Tag: Health

General interest
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Fear (and the high cost) of falling

by Fran Johns

My husband was face down on the floor of the breakfast room, stretched below the table with one hand resting beside a chair he had pushed into the corner. As I came up from the garage, returning from a long opera just before midnight, he called out, hoping to spare me from alarm or a heart attack of my own. This is the sort of scene that tends to cause alarm at any age. According to an article in last Sunday’s New York Times, a similar scene occurs with alarming frequency: more than one-third of people ages 65 or older fall each year, writes Steve Lohr in an “Unboxed” feature, “Watch the Walk and Prevent a Fall.”

In our recent case, all was soon well. My husband had lost his balance while setting dinner on our not-too-sturdy table, and more or less slid to the floor. Still recovering from spinal fusion surgery 8 months earlier, he had done everything possible not to break anything — old bones or new rods and bolts that is; he wasn’t worried about the china — as he went down. But once down, getting back up was not an easy assingment. You know those awful “I’ve fallen, and I can’t get up” ads? Believe them. He tried shoving a chair into the corner to gain traction, but soon realized there was not enough strength in his lower legs to do the job, and decided just to wait. (Some people do carry cell phones… but that’s another story.) At 6’3″ and over 200 pounds, Bud outweighs me approximately two to one, so my getting him up was, we already knew, not an option. Happily we have a neighbor who seldom goes to bed early. Once he came over and the three of us strategized a while we were able to set my husband upright again. More specifically, John and Bud accomplished the deed; I supervised. Bud was tired and hungry, but otherwise fine.

Most of the falling elderly are not so lucky. About one fall in 10 results in serious injury such as a hip fracture, according to the Times story. Some 20 percent of older adult victims of hip fractures die within a year. If that weren’t enough to get one’s attention, reporter Lohr writes that “the estimated economic cost of falls ranges widely, up to $75 billion a year in the United States, if fall-related home care and assisted living costs are added to medical expenses.”

The last time I fractured my ankle, which I tend to do with dismaying frequency, I grumbled to a friend about “that dumb accident.” There are no smart accidents, she replied. (I was running late, and carrying a very large empty computer box down the stairs.) And this is a good thing to keep in mind. Somewhere not far past the age of 50 (I throw that in for all those weekend soccer-playing dads) bone breakage gets easier and healing begins to take longer. Somewhere a little farther along in the aging process, falling takes over from dumb accidents as #1 cause.

“Watch the Walk and Prevent a Fall” focuses on early research, backed by the National Institute on Aging, into the relationship between activity patterns and falls. “Fall prevention also promises to be part of an emerging — and potentially large — worldwide industry  of helping older people live independently in their homes longer,” Lohr writes. New technologies such as sensors that track behavioral and activity patterns will play growing roles in fall prevention, along with customized exercise programs and close attention to the role of medications.

Considering the risks and the cost, fall prevention may fast claim serious attention. But for now, especially if you’re over 65: get up slowly, watch your balance, and be careful setting your dinner plate down on a wobbly table.

General interest
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Doctors, lies and half-truths about dying

by Fran Johns

Is it painful? Will I be okay? Do I have any options? It’s hard to get answers to the first two of those questions about life’s end unless you know a really good psychic.  But as to the last one: Yes. The problem is, no one wants to talk about them.

When they do talk about them, medical professionals ignore reality, dismiss those with whom they disagree, and stop little short of outright dishonesty. For confirmation of this fact you are welcome to skip the next few paragraphs, which are included for the sake of trying to report facts while still a little angry.

A recent panel discussion at the Commonwealth Club of San Francisco was billed as a debate on the ethical issues of making end-of-life decisions. “A Good Death: Intersection of Policy and Practice” featured four experts in end-of-life policy and care. The focus was on palliative care, which has been the Big New Thing in medicine for the past decade or so. Palliative care — read: address the symptoms and keep the patient as pain-free as possible — has been around since about the beginning of time. Someone figured out, though, that if you gave it a fancy name and made it a medical specialty, which it now is, you could encourage doctors to concede that dying is part of the process and that dying patients might be better off, occasionally, if they were not treated to death. This was a step in the right direction.

The discussion, moderated by Steven Z. Pantilat MD, Professor of Clinical Medicine at the University of California San Francisco and Founding Director of the UCSF Palliative Care Program, addressed all of the proper, traditional issues: the importance of having advance directives, the need for open conversations with family and loved ones, the significance of cultural diversity around the end of life. The issues of hastened dying and physician aid-in-dying, of concern to many in the audience according to unscientific exit interviews conducted by several of us, were firmly brushed aside. A majority of Californians favor legalizing physician aid-in-dying and would want that palliative choice for themselves, but that’s what no one will talk about.

Panelists included Judy Citko, J.D., Executive Director, California Coalition for Compassionate Care , Sharon Fernekees-Jeans, Licensed Clinical Social Worker; Manager of Social Work Services and Spiritual Care, Eden Medical Center, Castro Valley, CA. and Kathe Kelly, R.N., B.S.N., O.C.N. City of Hope Nursing Research & Education, Duarte, CA.

“There really is no ‘good death’,” Pantilat said, likening life to a plane trip in which there is intense focus on the take-off (birth), followed by life experiences as the trip and concluding with attention needed for the landing at death. “The medical system wants to keep us aloft forever, with a bias toward prolonging life at all costs,” he said. Palliative care is in response to this philosoophy, which has led to “a source of suffering rather than the relief of suffering. In 2000, it was offered in one in five hospitals; now it is one in three.” Citko, explaining that “people are dying differently than in the past,” said that “today, most people have multiple chronic conditions.” Palliative care addresses this by allowing for curative treatment, as opposed to hospice care which requires forgoing curative treatment.

Panelists talked extensively about the need for advance directives and for conversations about medical treatments and end-of-life wishes.

Then came the audience questions. A number of sincerely posed questions (I read several of them) about aid-in-dying, or hastened dying for those who are near death and might wish to opt out of further suffering, brought this dismissal from Dr. Pantilat: “Regardless of what you say, if they have good care people don’t want that option.” This is simply not true. For 10 years the people of Oregon have shown that they want that option. In a poll taken when Californians were trying to pass a Death with Dignity law, despite well-funded opposition from the California Medical Association (to which a tiny percentage of physicians actually belong) and the Catholic Church, showed that a large majority of Californians want that option.

Citko, along those same lines, commented that there was “an undercover movement” afoot addressing aid in dying. I consider Citko a friend and I admire her expertise, but I had a Joe Wilson moment there. A long-time board member and committed volunteer with Compassion and Choices of N.CA, I am part of no undercover movement. Compassion and Choices is a widely respected nantional nonprofit, absolutely above ground and law-abiding. Among other things, we offer free consultation and support to dying individuals who want to know their options.

Recently I visited a comparatively healthy 93-year-old man who had called Compassion and Choices. He had had gall bladder surgery a few weeks earlier. “I will not go back to the hospital,” he said. “I’ve had a good life, and I want to have a good death.” I talked to him about his legal options should a life-threatening event recur. Shortly thereafter his daughter, a nurse who had met with us and taken notes, sent me an e-mail that sums up why we Compassion and Choices volunteers continue to work for this cause.

“You were like water for a thirsty man,” she wrote. I believe, despite Dr. Pantilat’s assertion that it does not exist, this man will have a good death. I wonder why so many people out there want to deny their fellow creatures such a small, humane thing.

General interest/Health
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Leaving Cancer Alone

by Fran Johns

We don’t talk a lot about not treating cancer. But as mentioned recently in this space, leaving it the heck alone is an option that merits consideration, particularly in the case of breast and prostate cancers detected very early on.  Now comes further news, reported by New York Times health writer Gina Kolata, of studies showing that some other cancers might also go away by themselves.

Call it the arrow of cancer. Like the arrow of time, it was supposed to point in one direction. Cancers grew and worsened.

But as a paper in The Journal of the American Medical Association noted last week, data from more than two decades of screening for breast and prostate cancer call that view into question. Besides finding tumors that would be lethal if left untreated, screening appears to be finding many small tumors that would not be a problem if they were left alone, undiscovered by screening. They were destined to stop growing on their own or shrink, or even, at least in the case of some breast cancers, disappear.

The Times article cites studies of testicular, cervical, kidney and other cancers that suggest some, left untreated, might simply go away; the trick now is to begin identifying which these would be.

I don’t know anyone who would opt out of treatment when it is likely to offer restored health. But especially for older populations, the choice of not treating a small cancer could be more frequently and seriously discussed.

Cancer cells and precancerous cells are so common that nearly everyone by middle age or old age is riddled with them, said Thea Tlsty, a professor of pathology at the University of California, San Francisco. That was discovered in autopsy studies of people who died of other causes, with no idea that they had cancer cells or precancerous cells. They did not have large tumors or symptoms of cancer. “The really interesting question,” Dr. Tlsty said, “is not so much why do we get cancer as why don’t we get cancer?”The earlier a cell is in its path toward an aggressive cancer, researchers say, the more likely it is to reverse course. So, for example, cells that are early precursors of cervical cancer are likely to revert. One study found that 60 percent of precancerous cervical cells, found with Pap tests, revert to normal within a year; 90 percent revert within three years.

And the dynamic process of cancer development appears to be the reason that screening for breast cancer or prostate cancer finds huge numbers of early cancers without a corresponding decline in late stage cancers.

If every one of those early cancers were destined to turn into an advanced cancer, then the total number of cancers should be the same after screening is introduced, but the increase in early cancers should be balanced by a decrease in advanced cancers.

That has not happened with screening for breast and prostate cancer. So the hypothesis is that many early cancers go nowhere. And, with breast cancer, there is indirect evidence that some actually disappear.

A sister who is six years older than I was diagnosed with breast cancer at 72, had a mastectomy and is cancer free. Six years later I was diagnosed with breast cancer, had a mastectomy and am cancer free. Last week I visited a college classmate who had been diagnosed two weeks ago with breast cancer; she had a mastectomy and is cancer free. Cancer free is good. But what if — just what if — one of those cancers might have disappeared without major surgery?

Disappearing tumors are well known in testicular cancer. Dr. Jonathan Epstein at Johns Hopkins says it does not happen often, but it happens.

It is harder to document disappearing prostate cancers; researchers say they doubt it happens. Instead, they say, it seems as if many cancers start to grow then stop or grow very slowly, as has been shown in studies like one now being done at Johns Hopkins. When men have small tumors with cells that do not look terribly deranged, doctors at Johns Hopkins offer them an option of “active surveillance.” They can forgo having their prostates removed or destroyed and be followed with biopsies. If their cancer progresses, they can then have their prostates removed.

Almost no one agrees to such a plan. “Most men want it out,” Dr. Epstein said. But, still, the researchers have found about 450 men in the past four or five years who chose active surveillance. By contrast, 1,000 a year have their prostates removed at Johns Hopkins. From following those men who chose not to be treated, the investigators discovered that only about 20 percent to 30 percent of those small tumors progressed. And many that did progress still did not look particularly dangerous, although once the cancers started to grow the men had their prostates removed.

In Canada, researchers are doing a similar study with small kidney cancers, among the few cancers that are reported to regress occasionally, even when far advanced.

One of the things we post-mastectomy women were talking about last week was how we might handle a recurrence. The reality is, as we have all already proved: you live long enough, you get stuff. Maybe someone at Johns Hopkins (or elsewhere; Kaiser San Francisco would suit me fine) will undertake a study in which older women with small breast cancers can opt for “active surveillance” rather than major surgery. Should I qualify, I would enroll. To this admittedly untrained and unscientific survivor it seems a study whose time has come.

Cancers Can Vanish Without Treatment, but How? – NYTimes.com.

Health/Politics & Causes
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How public is your option?

by Fran Johns

Not very, in all probability.

According to current reports, only those whose coverage exceeds 12.5 percent of their income, only the smallest businesses, or those who aren’t covered by Medicare or VA programs… a very few onlies will have access to the public option. Still, the public option is less important than the reform bill itself. We may have reached the point at which the perfect is indeed the enemy of the good.

Early on in this process my friend Catherine Dodd, whose extensive health policy credentials include stints on Nancy Pelosi’s staff and as a Regional Director for the Department of Health and Human Services, advised an audience inundated with numbers and percentages and data to remember just one figure: “Nineteen point seven,” she said. It has taken an average of 19.7 years after one health reform measure failed to raise the issue again.

Many of us do not have another 19.7 years to wait for the next battle.

General interest
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Who really needs H1N1 vaccine?

by Fran Johns

This new piece of the H1N1 puzzle – to vaccinate or not – does seem to be the first no-brainer we’ve been dealt, especially among all the full-brainer problems floating around with no apparent solutions. The whole business of whom to vaccinate, how to ration, whether to Be Very Afraid because the vaccine is dangerous and maybe the pandemic itself is a vast conspiracy, is becoming the stuff of legend as well as news. Also the stuff of comedy.

Unless, of course, you happen to catch the virus and turn out to be quite sick. A friend in Georgia had that experience and isn’t laughing. But she is the exception (58, otherwise healthy and unvaccinated) and recovered in less than two weeks.

Here’s what seems to be a good rule: if you’re over 65, maybe even over 55, just don’t get it. The vaccine, that is; try not to get H1N1 either; with reasonable precaution you probably won’t. If all of us in this category would quit obsessing and worrying and adopt this just-don’t-get-it policy, there will probably be quite enough to go around for those who do need it: children, pregnant women, people with cystic fibrosis, healthcare workers, etc.

The pandemic could be on its way out anyway. Although President Obama has declared H1N1 flu to be a national emergency (a good move, since it freed up hospitals to pitch triage tents in parking lots, etc, if necessary, and allows other emergency steps to be taken) some experts including Ira M. Longini Jr., an epidemiologist at the Fred Hutchinson Cancer Research Center in Seattle (quoted in the October 24 New York Times) believe the peak has about been reached. “Indeed,” writes Times reporter Donald G. McNeil, Jr. in that same news summary, “cases have already started to decline in the Southeastern states, where they spiked in August when schools opened.”

The best news of the pandemic is probably the fact that it has become fodder for stand-up comics and comedy shows. Once we start laughing at things they tend to whittle themselves down to sanity. My favorite message so far came from host Jon Stewart on the Daily Show, in response to some of the craziness coming from the likes of Sean Hannity and Glenn Beck. What we need, Daily suggested, is a vaccine against the vaccine, so we could have peace of mind while being vaccinated. Or while passing on the vaccine altogether.

A little peace of mind goes a long way these days.

General interest/Health/Money
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Cancer, Viruses & Informed Consent

by Fran Johns

A commentary about cancer screenings and surrounding questions posted yesterday brought a thoughtful reader response: “Science, including public health,” wrote davidlosangeles, “is an evolving process.”  Unquestionably so.

What we the consuming public need to understand is not the science as much as the personal responsibility. Today’s New York Times features another story on the front page of the Business section (some of us still follow old-fashioned newsprint) by Duff Wilson about “Research Uproar at a Cancer Clinic”, namely the highly regarded Carle Foundation Cancer Center in Urbana, IL. It’s another instance of respected professionals questioning each others’ respectability — or protocols, or carefulness, to use gentler terms than are actually being used. One of the issues raised is that of informed consent, and here is where we the consuming public come in. Whether we are cancer patients, CFIDS sufferers or mostly healthy people susceptible to the usual ails, it is incumbent upon the individual to know what he or she is agreeing to, and to know as much as possible about the projected outcome. We’re all in a giant clinical trial here on the planet. Nobody really knows about the outcome, but participation in mini-trials along the way can be valuable and is certainly laudable. Just know what you’re doing.

I am a continuing participant in the Women’s Health Initiative study now well into its second decade, though the primary issues are over and done with. I didn’t try any new hormone replacement therapies or drastic lifestyle changes, mainly because I’m pretty wimpish, but I read every word of the small print in the reams of documents that came along and tried hard to appreciate what the pitfalls and premises were. It was a valuable study, and hopefully will continue to turn up usable data.

Other studies are underway, and more will undoubtedly begin, regarding the current hoopla over XRMV, and H1N1. And heaven only knows how many other viruses, techonological advances, genetic possibilities and scientific wonders are out there to create great harm or great benefit.

Since the benefits are to the buyers, it’s appropriate that the buyer beware.

California/General interest/Health/Politics & Causes
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Cancer Gurus, CDC – Whom can you trust?

by Fran Johns

In the news of the past several days are reports that the American Cancer Society is about to concede that screenings for breast and prostate cancer — long touted as the holy grail of preventive medicine — have instead led to a great deal of over-treatment, and worse. Plus admission by the Centers for Disease Control and Prevention that their pooh-poohing of Chronic Fatigue Syndrome has left a lot of folks suffering, perhpas needlessly, for decades.

Who in the world is there left to trust?

I do trust my physicians at Kaiser, and continue to hope the crafters of our elusive health reform bills are looking in Kaiser’s direction. My breast cancer was detected through a regular mammogram. How frequent these screenings should be is still a matter of debate, but in my case early detection led to a quick mastectomy, a small price to pay for living happily a few more years after. (The ever-after business is not a principal to which I subscribe.) On the other hand, small as my tumor was, who’s to say it might have sat there harmlessly a few more years untreated? Please don’t get me wrong; I would not have opted for waiting to see. Just wondering.

I’m not so sure about prostate cancer screening. But since what seems nearly every man I know over 65 has been diagnosed with prostate cancer after a routine screening, it’s possible to wonder about this too. An October 21 New York Times article cites a new analysis by Dr. Laura Esserman, a professor of surgery and radiology at the University of California, San Francisco and director of the Carol Frank Buck Breast Cancer Center and Dr. Ian Thompson, professor and chairman of the department of urology at the University of Texas Health Science Center, San Antonio that “runs counter to everything people have been told about cancer: They are finding cancers that do not need to be found because they would never spread and kill or even be noticed if left alone.” We the healthcare consumers aren’t getting any breaks. Here’s a whole new dilemma to mull over and decide upon: to screen or not to screen, to treat or not to treat. In one group of gentlemen friends I know, others newly diagnosed with prostate cancer are invited to hang out for an hour or so and listen to the pros and cons of the various treatment options — because within the group are men who have gone down at least 4 or 5 different paths.

Another re-evaluation, this one a little more sinister, centers around the dismissive attitude long held by the venerable Centers for Disease Control and Prevention, guardian of our national health and welfare where things like viruses and other causes of infectious disease are concerned. In a Times op ed piece titled ‘A Case of Chronic Denial‘, Hillary Johnson reports on a recent study in the journal Science about a virus found in prostate cancers which will be referred to here by its shorter name, XRMV. It now turns out that there may be a link between XRMV and Chronic Fatigue Syndrome, more commonly referred to these days as CFIDS, and the work now going on in this area of research could be significant in treatment of the latter. Having had a number of friends and family members suffering from CFIDS, I admit to being among those who occasionally thought it might be partly in one’s head, but also aware of the degree of misery and disability CFIDS can bring.

This space is not a health authority. It is, rather aimed at those of us 50-somethings and over, many of whom have trusted many of the above. Trust is good. Open-mindedness is better. Questioning might be best of all.

California/General interest/Health/Lifestyle/Money/Politics & Causes/USA
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The aches & pains of medical marijuana

by Fran Johns

An article in Sunday’s New York Times details the struggle in Los Angeles to regulate the cannabis dispensaries which have proliferated around the  city over the past six or eight years, raising the old medical marijuana questions about how to control, whether to tax and how useful it is in the first place. Reporter Solomon Moore cites Oakland, California’s Harborside Health Center as the place to which many are looking for a model.

‘Our No. 1 task is to show that we are worthy of the public’s trust in asking to distribute medical cannabis in a safe and secure manner,’ said Steve DeAngelo, the pig-tailed proprietor of Harborside, which has been in business for three years.

Harborside is one of four licensed dispensaries in Oakland run as nonprofit organizations. It is the largest, with 74 employees and revenues of about $20 million. Last summer, the Oakland City Council passed an ordinance to collect taxes from the sale of marijuana, a measure that Mr. DeAngelo supported.

Mr. DeAngelo designed Harborside to exude legitimacy, security and comfort. Visitors to the low-slung building are greeted by security guards who check the required physicians’ recommendations. Inside, the dispensary looks like a bank, except that the floor is covered with hemp carpeting and the eight tellers stand behind identical displays of marijuana and hashish.

There is a laboratory where technicians determine the potency of the marijuana and label it accordingly. (Harborside says it rejects 80 percent of the marijuana that arrives at its door for insufficient quality.) There is even a bank vault where the day’s cash is stored along with reserves of premium cannabis. An armored truck picks up deposits every evening.

City officials routinely audit the dispensary’s books. Surplus cash is rolled back into the center to pay for free counseling sessions and yoga for patients. “Oakland issued licenses and regulations, and Los Angeles did nothing and they are still unregulated,” Mr. DeAngelo said. “Cannabis is being distributed by inappropriate people.”

I don’t know where Los Angeles will go with all this, or how well Harborside will continue to operate for how long. What I do know is that marijuana serves a real medical purpose. Probably serves a real recreational purpose too, and there’s the rub; but since I missed the pot party — thank heavens, as I am addicted to anything that comes down the pike, and please don’t try to tell me one cannot get addicted to marijuana — I can’t address that issue. Everything I know is anecdotal, but convincing.

Decades ago my beloved sister was suffering acute gastro intestinal distress, much later identified as a symptom of celiac disease but this was before anybody really knew anything about celiac sprue. One day she said, “You know, everybody at X High School either smokes pot or knows where to get it. Could you get me some so I could at least try it?” Well, even though the statute of limitations would probably protect the surviving players I think I won’t go into details of this adventure. But what I learned was: buying and selling illegal pot is a little scary for the novice, but the deal was easy and nobody went to jail. It did indeed give relief to my suffering sister. Though both of us wished she could have that relief on an ongoing basis, we reached a mutual conclusion that the risk was not worth the reward, and that was the end of that.

Fast forward to the 1990s, when everyone I knew with AIDS knew how marijuana could relieve some symptoms of the disease, and most had a supply. I was in San Francisco by then, and celiac disease pales in comparison to AIDS. I don’t even recall how legal it was for this relief; too many other issues were more important. But again, I saw its usefulness.

The Times article quotes Christine Gasparac, a spokeswoman for California Attorney General Jerry Brown, as saying his office is getting calls from law officials and advocates around the state asking for clarity on medical marijuana laws. I know that’s tough, and that the answer will in many cases be left to the courts. I also know that legalizing marijuana, whether here in woo-hoo California or elsewhere, raises a multiplicity of sticky issues.

But still. It’s a useful drug. If Big Pharma were producing and marketing it, it would probably come in a little pill that costs a fortune and would be covered by expensive insurance policies. Every governmental body in the U.S. needs money. Taxes raise money. Are there not some dots that could be connected here?

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