherited metabolic disorders, kidney disease, bladder cancer, diabetes, substance abuse, exposure to toxins, inadequate or excessive fluid intake and, as many competing athletes know all too well, the use of performance-enhancing drugs.
Recently, in an eight-year European study, the sodium content of 24-hour urine samples from 3,681 adults was used to estimate the effect of daily sodium intake on the development of high blood pressure and illness and death from heart disease. The authors’ conclusion that too little dietary sodium was riskier than too much has been widely challenged, and until further notice most Americans would be wise to reduce significantly how much salt and other dietary sources of sodium they regularly consume.
Color and Odor
Urine can acquire off-odors from consumption of a few foods like asparagus (a genetic factor in some people is most likely responsible) and beverages like coffee, or as a consequence of health problems like aurinary tract infection or diabetes (a sweet smell from excess sugar). But the characteristic of urine most likely to be noted by a lay person is color.
If you are well hydrated, normal urine is clear and pale yellow, a color imparted by the pigment urochrome. Dehydration — which can be the consequence of drinking too little, sweating too much or suffering from repeated bouts of vomiting or diarrhea — results in dark urine with a smell of ammonia; it should be treated as a warning to drink more water or other plain fluids.
But consistently dark-colored urine can be a sign of hepatitis, a liver disease that requires prompt medical attention.
Less seriously, many foods and certain medications can impart an unusual and, to the unsuspecting, sometimes alarming color. For example, beets, which contain a betalain pigment that turns hands and cooking water red, can turn urine a color that may resemble blood. Likewise, blackberries and rhubarb can result in red or pink urine.
Tea-colored urine can follow the consumption of fava beans and sometimes rhubarb. The beta carotenein carrots, carrot juice and high doses of vitamin C can cause orange-colored urine, and B vitamins and asparagus may turn urine a greenish color.
Among medications that can affect urine color are the laxative senna, which can bring a red or reddish brown tinge; chlorpromazine (Thorazine) and thioridazine (Mellaril), which may add redness; indomethacin (Indocin), cimetidine (Tagamet) and promethazine (Phenergan), which can color urine blue or green; warfarin (Coumadin), phenazopyridine (Pyridium) and rifampin, which can add orange; and chloroquine (Aralen), metronidazole (Flagyl), nitrofurantoin (Furadantin) and primaquine, which can make urine brown. Of course, sometimes blood does appear in urine — for example, as a result of a urinary tract infection, a kidney or bladder stone, an enlarged prostate, or a jarring accident that injures the bladder or urethra. Or blood-tinged urine may follow strenuous exercise like a long run or triathlon.
If there is no obvious explanation for blood in the urine or if it persists, a visit to the doctor is mandatory to check for kidney disease or cancer. If no other explanation for red-tinged urine is uncovered, a test for toxic levels of lead and mercury should be done.
If urine is excreted very rapidly, it may appear foamy. But consistently foamy urine can be a sign that protein is being lost, a symptom of kidney disease, and that a medical exam is needed.
Cloudy urine is typically a result of a bladder or urinary tract infection, which is typically accompanied by a frequent urge to urinate and a burning sensation or pain when urinating.
Other Important Factors
The volume of urine produced can be an important indicator of hydration. Normally, a healthy person produces about 100 milliliters (about 3.4 ounces) of urine an hour, or about one cup in 2 ½ hours. If the hourly output exceeds 300 milliliters, it could be a sign of excessive fluid intake; if the volume drops below 30 milliliters, it is probably a sign of dehydration.
Consuming lots of salty foods or carbohydrates can temporarily reduce urine output, because salt, sugar and starch hold more water in the body than, say, protein. And consuming foods or beverages that are diuretics — including caffeine-containing drinks (like coffee, tea and many soft drinks), alcoholic drinks (especially beer), and foods with a high water content, like watermelon or asparagus — can temporarily result in higher-than-average urine output.
The urine of two-legged and four-legged athletes is now commonly tested for signs that performance-enhancing drugs were responsible for an unfair competitive advantage. Sometimes athletes who take medication for legitimate medical problems get caught in the net.
When you provide a urine sample as part of a routine medical checkup, it is likely to be tested for the presence of sugar (an indicator of diabetes) and protein (a sign of kidney disease), and perhaps for bile acids (an indicator of liver disease) or white blood cells (the result of an infection).
If symptoms of a urinary tract infection are present, the culprit organism — often the bacterium E. coli, a common resident of the lower digestive tract — can be isolated from urine and, if necessary, tested for antibiotic sensitivity.
Young girls who take bubble baths and sexually active women (especially those who are new or returning participants to the game of love) are especially prone to urinary tract infections. Doctors have a not-so-amusing name for this common plague of women in the throes of a new sexual relationship: They call it honeymoon cystitis.
In a healthy person, however, urine is sterile and contains neither infectious microorganisms nor white blood cells trying to fight them. Thus, in producing a urine sample for analysis, it is critically important that it be what doctors call a “clean-catch” specimen.
This entails first depositing some urine in the toilet before collecting the amount needed for testing. And be sure to cover the sample immediately to reduce the risk of contamination.
What You Should Know About The Color Of Your Pee
The Huffington Post | By Leigh Weingus
If your pee is a transparent yellow, you're probably healthy and hydrated. If not, we have a few things to talk about.
A new video from AsapScience breaks down the different colors our pee can turn due to different factors. Our urine can be every color of the rainbow, it turns out, and each color means something different. Here's the scoop:
If it's yellow...
You're probably healthy, but different shades mean different things. A honey hue may indicate you have high levels of urobolin in your pee, meaning you're a bit dehydrated and should drink water. A bright, darkish yellow means you're on the verge of being dehydrated and should drink water soon, while clear pee means you've either been drinking a lot of water or you've been drinking caffeine and alcohol. If your pee is a transparent yellow (as noted above), you're good.
If it's brown...
Don't be alarmed! This may mean you've been eating a lot of rhubarb, fava beans or aloe, or it could be a side effect of a laxative, muscle relaxer or antibiotic.
If it's purple...
You might have porphyria, which means your body is deficient in the enzymes it needs to produce heme, an essential part of red blood cells, according to AsapScience. So if you're peeing purple, talk to your doctor.
If it's blue...
This could be a sign of familial hypercalcemia, a rare genetic disease caused by excess calcium in the blood that's usually found in children. Additionally, some medications have methylene blue in them, which causes a blue hue.
If it's green...
It's weird, sure, but AsapScience says green pee probably isn't a huge deal. It could be a result of vitamin intake, a new medication or green food dye.
It's red or pink...
It's probably time to have a chat with your doctor. While red or pink pee could be a result of eating too many beets or blackberries, it could also be a sign of an an enlarged prostate or bladder cancer.
If it's orange...
You probably have a lot of vitamin C in your body, or maybe you've been eating a bunch of carrots, which produces carotene. It could also be a side effect of a drug like Pyridium, which is used to treat urinary tract infections.
If your pee is anything but transparent yellow, don't ignore it. As the Cleveland Clinic puts it, "human urine has been a useful tool of diagnosis since the earliest days of medicine. The color, density, and smell of urine can reveal much about the state of our health."
So think about what you're putting into your body, and if anything seems really off, see a doctor.
Among Doctors, Fierce Reluctance to Let Go
Paula Span : NT Times : 03-29-2012
The conversation took place two years ago, but Dr. Daniel Matlock still recalls it quite vividly. You tend to remember when a physician colleague essentially brands you a Nazi.
Dr. Matlock, a geriatrician who specializes in palliative care, had been called in to consult when a woman in her 70s arrived at the University of Colorado Hospital, unresponsive after a major stroke.
She’d done what we’re forever chiding people for not doing: She’d drafted a very specific advance directive and had even taken the trouble to have it notarized. It unambiguously said: no life support, no artificial nutrition or hydration, no nursing home.
The ambulance crew had put her on a ventilator — standard procedure. After the palliative team removed it, she was able to breathe on her own, which isn’t uncommon. She even opened her eyes, though she couldn’t track or follow objects and remained unresponsive. That’s when the prominent surgeon directing her care ordered intravenous fluids.
Dr. Matlock, alarmed at this direct contradiction of her preferences, tells the rest of the story in a post on the GeriPal blog, published by geriatricians and palliative care docs at the University of California, San Francisco. After talking with the patient’s sister, who held her medical power of attorney, he called the surgeon to suggest stopping the IV.
“You would have been hung in World War II for doing what you are doing now,” the surgeon said.
Let’s pause to think about that for a moment.
Within a few days, the woman was transferred to a hospice unit, where the IV was removed and she was permitted to die. But Dr. Matlock’s anger at his colleague and his sorrow at the woman’s treatment, or mistreatment, have persisted. “You work so hard to do what’s right for the patient,” he told me.
And he was sure he was right. Administering fluids to a dying patient increases the person’s secretions and makes breathing more difficult, palliative care doctors are taught. “Dehydration is a gentler death, with less agitation,” he said. But quite apart from that, the woman had done everything but stencil “no IV” across her forehead.
A palliative care consultant, however, couldn’t overrule the surgical team whose patient she was. “I went home that night feeling really bad,” Dr. Matlock said.
What prompted his account of this unpleasant exchange, all these months later, was a startling study recently published in The Journal of Palliative Medicine. After surveying nearly 700 physician-members of a national hospice and palliative medicine organization, the authors report that more than half had had at least one experience in the past five years of another physician or health care professional referring to their treatments as “euthanasia,” “killing” or “murder.”
This, despite palliative practices being broadly accepted as legal and ethical, as reducing suffering while honoring patients’ autonomy.
About a quarter of the respondents had heard similar accusations from a personal friend or family member, the study found. And 25 doctors (4 percent of the respondents) had been formally investigated on the question of whether they had hastened a patient’s death.
“It was cathartic for me” to read the study, Dr. Matlock said. “It was helpful to know I wasn’t alone.” But it’s not exactly reassuring news for the rest of us.
We’ve had frequent discussions here of end-of-life care and why the “good death” so many people want proves so elusive. We can, with ample reason, blame physicians who don’t want to talk or think about dying. (A favorite joke among hospice workers, who tend toward a dark sense of humor: Why are coffins nailed shut? To keep oncologists from administering more chemotherapy.)
And physicians have often responded with their own stories of family members who won’t accept that further treatment is futile and urge another operation, another drug, another something.
But here’s another part of the dynamic, apparently: Even when the system works as it’s supposed to, and palliative care specialists arrive like the cavalry to provide comfort care, to stop fruitless and painful interventions and to support what patients want, their own colleagues may brand them murderers.
It takes strong doctors to stand up to that kind of verbal abuse, to explain that courts and ethics committees have approved care that’s intended to reduce suffering, to point out that the patient’s own wishes are paramount. Perhaps they have to be stronger than we know.
“The culture is changing,” Dr. Matlock told me. “But it’s not changed yet.”
Paula Span : NT Times : 03-29-2012
The conversation took place two years ago, but Dr. Daniel Matlock still recalls it quite vividly. You tend to remember when a physician colleague essentially brands you a Nazi.
Dr. Matlock, a geriatrician who specializes in palliative care, had been called in to consult when a woman in her 70s arrived at the University of Colorado Hospital, unresponsive after a major stroke.
She’d done what we’re forever chiding people for not doing: She’d drafted a very specific advance directive and had even taken the trouble to have it notarized. It unambiguously said: no life support, no artificial nutrition or hydration, no nursing home.
The ambulance crew had put her on a ventilator — standard procedure. After the palliative team removed it, she was able to breathe on her own, which isn’t uncommon. She even opened her eyes, though she couldn’t track or follow objects and remained unresponsive. That’s when the prominent surgeon directing her care ordered intravenous fluids.
Dr. Matlock, alarmed at this direct contradiction of her preferences, tells the rest of the story in a post on the GeriPal blog, published by geriatricians and palliative care docs at the University of California, San Francisco. After talking with the patient’s sister, who held her medical power of attorney, he called the surgeon to suggest stopping the IV.
“You would have been hung in World War II for doing what you are doing now,” the surgeon said.
Let’s pause to think about that for a moment.
Within a few days, the woman was transferred to a hospice unit, where the IV was removed and she was permitted to die. But Dr. Matlock’s anger at his colleague and his sorrow at the woman’s treatment, or mistreatment, have persisted. “You work so hard to do what’s right for the patient,” he told me.
And he was sure he was right. Administering fluids to a dying patient increases the person’s secretions and makes breathing more difficult, palliative care doctors are taught. “Dehydration is a gentler death, with less agitation,” he said. But quite apart from that, the woman had done everything but stencil “no IV” across her forehead.
A palliative care consultant, however, couldn’t overrule the surgical team whose patient she was. “I went home that night feeling really bad,” Dr. Matlock said.
What prompted his account of this unpleasant exchange, all these months later, was a startling study recently published in The Journal of Palliative Medicine. After surveying nearly 700 physician-members of a national hospice and palliative medicine organization, the authors report that more than half had had at least one experience in the past five years of another physician or health care professional referring to their treatments as “euthanasia,” “killing” or “murder.”
This, despite palliative practices being broadly accepted as legal and ethical, as reducing suffering while honoring patients’ autonomy.
About a quarter of the respondents had heard similar accusations from a personal friend or family member, the study found. And 25 doctors (4 percent of the respondents) had been formally investigated on the question of whether they had hastened a patient’s death.
“It was cathartic for me” to read the study, Dr. Matlock said. “It was helpful to know I wasn’t alone.” But it’s not exactly reassuring news for the rest of us.
We’ve had frequent discussions here of end-of-life care and why the “good death” so many people want proves so elusive. We can, with ample reason, blame physicians who don’t want to talk or think about dying. (A favorite joke among hospice workers, who tend toward a dark sense of humor: Why are coffins nailed shut? To keep oncologists from administering more chemotherapy.)
And physicians have often responded with their own stories of family members who won’t accept that further treatment is futile and urge another operation, another drug, another something.
But here’s another part of the dynamic, apparently: Even when the system works as it’s supposed to, and palliative care specialists arrive like the cavalry to provide comfort care, to stop fruitless and painful interventions and to support what patients want, their own colleagues may brand them murderers.
It takes strong doctors to stand up to that kind of verbal abuse, to explain that courts and ethics committees have approved care that’s intended to reduce suffering, to point out that the patient’s own wishes are paramount. Perhaps they have to be stronger than we know.
“The culture is changing,” Dr. Matlock told me. “But it’s not changed yet.”
Seeing Things? Hearing Things? Many of Us Do
By Oliver Sacks : NY Times : November 3, 2012
Hallucinations are very startling and frightening: you suddenly see, or hear or smell something — something that is not there. Your immediate, bewildered feeling is, what is going on? Where is this coming from? The hallucination is convincingly real, produced by the same neural pathways as actual perception, and yet no one else seems to see it. And then you are forced to the conclusion that something — something unprecedented — is happening in your own brain or mind. Are you going insane, getting dementia, having a stroke?
In other cultures, hallucinations have been regarded as gifts from the gods or the Muses, but in modern times they seem to carry an ominous significance in the public (and also the medical) mind, as portents of severe mental or neurological disorders. Having hallucinations is a fearful secret for many people — millions of people — never to be mentioned, hardly to be acknowledged to oneself, and yet far from uncommon. The vast majority are benign — and, indeed, in many circumstances, perfectly normal. Most of us have experienced them from time to time, during a fever or with the sensory monotony of a desert or empty road, or sometimes, seemingly, out of the blue.
Many of us, as we lie in bed with closed eyes, awaiting sleep, have so-called hypnagogic hallucinations — geometric patterns, or faces, sometimes landscapes. Such patterns or scenes may be almost too faint to notice, or they may be very elaborate, brilliantly colored and rapidly changing — people used to compare them to slide shows.
At the other end of sleep are hypnopompic hallucinations, seen with open eyes, upon first waking. These may be ordinary (an intensification of color perhaps, or someone calling your name) or terrifying (especially if combined with sleep paralysis) — a vast spider, a pterodactyl above the bed, poised to strike.
Hallucinations (of sight, sound, smell or other sensations) can be associated with migraine or seizures, with fever or delirium. In chronic disease hospitals, nursing homes, and I.C.U.’s, hallucinations are often a result of too many medications and interactions between them, compounded by illness, anxiety and unfamiliar surroundings.
But hallucinations can have a positive and comforting role, too — this is especially true with bereavement hallucinations, seeing the face or hearing the voice of one’s deceased spouse, siblings, parents or child — and may play an important part in the mourning process. Such bereavement hallucinations frequently occur in the first year or two of bereavement, when they are most “needed.”
Working in old-age homes for many years, I have been struck by how many elderly people with impaired hearing are prone to auditory and, even more commonly, musical hallucinations — involuntary music in their minds that seems so real that at first they may think it is a neighbor’s stereo.
People with impaired sight, similarly, may start to have strange, visual hallucinations, sometimes just of patterns but often more elaborate visions of complex scenes or ranks of people in exotic dress. Perhaps 20 percent of those losing their vision or hearing may have such hallucinations.
I was called in to see one patient, Rosalie, a blind lady in her 90s, when she started to have visual hallucinations; the staff psychiatrist was also summoned. Rosalie was concerned that she might be having a stroke or getting Alzheimer’s or reacting to some medication. But I was able to reassure her that nothing was amiss neurologically. I explained to her that if the visual parts of the brain are deprived of actual input, they are hungry for stimulation and may concoct images of their own. Rosalie was greatly relieved by this, and delighted to know that there was even a name for her condition: Charles Bonnet syndrome. “Tell the nurses,” she said, drawing herself up in her chair, “that I have Charles Bonnet syndrome!”
Rosalie asked me how many people had C.B.S., and I told her hundreds of thousands, perhaps, in the United States alone. I told her that many people were afraid to mention their hallucinations. I described a recent study of elderly blind patients in the Netherlands which found that only a quarter of people with C.B.S. mentioned it to their doctors — the others were too afraid or too ashamed. It is only when physicians gently inquire (often avoiding the word “hallucination”) that people feel free to admit seeing things that are not there — despite their blindness.
Rosalie was indignant at this, and said, “You must write about it — tell my story!” I do tell her story, at length, in my book on hallucinations, along with the stories of many others. Most of these people have been reluctant to admit to their hallucinations. Often, when they do, they are misdiagnosed or undiagnosed — told that it’s nothing, or that their condition has no explanation.
Misdiagnosis is especially common if people admit to “hearing voices.” In a famous 1973 study by the Stanford psychologist David Rosenhan, eight “pseudopatients” presented themselves at various hospitals across the country, saying that they “heard voices.” All behaved normally otherwise, but were nonetheless determined to be (and treated as) schizophrenic (apart from one, who was given the diagnosis of “manic-depressive psychosis”). In this and follow-up studies, Professor Rosenhan demonstrated convincingly that auditory hallucinations and schizophrenia were synonymous in the medical mind.
While many people with schizophrenia do hear voices at certain times in their lives, the inverse is not true: most people who hear voices (as much as 10 percent of the population) are not mentally ill. For them, hearing voices is a normal mode of experience.
My patients tell me about their hallucinations because I am open to hearing about them, because they know me and trust that I can usually run down the cause of their hallucinations. For the most part, these experiences are unthreatening and, once accommodated, even mildly diverting.
David Stewart, a Charles Bonnet syndrome patient with whom I corresponded, writes of his hallucinations as being “altogether friendly,” and imagines his eyes saying: “Sorry to have let you down. We recognize that blindness is no fun, so we’ve organized this small syndrome, a sort of coda to your sighted life. It’s not much, but it’s the best we can manage.”
Mr. Stewart has been able to take his hallucinations in good humor, since he knows they are not a sign of mental decline or madness. For too many patients, though, the shame, the secrecy, the stigma, persists.
Oliver Sacks is a professor of neurology at the N.Y.U. School of Medicine and the author, most recently, of the forthcoming book “Hallucinations.”
New Outlook on Colorblindness
Phone Apps, Videogames Offer Color Help; Seeking a Cure Through Gene Therapy
By Melinda Beck : WSJ : November 5, 2012
For people who are colorblind, life involves little workarounds and big compromises alike. Daily challenges range from not knowing whether meat is fully cooked to not being able to read whether a horizontal traffic light is showing green or red. More serious repercussions include being shut out of a dream job, like piloting planes, because misreading landing-strip lights can have life-or-death consequences.
Now, a host of new research and tools promise to improve life for the estimated 32 million Americans—8% of men and 0.5% of women—who have some degree of colorblindness. For many, getting through the day—avoiding wardrobe perils and worse—has often involved bringing in a second pair of eyes. But new websites and smartphone apps offer to help identify or enhance hard-to-see colors. Videogame manufacturers are increasingly including "colorblind" modes in their games. And researchers are homing in on more specific vision tests that may allow mildly colorblind people to qualify for jobs that, until now, have been closed to them.
A genetic test, made by Genevolve Vision Diagnostics, will soon be available that can identify the exact type of colorblindness someone has, which the company hopes could pave the way for customized tools.
A cure for colorblindness might even be in the offing. Vision scientist Jay Neitz and his colleagues at the University of Washington are building on their 2009 breakthrough in which they restored red-green vision in two colorblind squirrel monkeys by inserting the missing gene into a virus and injecting it into their retinas. Four years later, the monkeys, Sam and Dalton, still pass daily vision tests, identifying colors on a computer screen correctly. They also have a newfound liking for green M&M's, Dr. Neitz says.
He and his colleagues are working on a similar therapy for humans, but many hurdles remain. "We know it's effective. The issue is whether it's safe," says Dr. Neitz.
Many colorblind people aren't even aware they have a "color-vision deficiency," as it's officially known, unless they apply for a job that requires precise color recognition. Even people with mild colorblindness can be barred from being pilots, air-traffic controllers, police officers, lab technicians and electricians—usually for safety reasons.
The term "colorblindness" is actually a misnomer. "People think you're living in a black-and-white TV show and that's not true. There are all different degrees, from mild to severe. And you can see colors—they're just different," says Terrance Waggoner, an ophthalmologist consulting on color vision for the U.S. Navy.
But the impact does go beyond missing just one color. "A colorblind person who can't see red can't see the red in purple—he just sees blue," says Dr. Neitz. Since red and green make brown, people with red-green blindness often have trouble telling the three colors apart.
The vast majority of colorblind people have trouble seeing red or green, due to a genetic defect in the color-sensing cells, called cones, at the back of the eye. About 75% of them are specifically green-deficient; another 20% are red-deficient. Either way, the impact on their vision is so similar that it's considered one disorder, red-green colorblindness, which is the most common single-gene disorder in humans, affecting 1 in 8 men and 1 in 230 women of Northern European descent world-wide (and slightly fewer in other racial groups).
Blue-yellow colorblindness is rarer and develops later in life, often brought on by aging, illness, medication or head injuries. Rarer still is achromatopsia, the inability to see any color.
Red-green colorblindness is far more common in men than women because it's a recessive gene carried on the X chromosome. Men have one X and one Y, so a defective gene on the X shows itself readily. Women have two X chromosomes, and a normal copy of the gene will override the defective one. But women who have one defective X will be carriers of color blindness. Each of their children has a 50% chance of inheriting the defective gene. Within families, red-green colorblindness typically travels from the maternal grandfather to grandson. A woman can only exhibit colorblindness if she receives a defective X chromosome from a colorblind father and another from a carrier mother.
But it does happen—and it can come as a surprise if previous generations didn't notice or didn't discuss their colorblindness. Ingrid Perri, a life coach in Melbourne, Australia, discovered she was mildly colorblind at age 47. "My family howled, 'That explains so much!'" says Ms. Perri.
Experts recommend that children have regular eye exams, including color-vision tests, starting between ages 3 and 5. Some children with color vision problems are labeled "learning-disabled" if they can't follow instructions. That happened with Dr. Waggoner's son at age 6, prompting the doctor to develop pediatric color-vision tests using shapes instead of numbers, now used by about 15% of school nurses.
Many colorblind people say they have no problem recognizing pure, strong colors. It is the blended and muted colors in between that are often difficult to tell apart.
The DanKam, an augmented-reality app for iPhone and Android, works on the same principle. Users look through the phone's camera and the program converts all the reds and greens in view into pure, basic versions that are easier for colorblind people to see. "It is like having magic eyes," says Andy Baio, a writer and programmer in Portland, Ore., who is red-green colorblind. "It doesn't make me see red or green the way you see them, but it makes it blazingly obvious the difference between them."
Contact lenses and glasses for colorblind people, which can cost up to $700, use tinted lenses to alter light coming into the eye. Manufacturers say they make hard-to-see colors brighter. Many employers don't let applicants use them during vision tests. Other online tools, such as Color Name & Hue, can identify colors by name or numerical codes, so that graphic artists, say, can "see" what colors they are using. Apps such as Colorblind Avenger let people do the same thing through smartphone cameras. Other apps, such as HueVue and Colorblind Helper, assist with matching or harmonizing colors.
Some tools, like Colorblind Vision, help businesses and marketers see what their materials look like to colorblind people by simulating various color-vision deficiencies.
To help colorblind users in the trading world, Bloomberg financial-data terminals include plus and minus symbols or up and down arrows to indicate the direction of the market or stock price, says a spokeswoman for Bloomberg LP. After speaking with many traders with color-vision deficiencies, designers of DJ FX Trader, a foreign exchange tool offered by Dow Jones, the publisher of The Wall Street Journal, say they made a point of using icons to supplement color. FactSet Research Systems Inc., a financial information company, says it uses patterns and labels in its graphs, and avoids using colors that most colorblind people can't discern.
Some popular videogames, such as PopCap's Peggle and Zuma Blitz, now let gamers switch to colorblind modes, where color codes turn into shapes.
Advocates for the colorblind say the world could be more accommodating to the nearly 10% of people who have trouble seeing shades of red and green. Battery chargers blink orange for empty and green for full. Hotel keycards flash green for entry and red for stop.
Vision and design experts say the best maps, charts and presentations use words and icons in addition to color. "Color deficiency is way low on the totem pole of accessibility problems, but when doing the right thing isn't hard, you should at least take that into account," says Mr. Baio.
Why Stress Makes You Sweat
What Is Really Going On When Pressure Makes You Perspire?
Sumathi Reddy : WSJ : February 4, 2013
Stressful work and social occasions are often made much worse by what comes with them: sweat.
This type of sweat is different than the perspiration brought on by hot weather, which is intended to cool the body. The purpose of stress-triggered sweat mostly remains a mystery, but now scientists are piecing together new clues about the role it might play in the way people function.
Although most of us try to avoid sweating in public, some scientists believe it has an evolutionary role in sending warning signals to people around us. The body odor of a stranger provokes the brain to negatively interpret social stimuli, even friendly facial expressions, recent research has shown. Meanwhile, the scent of a family member can help calm a person who is under stress, according to a soon-to-be-presented study.
Women and men respond differently to signals sent by bodily smells such as sweat. When researchers tested some 40 different fragrances to see if they could cover up other people's body odor, they found that men were fooled the bulk of the time. But for women, the masking scents almost never lessened the intensity of the body odor.
"We concluded that body odor must be something special for women," says Charles Wysocki, a faculty member at Monell Chemical Senses Center, a scientific research institution in Philadelphia, and a co-author of the gender-based study. "The more I study this the more I'm amazed at how much information is being conveyed from one individual to another by their odor," he says. The research was published in Flavour and Fragrance Journal in 2009.
Most people devote a lot of effort trying not to sweat or smell from stressful situations. Americans spent $2.69 billion on deodorants and antiperspirants in 2011, up about 13% from five years earlier, according to market-research firm Euromonitor International.
Sweat from being overheated is produced by eccrine glands, which are located just under the skin all over the body. But sweat caused by stress, fear, anxiety and sexual arousal is produced in the apocrine glands, found only in certain areas, such as under the arms. In addition to water and salt, the main ingredients of heat sweat, stress sweat also contains fatty substances and proteins that readily interact with bacteria living on the skin to create what is commonly called body odor.
Choose Your WeaponTwo ways to fight the effects of stress sweat:
Stress sweat is triggered by the same hormones, mainly adrenaline, that prompt us to react quickly when faced with a threatening situation. "It's highly tied to the fight or flight response," says George Preti, a faculty member at Monell Center. Still, the purpose of sweating while under stress isn't clearly understood.
In a study published in the journal Social Cognitive and Affective Neuroscience in 2011, researchers found that exposure to another person's stress sweat sharpened alertness. "It enhanced the brain's perception across the board, not only to things that are obviously a threat but also to things that aren't obvious but might be threats," says Lilianne Mujica-Parodi, an associate professor of biomedical engineering at Stony Brook University in New York and lead author of the article.
Researchers collected sweat from 64 men during their first time skydiving and again while exercising. They then looked at the response of 14 other people while inhaling the different sweats. Those inhaling the stress sweat had a heightened brain response—measured by prefrontal cortex response using an EEG—-when looking at faces of all expressions, not just the threatening ones.
An earlier study conducted by Dr. Mujica-Parodi and other researchers found that the activity in the amygdala region of the brain, which processes emotions such as fear, was more active in people exposed to stress sweat rather than exercise sweat.
The study was published in the online journal PLOS ONE in 2009.
Johan Lundström, an associate member of the Monell Center, has conducted studies showing that when a person smells the body odor of a stranger the body's neural fear network gets activated, even when the person isn't aware of what they are smelling. Also at Monell Center, faculty member Pamela Dalton showed that stress levels decreased faster when people were exposed to the body odor of a family member rather than that of a stranger or a neutral fragrance.
The findings suggest that familiar and stranger body odors may be cues for emotional responses, Dr. Dalton says. The study, which involved 66 participants and was funded by the U.S. Army Research Office, will be presented at the Association of Chemoreception Sciences conference in April, she says.
Scientists are divided about whether underarm sweat—which includes apocrine and eccrine sweats, along with naturally occurring bacteria —contains compounds that may have a pheromone-like affect on humans. Pheromones are common in animals and insects to communicate sexual attraction and other messages and to trigger certain behaviors. But it's unclear if humans communicate through chemical methods.
Dr. Preti, of the Monell Center, believes such messages do exist. In a 2003 study he was involved with, 18 women exposed to the underarm odor of several men showed evidence of altered mood, including increased relaxation. Still, he says, it isn't clear which chemical compounds in sweat scent might account for the changes.
Stress and anxiety can intensify sweating disorders, but these typically involve excess activity by the eccrine gland, which is responsible for producing heat-related sweat. A common disorder, hyperhidrosis, which is estimated to affect as many as 3% of Americans, can occur in one area, such as the palms, or all over the body.
Possible treatments for hyperhidrosis include oral medications or prescription antiperspirants. Botox injections, which cost about $1,000 or more for both underarms and can last about six months, block neurotransmitters that stimulate the sweat glands. Serious complications from Botox use are rare though some patients can experience some bruising or temporary muscle weakness, says David Pariser, a Norfolk, Va., dermatologist.
Other treatments for very sweaty palms or feet include placing the appendage in water with a very low electric current. If done regularly, it temporarily prevents the nerves from producing sweat.
Michael May, a jewelry specialist at a New Orleans department store, says he worried that his underarm hyperhidrosis was affecting how customers perceived him. "My shirts were wet underneath and if I had to take my jacket off I'd have big wet marks underneath my jacket. I just couldn't handle it."
Mr. May, 32, two years ago started getting Botox treatments under his arms. It didn't completely eliminate the sweating but he says he now has it under control. "I just sweat like a normal person now," he says.
What Is Really Going On When Pressure Makes You Perspire?
Sumathi Reddy : WSJ : February 4, 2013
Stressful work and social occasions are often made much worse by what comes with them: sweat.
This type of sweat is different than the perspiration brought on by hot weather, which is intended to cool the body. The purpose of stress-triggered sweat mostly remains a mystery, but now scientists are piecing together new clues about the role it might play in the way people function.
Although most of us try to avoid sweating in public, some scientists believe it has an evolutionary role in sending warning signals to people around us. The body odor of a stranger provokes the brain to negatively interpret social stimuli, even friendly facial expressions, recent research has shown. Meanwhile, the scent of a family member can help calm a person who is under stress, according to a soon-to-be-presented study.
Women and men respond differently to signals sent by bodily smells such as sweat. When researchers tested some 40 different fragrances to see if they could cover up other people's body odor, they found that men were fooled the bulk of the time. But for women, the masking scents almost never lessened the intensity of the body odor.
"We concluded that body odor must be something special for women," says Charles Wysocki, a faculty member at Monell Chemical Senses Center, a scientific research institution in Philadelphia, and a co-author of the gender-based study. "The more I study this the more I'm amazed at how much information is being conveyed from one individual to another by their odor," he says. The research was published in Flavour and Fragrance Journal in 2009.
Most people devote a lot of effort trying not to sweat or smell from stressful situations. Americans spent $2.69 billion on deodorants and antiperspirants in 2011, up about 13% from five years earlier, according to market-research firm Euromonitor International.
Sweat from being overheated is produced by eccrine glands, which are located just under the skin all over the body. But sweat caused by stress, fear, anxiety and sexual arousal is produced in the apocrine glands, found only in certain areas, such as under the arms. In addition to water and salt, the main ingredients of heat sweat, stress sweat also contains fatty substances and proteins that readily interact with bacteria living on the skin to create what is commonly called body odor.
Choose Your WeaponTwo ways to fight the effects of stress sweat:
- Deodorants often contain a mild antimicrobial to make the skin less attractive to bacteria. Scents may help mask odor.
- Antiperspirants usually contain aluminum compounds that help block sweat pores and reduce sweat.
Stress sweat is triggered by the same hormones, mainly adrenaline, that prompt us to react quickly when faced with a threatening situation. "It's highly tied to the fight or flight response," says George Preti, a faculty member at Monell Center. Still, the purpose of sweating while under stress isn't clearly understood.
In a study published in the journal Social Cognitive and Affective Neuroscience in 2011, researchers found that exposure to another person's stress sweat sharpened alertness. "It enhanced the brain's perception across the board, not only to things that are obviously a threat but also to things that aren't obvious but might be threats," says Lilianne Mujica-Parodi, an associate professor of biomedical engineering at Stony Brook University in New York and lead author of the article.
Researchers collected sweat from 64 men during their first time skydiving and again while exercising. They then looked at the response of 14 other people while inhaling the different sweats. Those inhaling the stress sweat had a heightened brain response—measured by prefrontal cortex response using an EEG—-when looking at faces of all expressions, not just the threatening ones.
An earlier study conducted by Dr. Mujica-Parodi and other researchers found that the activity in the amygdala region of the brain, which processes emotions such as fear, was more active in people exposed to stress sweat rather than exercise sweat.
The study was published in the online journal PLOS ONE in 2009.
Johan Lundström, an associate member of the Monell Center, has conducted studies showing that when a person smells the body odor of a stranger the body's neural fear network gets activated, even when the person isn't aware of what they are smelling. Also at Monell Center, faculty member Pamela Dalton showed that stress levels decreased faster when people were exposed to the body odor of a family member rather than that of a stranger or a neutral fragrance.
The findings suggest that familiar and stranger body odors may be cues for emotional responses, Dr. Dalton says. The study, which involved 66 participants and was funded by the U.S. Army Research Office, will be presented at the Association of Chemoreception Sciences conference in April, she says.
Scientists are divided about whether underarm sweat—which includes apocrine and eccrine sweats, along with naturally occurring bacteria —contains compounds that may have a pheromone-like affect on humans. Pheromones are common in animals and insects to communicate sexual attraction and other messages and to trigger certain behaviors. But it's unclear if humans communicate through chemical methods.
Dr. Preti, of the Monell Center, believes such messages do exist. In a 2003 study he was involved with, 18 women exposed to the underarm odor of several men showed evidence of altered mood, including increased relaxation. Still, he says, it isn't clear which chemical compounds in sweat scent might account for the changes.
Stress and anxiety can intensify sweating disorders, but these typically involve excess activity by the eccrine gland, which is responsible for producing heat-related sweat. A common disorder, hyperhidrosis, which is estimated to affect as many as 3% of Americans, can occur in one area, such as the palms, or all over the body.
Possible treatments for hyperhidrosis include oral medications or prescription antiperspirants. Botox injections, which cost about $1,000 or more for both underarms and can last about six months, block neurotransmitters that stimulate the sweat glands. Serious complications from Botox use are rare though some patients can experience some bruising or temporary muscle weakness, says David Pariser, a Norfolk, Va., dermatologist.
Other treatments for very sweaty palms or feet include placing the appendage in water with a very low electric current. If done regularly, it temporarily prevents the nerves from producing sweat.
Michael May, a jewelry specialist at a New Orleans department store, says he worried that his underarm hyperhidrosis was affecting how customers perceived him. "My shirts were wet underneath and if I had to take my jacket off I'd have big wet marks underneath my jacket. I just couldn't handle it."
Mr. May, 32, two years ago started getting Botox treatments under his arms. It didn't completely eliminate the sweating but he says he now has it under control. "I just sweat like a normal person now," he says.
