Friday, October 26, 2007

Suicide 3rd leading cause of death

 
"Suicide is the third-leading cause of death among Americans ages 15 to 24," according to the CDC.
 
Suicides "among college students nationwide are second only to traffic accidents," with approximately 1,000 college students taking their lives every year. Previous research has indicated that "about 15 percent of people between 18 and 24 experience mental health challenges such as depression and bipolar disorder. About one-tenth find life unbearable enough to consider ending it."
 
In one survey, nearly half of the respondents "were deemed 'so depressed [that] they found it difficult to function.'"
 
Another survey of "300 counseling center directors [found that] about 80 percent said that students have more psychological difficulties than just five years ago."
 
However, campus counseling centers "are responding with a growing number of mental health services and programs on campuses nationwide."

Monday, October 22, 2007

Medical Education in USA

60% of U.S. medical school leaders have financial ties to drugmakers, What do they teach then? how to care for people vs earn money.

"Nearly two-thirds of academic leaders surveyed at U.S. medical schools and teaching hospitals have financial ties" to the pharmaceutical industry, according to a study published in the October 17 issue of the JAMA Eric Campbell, Ph.D., of the Massachusetts General Hospital and Harvard Medical School, and colleagues, "sent surveys last year to 688 department heads at all 125 accredited U.S. medical schools and the 15 largest teaching hospitals."

A total of 67 percent (459 people) responded. "Included were departments closely related to patient care, such as surgery or anesthesiology, and 'nonclinical' departments more closely related to basic science." The survey indicated that "60 percent of department heads reported some type of personal financial relationship with industry," and 27 percent of respondents said that "they had recently served as a paid consultant.

" The survey "was sent to the chairs of medicine and psychiatry, specialties more likely to receive industry funding for educational activities, and two randomly selected chairs of other clinical departments. Surveys also were sent to the chairs of microbiology and one randomly selected non-clinical chair." "The survey is the first to show ties between drugmakers and leaders of institutions that research diseases and new drugs." According to Dr. Campbell, "Drug companies have influence in every single aspect of medical education in the United States, and the question is how much is too much?"

Campbell added, "Anything that compromises the mission of medical schools, which is unbiased and independent research and education, shouldn't be allowed." "Institutional relationships" with drug companies "seemed to be just as widespread as those of individual physicians or scientists with industry.

'There is not a single aspect of medicine in which the drug companies do not have substantial and deep relationships, affecting not only doctors-in-training, resident physicians, researchers, physicians-in-practice, the people who review drugs for the federal government, and the people who review studies,'" Campbell said. He added that "policymakers and people who run medical schools...need to come up with some...new rules."

Deadly MRSA in several states

Staph infections confirmed at schools in several states.

"School officials around the country have been scrambling this week to scrub locker rooms, reassure parents and impress upon students the importance of good hygiene." This "heightened alarm comes in response to a federal report indicating that...bacteria, methicillin-resistant Staphylococcus aureus, or MRSA, are responsible for more deaths in the United States each year than AIDS."

"MRSA...is a strain of staph bacteria that does not respond to penicillin or related antibiotics, though it can be treated with other drugs." MRSA "infection can be spread by sharing items, like a towel or a piece of sports equipment that has been used by an infected person, or through skin-to-skin contact with an open wound."

Last "Wednesday and Thursday, scores of schools were closed and events were canceled in Connecticut, Maryland, North Carolina, Ohio, and Virginia as cleaning crews disinfected buses, lockers and classrooms." Additional closings were slated for Friday.

"Reports of MRSA in the nation's schools has shifted the focus and raised concerns about the dual challenges of school-based infection control and treatment of MRSA in a pediatric population." Buddy Creech, M.D., of Vanderbilt, stated earlier this month that "the problem is compounded by the lack of agreement about 'choice of first-line therapy or the duration of therapy.'"

Clindamycin & trimethoprim/sulfamethoxazole among others are used as the preferred first line treatment and treatment are usually continued for 7 to 14 days."

Warning against Physician-Ranking Schemes

New York state warns against physician-ranking schemes.

"Warning that physician-ranking schemes may be deceptive and driven by financial motives, New York state has demanded that three large health insurers justify their programs before implementing them."

Attorney General Andrew M. Cuomo "sent stern letters to

  1. Empire Blue Cross Blue Shield (533,000 covered patients),
  2. Preferred Care (185,000) and
  3. HIP Health Plan of New York/GHI (995,000)

as part of an expanding industry-wide investigation into how insurers plan to rank physicians."

He is concerned "that inaccurate physician-ranking programs may cause financial harm to consumers."

Widening Income Gap: Scary

Income-Inequality Gap Widens

Boom in Financial MarketsParallels Rise in ShareFor Wealthiest Americans

The richest Americans' share of national income has hit a postwar record, surpassing the highs reached in the 1990s bull market, and underlining the divergence of economic fortunes blamed for fueling anxiety among American workers.The wealthiest 1% of Americans earned 21.2% of all income in 2005, according to new data from the Internal Revenue Service. That is up sharply from 19% in 2004, and surpasses the previous high of 20.8% set in 2000, at the peak of the previous bull market in stocks.•

Widening Gap:

The wealthiest Americans' share of national income has hit a postwar record, surpassing the highs reached in the 1990s bull market, and highlighting the divergence of economic fortunes blamed for fueling anxiety among American workers.• Behind the Numbers: Scholars attribute rising inequality to several factors, including technological change that favors those with more skills, and globalization and advances in communications that enlarge the rewards available to "superstar" performers whether in business, sports or entertainment.

• Political Fallout:

The data pose a potential challenge for President Bush and the Republican presidential field. They have sought to play up the strength of the economy and low unemployment, and the role of Mr. Bush's tax cuts in both. Democrats may use the data to exploit middle-class angst about stagnant wages.The bottom 50% earned 12.8% of all income, down from 13.4% in 2004 and a bit less than their 13% share in 2000.The IRS data, based on a large sample of tax returns, are for "adjusted gross income," which is income after some deductions, such as for alimony and contributions to individual retirement accounts.

While dated, many scholars prefer it to timelier data from other agencies because it provides details of the very richest -- for example, the top 0.1% and the top 1%, not just the top 10% -- and includes capital gains, an important, though volatile, source of income for the affluent.The IRS data go back only to 1986, but academic research suggests the rich last had this high a share of total income in the 1920s.

Scholars attribute rising inequality to several factors, including technological change that favors those with more skills, and globalization and advances in communications that enlarge the rewards available to "superstar" performers whether in business, sports or entertainment.In an interview yesterday with The Wall Street Journal, President Bush said, "First of all, our society has had income inequality for a long time. Secondly, skills gaps yield income gaps. And what needs to be done about the inequality of income is to make sure people have got good education, starting with young kids. That's why No Child Left Behind is such an important component of making sure that America is competitive in the 21st century."

Jason Furman, a scholar at the Brookings Institution and an adviser to Democratic politicians, said: "We've had a 30-year trend of increasing inequality. There was an artificial reduction in that trend following the bursting of the stock-market bubble in 2000."The IRS data don't identify the source of increased income for the affluent, but the boom on Wall Street has likely played a part, just as the last stock boom fueled the late-1990s surge.

Until this summer, soaring stock prices and buoyant credit markets had produced spectacular payouts for private-equity and hedge-fund managers, and investment bankers.One study by University of Chicago academics Steven Kaplan and Joshua Rauh concludes that in 2004 there were more than twice as many such Wall Street professionals in the top 0.5% of all earners as there are executives from nonfinancial companies.Mr. Rauh said "it's hard to escape the notion" that the rising share of income going to the very richest is, in part, "a Wall Street, financial industry-based story."

The study shows that the highest-earning hedge-fund manager earned double in 2005 what the top earner made in 2003, and top 25 hedge-fund managers earned more in 2004 than the chief executives of all the companies in the Standard & Poor's 500-stock index, combined. It also shows profits per equity partner at the top 100 law firms doubling between 1994 and 2004, to over $1 million in 2004 dollars.

The data highlight the political challenge facing Mr. Bush and the Republican contenders for president. They have sought to play up the strength of the economy since 2003 and low unemployment, and the role of Mr. Bush's tax cuts in both. But many Americans think the economy is in or near a recession.

The IRS data show that the median tax filer's income -- half earn less than the median, half earn more -- fell 2% between 2000 and 2005 when adjusted for inflation, to $30,881. At the same time, the income level for the tax filer just inside the top 1% grew 3%, to $364,657.Democrats, on the other hand, have sought to exploit angst about stagnant middle-class wages and eroding benefits in showdowns with Mr. Bush over issues such as health insurance and trade.

Impending Penury in usa

NEW YORK -

In a time when incompe gap is widening and the USA is being bitten by the continuing crisis of subprime mortgage crisis, another impending disaster is likely to hit USA in no time, so beware.

The calculus of living paycheck to paycheck in America is getting harder. What used to last four days might last half that long now. Pay the gas bill, but skip breakfast. Eat less for lunch so the kids can have a healthy dinner.

Across the nation, Americans are increasingly unable to stretch their dollars to the next payday as they juggle higher rent, food and energy bills. It's starting to affect middle-income working families as well as the poor, and has reached the point of affecting day-to-day calculations of merchants like Wal-Mart Stores Inc., 7-Eleven Inc. and Family Dollar Stores Inc.
Food pantries, which distribute foodstuffs to the needy, are reporting severe shortages and reduced government funding at the very time that they are seeing a surge of new people seeking their help.

While economists debate whether the country is headed for a recession, some say the financial stress is already the worst since the last downturn at the start of this decade.
From Family Dollar to Wal-Mart, merchants have adjusted their product mix and pricing accordingly. Sales data show a marked and more prolonged drop in spending in the days before shoppers get their paychecks, when they buy only the barest essentials before splurging around payday.

"It's pretty pronounced," said Kiley Rawlins, a spokeswoman at Family Dollar. "It seems like to us, customers are running out of food products, paper towels sooner in the month."
Wal-Mart, the world's largest retailer, said the imbalance in spending before and after payday in July was the biggest it has ever seen, though the drop-off wasn't as steep in August.
And 7-Eleven says its grocery sales have jumped 12-13 percent over the past year, compared with only slight increases for non-necessities like gloves and toys. Shoppers can't afford to load up at the supermarket and are going to the most convenient places to buy emergency food items like milk and eggs.

"It even costs more to get the basics like soap and laundry detergent," said Michelle Grassia, who lives with her husband and three teenage children in the Bedford-Stuyvesant section of Brooklyn, N.Y.

Her husband's check from his job at a grocery store used to last four days. "Now, it lasts only two," she said.

To make up the difference, Grassia buys one gallon of milk a week instead of three. She sometimes skips breakfast and lunch to make sure there's enough food for her children. She cooks with a hot plate because gas is too expensive. And she depends more than ever on the bags of free vegetables and powdered milk from a local food pantry.

Grassia's story is neither new nor unique. With the fastest-rising food and energy prices since the 1980s, low-income consumers are stretching their budgets by eating cheap foods like peanut butter and pasta.

Industry analysts and some economists fear the strain will get worse as people are hit with higher home heating bills this winter and mortgage rates go up.

It's bad enough already for 85-year-old Dominica Hoffman.

She gets $1,400 a month in pension and Social Security from her days in the garment industry. After paying $500 in rent on an apartment in Pennsauken, N.J., and shelling out money for food, gas and other expenses, she's broke by the end of the month. She's had to cut fruits and vegetables from her grocery order — and that's even with financial help from her children.
"Everything is up," she said.

Many consumers, particularly those making less than $30,000 a year, are cutting spending on nutritious food like milk and vegetables, and analysts fear they're further skimping on basic medical care and other critical services.

Coupon-clipping just isn't enough.

"The reality of hunger is right here," said the Rev. Melony Samuels, director of The BedStuy Campaign against Hunger, a church-affiliated food pantry in Brooklyn.
The pantry scrambled to feed 5,000 new families over the past 12 months, up almost 70 percent from 3,000 the year before.

"I am shocked to see such numbers," Samuels said, "and I am really concerned that this is just the beginning of what we are going to see."

In the past three months, Samuels has seen more clients in higher-paying jobs — the $35,000 range — line up for food.

The Regional Food Bank of Northeastern New York, which covers 23 counties in New York State, cited a 30 percent rise in visitors in the first nine months of this year, compared with 2006.

Maureen Schnellmann, senior director of food and nutrition programs at the American Red Cross Food Pantry in Boston, reported a 30 percent increase from January through August over last year.

Until a few months ago, Dellria Seales, a home care assistant, was just getting by living with her daughter, a hairdresser, and two grandchildren in a one-bedroom apartment for $750 a month. But a knee injury in January forced her to quit her job, leaving her at the mercy of Samuels' pantry because most of her daughter's $1,200 a month income goes to rent, energy and food costs.

"I need it. Without it, we wouldn't survive," Seales said as she picked up carrots and bananas.
John Vogel, a professor at Dartmouth College's Tuck School of Business, worries that the squeeze will lead to a less nutritious diet and inadequate medical or child care.
In the meantime, rising costs show no signs of abating.

Gas prices hit a record nationwide average of $3.23 per gallon in late May before receding a little, though prices are expected to soar again later this year. Food costs have increased 4.5 percent over the past 12 months, partly because of higher fuel costs. Egg prices were 44 percent higher, while milk was up 21.3 percent over the past 12 months to nearly $4 a gallon, according to the Bureau of Labor Statistics.

The average family of four is spending anywhere from $7 to $10 extra a week — $40 more a month — on groceries alone, compared to a year ago, according to retail consultant Burt Flickinger III.

And while overall wage growth is a solid 4.1 percent over the past 12 months, economists say the increases are mostly for the top earners.
Retailers started noticing the strain in late spring and early summer as they were monitoring the spending around the paycheck cycle.

Wal-Mart and Family Dollar key on the first week of the month, when government checks like Social Security and public assistance generally hit consumers' mailboxes.
7-Eleven, whose customers are more diverse, looks at paycheck cycles in specific markets dominated by a major employer, such as General Motors in Detroit, to discern trends in shopping.

To economize, shoppers are going for less expensive food.
"They're buying more peanut butter and pasta. And they're going for hamburger meat," Flickinger, the retail consultant, said. "They're trying to outsmart the store by looking for deep discounts at the end of the month."
He said the last time he saw this was 2000-2001, when the dot-com bubble burst and the economy went into a recession after massive layoffs.

For now, low-price retailers are readjusting their merchandising and pricing.
Wal-Mart is becoming more aggressive on discounting. It announced Thursday it is expanding price cuts to 15,000 items, ranging from Motts apple juice and Progresso soups to women's fleece tops, heading into the holidays.

Family Dollar, whose food offerings were limited to candy and snacks until two years ago, has expanded its mix of groceries like fruit cups, cereal and such refrigerated items as milk and ice cream while cutting back on shoes. This summer the chain began accepting food stamps.
Food pantries are also getting creative. Samuels said her church, Full Gospel Tabernacle of Faith, just started offering free cooking classes to teach clients who are diabetic or have other health conditions how to prepare vegetables like squash. It's also offering free exercise classes.
"We are trying to make them health conscious," Samuels said. "It's not right to give them just anything. Our mantra is eat well and live well."

Saturday, October 20, 2007

Exciting article for 2b Residents

The Code"Code Call Baker 723," announced an urgent voice over the hospital intercom.
Simultaneously, the code beeper worn by our team's resident went off. We sprinted to the 6th floor of the Baker building. As we rounded the corner, we saw the crash cart in the hall, which directed us to the right room. Several residents were already there when we arrived. The chaos of the residents rapidly sorted itself out under the calm guidance of the senior resident, who directed the chest compressions and the Ambu bagging until the resident who would intubate the patient was ready. Someone else slipped a central line into place, and fluids were administered.The EKG leads were placed, and the senior resident quietly said, "V Fib — shock." Zap went the defibrillator pads. The body reflexively jerked. "Still in VF, keep pumping. Give an amp of bicarb and start lidocaine."

Meanwhile, the endotracheal tube had been inserted, and each side of the chest was auscultated to be sure the tube was in position. During the next 20 minutes, multiple vials of bicarb, epinephrine, procainamide, lidocaine, and finally bretylium were given, stat blood gases sent, and the results analyzed while we worked together to bring back a viable rhythm, pulse, and blood pressure.As often happened, the code was unsuccessful. Deciding that we had tried everything, the senior resident said, "The code is called."

We all stopped what we were doing, and then, as though the whole episode had been some minor distraction in our otherwise packed day, we filed out of the room. We were no longer involved. We left to others the jobs of cleaning up the mess we'd created and of notifying the patient's doctor and family. We returned to our rounds, picking up as though nothing had happened.As a newly minted intern, I was most aware of my own uncertainty about what to do, what drugs to give, how to tell what was happening.

The senior resident seemed almost godlike — leading us through our tasks in his calm, methodical way until he was convinced we had done enough. I was sure I would never be able to do this. Codes were one more situation that made me wonder how I had come to be here, where I so often felt in over my head.The learning curve is steep in those first months of internship, and as with so many other medical tasks, codes gradually became less chaotic and more comprehensible. I came to anticipate what the senior resident would ask for. I found I could put in central lines, intubate a patient, and do chest compressions; I came to know the medicines being asked for and to grasp why they were needed.

I began to think about matters other than my own inadequacies. But I found that when someone said "the code is called" and we all walked out of the room, returning to rounds or going off to lunch, perhaps laughing about some goof-up, some part of me was aware that I was forgetting something. Eventually I realized what it was: the patient. Someone had just died. But we all behaved as though that was not at all what had happened. What had happened was that the code was unsuccessful.

How do you deal with the emotionally challenging aspects of clinical care?

We invite readers to respond to The Code in an online Perspective Forum with Dr. Treadway. New comments and responses from Dr. Treadway will continue to be posted through October 10.

Where did we learn this detachment? For most of us, the first lessons came very early in medical school, when we were confronted with the dissection of a human body — conveniently called a cadaver, as though that made it something different from a person who had died. How rapidly we moved from our first tentative slices through the chest wall to look at the heart and lungs and then into the abdomen, finding ourselves lost in the fascination of how our bodies are arranged and overwhelmed by all we had to learn. Soon, we were casually slicing the head in half with a saw to see how it looked from the middle, having paused only briefly when we first unwrapped the hand, which struck us as uniquely and somehow poignantly human.

We learned to bury our fear of death in an avalanche of knowledge. We learned the trick of silencing the parts of our brain that didn't really want to be this close to death. And for good reason. We could not do what we do — take responsibility for the lives of our patients — if we were aware, minute to minute, of the true significance of what we were actually doing. We could not come into a code fully aware of the profound event taking place and still be able to do our job. So we learned to put those feelings away. The question, of course, is how to avoid losing them altogether, how to come back to them later, when we have time to think about them.

Sometime late in the fall of my internship year, I happened to be the last person to leave the room after a code. Once again, it had been unsuccessful. Once again, we had come from all over the hospital to try to save the life of a patient few of us knew. For whatever reason, perhaps because I was alone, I was struck by the reality that a person had just died. I made myself turn around and look at the body of this stranger. He was lying on the stretcher, a pacer wire sticking out of his chest, the endotracheal tube now disconnected and hanging uselessly in the air, EKG leads still in place, and reams of readouts on the floor surrounding the now-silent EKG machine. I tried to imagine his family — who in minutes would be told that someone they loved had died and for whom this would be a devastating loss. And what of the person himself, who had died despite our attempts to pummel and pound him back to life?

Half-remembered words from the end of a requiem mass came into my head, and I said aloud, "May choirs of angels greet thee at thy coming" — less a statement of faith than a simple attempt to acknowledge the passing of a life. Since that day, I have never had a patient die and not said those words — my small attempt to remember what it is that we are ultimately doing: trying to protect our patients' lives.

In recent years, other physicians have told me about the rituals they perform when a patient dies — offering a prayer, a poem, a gesture — something that each has felt compelled to do to recognize the life lost and the fact that, in the final analysis, death will always win. What is striking is that most of us do this in private. We don't share these rituals. We don't talk easily about how hard it is to lose a patient, to confront death. In the anatomy laboratory, we learned to focus on the path of the vagus nerve, not the human being to whom it belonged.

Early in our training, bending over our cadavers, we learned to silence a part of ourselves. We learned the power of humor as a means of avoiding hard conversations about more complicated feelings. Often we kept those feelings to ourselves, rarely giving voice to them as we proceeded through far more challenging situations during our clerkships — a newly diagnosed lung cancer, a 2-year-old with an inoperable and therefore fatal brain tumor, a young man with quadriplegia from diving into shallow water. We discussed the medical management and the complications in detail and with intense care, but we could not give voice to the feelings these events evoked, often reducing them, in the formal case presentation, to the single word "unfortunate."

And because we cannot comfortably express these feelings, sometimes we put them away forever or feel incompetent and overwhelmed when we do try to express them. Perhaps if we could discuss this part of our practice lives as easily as we discuss a diagnostic dilemma or the proper management of a complex case, we might create a culture that supports and nourishes us as we try to come to terms with experiences that are part of our daily lives. Being able to communicate more honestly with each other might help us to do so with our patients as well. How different might those codes have felt if, at the end, having declared, "The code is called," the resident then said, "Let's have a moment of silence to honor this life."

Source Information

Dr. Treadway is on the faculty of Harvard Medical School and in the Department of Medicine at Massachusetts General Hospital — both in Boston.