1. Featured Article:
The Brain's Memory-Forming Neurons, Scientific American
The Brain May Use Only 20 Percent of
Its Memory-Forming Neurons By Nikhil Swaminathan
Study shows that that pace at which a brain cell
activates a key protein may influence its role in memory formationa finding
that could lead to new Alzheimer therapies
Remember the old myth that people only use
10 percent of their brains? Although a new study confirmed that bromide to be
apocryphal, it did find that we may only use 20 percent of the nerve cells in
our midbrain to form memories.
Researchers at the University of
California, Los Angeles, and The Hospital for Sick Children in Toronto monitored
neurons in the lateral amygdalae (two almond-shaped regions on either side of
the midbrain associated with learning and memory) of mice to see whether the
presence of the CREB (cAMP response element binding) protein plays a key role
in signaling brain cells to make memories. CREB, a transcription factor that
typically increases the production of other proteins in cells, is believed to
be involved in memory formation in organisms from sea slugs to humans.
Scientists hope that their findings, reported in the current issue of Science,
may help pave the way to new treatments for Alzheimer's Disease.
Researchers injected a vector designed to
return CREB production to normal in mice that had been genetically modified to
underproduce the protein. After being injected, these mice, who also were
memory-impaired, performed as well as normal mice in memory tests. During the
trials, researchers played a sound and then shocked the animals; when the sound
was played again, normal mice and those with rescued CREB function frozefor a
certain[short?] period of timea reaction typical of fear.
When the researchers later dissected the
mice's brains, they found that the fluorescent probes they had attached to the
CREB vectors showed they had affected only about 20 percent of the neurons in
the lateral amygdala. "That surprised us. We thought that we would have to
affect a lot more neurons in order to see a big change in memory," says
study co-author Sheena Josselyn, a neurophysiologist at The Hospital for Sick
Children. "Not all [neurons] participate in every memory. Maybe we're
biasing these neurons to participate in this memory and [CREB is] all you
need'' to compel it."
To determine if the CREB-producing cells
were involved, the scientists then tried to follow the memory-making process by
inserting a probe, which would give off a fluorescent tag if RNA from a gene
known as Arc had recently been transcribed in brain cells. Arc
levels are normally low in a cell but increase considerably when neuronal
activity has taken place. The RNA is transcribed in the nucleus of a cell and
then transported through the cell's body to its dendrite, the projection of the
neuron that receives information from other cells. "Arc RNA
provides a really good molecular marker of when this neuron was active,"
says Josselyn. She adds that if the team found RNA in the nucleus of neurons
immediately after a training event, they knew cells had been active within the
last five minutes; if the probe was in the dendrite, they estimated activity
had taken place 20 minutes earlier. . .
The results: the memory trace, signified
by Arc, showed that activity had taken place in 20 percent of neurons.
"We think that it's really a competition, that neurons are really battling
it out" amongst each other to be involved in the memory-making process,
says Josselyn. "It's like grading on a curve
the same number [20
percent] of students are going to get As"or in this case help make the
memory.
It is the same percentage, but not the
same neurons, however, that create each memory. Also, researchers are not
certain what causes naturally boost CREB function and, therefore, the
likelihood of any particular neuron participating in making a memory. But
Josselyn speculates that the brain likely "differentiates different memories
by having different neurons encode them."
In the future, Josselyn says, this mechanism could be
harnessed to produce a new treatment for Alzheimer's disease. "In time,
we're going to have some sort of neuron-replacement therapy for
Alzheimer's," she says, conceding, "It's a little sci-fi right
now." But, if new neurons are inserted into a damaged brain, modulating
CREB function could help bias the healing brain to use the functioning neurons
and not its injured population.
www.sciam.com/article.cfm?id=the-brain-may-use-only-20&print=true
* * * * *
2.
In the News: How
to improve health in old age and increase life span, Scientific
American
Socializing with Youth Improves
the Elderly's Health, Life Span, by Erica
Westly,
A gene
associated with Alzheimer's disease may play a role
"Youth is a wonderful thing,"
George Bernard Shaw once said. "What a crime to waste it on
children." Humor aside, recent research suggests that youthful energy may
not be "wasted" after all. Through social interactions alone, the
young can pass some of their vigor on to the elderly, improving the older
generation's cognitive abilities and vascular health and even increasing their
life span.
Although
researchers have documented these benefits in mammals, such as rats, guinea
pigs and nonhuman primates, the reason for the effect has remained unclear. Now
biologist Chun-Fang Wu of the University of Iowa offers a genetic explanation in the May
27 issue of the Proceedings of the National Academy of Sciences. Wu
and graduate student Hongyu Ruan found that the presence of youthful, active
fruit flies doubled the life span of a group of flies with a mutation in Sod1,
a gene that has been linked in humans to Alzheimer's disease and amyotrophic
lateral sclerosis (ALS), a motor-neuron disorder also known as Lou Gehrig's
disease.
Fruit flies
are quite social, Wu explains; social cues govern both their reproduction and
aging process. And their genes are easier to manipulate than those of their
mammalian counterpartsby altering Sod1, Wu created flies that died
after only about two weeks, a quarter of their normal life span. When housed
with younger flies, however, the Sod1 mutants lived for about 30 days. The
mutant flies also became more physically fit, according to heat-stress tests
and other measures, when housed with the younger "helpers." Clipping
the younger flies' wings significantly reduced the positive effects on the
mutants' life span, suggesting that physical activity plays a key role in the
life-extending mechanism.
Physical
activity is well known to benefit elderly humans, but working out in a social
setting with younger people seems to be especially valuable. Sharon Arkin, a
psychiatrist at the University of Arizona, runs a clinical program in which
Alzheimer's patients engage in communal exercise sessions with college
students. She showed that her program stabilizes cognitive decline and improves
patients' moods.
So could the
Sod1 gene be playing a part in humans? Wu thinks it is possible.
Besides the gene's association with Alzheimer's, Wu found that flies with the
Sod1 mutation were more receptive to social cues than flies with other
age-accelerating mutations were. Further studies are needed to determine the
therapeutic potential of intergenerational socializationbut visiting the
grandparents probably couldn't hurt.
Editor's
Note: This story was originally printed with the title "Talk to Teens,
Live Longer"
www.sciam.com/article.cfm?id=talk-to-teens-live-longer
* * * * *
3.
International
Medicine: Why the National Health Service is Doomed. From
The Sunday TimesAugust 31, 2008. Click on the response from the ones trying to survive.
Swallow this and you'll get a better
NHS by Karol Sikora
A
40-year-old mother of two young children with kidney cancer wants a new drug
it's her only hope. The emergency room wants another triage nurse to reduce
waiting times from four to two hours. And the ophthalmologists want to give two
patients a new drug to prevent age-related blindness. Each intervention will
cost £30,000. You only have £30,000 left it's your call.
Rationing
healthcare is never easy. Ageing populations, technological innovation and an
informed, demanding public are causing financial meltdown in all healthcare
systems across the world. Insurance schemes, such as the NHS, that rely on tax
as the main source of funding are doomed. The elderly and retired pay little
tax yet consume the majority of healthcare. So the young have to pay for
innovative medicines for the old out of their pay packets. This is just not
sustainable.
The
sentimentality we attach to Britain's NHS will disappear as a new generation
realises the financial implications. The Ipod (insecure, pressurised, overtaxed
and debt-ridden) generation, now in their thirties, will simply rebel by voting
out politicians who want to maintain the current system. A major change in how
we pay for healthcare is inevitable.
Innovation
is everywhere. The human genome project, robotics, nanotechnology, new imaging
methods and gene therapy are all leading to new drugs and procedures to improve
our quality and length of life. We are converting previous killers such as
coronary artery disease, stroke and cancer into chronic, controllable
illnesses. Stem cells from different organs will be used to create tissue banks
to replace defective body parts. Brain implants will repair the defects that
lead to dementia and disorders such as Parkinson's. All come with a hefty price
tag.
Medicine
will become personalised. By understanding the individual's genetic make-up and
by using a set of sophisticated molecular diagnostics, we will prescribe
courses of treatment optimised for them. Personalised care will not just be
about drugs. It will involve choices about lifestyles and retirement plans. The
current one-size-fits-all model will disappear.
Living
long and healthily will end in a speedy downward trajectory to death for most
people in their eighties. Superb palliative and end-of-life care will be
normal. This will provide a more financially balanced system making a
good-quality, healthy life affordable for all. In the good old days doctors did
the rationing covertly. Now we have the National Institute for Health and
Clinical Excellence (Nice) providing central guidance based on complex economic
formulae and 149 primary care trusts (PCTs) who buy healthcare for their
constituents. You can't choose which PCT you use it chooses you by your
postcode. Naturally they all come to different conclusions about the best way
of spending their money. That creates the postcode lottery.
Politicians
intervene directly in the workings of Nice. Two years ago Patricia Hewitt
suddenly announced that Herceptin would be available for women with breast
cancer even though it had not gone through the Nice process. And we've not
heard the last of the current furore over drugs for kidney cancer rejected by
Nice three weeks ago. In June, Alan Johnson, the health secretary, said:
"All the cases I've seen involve kidney cancer and drugs that have been
too slow getting through the system. They've been licensed but Nice have spent
a long time before they've approved them. We need to bring the time right down
so those drugs are available on the NHS very quickly." He clearly didn't
anticipate a negative Nice decision. I suspect by Christmas the drugs will be
approved. Otherwise this episode could lose too many votes.
It's
time to open the debate about whether the NHS should be able to provide not
just an efficient, well-defined core package of services but allow patients to
contribute or insure for improved services, such as top-up medicines. This could
reduce the inequity resulting from the current confusion where some patients
have to receive all their care privately. This is simply unaffordable to many
who have paid their tax-based insurance premium to the NHS for the core
package. Being open about the possibilities could lead to a set of innovative
insurance products to pay for specific options and herald an era of real
patient choice.
How
much we are willing to pay for an extra year of good-quality life is a key
question for the baby-boomer generation. And how we will allow individuals to
contribute to their care in an equitable way. Consumerism and social solidarity
are not comfortable companions. We are impinging on the very core of NHS
doctrine care given freely on the basis of medical need and not ability to
pay. Its high priests are now very worried.
Radical
structural change to the NHS is vital. Competition and choice drive up quality
and access, so leading to greater value, just as we've seen in other consumer
areas such as mobile phones, budget airlines and the high street. Sensible
incentives linked to performance and outcomes are essential. Drastic reform,
not more money, is now needed. Treating the NHS as a religion is irrational,
bad for our health and not a good solution.
Professor Karol Sikora is medical director at CancerPartners UK, a private
cancer company.
HAVE
YOUR SAY. The
question is surely how much extra cash an individual is willing to pay for an
addition to the life span of SOMEONE ELSE who is not a family member of his and
unknown to the individual. UK medical services are the worst of any developed
major European country. The NHS must be scrapped and replaced. G McKay, Epping,
England
www.timesonline.co.uk/tol/comment/columnists/guest_contributors/article4641109.ece
The NHS does not give timely
access to health care; it only gives access to a waiting list.
* * * * *
Medicare Spending Across the Map by Amy Hopson, Research Associate, and Andrew J.
Rettenmaier, Executive Associate Director, Private Enterprise Research Center,
Texas A&M University
Executive Summary Though talk of fundamentally reforming Medicare has
been limited lately, the baby boomers' imminent retirement and the continued
rise in health care costs will force Medicare back to the forefront of upcoming
policy discussions.
The Medicare Trustees and the Congressional Budget
Office both predict that Medicare spending as a percentage of gross domestic
product (GDP) will double by 2030. Therefore, all possible means of making
Medicare more efficient should be considered in light of its increasing
importance to taxpayers. One possible avenue for reform is seen in the wide
regional variations in Medicare spending that exist and have persisted through
time. If Medicare reimbursements could be constrained to the levels existing in
the lower cost areas, the program's costs could be reduced significantly.
But why do Medicare costs vary so dramatically from
area to area? Why, for example, is average Medicare spending in Los Angeles
almost 70 percent higher than in Green Bay, Wisconsin? The purpose of this
study is to examine the county-by-county variation in Medicare spending, look
for causes of this variation and suggest reforms that can narrow the variation
that can't be explained by the causes we can observe. These reforms not only
address the regional variation, but more importantly reduce the program's
costs. Most previous studies have analyzed Medicare spending differences at the
state or hospital referral region (HRR) level. Since there are just over 300
HRRs and over 3,100 counties, this study allows for closer examination and more
precise analysis of the regional variation.
Among the regional variations in Medicare spending
that were found:
·
County-level Medicare spending is high states
like New Jersey, with 95 percent of its counties in the top fifth of spending.
·
Maryland, Louisiana,
Massachusetts and Texas are also high cost areas, with all having more than
half of their counties in the top fifth of spending.
·
In contrast, average
county-level Medicare spending is low in Vermont, Idaho, New Mexico, South
Dakota, Oregon and Iowa, all with more than half of their counties in the
bottom fifth of spending.
But perhaps the high-cost counties are high cost
simply because they have higher risk Medicare populations, or possibly the
retiree population's income or demographic characteristics are associated with
higher spending. Additionally, the health care market's characteristics may be
driving the higher costs. All of these causes are considered in explaining the
average total Medicare spending in each county. The results indicate that:
·
Higher Social Security
benefits as well as more Supplemental Security Income imply higher spending.
·
Higher percentages of
Hispanics and Blacks are related to higher average Medicare spending in the
counties.
·
Higher percentages of
female retirees in a county are positively related to spending, while higher
percentages over age 85 are negatively related.
·
Higher health care
sector wages are associated with lower Medicare spending, but managed care
penetration has a positive effect on spending.
·
The most important
factors are the health risks among a county's Medicare beneficiaries which are
(as expected) associated with higher spending.
·
The observable county characteristics along
with a measure of the health care risks explains about 40 percent of the
variation in average Medicare spending across the counties in the continental
United States.
Does the regional variation observed in the raw county
by county averages persist after removing the effects associated with the
observable differences in county characteristics? The geographic concentration
of high and low cost counties is lessened to some degree, but it is still true
that many of the high cost counties remain in the high cost categories.
Specifically:
·
Of the six states that
had more than half of their counties in the highest fifth of spending, four
continued to have more than half of their counties in the top fifth of spending
after adjusting for county characteristics.
·
New Jersey was a notable
exception in that only 24 percent of its counties remain in the top fifth of
spending after accounting for the county characteristics. This indicates that
the New Jersey counties' retired population's health risks, income,
demographics and health care market explain much of the reason why they are
high cost counties.
·
At the other end of the
distribution, two of the five states that had more than half of their counties
in the lowest fifth of spending still have more than half in the bottom fifth
after adjusting for county characteristics.
·
This persistence
indicates that factors other than those controlled for cause some areas to be
high or low cost. There are several possible reasons why some areas have higher
than expected costs. Higher concentrations of uninsured individuals in a county
may lead to cross subsidization from Medicare. The legal environment in some
states may lead to more aggressive use of protective medicine. Also, the
practice of medicine may vary from area to area in a persistent way. Regardless
of the cause, there are remedies that address the high cost areas leading to
more efficient use of taxpayers' dollars. . .
To read the proposed remedies and the entire study, go to www.ncpa.org/pub/st/st313/st313.pdf.
Amy Hopson Research Associate, Private Enterprise
Research Center, Texas A&M University, and Andrew J. Rettenmaier, Executive
Associate Director, Private Enterprise Research Center, Texas A&M
University, Senior Fellow, National Center for Policy Analysis, NCPA Policy
Report No. 313, July 2008. ISBN #1-56808-188-x,
National Center for Policy Analysis, 12770 Coit Rd., Suite 800, Dallas, Texas
75251, (972) 386-6272
Government is not the solution to our problems,
government is the problem.
- Ronald Reagan
* * * * *
5. Medical Gluttony: Excessive utilization is ubiquitous;
but it's not entirely the patient's fault.
MedicalTuesday has had this section on excessive medical
utilization since its inception seven years ago. We don't even highlight
excessive use such as five or ten percent, items on which the government
devotes years of discussion in Congress, debates, hearings, and then passes
legislation which generally makes the situation worse. Most of our examples are
100 percent, 1,000 percent or even 10,000 percent excessive utilization without
the patient perceiving it as over use. Patients actually brag that the best way
to get a complete medical evaluation and physical examination is to go to the
hospital emergency room and enjoy. A patient told me last week, that he'd never
been to the emergency room before, but that he got royal treatment in the
finest hotel with plush surroundings. He said, "I think I got everything
that the Mayo Clinic could possible offer in six hours and didn't even have to
fly to Rochester, Minnesota."
Would you or I act any differently? If you're in your
late 60s and your spouse has been after you to go to a cardiologist and get
"checked out" and a hospital ER doctor says you need "this 'n'
that" and you know that Medicare is footing the bill, could you face your
spouse who has been very worried and say you declined the "Full
Monty" evaluation for your heart? Could you forgive yourself if you really
had a coronary as you lie in the casket thinking, "I should have been a
Glutton and maybe avoided this trip."
There's no real dialogue between the doctor and the
patient with chest pain when the doctor looks out the window and sees the $100
million hospital expansion that depends on his/her holding up his/her end of
the Faustian bargain when paying the expansion price, which does not affect him
or her or the patient. Medicare is going under anyway and poor ole little me
can't make a difference in saving it. So, nurse, where did you put that order
sheet?
Saving Medicare involves a simple solution - not easy,
but simple. By going back to the original law and have patients pay a healthy
deductible when going into the hospital (or better yet a 5 percent co-payment)
as well as a 20 percent co-payment on all items in Medicare B and D, and
outlawing MediGap insurance, cost control would be achieved immediately. Very,
very simple, but not easy to do and stay elected.
Congress is not interested in saving Medicare and not
getting re-elected. Once, the government is involved in an entitlement, there
is no hope for rational thinking. The Medicare age should have been indexed for
life expectancy and since people live 15 to 20 years longer, the Medicare Age
should be at least 75 and continue to be indexed. One can't add an extra 10
years of retirement income and retirement health benefits and not expect
bankruptcy. My patients at age 75 look far younger than my patients at age 60
looked twenty years ago.
Designing
the Patient-Centered Health Plan for America
www.healthplanusa.net/index.htm.
A National Health Care
Plan www.healthplanusa.net/DelMeyer.htm.
* * * * *
6.
Medical Myths:
Europeans wonder why we persist in the myth about medical killing.
The Economist is in the habit of ridiculing America's moral
torpidity. This came up because of the moral stand of Sarah Palin. They don't
understand prenatal killing or even partial birth killing as bad. They don't
understand why Sarah Palin didn't kill her Downs or mongoloid child while still
in utero.
But then European physicians have never had a problem
killing humans, even if they were not their patients. Some even think that the
disabled should be put out of their misery with a lethal injection like we give
first-degree murderers. However, Europeans take issue with the killing of
killers who are truly evil persons. They will kill the aged and infirmed and
sometimes those that aren't so aged or infirmed. Sometimes it's just because
they need the bed.
At an international medical meeting, I was sitting at
a table of mostly European doctors. I asked about how common Euthanasia was in
their countries. Several of the doctors had participated in it. The doctor
sitting next to me was from The Netherlands. He stated that he felt badly about
one instance where he wanted to put a patient in the hospital and the patient
declined stating that she feared she would be put to death and she wasn't ready
to die. He assured her that he would be watching over her to make sure that
didn't happen. Sunday was his day off. On Monday, when he went to look for his
patient, he could not find her and after inquiry located the doctor who was
caring for her. He was told that she was given "the injection"
because they needed the bed.
Once you have a culture of death, it's hard to stop.
Where would you stop? How many days after conception? How many months into a
pregnancy? Or if you missed, could you still suck out the brains as the baby is
crowning into the world? Or if you missed a Mongoloid or Downs Syndrome, snuff
out the life right after birth? Or if the patient becomes disabled and
crippled, do it any time which is recommended by some Princeton professors
already. Or if the patient is aged and feeble, move things along with a
"lethal injection" but make sure the patient isn't a criminalthat
would be capital punishment. Or if the patient is doing well, but occupies a
hospital bed and someone younger needs it worse, just give her the "lethal
injection" to free up a bed.
Where does it all end?
Oregon offers state-assisted suicide if Medicaid
treatments are too expensive. And that's in our own country - pretty close to
home.
It never ends once it starts. Are we all headed for
the slippery slope? Are we all Hitlers who decide when life is not worth
living?
Or maybe Sarah Palin came along at just the right
moment in history. She may effectively turn a few things around as Vice
President. But she will be even more effective when she makes history as the
first woman president in 2016. And she will make further history when she
starts her second term on the 100th anniversary of the Women's
Suffrage Amendment in 2020. As a member of Feminist for Life, she may do more
for Women's Liberation in the next eight years than the entire feminist
movement for the past 60 years. Hats off to her.
* * * * *
7.
Overheard in the
Medical Staff Lounge: The Elections have suddenly become interesting.
Dr. Ruth:
Wasn't Sarah Palin a breath of fresh air last week?
Dr. Dave: I
would certainly agree to that.
Dr. Michelle: And
not a day too soon.
Dr. Dave: The other
party is really scrambling all at once.
Dr. Edwards: We
haven't heard much from the other Vice Presidential candidate.
Dr. Dave: He
probably doesn't know what to say. He and his presidential running mate are the
first and third most liberal socialistic candidates in their party.
Dr. Rosen: The
most socialistic ticket in America in decades.
Dr. Edwards:
There certainly is no balance on that ticket.
Dr. Rosen: Do
you think this sudden turn of events will return the doctors to their
traditional conservative roots?
Dr. Yancy: I
certainly hope so. I wasn't going to vote this year, but suddenly changed my
mind. All at once, there's hope for America.
Dr. Dave:
There's hope. But will it change the playing field?
Dr. Rosen: You
don't think this is just a fluke, do you?
Dr. Ruth: I
certainly hope it's not.
Dr. Dave: If we
can get her elected as the first Woman Vice President, then in 2016, we may
have the first Woman President.
Dr. Michelle:
Wouldn't that be great if by 2020 on the 100th anniversary of the
women's suffrage amendment, we would have a Lady President?
Dr. Dave: And
people are already referring to her husband as the First Dude. I think that
rather fits.
Dr. Rosen:
Coming out of the oil fields and into the White House? I haven't noticed, does
he wear cowboy boots?
Dr. Dave: He
certainly must if he goes moose hunting.
Dr. Rosen: Good
point. I'll keep my eyes peeled.
Dr. Ruth: He's
a breath of fresh air also.
Dr. Rosen: It's
turning out to be the most fascinating campaign of my life!
* * * * *
8.
Voices of
Medicine: A Review of Local and Regional Medical Journals
SONOMA MEDICINE, the Magazine of the Sonoma
County Medical Association, Summer 2008
At Home in Guatemala By Julie Kiser,
MD
I work in a three-room clinic
in Las Cruces, a small town in northern Guatemala. We have dirt roads and draw
our water from a well, and we usually have electricity.
A few weeks ago, a 17-year-old mother came to our front porch with her two
small children. The 10-month-old had rotavirus and was dehydrated, so I brought
water, sugar and salt from our kitchen, and together the mother and I made one
liter of oral rehydration drink.
The mother said the 3-year-old, a girl, had an earache. I examined both kids:
temperature, pulse, respiration, ears, lungs, belly. The girl had a fever and a
tender liver. From the clinic I got microscope slides, cloroquine and
primaquine. Back on the porch, I stuck the girl's finger and made a thick and
thin smear to read in the afternoon. As the mother held her daughter, we pushed
in the first dose of three days of bitter cloroquine. Then I wrote the record
of the visit on two green cards, one for each child, and gave them to the
mother. She paid me a few coins, which I returned to our pharmacy fund.
During the mother's visit, I was nurse, pharmacist, lab tech, records clerk,
doctor, accountant and mom's helper. We were outside in the fresh air. The only
copy of the medical chart went home with the patient, who will bring it when
she returns.
Dr. Kate Feibusch and I have
lived in Guatemala with our daughter, Mira Moore, since December 2000. We live
in the northern state of Petιn. Kate and I graduated from the Santa Rosa Family
Practice Residency in 1999 and 1997, respectively. The residency sent us off
with an excellent education and an ethic of service. When Sonoma Medicine
asked us to write about our lives here, I saw a way of sending gratitude to our
teachers and our circle of Santa Rosa friends.
Although we love seeing patients, direct patient care is not our only job here;
we also administer a project that supports rural health workers. Last week, for
example, I rode with Mira in the back of a pickup truck over dusty roads for
three hours, carrying a box of medicines and a mosquito net. My destination was
the Uniσn Maya Itzα, a community established in 1996 by refugees who returned
at the end of Guatemala's civil war. They and their children now farm near the
Usumacinta River, Guatemala's western border with Mexico.
We stayed in the community for two days with a rural health worker named
Angelina, a 34-year-old mother of three. She has seen about 70 patients a week
for the last five years. She receives emergencies at all hours, including
births and wounds requiring suturing. When necessary, she keeps patients
overnight in her home.
During my stay, Angelina and I consulted on her difficult cases, including a
neighbor with psychosis who takes chlorpromazine. The day I arrived, I visited
a man with high fever and vomiting, possibly caused by leptospirosis. I
repaired Angelina's sphygmometer and restocked her chest of medicines. I had
brought a dermatology book with me; we reviewed the appearance of tinea
corporis, tinea pedis and kerion. We set a date for my coworkers to apply
fluoride to school kids' teeth. I also talked with Angelina and her husband
about building an annex, in order to move the medical consult out of their
living room. Angelina taught Mira and me more words in Q'eqchi', one of 20
Mayan languages spoken in Guatemala. Angelina, like many indigenous
Guatemalans, is bilingual. She speaks Spanish and Q'eqchi' (pronounced
*EK-chee, where * is a click in the back of the throat).
Our main job is to visit
volunteer medical workers called "health promoters" and teach them in
formal classes. From January to March this year, for example, I presented three
five-day courses. The first course, in Spanish, covered musculoskeletal
medicine, including back pain and common knee and shoulder problems. The second
course was a Q'eqchi' version of the first course, presented to five women and
15 men. The same group received my third course a month later, on diagnosis and
treatment of skin problems. . .
Now Kate and I are
teachers. We remember warmly our teachers at the residency, including Drs. Rick
Flinders and Lou Menachof. Like them, we provide health care to the poor. As we
are the last stop for many difficult and challenging cases, we must go to the
limits of our abilities. The philosophy of the Santa Rosa residency was to
prepare for a broad practice, including procedures. We do a lot of minor
procedures, including using ketamine anesthesia for kids and trauma. We also
repair extensor tendons of the hand. We refer to a local hospital when a
patient needs an appendectomy or a cesarean section. Since we have no X-ray or
ultrasound, I especially appreciate the physical diagnosis skills from our
early training. Much of the musculoskeletal medicine I teach, I learned from
Dr. Veronica Vuksich. We do our own blood smears, Gram stains and TB slides,
and we use the intensivist skills learned from Dr. James Gude because we
receive emergencies from a 100-mile radius. Kate completed a fellowship at the
HIV clinic in Santa Rosa, and she is the main coordinator of HIV care in the
region. . .
People live very simply here.
A typical house is made of sticks and boards with a roof of palm leaves or tin
sheeting. Families sow the land with corn and store sacks of harvested corn in
their houses. To make a meal, women rub kernels off the cobs, cook the kernels
with lime and then grind them to make corn dough. They pat the dough into
tortillas, which they cook over a wood fire and serve with black beans.
We work for the service arm of the Catholic Church, but our financial support
comes from a U.S.-based organization called Concern America. Since its
establishment in 1972, Concern has worked quietly with refugees and materially
poor communities in 15 countries. It is a non-religious nonprofit that makes
long-term commitments. Our project has been in Las Cruces for 12 years and
employs six Guatemalan health workers whom we consider peers. Julia Martinez,
for example, has worked full-time for our project since 1999. She is my age,
46, and she has seven children aged 27 to 12. . . .
·
Guatemala is only 700
miles south of the United States, but its health indices are among the worst in
the world. Guatemalan women face 20 times the maternal mortality of American
women. The Guatemalan government spends $15 per capita on its public health
system, compared to the American expenditure of $2,000 per capita. Trade
agreements with the United States favor pharmaceutical companies and restrict
the use of generic medicines in public clinics. For these reasons, our project
involves itself in local and national politics. . . .
Specialist physicians
who are willing to give us their cell phone number can be especially helpful.
On occasion we get really stuck with a case requiring a specialist, and we need
somebody to call. We run into orthopedics, ophthalmology, oncology and surgery
cases out here in the sticks, and a friendly, informed American colleague could
help us think things through.
To find out more about supporting our work or visiting our clinic in Las
Cruces, go to www.concernamerica.org or contact Kate and me
directly at kate_julie@yahoo.com.
Dr. Kiser, a family physician, lives
and works in Guatemala with Dr. Kate Feibusch and their daughters Mira and
Toby.
To read the entire article, go to www.scma.org/magazine/scp/sm08/kiser.html.
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9.
Book Review:
Spiritual and Medical Perspectives on Euthanasia and Mortality
DENIAL OF THE SOUL - Spiritual and Medical
Perspectives on Euthanasia and Mortality, M. Scott Peck, MD, Harmony Books, New York, 1997, xi
& 242 pp, $23, ISBN: 0- 517-70865-5.
Physician, psychiatrist, theologian, and author of the
best-seller, The Road Less Traveled, F Scott Peck, MD, gives us an
in-depth look at the current euthanasia movement and its origins in the
inability of physicians to "pull the plug." Peck states that although
Dr Kevorkian gives him the shivers, he must credit him more than any other
individual for the genesis of this book. Almost single-handedly over the past
five years, Kevorkian has turned the debate over euthanasia into a national
issue within the United States.
But Kevorkian didn't inspire Dr Peck to write this
bookit was the public response to his behavior. Peck was surprised by the
number of people who admire Kevorkian..He was even further surprised by the
larger number who, though they feel no affections for Kevorkian, nevertheless
deeply approve of what he has been doing in assisting the suicides of those who
are ill. Most of all, Peck has been surprised by the huge number of Americans
who do not find Dr Kevorkian's work particularly objectionable.
The whole debate is strangely passionless and
seemingly simplistic. But the subject of euthanasia is far from simplisticit
involves questions about who, if anyone, has a right to terminate a life;
whether it's the same as or different from suicide or homicide; whether it
differs from merely "pulling the plug;" and what role does pain, both
physical and mental, play in euthanasia decisions. Among the stories he tells,
is one about Tony, a patient of his when he was a psychiatric resident. He felt
Tony's craziness was organic and referred him to neurology where he was found
to have a large frontal brain tumor. The tumor was inoperable and failed to
respond to radiation treatment.
Weeks later when Peck rotated on the neurology
service, Tony, now unresponsive and on a ventilator, reentered his life. He
wondered why anyone would decide to place Tony on life support. Was this
"heroic" medicine, or just a measure to prolong a life that had lost
its essence? Peck asked his chief of neurology at Letterman General Hospital
whether this effort to prevent inevitable death was the right thing to do? The
Colonel commended him, obtained a portable EEG, and found an occasional
distorted brain wave and pronounced that the patient was not yet certifiably
brain-dead.
Recalling the anguish of the family in waiting, Peck
looked at Tony for the next 15 minutes, cut the levophed drip in half, went to
the doctor's lounge, smoked a cigarette, returned 10 minutes later, found Tony
dead, and informed the family. As they wept, speaking to each other in Italian,
he could not tell whether they were weeping in grief or relief. He concluded,
probably both. He, of course, had the presence of mind not to tell anyone about
what he had done.
Peck wishes that he could have shared his solo
decision 30 years ago. If he had, he would have opened himself to court-martial
for unacceptable medical behavior. His actions would have been considered
euthanasia or physician suicide. Today the decision to "pull the
plug" is made in conjunction with the family and other physicians and
occasionally the ethics committee.
Peck then takes us on a journey of inadequately
treated pain, which is now a precursor to physician assisted suicide. Nothing
fuels the euthanasia debate so much as the fear of intractable pain. Peck
states that if there were such a thing as intractable untreatable agonizing
pain, one could make a case for physician-assisted suicide. In his entire
professional life, Peck has never found one case in which pain could not be
controlled with the appropriate type of morphine cocktail. Peck gives the fear
of pain a lengthy treatment because he feels that many people look to
euthanasia as a cure for physical pain they believe they will have to endure
during the natural process of dying. But according to Peck, it is emotionalnot
physical pain that is the center of the euthanasia debate.
Once Peck establishes that it is emotional, not
physical pain that is the center of the euthanasia debate, he then turns to
mental illnesses, to suicide, natural death, and murder. Although he believes
physician-assisted suicide should be illegal, he points out that not all people
can obtain Hospice care to relieve pain and suffering and there are many
unsympathetic physicians out there. He wishes there were a vigorous discussion
in religious congregations, but feels they will do almost anything to avoid
open debate. The author contends feels that all of these issues must be
adequately explored before the underlying simplicity of the spiritual
perspective will be accepted. We must become articulate in the
EuthanasiaPhysician Assisted Suicide debate before it's too late.
This book review is found at www.healthcarecom.net/Denial_of_the_Soul.htm.
To read more book reviews,
go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm.
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10. Hippocrates & His Kin: How to keep our memory
function working.
As we snooze, our brain is busily processing the
information we have learned during the day. Sleep makes memories stronger, and
it even appears to weed out irrelevant details and background information so
that only the important pieces remain. Our brain also works during slumber to
find hidden relations among memories and to solve problems we were working on
while awake.
The latest research suggests that
while we are peacefully asleep, our brain is busily processing the day's
information. It combs through recently formed memories, stabilizing, copying
and filing them, so that they will be more useful the next day. A night of
sleep can make memories resistant to interference from other information and
allow us to recall them for use more effectively the next morning. And sleep
not only strengthens memories, it also lets the brain sift through newly formed
memories, possibly even identifying what is worth keeping and selectively
maintaining or enhancing these aspects of a memory. When a picture contains
both emotional and unemotional elements, sleep can save the important emotional
parts and let the less relevant background drift away. It can analyze
collections of memories to discover relations among them or identify the gist
of a memory while the unnecessary details fadeperhaps even helping us find the
meaning in what we have learned.
www.sciam.com/article.cfm?id=how-snoozing-makes-you-smarter
Work and sleep continues to be our tradeoff challenge
- to get enough of both for a productive life.
Global Consultations
Consultants who are unable
to travel to remote areas of the world can now serve these people due to the
fact that world wide cell phones are nearly a local call. For those specialists
who are willing to give their cell phone number to workers in Guatemala or
other remote countries, they can discuss a patient's problem with the family
doctor providing consultative care and never leave their office or home. The
marvels of the technology age are unlimited.
Global medicine is indeed
coming into its own.
To read more HHK, go to www.healthcarecom.net/hhk2001.htm.
To read more HMC, go to www.delmeyer.net/hmc2005.htm.
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11. Organizations Restoring Accountability in HealthCare,
Government and Society: