Friday, March 24, 2017

Medical School Seeks To Make Training More Compassionate

After the SUICIDE of a 4th Year Medical Student, a Medical School is seeking to change its training culture

A New York City medical school has embarked on a soul-searching campaign of culture change after a 27-year-old student there jumped to her death last summer from her eighth-floor dorm residence.

“Rocked by waves of anguish, anger and frustration, guilt, fear and profound sadness,” the Icahn School of Medicine at Mount Sinai is trying to forge a kinder, gentler system of training, according to an essay by a dean at the school​in the New England Journal of Medicine.

The school is considering significantly expanding access to mental-health specialists, as well as changing aspects of its grading system. Another idea on the table: creating a hub for activities related to student health and well-being.

“Medical school is a cauldron,” says David Muller, the school’s dean for medical education, and the author of the essay that promises to improve conditions for Sinai’s doctors-in-training, both students and residents. The residents are at the front lines of care, Dr. Muller added in an interview, and “feel very often helpless and hopeless, the machine is intense and churns on relentlessly.”

One morning in August, the fourth-year medical student took her life on Mount Sinai’s campus on New York’s Upper East Side. Several months earlier, a medical resident, also female, committed suicide at the school’s West Side campus.

Jordyn Feingold, a first-year medical student, lived next door to the woman who committed suicide in August. Ms. Feingold had arrived at Sinai only 10 days before the tragedy and recalled how she and her peers were racked by “cognitive dissonance”—excited about starting training but distraught at the tragedy. “It was very weird,” she said.

Ms. Feingold, who is 24 and has a master’s in applied positive psychology, joined a task force Dr. Muller charged with figuring out how to improve Sinai’s academic culture and doctors’ well-being. “We are so focused on taking care of patients, to give quality care, but absent from our education is how we can take care of ourselves,” she said.

In 2014, two other young doctors-in-training at two different New York-area medical schools committed suicide. “We are all in the same very, very, scary boat,” Dr. Muller said.

The deaths underscore a broader problem, researchers say: That young doctors and medical students face grueling academic pressures and are experiencing high rates of burnout, depression and psychological strain.

But it isn’t because individuals drawn to medicine are necessarily more prone to angst. “We found at admission that the kids look fine,” says Liselotte Dyrbye, professor of medicine at Mayo Clinic in Rochester, Minn. “It is as if they go through our training process, and they develop worsening mental health.”

Dr. Dyrbye blames this on an “absurd” medical system: “It is the curriculum, it is the learning environment, it is the type of stuff you do as a [young] physician, and it is not unique to Mayo, it is not unique to Sinai.”

The Mayo researcher, who studies physician well-being, says in addition to mastering vast amounts of information, medical students and residents cope with “complex patient interactions, the suffering, the deaths.” Too often, “it is not a supportive environment—students are set up to compete with each other.”

Arthur Caplan, a bioethicist at the NYU School of Medicine, describes physician burnout as “a kind of epidemic” that can also hurt patients.

“There is trouble for patients in having a work force that is burned out,” he said in a video on the medical-information website Medscape, noting that these physicians may have “compassion fatigue” and could be prone to making medical errors.

It isn’t clear what drove Kathryn Stascavage—the student referred to as “Kathryn” in the New England Journal essay—to suicide, nor what role the pressures of medical school may have played.Through Dr. Muller’s office, the family declined to comment.

Even so, Prameet Singh, vice chair of psychiatry at Mount Sinai’s West Side campus, says the tragedy “gives us a chance to pause and look at what is the matter with our medical system—what do we do to contribute to the stresses and tribulations.”

Dr. Singh, along with about 30 faculty members, medical students, fellows and residents, took part in the task force, and proposed steps to remedy the academic culture. They were split into three areas—mental health, physician well-being and the learning environment.

Dr. Singh’s group, which focused on mental health, grappled with making it easier to consult a therapist. That meant both removing the stigma of psychiatric care, and arranging access to affordable practitioners, since many don’t accept insurance. One proposal calls for making more therapists in the institution available to students. Another idea: identifying 15 to 20 therapists willing to lower their fees for students. The school also would like to ask students to have regular mental-health checkups, with an “opt-out” possibility if they don’t wish to have them.

Jonathan Ripp, an internist on the faculty of the Icahn School who co-chaired the working group on well-being, believes young doctors and trainees are suffering because medicine has changed dramatically.

“There are a lot of new pressures and physicians are being scrutinized more than before,” Dr. Ripp says. An older generation “could spend most of the time looking at the patient and speaking with the patient,” whereas now, “you have 15 minutes to see someone.”

Dr. Ripp’s group suggests dedicating space on campus to a clearinghouse where young doctors and students could avail themselves of a “menu of well-being”—such as finding a psychiatrist or signing up for a mindfulness training session.

His group wants “protected dedicated time” built into the schedules of medical students and trainees, to allow them to take a break, meet with peers, and review stressful incidents such as the death of a patient. “Until now, it was expected you would deal with it,” Dr. Ripp said, “but it is not normal to experience a death and go about your business.”

Dr. Muller is most concerned about the academic culture: “I said to the group, we can have an army of psychiatrists, and have mindfulness and yoga every day, but if we don’t change the fundamental culture of academic medicine, all we will do is produce more burned-out people.”

Sinai tackled one source of angst—a high-stakes grading system marked by quotas for third- and fourth-year students that limited “honors,” a coveted distinction that helps an individual enter residency programs—to 25% of the class. After “honors,” the “high pass” distinction was limited to 25%, while the remaining half of the class would receive a “pass” grade. The system provoked intense rivalry among students, Ms. Feingold says.

The school has rejiggered the distribution to allow one-third of students to receive “honors,” one-third “high pass” and one-third “pass,” Dean Muller said, with an eye to creating a system that will drop the limits altogether.

Dr. Muller is hopeful the tragedy will accelerate change: “The same kind of compassion and humanism we are teaching them to show patients, they should be showing each other and we should be showing them.”

Source:     WSJ

Wednesday, March 22, 2017

Doctors Say: Deadly Spider Venom Could Ward Off Stroke Brain Damage

Ingredient in funnel web spider venom can protect cells from being destroyed by a stroke, even when given hours after the event, study shows

Doctors have stumbled on an unlikely source for a drug to ward off brain damage caused by strokes: the venom of one of the deadliest spiders in the world.

A bite from an Australian funnel web spider can kill a human in 15 minutes, but a harmless ingredient found in the venom of one species can protect brain cells from being destroyed by a stroke, even when given hours after the event, scientists say.

If the compound fares well in human trials, it could become the first drug that doctors have to protect against the devastating loss of neurons that strokes can cause.

Researchers discovered the protective molecule by chance as they sequenced the DNA of toxins in the venom of the Darling Downs funnel web spider (Hadronyche infensa) that lives in Queensland and New South Wales.

Venom from three spiders was gathered for the study after scientists trapped and “milked exhaustively” three spiders on Orchid beach, about 400km north of Brisbane.

The molecule, called Hi1a, stood out because it looked like two copies of another brain cell-protecting chemical stitched together. It was so intriguing that scientists decided to synthesise the compound and test its powers. “It proved to be even more potent,” said Glenn King at the University of Queensland’s centre for pain research.

Strokes occur when blood flow to the brain is interrupted and the brain is starved of oxygen. About 85% of strokes are caused by blockages in blood vessels in the brain, with the rest due to bleeds when vessels rupture. Approximately six million people a year die from stroke, making it the second largest cause of death worldwide after heart attacks.

When a stroke happens, the oxygen level in the brain drops. This forces the brain to burn its primary fuel, glucose, very differently. Instead of oxidising glucose for energy, the brain switches to a process called anaerobic glycolysis. The reaction releases energy to keep the brain working, but it also produces acid, which can cause brain cells to die.

In a series of studies on rats, King showed that a single small dose of the spider venom molecule protected neurons from induced strokes. The compound works by blocking what are called ion channels in cells, specifically those that respond to the onset of acidic conditions in the brain.

Reporting in the journal, Proceedings of the National Academy of Sciences, King describes how administering Hi1a two hours after stroke reduced the extent of brain damage in rats by 80%. But the compound was still effective eight hours after stroke, reducing the amount of brain damage by about 65% when compared with untreated animals.

Rats that had the compound recovered far better than those that went without. “The untreated rats performed very badly after stroke. Their neurological and motor performance were terrible,” said King. But treatment with Hi1a “almost restored these functions to normal,” he added.

The researchers hope to start human trials of the compound in the next two years, but have more experiments to perform first. These will test whether the molecule works in all cases of stroke and is safe to use when blood vessels rupture in the brain, rather than become blocked. In the latest study, the compound was infused directly into the brain, but the scientists have found since that nasal deliver works too.

If trials show that the compound works, it could potentially transform the treatment of stroke patients. There are no drugs on the market that can protect the brain from stroke injuries. The best hospitals can offer are infusions of clot-busting drugs if a clot is to blame, or a surgical procedure called endovascular thrombectomy, which physically pulls the clot from the brain

Before doctors can administer clot-busting drugs, they must confirm with a brain scan that the stroke was caused by a blockage. This is because the treatment thins the blood and could make matters worse if the stroke was caused by a haemorrhage.

If Hi1a is found to be safe for people who have had with brain bleeds, it could be given to patients as soon as they reach a doctor. 

“The drug could be given in the ambulance to most stroke patients before hospital arrival, maximising the number of neurons that can be saved,” said King. “This should diminish the mortality from stroke and provide much better outcomes for those that survive as more brain function will be retained.”
Kate Holmes at the Stroke Association, said it was unknown whether Hi1a could be an effective treatment in humans. “We welcome any treatment that has the potential to reduce the damage caused by stroke, particularly if this can benefit people who are unable to arrive at hospital quickly,” she added. “Current treatments must be given in half this time period and it is too early for us to know if this research can offer an alternative for stroke patients. 

“We urge for stroke to be treated as an emergency. The sooner a person can get to hospital after a stroke, the sooner the right treatment can be received which can improve survival and help recovery,” she said.

Source:     The Guardian

Monday, March 20, 2017

Diagramatic Representation Of Bacterial Infections

Tuesday, March 7, 2017

If You Are Really Sick, Would You Really Tell?

Last year, my mother, a few weeks before a milestone birthday, learned she needed major surgery. The circumstances were not life-threatening. She would not be in the hospital long. But the recovery would still be protracted and restrict her ability to care for my father, who has Parkinson’s.

No worries. Her three grown children, all of whom live in distant cities, snapped into action. We would fly in for the surgery, call in extra help, telephone a few of her friends and ask them to check in, drop off some food, otherwise be on call.

We congratulated ourselves for a well-designed plan. There was only one problem.
My mother insisted we not tell a soul.

“I don’t want to inconvenience my friends,” she said. “Also, I don’t want people to feel sorry for me, and I absolutely don’t want to listen to all their medical stories. It’s just so wearying.”

How people decide whether to go public with their medical conditions has long been highly sensitive and deeply personal.

Certain situations, like broken limbs and cancers that require chemotherapy, are virtually impossible to keep secret.

Others, like H.I.V. and mental illness, are easier to keep under wraps, at least for a time. Older people, in my experience, lean more toward secrecy; younger toward disclosure.
These days, all of the old rules have been thrown out. With more and more people used to sharing even the most minute details of their daily lives on social media, centuries of customs have been upended.

If you post photos of yourself emptying your cat litter, filing your taxes or getting your cavity filled, you can’t as easily come out later and say, “Oh, I’ve had muscular dystrophy all these years and didn’t want to tell you.”

Or can you?

My father kept his Parkinson’s quiet from even close friends for nearly a decade. “I was in business,” he said. “I was building things and borrowing money. I didn’t want to be considered a risk.” (Both of them approved my writing this here.)

So in our time of radical disclosure, how should patients evaluate the risks and benefits of sharing medical information?

You might save your life. 
Paul Wicks is a neuroscientist and A.L.S. specialist who now serves as a vice president of the online support network Patients Like Me. His research shows that patients are most open with their family and current friends, least open with neighbors and childhood friends. Work colleagues rank in the middle. Multiple sclerosis, A.L.S. and epilepsy rank highest on conditions people disclose; fibromyalgia, mood disorders and H.I.V. rank lowest.

“With something like H.I.V., there are very clear issues about cultural reactions and risk of infection,” he said. “But something like organ transplants are the opposite. If you need a kidney transplant, trust me, everyone will have to know. Finding a match is nearly impossible.”

With these qualifications, Dr. Wicks comes down strongly in favor of disclosure. His reason: You never know where you can learn something that might save your life.

“As a doctor, I used to give patients nuggets of wisdom,” he said, adding, “But I can’t meet every patient.”

When patients seek out others with similar illnesses, their knowledge grows exponentially. “It’s more scalable, less serendipitous,” he said.

Even my mother, when she broke down and divulged her operation to a friend, who happened to have the same condition, radically changed her course of treatment.

Dr. Wicks’s research shows that patients who participate in peer groups have learned tips about drug sequencing or little-known specialists that proved critical to their care.

“The value of a tweet-length piece of information can be the difference between life and death,” he said.

Keep calm and lurk. 
Stefania Vicaria is a sociologist at the University of Leicester in Britain who has studied the effect of social media on medicine.
A primary thing people gain from going public is a sense of comfort in connecting with others, she told me.

“The first thing people get on social media is emotional support,” she said. “But it quickly shifts to medical information as the patients go onto specialized websites and become more expert in treatments, scientific trials and so on.”

Most people are comfortable sharing their names in disease-specific forums, she said, even if those forums are on Facebook, where membership in such a group can be visible to their friends. The information in these discussions is so valuable that if you still prefer anonymity, you should join under a pseudonym.

Dr. Wicks called this lurking. “The ratio of people who contribute to Wikipedia versus people who use Wikipedia is quite tiny,” he said. “You can just lurk in these forums and still get much of the benefit.”

Tweet defensively. For those who choose to share their conditions with their wider social networks, there is reason to be cautious. Heidi Adams is a pediatric cancer survivor who has devoted her career to helping young adults with cancer. Now the chief patient advocate at Rx4good, Ms. Adams said that while it was harder for older people to share information about their medical conditions, it was harder for young people to keep quiet.

“If anything, young people are likely to overshare,” she said.

“You’ve been living your life in public all these years, and suddenly you have this thing you may not want to talk about.

Yet posting about that scoop of ice cream you just had feels dumb. There’s a lot of pressure.”

Ms. Adams recommends beginning conservatively, restricting the most intimate information to the most limited outlets, like a blog or a CaringBridge site, whose privacy settings can be changed later.

“Once you put things on Facebook or Twitter, it’s out there forever,” she said. “You may want to share things now, but sometime down the road, are you going to want those pictures of you with your scars in public?”

In her case, she wanted those things out there at the time of her treatment, she said, but as she moves further away from it, she has changed her mind.

Control your surrogates. 
When I got a cancer diagnosis nine years ago, I made a critical misstep in disclosure in my early days. I told everyone the date of my biopsy. That meant when that day came, I got way more calls than I could handle.
From that day forward, I appointed a chief information officer — in my case, my brother — whose job it was to keep everyone informed.

While designating such a figure can be helpful, Ms. Adams said, today it’s not sufficient. Patients have to set clear parameters about what that person is allowed to say, share or post in public.

“I don’t think you should have any hesitation in telling that person: ‘Hey, can you please take that photo down? I’m not ready to go public about that aspect of my condition.’” Her one firm rule: “Don’t let people post pictures of you in the operating room.”

Victim no more. 
The most surprising thing I learned about this issue is that going public has one unexpected side effect: It gives patients a sense of control over their lives at a time of often intense helplessness.

“When you open up about your condition, you don’t just receive information,” Dr. Wicks said, “you also start sharing your own information with others. You get to be the helper sometimes, and helping people makes you feel really good.”`

Ultimately, what I had thought of as a black-and-white decision — tell or don’t tell — is now much more nuanced: tell or don’t tell; tell, but not too much; or don’t tell but stalk the web for tips among people who do tell. In other words, the best professional advice on this issue is almost exactly the same as the best professional advice on other medical matters:

Whatever you do, do it in moderation.

Source:     NYTimes

Sunday, March 5, 2017

Unbelievable!!!! Sickle Cell Disease REVERSED!!!!

A French teenager's sickle cell disease has been reversed using a pioneering treatment to change his DNA.
The world-first procedure at Necker Children's Hospital in Paris offers hope to millions of people with the blood disorder.
Scientists altered the genetic instructions in his bone marrow so it made healthy red blood cells.
So far, the therapy has worked for 15 months and the child is no longer on any medication.
Sickle cell disease causes normally round red blood cells, which carry oxygen around the body, to become shaped like a sickle.
These deformed cells can lock together to block the flow of blood around the body. This can cause intense pain, organ damage and can be fatal.
The teenager who received the treatment had so much internal damage he needed to have his spleen removed and his hips replaced.
Every month he had to go into hospital to have a blood transfusion to dilute his defective blood.
But when he was 13, doctors at the Necker Children's Hospital in Paris did something unique.

'No sign of disease'

Doctors removed his bone marrow - the part of the body that makes blood. They then genetically altered it in a lab to compensate for the defect in his DNA that caused the disease.
Sickle cell is caused by a typo in the instructions for making the protein haemoglobin, which is densely packed into red blood cells.
A virus was used to infect the bone marrow with new, correct instructions.
The corrected bone marrow was then put back into the patient.
The results in the New England Journal of Medicine showed the teenager has been making normal blood since the procedure 15 months ago.
Philippe Leboulch, a professor of medicine at the University of Paris, told the BBC News website: "So far the patient has no sign of the disease, no pain, no hospitalisation. He no longer requires a transfusion so we are quite pleased with that.
"But of course we need to perform the same therapy in many patients to feel confident that it is robust enough to propose it as a mainstream therapy."

'Given his life back'

Prof Leboulch is nervous about using the word "cure" as this is just the first patient to come through clinical trials.
But the study does show the potential power of gene therapy to transform the lives of people with sickle cell.
"I think it's very significant, essential they've given him his life back," said Dr Deborah Gill from the gene medicine research group at the University of Oxford.
She told the BBC: "I've worked in gene therapy for a long time and we make small steps and know there's years more work.
"But here you have someone who has received gene therapy and has complete clinical remission - that's a huge step forward."
However, the expensive procedure can only be carried out in cutting-edge hospitals and laboratories, while most sickle cell patients are in Africa.
The next big challenge will be to transform this pioneering science into something that really can help millions of people.
Follow James on Twitter.

What is sickle cell disease?

  • Sickle cell disease is a lifelong condition caused by a faulty gene that affects how red blood cells develop
  • SCD mainly affects people of African, Caribbean, Middle Eastern, Eastern Mediterranean and Asian origin
  • People with sickle cell are often at an increased risk of contracting serious infections or they could become anaemic, which is when red blood cells cannot carry enough oxygen around the body. This can cause tiredness and shortness of breath
  • Some patients have regular blood transfusions - usually every three to four weeks - as a form of treatment for the condition
  •  Source:     BBC
Source: NHS Choices