Learning to Say No to Dialysis

Gerald J. Hladik was 74 when the day long anticipated by his doctors arrived: His kidneys, damaged years earlier by a viral infection, had lost 85 percent of their function.

Time to begin dialysis.

But from the beginning, Mr. Hladik resisted. An IBM retiree, he loved fishing, boating and gardening — and hated hospitals. “He said, ‘I don’t want to spend my time doing this,’ ” recalled his son, Dr. Gerald A. Hladik. “He wanted to be at home with his dog. He wanted to be able to go to the beach.”

A nephrologist at the University of North Carolina School of Medicine, Dr. Hladik understood better than most how kidney dialysis could consume a patient’s days. His father’s eventful medical history included a serious stroke and coronary bypass surgery.

“Dialysis may have prolonged his life, but I suspect only by a couple of months,” Dr. Hladik said.

So after considerable discussion, Mr. Hladik decided to skip the three weekly trips to a renal center, along with the resulting fatigue and dietary and travel restrictions. His doctors managed his heart disease and hypertension with drugs. He died at home in November, a year and a half after saying no to dialysis.

People over age 75 are the fastest-growing segment of patients on dialysis, and the treatment’s benefits and drawbacks add up differently for them than for younger patients. A growing number of nephrologists and researchers are pushing for more educated and deliberative decision making when seniors contemplate dialysis.

It is a choice, they say, not an imperative.

“Patients are not adequately informed about the burdens. All they’re told is, ‘You have to go on dialysis or you’ll die,’ ” said Dr. Alvin H. Moss, a nephrologist at West Virginia University School of Medicine and chairman of the Coalition for Supportive Care of Kidney Patients. “Nobody tells them, ‘You could have up to two years without the treatment, without the discomfort, with greater independence.’ ”

Dialysis involves filtering impurities from the blood when a patient’s faltering kidneys can no longer do so. Originally a temporary stopgap for those awaiting transplants, it has become the standard treatment for advanced kidney failure. Fewer than 10 percent of patients opt forperitoneal dialysis, which can be done at home. Most undergo hemodialysis at a center where machines clean the blood and correct chemical imbalances.

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Region is producing different types of docs

CLEVELAND CLINIC
Given the desperate need for primary care docs as health care access expands under the Affordable Care Act and the horde of aging baby boomers requires more hands-on care, a lesser-known form of medical education is taking root in Northeast Ohio.

The region has long produced MDs — short for the Latin phrase “medicinae doctor” — at its venerable medical schools, Case Western Reserve University and Northeast Ohio Medical University. But soon, the region will be churning out more DOs, or doctors of osteopathic medicine.

It’s not a new form of medical education, given that its roots go back more than a hundred years, but it is different.

Simply put, DOs tend to focus on treating the whole patient, not just their symptoms. They also tend to focus less on research and gravitate toward careers in primary care.

“We take care of people, not problems,” said Dr. Robert Juhasz, president of Cleveland Clinic’s South Pointe Hospital in Warrensville Heights and head of the American Osteopathic Association.

“We believe in taking care of the whole person — body, mind and spirit. We believe in enhancing the body’s innate ability to heal itself.”

Leading the teaching charge regionally is Ohio University, whose Heritage College of Osteopathic Medicine has been on a tear over the last few years expanding beyond its Athens headquarters.

Last year, for one, it opened a $24.7 million campus in Dublin, Ohio, and this summer plans to open a new outpost in 60,000 square feet of renovated space at South Pointe.

This summer, the Clinic collaboration — one valued at about $49.1 million — will welcome its first class of 50 students, 18 more than originally expected.

Moreover, Erie, Pa.-based Lake Erie College of Medicine, or LECOM for short, has been deepening its relationship with University Hospitals. UH’s Richmond and Bedford hospitals have hosted LECOM’s graduates as residents for several years, and this summer UH Parma Medical Center will welcome its first class of residents. LECOM is also developing a residency program at UH Elyria Medical Center, which along with Parma’s hospital joined the UH system a little more than a year ago.

“There’s been a lot of expansion and growth in this field,” said Dr. Christopher Loyke, Parma’s chief medical officer and director of medical education. “Osteopathic physicians are pushing hard to fill the need for primary care.”

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Why Health Care Is Different If You’re Black, Latino Or Poor

From Forbes.com

The country is in a state of health care denial. Politicians, pundits and executives proudly declare America’s medical care is the best in the world. But it isn’t.

The U.S. lags behind other industrialized nations in many important health measures – partly because citizens of certain races, ethnicities and incomes experience poorer versions of U.S. health care than others. The disparities are glaring. The solutions aren’t nearly as obvious – but we’ll explore some of the best ones in this article. First:

U.S. Results Shoddy Compared To Global Counterparts

The U.S. ranks dead last in life expectancy for men and second to last for women among the 17 wealthiest nations. Infant mortality in the U.S. ranks last among the most advanced countries in the world. And worse, among the 34 most developed countries,U.S. health care outcomes fell from 20th to 27th from 1990 to 2010.

The world’s richest economy scores dismally no matter which health care measures we examine.

Why So Bad?

One reason the U.S. ranks so poorly globally is that health outcomes for certain racial, ethnic and socioeconomic groups fare so poorly domestically. African-Americans, Latinos and the economically disadvantaged experience poorer health care access and lower quality of care than white Americans. And in most measures, that gap is growing.

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Smoking’s Toll on Health Is Even Worse Than Previously Thought, a Study Finds

However bad you thought smoking was, it’s even worse.

A new study adds at least five diseases and 60,000 deaths a year to the toll taken by tobacco in the United States. Before the study, smoking was already blamed for nearly half a million deaths a year in this country from 21 diseases, including 12 types of cancer.

The new findings are based on health data from nearly a million people who were followed for 10 years. In addition to the well-known hazards of lung cancer, artery disease, heart attacks, chronic lung disease and stroke, the researchers found that smoking was linked to significantly increased risks of infection, kidney disease, intestinal disease caused by inadequate blood flow, and heart and lung ailments not previously attributed to tobacco.

Even though people are already barraged with messages about the dangers of smoking, researchers say it is important to let the public know that there is yet more bad news.

“The smoking epidemic is still ongoing, and there is a need to evaluate how smoking is hurting us as a society, to support clinicians and policy making in public health,” said Brian D. Carter, an epidemiologist at the American Cancer Society and the first author of an article about the study, which appears in The New England Journal of Medicine. “It’s not a done story.”

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Google Now Gives Hypochrondriacs What They Want

Meet the new health and medical search in Knowledge Graph.

From readwrite.com

google medical health knowledge graph search

Google has now made it easier for armchair physicians to find things to freak out about.

The tech giant just announced the inclusion of medical information to its Knowledge Graph searches, allowing anyone to contradict their doctors right in their offices. Essentially, it amounts to Google’s own souped-up version of WebMD, but with a simpler interface and more direct access. (Of course, it could spell doom for the actual WebMD website, which is still alive and kicking, at least for now.)

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New York Attorney General Targets Supplements at Major Retailers

Health supplements on display at Walgreens in Times Square in Manhattan.
YANA PASKOVA FOR THE NEW YORK TIMES

The New York State attorney general’s office accused four major retailers on Monday of selling fraudulent and potentially dangerous herbal supplements and demanded that they remove the products from their shelves.

The authorities said they had conducted tests on top-selling store brands of herbal supplements at four national retailers — GNC, Target, Walgreens and Walmart — and found that four out of five of the products did not contain any of the herbs on their labels. The tests showed that pills labeled medicinal herbs often contained little more than cheap fillers like powdered rice, asparagus and houseplants, and in some cases substances that could be dangerous to those with allergies.

The investigation came as a welcome surprise to health experts who have long complained about the quality and safety of dietary supplements, which are exempt from the strict regulatory oversight applied to prescription drugs.

 

The Food and Drug Administration has targeted individual supplements found to contain dangerous ingredients. But the announcement Monday was the first time that a law enforcement agency had threatened the biggest retail and drugstore chains with legal action for selling what it said were deliberately misleading herbal products.

Among the attorney general’s findings was a popular store brand of ginseng pills at Walgreens, promoted for “physical endurance and vitality,” that contained only powdered garlic and rice. At Walmart, the authorities found that its ginkgo biloba, a Chinese plant promoted as a memory enhancer, contained little more than powdered radish, houseplants and wheat — despite a claim on the label that the product was wheat- and gluten-free.

Three out of six herbal products at Target — ginkgo biloba, St. John’s wort and valerian root, a sleep aid — tested negative for the herbs on their labels. But they did contain powdered rice, beans, peas and wild carrots. And at GNC, the agency said, it found pills with unlisted ingredients used as fillers, like powdered legumes, the class of plants that includes peanuts and soybeans, a hazard for people with allergies.

The attorney general sent the four retailers cease-and-desist letters on Monday and demanded that they explain what procedures they use to verify the ingredients in their supplements.

“Mislabeling, contamination and false advertising are illegal,” said Eric T. Schneiderman, the state attorney general. “They also pose unacceptable risks to New York families — especially those with allergies to hidden ingredients.”

The attorney general’s investigation was prompted by an article in the New York Timesin 2013 that raised questions about widespread labeling fraud in the supplement industry. The article referred to research at the University of Guelph in Canada that found that as many as a third of herbal supplements tested did not contain the plants listed on their labels — only cheap fillers instead.

Industry representatives have argued that any problems are caused by a handful of companies on the fringe of the industry. But New York’s investigation specifically targeted store brands at the nation’s drugstore and retail giants, which suggests that the problems are widespread.

“If this data is accurate, then it is an unbelievably devastating indictment of the industry,” said Dr. Pieter Cohen, an assistant professor at Harvard Medical School and an expert on supplement safety. “We’re talking about products at mainstream retailers like Walmart and Walgreens that are expected to be the absolute highest quality.”

In response to the findings, Walgreens said it would remove the products from its shelves nationwide, even though only New York State had demanded it. Walmart said it would reach out to the suppliers of its supplements “and take appropriate action.”

A spokeswoman for GNC said that the company would cooperate with the attorney general “in all appropriate ways,” but that it stood behind the quality and purity of its store brand supplements. The company said it tested all of its products “using validated and widely used testing methods.”

Target did not respond to requests for comment.

The F.D.A. requires that companies verify that every supplement they manufacture is safe and accurately labeled. But the system essentially operates on the honor code.

Under a 1994 federal law, supplements are exempt from the F.D.A.’s strict approval process for prescription drugs, which requires reviews of a product’s safety and effectiveness before it goes to market.

The law’s sponsor and chief architect, Senator Orrin G. Hatch, Republican of Utah, is a steadfast supporter of supplements. He has accepted hundreds of thousands of dollars in campaign contributions from the industry and repeatedly intervened in Washington to quash proposed legislation that would toughen the rules.

Mr. Hatch led a successful fight against a proposed amendment in 2012 that would have required supplement makers to register their products with the F.D.A. and provide details about their ingredients. Speaking on the floor of the Senate at the time, Mr. Hatch said the amendment was based on “a misguided presumption that the current regulatory framework for dietary supplements is flawed.”

Critics say it is all too easy for dangerous supplements to reach the market because they are not subject to a review or approval process. Under current law, supplements are assumed to be safe until the authorities can prove otherwise. And in general, they are pulled from shelves only after serious injuries occur — which is not uncommon.

In 2013, for example, an outbreak of hepatitis that struck at least 72 people in 16 states was traced to a tainted supplement. Three people required liver transplants, and one woman died.

It is not only consumers. Hospitals have been affected, too. In December, an infant at a Connecticut hospital died when doctors gave the child a popular probiotic supplement that was later found to be contaminated with yeast. After the child’s death, the F.D.A. issued a warning to the public that reiterated its limited control over supplements.

“These products are not subject to F.D.A.’s premarket review or approval requirements for safety and effectiveness,” the F.D.A. stated, “nor to the agency’s rigorous manufacturing and testing standards for drugs.”

As part of its investigation, the attorney general’s office bought 78 bottles of the leading brands of herbal supplements from a dozen Walmart, Target, Walgreens and GNC locations across New York State. Then the agency analyzed the products using DNA bar coding, a type of genetic fingerprinting that the agency has used to root out labeling fraud in the seafood industry.

The technology allows scientists to identify plants and animals by looking for short sequences of DNA unique to each organism, which can then be quickly analyzed — much like the bar codes on grocery items — and compared with others in an electronic database. The technology can single out which plants a supplement contains by identifying its unique DNA.

Dr. Cohen at Harvard said that the attorney general’s test results were so extreme that he found them hard to accept. He said it was possible that the tests had failed to detect some plants even when they were present because the manufacturing process had destroyed their DNA.

But that does not explain why the tests found so many supplements with no DNA from the herbs on their labels but plenty of DNA from unlisted ingredients, said Marty Mack, an executive deputy attorney general in New York. “The absence of DNA does not explain the high percentage of contaminants found in these products,” he said. “The burden is now with the industry to prove what is in these supplements.”

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Medical Costs Rise as Retirees Winter in Florida

Eugene Levich, who is moving from New York to Delray Beach, Fla., where he has wintered, worries about leaving his doctors.
By ELISABETH ROSENTHAL for NYTimes.com
JANUARY 31, 2015
Like many retirees, one couple from upstate New York visit doctors in their winter getaway in Florida. But on a recent routine checkup of a pacemaker, a cardiologist there insisted on scheduling several expensive tests even though the 91-year-old husband had no symptoms.

“You walk in the door, and they just start doing things,” said Sally Spencer, 70, who canceled the tests after her husband’s longtime doctor advised her by phone that none of them were needed.

The couple’s experience reflects a trend that has prompted some doctors up north to warn their older patients before they depart for Florida and other winter getaways to check in before agreeing to undergo exams and procedures. And some patients have learned to be leery after being subjected to tests — and expenses — that long-trusted physicians at home never suggested.

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GM Healthcare News

Epidemic of diabetes in New York
High numbers of New York’s poorest residents are seeking treatment for medical complications arising from diabetes, according to data compiled and released by the United Hospital Fund. As with other chronic illnesses, it is more prevalent downstate. Medicaid recipients in downstate counties have higher rates of preventable hospitalizations for long-term diabetes-related complications than many of their upstate counterparts. In 2012, New York City had 222 preventable hospitalizations of this kind for every 100,000 Medicaid patients, compared with the statewide rate of 196.Projects to improve diabetes management abound in the Delivery System Reform Incentive Payment (DSRIP) application, with good reason: The disease’s prevalence has been growing. The portion of adults in New York state with diabetes nearly doubled in the last decade, from 4.6% in 1998 to 8.5% in 2009. On average, health care costs for people with diabetes cost 4.5 times more per year than for those without the disease, according to the state Department of Health. Diabetes-related complications were the 12th most common diagnosis for residents of New York City overall and seventh most common in the Bronx.
Rates of diabetes often correlate to high rates of poverty. In Brooklyn’s East New York and New Lots neighborhoods, with median household incomes around $34,000, more than 20% of adults have been diagnosed with diabetes at some point in their lives, according to the city’s Department of Health and Mental Hygiene.
Half of clinical trial outcomes never published

Healthcare providers and patients enrolled in clinical trials have a major stake in a proposal by the National Institutes of Health that would significantly expand the amount of clinical trial data posted on the publicly available government website, www.ClinicalTrials.gov.

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Hard Lesson in Sleep for Teenagers

By JANE E. BRODY (original article)

Within a week of my grandsons’ first year in high school, getting enough sleep had already become an issue.

Their concerned mother questioned whether lights out at midnight or 1 a.m. and awakening at 7 or 7:30 a.m. to get to school on time provided enough sleep for 14-year-olds to navigate a demanding school day.

The boys, of course, said “yes,” especially since they could “catch up” by sleeping late on weekends. But the professional literature on the sleep needs of adolescents says otherwise.

Few Americans these days get the hours of sleep optimal for their age, but experts agree that teenagers are more likely to fall short than anyone else.

Researchers report that the average adolescent needs eight and a half to nine and a half hours of sleep each night. But in a poll taken in 2006 by the National Sleep Foundation, less than 20 percent reported getting that much rest on school nights.

With the profusion of personal electronics, the current percentage is believed to be even worse. A study in Fairfax, Va., found that only 6 percent of children in the 10th grade and only 3 percent in the 12th grade get the recommended amount of sleep. Two in three teens were found to be severely sleep-deprived, losing two or more hours of sleep every night. The causes can be biological, behavioral or environmental. And the effect on the well-being of adolescents — on their health and academic potential — can be profound, according to a policy statement issued in August by the American Academy of Pediatrics.

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Genetic Variant May Shield Latinas From Breast Cancer


By ANAHAD O’CONNOR (original article)
OCTOBER 20, 2014
A genetic variant that is particularly common in some Hispanic women with indigenous American ancestry appears to drastically lower the risk of breast cancer, a new study found.

About one in five Latinas in the United States carry one copy of the variant, and roughly 1 percent carry two.

The function of the gene is not entirely clear. But the authors of the study, which was led by a team at the University of California, San Francisco, and funded by the National Cancer Institute, said women who carry the variant have breast tissue that appears less dense on mammograms — a factor that is known to play a role in breast cancer risk. They suspect that the genetic variant may affect the production of estrogen receptors.

“This is a really important study,” said Marc Hurlbert, executive director of the Avon Foundation Breast Cancer Crusade, who was not involved in the study. “If we can understand how this is protective, it might help us to develop better treatments for those who do get breast cancer.”

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