Monday, August 28, 2006

Mood Shifters

Most people are aware that music evokes all sorts of emotions. Good, bad, happy, sad. The question that struck me recently while in a melancholy mood and listening to melancholy music was this: Even though my mood drew me to listen to soulful music to give myself a kind of emotional hug, would I be better served listening instead to more upbeat music? Can we use the power of music to actually change our mood? Could it be a form of medication? If I changed my tune on that melancholy day and put on happy, inspiring music instead, would my mood follow suit? "You can absolutely use music to affect someone's mood," says Elizabeth J. Miles, an ethnomusicologist who has been working with music and mood for a decade and has written extensively about the power of music to actually change states in our body and mind. "Psychologists have been using music as a therapeutic technique for more than 100 years." I asked her to explain what actually makes music "sound" happy in the first place.
"Music sounds happy and uplifting when there's a lively tempo and major key harmonies," she told me. "Upward leaps in the melody can help too, as in the 'power ballad.' Words help a lot as well. The music is thought to engage a place in your brain called the hypothalamus, which regulates hormones and is part of the limbic system, which is the brain's center of emotions. All sound, including music, is processed there and in the thalamus before it is processed by the cortex, the part of your brain that actually thinks." So that's the reason I get all mushy when I hear the song that reminds me of my high school prom? "Yes," Miles explained. "Reading, for example, goes directly to the cortex. But music comes through the ear and must pass through the 'feeling center' first on its way to being processed. That's why music can evoke such emotion."
Miles suggested some ways music could be used to attempt to change one's mood. The first is a mood treatment called vectoring -- also known as the iso principle. "Vectoring -- the iso principle -- starts with where you are now," Miles explained. "For example, if you're feeling really down and someone puts on a high-intensity 'up' anthem, it might turn you off. So instead, you start with music that's closer to the mood you're in right now, or maybe one that's just a tad 'happier.' For example: Jack Johnson's song "Upside Down" from Curious George. Then, with each successive song you put on, you notch it up one rung on the emotional ladder. Just keep turning it up -- making the music a little happier, a little faster, a little more upbeat." This technique is an application of a behavior modification technique called chaining.
Miles suggested the following as a sample of an "iso" or "vector" sequence to "ramp up gradually when you're feeling down"...
1) Jewel, "Hands" or Jack Johnson, "Upside Down" 2) The Staple Singers, "I'll Take You There" 3) U2, "Beautiful Day"
What happens when you don't have time for all that music? Let's say you're in the office, and feeling just a tad sad about something or maybe you're short on energy, and need to get up to "workplace speed" quickly. Miles' suggestions for a quick mood elevator -- Beethoven's "Symphony No. 9" (Finale: "Ode to Joy") or Otis Redding's "Try a Little Tenderness." "You can also try show tunes, or any song that takes you back to a good place," she said. Miles suggested anything from the CD "Absolutely the Best of the 70's." "But don't just listen -- sing along! Or better yet, dance, assuming you have some privacy." If you don't have privacy, just tapping your toes can get your body changing. Any favorite psych-up song will do. "If you're not really down but just a little blasé and maybe have the 'afternoon slumps,' just take your happy song with you. One listen to Gloria Gaynor's song "I Will Survive" can turn a whole afternoon around."
But what about when you feel kind of sad and melancholy and actually want to stay there or need to stay there to work through some emotional pain? "Perfectly normal," said Miles. "Sure it's a kind of wallowing. But it can be very cathartic -- you're expelling negative feelings out of your body." She explained that "cleansing music" can fall into two categories -- one is the kind of "sad" melancholy music I tend to listen to when feeling sorry for myself and the other is loud, angry, music with lots of buzzing and distortions. "Teenagers listen to a lot of that kind of music," Miles explained, "because their hormones are raging and they've got a bunch of feelings they have to get out." Miles suggested that this kind of "cleansing" or cathartic music might be a great option for women who tend to feel pain and hurt in a different way than men. When feeling hurt, women could react well to a quick break of cleansing music. Her choices?
1) Anything by Metallica or Megadeth (the heavy metal bands) or Public Enemy (rap) or 2) "Mars" from "The Planets" by Gustav Holst
Note: Since I know many readers are not familiar with Metallica or Megadeth, I asked Miles about other options. Alternative: Classical music by the late Sergei Rachmaninoff, a Russian composer, pianist and conductor. "If you're cleansing with that kind of music, you should limit it to just one or two songs," Miles told me. "Then 'reset' yourself afterward by listening to something relaxing. It's like taking a warm bath after a hard run on the treadmill." She also suggested that for maximum results you get physically involved in the music by drumming along on the table. And if you don't want to "cleanse" but prefer to wallow? "Make a deal with yourself," she suggested. "You get two sad songs -- you get to cry it out -- and then you start the vectoring technique to return to happiness." "Remember," she told me, "one of the absolute best things about music as a mood manager is that you can do it anywhere."

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Sunday, August 27, 2006

Health Food Or Sweet Dessert?

Theoretically, yogurt is a health food. The key word: theoretically.Many people first heard about yogurt when stories of robust, rugged centenarians living high up in the mountains of Bulgaria attributed their longevity to their yogurt-heavy diet. Yogurt started showing up in grocery stores in the US and soon became a dietary staple of the health-conscious crowd. The problem is that most commercially available yogurts today contain more sugar than live bacterial cultures. And there's the dairy debate. Is this the same food that the rugged mountaineers were eating?
To get to the bottom of the yogurt debate, I talked to naturopathic physician Sonja Pettersen. She explained that the health effects of yogurt are completely dependent on the presence of live bacteria. "Why did those people in Bulgaria have such great longevity?" she asked rhetorically. "Why didn't they have degenerative diseases? It turns out that the yogurt they were eating was very rich in a particular bacteria called Lactobacillus bulgaricus. And L. bulgaricus has antiviral, antibacterial and antifungal properties as well as many other health benefits." Bulgaricus is a species of the genus of bacteria called Lactobacillus, which in turn is part of a larger group known as probiotics. "Your gut is populated by a huge number of microbes," Dr. Pettersen explained, "some of them are "good" -- such as Lactobacillus acidophilus, L. bulgaricus, L. bifodobacteria -- and some of them not so good -- such as Staphylococcus aureus. We all have both good and bad bacteria in our gut, but it's a turf issue. You need to keep the good ones in the majority and the bad ones at a minimum. The live cultures in real yogurt help do that and provide many health benefits." Dr. Pettersen believes everyone should supplement with probiotics -- the good bacteria that live in the gut -- unless they're eating plenty of "real" yogurt with live cultures. "By maintaining good gut flora, you'll prevent all kinds of different diseases," she told me. "Especially chronic degenerative diseases." Why? Because the end result of a more balanced gut flora is decreased inflammation, which is a central feature of so many degenerative diseases including heart disease. Probiotics -- like the bulgaris found in the yogurt in Bulgaria -- help increase natural killer cells (a powerful immune system weapon). They increase antibodies when we have infections and have actual antibiotic properties of their own. They improve digestion. They have anticancer properties. And if this weren't enough, they can increase good cholesterol while decreasing the bad kind. Probiotics also may have a positive effect on blood sugar. An article in the August 2005 Journal of the American College of Nutrition reported that daily ingestion of tablets containing powdered -- in other words, yogurt -- fermented milk (yogurt) with Lactobacillus reduced elevated blood pressure in mildly hypertensive patients without any adverse side effects.
Originally, yogurt was milk that was left out to sour. Real yogurt is a fermented food, allowed to develop its own bacteria just like sauerkraut or any other fermented food. The National Yogurt Association (NYA) has developed a "Live and Active Cultures" (LAC) seal for the yogurt label to identify yogurt that contains significant levels of live and active cultures. Don't be fooled by the words "made with active cultures." All yogurts are made with live cultures, but no live cultures survive heattreatment. "The product has to actually contain live cultures at the time of consumption," Dr. Pettersen said. Some yogurt products may have live cultures but not carry the LAC seal. To determine whether the yogurt you buy contains living bacteria check the labels for the words "contains active yogurt cultures," or "living yogurt cultures". Three brands that contain live cultures are Stonyfield Farm, Dannon (plain) and Nancy's (
The NYA has been urging the FDA not to allow products that do not contain live and active cultures to be called "yogurt". The LAC label assures consumers that the healthful properties of the organisms are present at the time they eat the yogurt, not just at the time of manufacturing. PLAIN IS BEST
The best nutritional deal is plain yogurt, which has only two ingredients -- live cultures and milk (whole milk, low-fat or skim). In some highly sweetened containers of yogurt, you're getting more calories in the sweetener than you are in the yogurt. Be sure to read the protein and sugar values on the nutrition panel. The higher the protein and the lower the sugar content, the more nutritional value you will get from it.
For people who avoid cow's milk, there are also goat's milk yogurt and soy yogurt options. Goat's milk yogurt tends to be less allergenic than cow's milk yogurt. You still need to check for the live cultures in the product ,however. Soy and goat's milk yogurt are generally available at health-food and whole foods markets. What about the commercial kind of yogurt we see commonly on supermarket shelves? The kind with the fruit on the bottom that tastes so delicious? "A sweet treat masquerading as something healthy," Dr. Pettersen told me. As for frozen yogurt, "It's delicious, but it has absolutely no relation to yogurt's health benefits."

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Friday, August 25, 2006

Living Donors Help Diabetics

If at first you don't succeed, try, try again. Such is the lesson learned from a recent experimental surgery in Japan in which doctors implanted pancreatic cells from a living donor into a woman with severe diabetes. Results so far are encouraging -- the woman with diabetes is no longer insulin-dependent. According to David Sutherland, MD, PhD, head, transplant division, and director, Diabetes Institute for Immunology and Transplantation at the University of Minnesota Medical Center, a similar surgery was tried in the 1970s at the University of Minnesota Medical Center, though with unsuccessful results. The recent attempt by Japanese doctors is very encouraging for the possibility of using living donor pancreas tissue donations to aid cases of severe diabetes. To date, most pancreas replacement surgery has involved taking the pancreas from a cadaver, but results have been poor. With live tissue donation, there is a greater chance of not being rejected and of the tissue proliferating.
The pancreas uses groups of pancreatic cells called islets of Langerhans in combination with digestive enzymes to produce insulin. Dr. Sutherland describes the islets as being like BBs scattered throughout the pancreas. However, because the pancreas is made up of two separate parts, each with its own blood supply, it is possible to transplant tissue from a living donor, much as doctors now do routinely with kidneys. Pancreas transplants from living donors sounds like the future, and perhaps it will be, says Dr. Sutherland. People can survive with half a pancreas (or for that matter, no pancreas at all -- though they become instantly diabetic and must take digestive enzymes as well as insulin for life). However, even with the less-invasive islet surgery, the donor requires careful and extensive immunosuppressive medications.
The Japanese team removed half the pancreas of a woman, harvested the islet cells and transplanted them to the woman's 27-year-old daughter, who was suffering severe attacks of hypoglycemia. (Most diabetics are able to anticipate and prevent such extreme blood sugar drops, but some are not and they often pass out as a consequence.) The newsworthy aspect is that now, almost a year later, the donor is doing well and her diabetic daughter remains insulin-independent. Part of this latest success may be the fact that the closer the donor and recipient are genetically, the greater the chances of success. Dr. Sutherland says he salutes this effort for its success. Even so, most transplant patients who received their pancreas from a cadaver eventually reject it five or more years later. Transplant surgery is not useful for pancreatic cancer because the cancer is virtually never detected until it has already metastasized. However, for people with diabetes or whose pancreas has been removed because of severe pancreatitis, Dr. Sutherland says doctors hope that someday beta cell islet transplantation from living donors will be routine. In this country, the procedure is still considered investigational and needs approval from the Institutional Review Board and the FDA before doctors can move forward with it. We'll keep watching.

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Monday, August 21, 2006

New, Safer prostate Treatment

Men with a diagnosis of prostate cancer are often frustrated by an array of unsatisfactory treatment options that may leave them either impotent or incontinent. Now, a less-known treatment is offering many men with prostate cancer an alternative therapy that destroys the tumor but not the prostate -- and so for many patients this means a future free of impotence or incontinence. The technique is called cryoablation, a sort of male lumpectomy that removes the tumor, leaving the prostate gland and its normal functioning in place.
The pioneer of this technique is radiologist Gary Onik, MD, director of the Florida Hospital/Celebration Health's prostate cancer research program. He performed his first prostate cancer cryoablation surgery about 15 years ago, but it has been only in the last year or so that the technique has been receiving national attention, through journal articles and meeting presentations. The technique uses an exceedingly cold gas to freeze a portion of the prostate and some surrounding tissue, including one of the prostate nerves, to destroy the targeted tissue. In an ongoing study of 60 cryoablation patients, one year later 95% had stable prostate specific antigen tests and no evidence of cancer... 78% remained potent... and none reported incontinence. I spoke with Dr. Onik about this surgery and what it offers prostate cancer patients.
According to Dr. Onik, 75% of all patients are candidates for this type of surgery. The key is that the cancer be mostly contained in one-half the gland. It is available to men with a single cancer but also those who have a "single index" cancer, a small tumor elsewhere in the prostate in addition to the primary one. If the smaller tumor eventually gains in size, Dr. Onik explains that the patient can have a later cryoablation to treat it as well. Even an advanced cancer can respond to cryosurgery, he says, so long as it has not spread beyond the prostate gland. Doctors can tailor the procedure to destroy as much or little tissue as the patient needs. Patients also can have this surgery after radiation if radiation has failed. Dr. Onik says that cryoablation surgery is now starting to be available in other areas around the country. For anyone with a diagnosis of prostate cancer, he advises getting a thorough understanding of the extent of the disease and then looking at all the options, including, of course, cryoablation surgery. If cryoablation is the right course, find a doctor/hospital that is experienced with this procedure. While use of it is expanding, you still want to go where they have the most experience.

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More Coffee... Less Diabetes

Good news for coffee lovers comes from researchers at the Harvard School of Public Health. They found that people who drink coffee on a regular basis experience a substantially lower risk for type 2 diabetes. These findings appeared in an issue of the Journal of the American Medical Association (JAMA).
In a retrospective review of nine studies of coffee consumption and type 2 diabetes risk, Harvard researcher Rob M. van Dam, PhD, and his colleagues looked at 193,473 regular coffee drinkers who experienced 8,394 cases of type 2 diabetes. They excluded from consideration studies that involved type 1 diabetes, animals or short-term exposure to coffee or caffeine. Next, researchers calculated the relative risk of type 2 diabetes in relation to how many daily cups of coffee the participants consumed.
It turned out that the more coffee, the better...
The incidence of diabetes was lowest -- 0.65 (or between six and seven in 10) -- for people who consumed the most coffee each day (six or more cups).
Those who drank four to six cups daily faced a slightly more than seven in 10 (0.72) incidence.
People who drank the least coffee (which was no consumption in US studies, and two or fewer daily cups for Europeans) had a relative risk of 0.94 -- or very little risk reduction.
These numbers did not differ significantly according to sex, obesity or geographic region (which in this case meant the US and Europe). However, Dr. van Dam adds that the results were rather diverse in the lowest consumption category. He would not be surprised if future studies that are able to measure coffee consumption more precisely find a lower diabetes incidence for any amount of coffee.
These current findings serve to underscore the results of an earlier HSPH study in 2004, in which men who drank more than six cups of coffee a day reduced their risk of type 2 diabetes by more than 50% in comparison with men who did not drink coffee... and women by 30% in comparison with women who were not coffee drinkers. This beneficial effect was observed independent of lifestyle choices such as smoking, exercise and obesity. Scientists don't know exactly how coffee cuts diabetes risk. Paradoxically, caffeine reduces insulin sensitivity and raises blood sugar -- both no-nos for diabetes. However, Dr. van Dam emphasizes that coffee is a complex beverage that contains numerous chemical compounds and minerals, which may have both helpful and harmful impacts on the body. Components other than caffeine -- such as the antioxidants chlorogenic acid and magnesium -- actually improve sensitivity to insulin and thus help lower diabetes risk. In animal studies, trigonelline and lignans improved glucose levels. Dr. van Dam adds that additional studies on effects of coffee components in humans are clearly needed.
For those of us who prefer decaf, coffee still packs some protection against type 2 diabetes. Although the effect appears to be more modest, some of this discrepancy may be attributed to study limitations. Decaffeinated coffee consumption was substantially lower than caffeinated coffee consumption, and this may have affected the estimates, explains Dr. van Dam. He points out that it is easier to detect larger contrasts in consumption than smaller differences. In addition, one can expect some misclassification when you ask for the amount of coffee people consume (change over time, differences in strength and cup size, etc.). Dr. van Dam notes that in a recently published study on coffee consumption and C-peptide concentrations (a marker for insulin resistance), the association was actually similar for decaffeinated and caffeinated coffee consumption (June 2005, Diabetes Care). He adds that it is currently unclear whether caffeine has detrimental effects on insulin sensitivity over the long term, because only short-term studies have been conducted. Nor is it clear if non-coffee sources of caffeine would have similar effects.
Other trials have already lined up in coffee's favor, demonstrating that it can lower the risk of liver problems, gallstones, colon cancer and Parkinson's disease. Of course, there's also a downside to coffee (which pregnant women, children and people with colitis, hepatitis and other dietary challenges should not drink), such as jitteriness, insomnia and a rapid heartbeat. (Coffee stimulates liver function, which in healthy people is fine in moderation, but those with active liver disease may have symptoms worsen when they consume coffee.) Promising as it seems, Dr. van Dam and his colleagues do not go so far as to recommend drinking coffee to prevent type 2 diabetes. They emphasize that while coffee consumption may provide greater control over diabetes and possibly reduce the need for pharmaceuticals, it cannot replace the myriad health benefits of diet, exercise and weight management. Many people stop drinking coffee because they think this is good for their health. Now coffee drinkers can take comfort in knowing that their daily jolt of java not only gets them up and moving, it also provides a definite health benefit.

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Sunday, August 20, 2006

Silent Sight Stealer

At this moment, experts estimate that several million Americans are on the road to blindness and don't know it. The disease that wreaks this visual havoc is glaucoma and it has no symptoms -- at first. Eventually, patients begin to lose peripheral vision, but by this time, damage is already considerable and permanent. Everyone over age 40 needs to be aware of the disease to prevent suffering needless loss of sight. How can you reduce your risk? Ophthalmologist Gregory K. Harmon, MD, is director of glaucoma services at the New York Presbyterian Hospital-Weill Cornell Medical Center and coauthor of What Your Doctor May Not Tell You about Glaucoma -- The Essential Treatments and Advances That Could Save Your Sight (Warner Books). I spoke with him about the latest findings regarding glaucoma. Dr. Harmon told us that the condition isn't a single disease, but rather several different ones that have a common denominator -- they damage the optic nerve (a bundle of fibers in the back of the eye). By far the most common type of glaucoma in the western world -- and the focus of our discussion -- is one called open-angle glaucoma with its slow, early asymptomatic progression. (The other principal type is narrow-angle glaucoma -- which is most likely to affect Asians and has an acute, dramatic onset.) African Americans are much more prone to glaucoma than are whites -- their risk of it is four to six times higher, says Dr. Harmon. And, it appears that Hispanics probably have the same vulnerability as African Americans.
Until recently, doctors believed that the common factor for all conditions leading to glaucoma was pressure from a build-up of fluid in the eyeball. They have now discovered that people with a normal pressure reading can still have the disease -- a condition called "normal-tension glaucoma." This makes the old-fashioned eye pressure test, routinely administered to patients after age 40, insufficient for diagnosis. Rather, the best way to diagnose glaucoma is to have an optometrist measure eye pressure (tonometry) and examine the optic nerve to see if there is nerve damage.
The most important risk factor for glaucoma is pressure in the eye, says Dr. Harmon. However, you can have elevated eye pressure and not have glaucoma (a condition called ocular hypertension.) Other risks include...
Being 45 or older (although even babies can have the disease).
Having a family history of the disease.
Being substantially nearsighted -- farsighted folks are more vulnerable to narrow-angle glaucoma.
Having high or low blood pressure.
Having experienced trauma to the eye.
Use of corticosteroids, such as prednisone, whether taken internally, inhaled or used topically in the eyes.
A note about steroid use: The degree of risk concerning steroid use has to do with the strength of the medication and duration of use. Dr. Harmon says that, generally, if steroids were going to increase eye pressure, it would show up right away. Contributing editor Andrew L. Rubman, ND, reminds people that long-term use of steroids can also sometimes increase risk of glaucoma.
Doctors also evaluate the thickness of the cornea in glaucoma exams because people with thin central corneas are at much greater risk than others.
The goal of treatment is to reduce eye pressure, including in those patients with normal pressure glaucoma. Even in people with normal pressure, reducing it further prevents disease progression just as it does for patients with elevated pressure. Eye drops -- either to reduce the fluid in the eyeball or improve the efficiency of its drainage -- are the first line of treatment. The side effects of the most commonly used drops are few -- lashes get longer and thicker and blue-green eyes may turn brown -- and patients generally use drops for life. However, drops are not effective enough for everyone, in which case the next step is laser surgery. There is a new laser, Dr. Harmon explains, that creates a small amount of inflammation within the eye's drainage system. This, in turn, causes macrophages to come into the eye's drain and chomp up the debris inside the drain, a sort of Liquid Plumber effect, and leave it flowing more smoothly. There doesn't appear to be a downside to this surgery, and it can be performed multiple times without any known harm as of now. Patients generally continue using drops after laser, and the surgery allows much better success for the drops. When all else fails, the last measure is to have traditional surgery that creates a new drain. Whatever the treatment, all patients require regular monitoring to be sure the glaucoma doesn't begin to progress once again. Should that happen, more aggressive treatment is called for (or in the case of post-surgery patients, a return to drops).
Traditional medicine can not prevent glaucoma, says Dr. Harmon, but there are definitely ways to lower your risk of vision loss. He says that the healthier you are, the better your chances of avoiding it. In particular, he recommends regular aerobic exercise -- studies have shown it lowers eye pressure -- and eating foods that contain lots of antioxidants, such as green leafy vegetables and brightly colored fruits. It is critical to be checked annually. Glaucoma screening can be done by either an optometrist or an ophthalmologist. Should an optometrist find a problem, the patient is referred to the ophthalmologist for medical treatment.

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Friday, August 18, 2006

New Drug-Free Depression Treatments

More than 14 million adult Americans experience a depressive disorder every year. This doesn't describe just feeling "down" -- the problem affects many aspects of a person's life, including sleep and eating patterns, and manifests itself in feelings of worthlessness and despair and an inability to focus or believe life will get better. However, most people go on to recover within 10 months, says psychiatrist John O'Reardon, MD, assistant professor of psychiatry at the University of Pennsylvania School of Medicine in Philadelphia. There is a substantial subgroup of depressed people, more than 25% of patients, according to Dr. O'Reardon, who are "treatment resistant." For this group, standard treatment of talk therapy and/or medication, sometimes even after many years, proves to be of no help or of short-term help only. Now the FDA has approved a new device that may turn at least some of these people around, helping them to become depression-free at last. The device is called the vagus nerve stimulator (VNS), which Dr. O'Reardon told me is a sort of pacemaker for the brain. The VNS was originally developed for epilepsy patients some 15 years ago, but when doctors observed the improved moods of these patients, they began to investigate its applicability to severe depression.
Doctors surgically implant the one-ounce programmable device into the left chest wall, positioned to deliver electrical signals to the left vagus nerve, which is located in the neck along the side of the esophagus. A psychiatrist programs the device for appropriate pulse-generated stimulation of the nerve. It is actually on only about 10% of the time, but the VNS has been of significant benefit for many treatment-resistant patients. Albeit potentially skewed, data from the manufacturer (Cyberonics, Inc.) showed that 18% of VNS patients became depression free... 35% had reduced symptoms... and 57% had some benefit. Although the results sound good, they are not an overnight fix. Results can take as long as one year to be fully realized. On the upside: Side effects are generally minimal, with hoarseness or scratchy throat being the most common.
Dr. O'Reardon reports that he and others are currently conducting clinical trials on yet another mechanical device for depression that is already in use in Canada. Called the transcranial magnetic stimulator (TMS), this is basically a magnet that a doctor puts on the patient's scalp to stimulate appropriate areas of the brain. Depression mainly affects two parts of the brain -- the prefrontal cortex, which is involved in concentration and drive, and the limbic system, which regulates mood and emotion. Depression causes the prefrontal cortex to shut down and the limbic system, which controls anxiety and hypersensitivity to stress, to become overactive. TMS allows doctors to activate the prefrontal cortex and slow down the limbic system, thereby creating balance that had been lost. In 20-minute sessions, TMS sends out pulses for 10 seconds every minute. Patients need 15 to 20 sessions over three to four weeks to start getting results, and there are virtually no side effects. Patients may need several sessions per month as maintenance, although there are no studies yet to establish this. Dr. O'Reardon reports that TMS may get approval for use in this country in another year. Dr. O'Reardon explains that the idea behind all treatment, including psychotherapy and medication, is to reactivate and balance these neurological systems. For patients whose depression is deeply entrenched, however, a mechanical device such as the VNS or TMS may be the answer because they directly affect the brain and are generally quite low in side effects.

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Wednesday, August 16, 2006

Anesthesia Alert

Every day, patients hear physicians speak the following words -- "It's a simple procedure that we can do right here in the office." The number of office-based surgical procedures has increased by an estimated 93% since 1996. Approximately 25% of all surgeries occur in doctors' offices, and that number is expected to rise to 35% within the next few years. At first glance, that doesn't really seem like a bad thing since, for most patients, an in-office procedure is convenient, less threatening and, in general, faster than the same procedure done at a surgical center or hospital... but it's also riskier. A study published in Archives of Surgery compared surgeries conducted at ambulatory surgical centers in Florida with those done in doctors' offices, and found a tenfold increased risk for adverse incidents and death in the office setting. According to Frederick Ernst, MD, coauthor of Now They Lay Me Down to Sleep... What You Don't Know About Anesthesia and Surgery May Harm You, many of the complications and deaths are tied to the anesthesia used in office settings. "The complications occur primarily because the people who give sedation are not trained and certified in anesthesia delivery," he says. "We've had reports that office managers and secretaries are administering intravenous (IV) sedation while the surgeon does the procedure and tries to monitor the patient at the same time. That is absolutely ludicrous."
These days, most in-office IV sedation involves the use of the drug propofol (Diprivan) because it acts quickly and patients can recover from it quickly. But it can be unpredictable -- in some cases, propofol-anesthetized patients even stop breathing. Because of that unpredictability, the US Food and Drug Administration (FDA) says that propofol should be "administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure." Unfortunately, that doesn't always happen, either because the surgeon feels that an anesthesiologist isn't warranted or because he/she plans to use the anesthesia at a lower dose for conscious sedation -- meaning that the patient retains his/her swallowing reflex and can respond to verbal commands. (Many states do not require that an anesthesiologist be present for conscious sedation.) The problem, according to Dr. Ernst, is that there is essentially no such thing as conscious sedation using propofol. "A lot of these guys will tell you, 'Oh, we're just going to give you a little bit,'" Ernst says. "But that's a crock. It is unconscious sedation, period." Among other potential complications, such as respiratory and cardiac arrest, when unconscious sedation is used with any drug there is a loss of the protective swallowing reflex, so anything that comes up from the stomach can cause an airway obstruction or make its way into the lungs, causing aspiration pneumonia. So what's driving the decisions? The answer is simple: cost. "Insurance companies love office-based procedures because the facility fee for office surgery is less than that for a surgery center, which still is less than that for a hospital," says Dr. Ernst. "Surgeons love it because, if they do the surgery in their offices, they get the professional fee, the facility fee and a fee for the anesthesia, so they're making money on three fronts instead of one."
The good news is that it's easy to protect yourself from unnecessary risks when it comes to anesthesia -- you just need to ask the right questions before you agree to a procedure and be prepared to take action if you don't get the answers you want. According to Dr. Ernst, there are four basic areas to cover before you agree to an in-office procedure that requires any type of sedation, including diagnostic procedures such as colonoscopy and endoscopy.
Ask about privileges. Your doctor should be approved to perform the procedure at a nearby hospital. Ask your doctor point-blank: "At what nearby hospital do you have privileges to do this procedure?" If he doesn't have an answer, don't do the procedure in his office.
Check for certification. Make sure that your surgeon is board certified, which means that he has passed a medical specialty examination. Also ask if the office is accredited, which means that a state or national agency regularly inspects the office to see that minimum standards of patient care are met.
Get an anesthesiologist. If there is going to be any kind of IV sedation, general anesthesia or major work such as an epidural, insist that a board-certified anesthesiologist or nurse anesthetist administers and monitors sedation.
Prepare for trouble. If the answers to all your other questions have been satisfactory, there's one more hurdle to cross. What happens if something goes wrong? "Make sure that there is a transfer agreement in place in that doctor's office," says Dr. Ernst, "so that if you get into any kind of trouble, there can be immediate admission to a nearby hospital -- and that hospital should be within 10 miles." That said, safer yet is to insist that a procedure that requires anesthesia of any kind be done in a hospital unless absolutely necessary.
Remember, no insurance company can force you to have surgery in a doctor's office instead of a hospital or surgical center. If you ask for an anesthesiologist, and the doctor says one isn't available -- push to have the surgery done at another location. Or push for another doctor. Don't stop pushing until you get what you want. "You may have to be really aggressive," explains Dr. Ernst. "And that goes for dealing with the insurance company, as well. Right now, an insurance company cannot force you to have surgery in a doctor's office. Be strong, stick to your guns. The insurance company will know that you know what you're talking about. After all, your life is on the line."

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