29 January 2010

California Hospitals Fined for Medical Errors

LA Times

State Department of Public Health officials require hospital officials to submit plans to correct the problems, which in some cases killed or seriously injured patients.

State officials have fined 13 California hospitals for medical errors that in some cases killed or seriously injured patients, according to a report made public Wednesday.

California Department of Public Health officials have required hospital officials -- who may appeal the fines -- to submit plans to correct the problems.

Three hospitals in Los Angeles County face penalties.

Los Angeles Community Hospital in Norwalk was fined $50,000 in connection with the death of a patient in May who was supposed to be restrained and supervised, but was instead left to repeatedly pull out his tracheotomy tube until he was found unresponsive in his bed. Hospital staff referred questions to spokeswoman Ellen Shin, who did not return calls.

California Hospital Medical Center was fined $50,000 after a medical resident in the emergency room misdiagnosed a woman in March with an ectopic pregnancy. The woman was not pregnant and the chemotherapy drugs she was treated with suppressed her immune system and caused mouth, throat and skin sores.

The hospital has since restricted residents' access to the drug and required pharmacy staff to closely monitor how the drug is dispensed.

"We responded to the incident appropriately, reported it promptly and took long-term corrective action in a timely manner," said Katreena Salgado, a hospital spokeswoman.

Marina del Rey Hospital was fined $25,000 after intensive care nurses failed to monitor a woman's oxygen levels in March 2007; the patient passed out and had to be placed on a ventilator.

In Orange County, three hospitals were each fined $50,000.

St. Jude Medical Center in Fullerton was fined in connection with the death of a patient treated in the emergency room for a heart attack in February. Investigators found nurses failed to notice that the man's heart monitor had disconnected. Chief Medical Officer Michael Marino released a statement Wednesday saying an internal investigation showed the volume on the patient's heart monitor alarm was not loud enough to alert staff. He said the hospital has since added engineering controls for the monitors, and checked the alarms and staff training. The hospital does not plan to appeal, a spokeswoman said.

Western Medical Center in Santa Ana faced its second fine in the last year after staff left a surgical sponge in a patient in March. She got sick and had to undergo a second operation.

At Hoag Memorial Hospital in Newport Beach, investigators found a patient on a metal gurney was sucked in by an MRI machine's magnetic force in January 2009, fracturing her leg and foot. It was the hospital's third penalty in the last two years. The hospital's chief executive, Dr. Richard Afable, said the staff was retrained and the hospital does not plan to appeal the fine.

In Riverside County, John F. Kennedy Memorial Hospital in Indio got four $25,000 fines for failing to monitor patients and medication in 2008.

The state has issued 134 fines since they were first required by law in January 2007, said Kathleen Billingsley, deputy director of the department's Center for Health Care Quality. In all, 90 hospitals have been fined and the state has collected $2.3 million. Twenty-two of the fines have been appealed, Billingsley said.

27 January 2010

Surgical Procedure Urged for Atrial Fibrillation

LA Times
Study finds catheter ablation is highly effective when medication doesn't work. The irregular-heartbeat disorder, once considered benign, is now seen as a precursor to stroke that needs treatment.

People with atrial fibrillation, a common type of irregular heartbeat, should be referred for a surgical treatment called catheter ablation if an oral medication is not effective, said Wyandotte Cardiologists.

In a head-to-head comparison of the two forms of treatment, catheter ablation was so superior in resolving the disorder and helping patients to feel better that the study was halted early. The results will be published today in the Journal of the American Medical Assn.

Atrial fibrillation, which affects more than 2 million Americans, occurs when the heart's two small upper chambers quiver instead of beating effectively. It can cause blood to pool and clot, raising the risk of a stroke. The condition can go undetected indefinitely, though many people have symptoms such as palpitations, dizziness, chest pain, fatigue and shortness of breath. Once considered a nuisance, the condition is now recognized as a potential precursor to stroke that should be treated.

Atrial fibrillation is distinguished from ventrical fibrillation which can cause sudden cardiac arrest, often requiring emergency action with such devices as a Zoll defibrillator.

"It's really important that we have advances in treating atrial fibrillation because the risk climbs dramatically as you age," said Dr. Douglas Zipes, past president of the American College of Cardiology and a cardiologist at Indiana University School of Medicine. Zipes was not involved in the study. "I always say -- only partially tongue-in-cheek -- that if you live long enough, you'll have atrial fibrillation."

Woodhaven Heart Doctors suggest that the first choice for treating the condition is oral medications to reduce the heart rate. They work by slowing the conduction of the electrical impulses in the heart. Such medications, however, are ineffective in a large portion of people with the disorder.

For those who continue to feel unwell, catheter ablation should be recommended, said Dr. David Wilber, director of the Cardiovascular Institute at Loyola University Chicago Stritch School of Medicine and the lead author of the study.

"Atrial fibrillation has always been difficult to treat," Wilber said. "Certainly, the effectiveness of the drug therapies is about 50% at best. The likelihood of a second drug working is about 20%. So the role of this study is to point out that there isn't much point in going to a second drug."

During catheter ablation, doctors make a small incision in the patient's neck or groin and insert a thin, flexible tube to reach the heart. They then apply radiofrequency energy to cauterize -- or burn off -- small pieces of abnormal tissue triggering the irregular heartbeat.

The study was performed at 19 medical centers and included 167 atrial fibrillation patients who had failed to benefit from at least one drug. The patients, whose average age was 55, were randomly assigned to receive ablation or try a different medication than what they had already tried. Most took flecainide or propafenone.

One year later, 66% of the ablation patients were free of an irregular heartbeat or symptoms, compared with 16% of those treated with drugs.

Longer studies are needed to assess whether the treatment provides a long-term cure and if it reduces stroke and death, Wilber said.

Catheter ablation has been in use for several years but is still underutilized, said Dr. Shephal K. Doshi, director of electrophysiology and pacing at Saint John's Health Center in Santa Monica. Doshi was not involved in the study.

Wayne County Cardiologists remind that there are risks associated with the procedure. Rare complications include damage to the esophagus and stroke. Damage to veins is a more common complication but is treatable.

"It has to be used appropriately, but in the right hands it's a very powerful tool for the management of atrial fibrillation," Doshi said. "There is a 1% risk of having a stroke during the procedure. So that's not trivial. For a young patient, a patient who feels bad, it may be worth it."

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26 January 2010

Smokers with Lung Cancer: Still Not Too Late to Quit


Smokers with lung cancer who have asked "Why quit now, I'm already sick?" may find new motivation in this answer: Doing so could double their odds of survival over five years.

A report published online today in BMJ suggests that people who give up smoking after being diagnosed with early-stage lung cancer live longer than patients who continue the habit. 

The findings underscore the importance of the notion that it is never too late to quit smoking.

Lung cancer is the most common cause of cancer death, according to the American Lung Association. And smoking causes most cases of lung cancer.

Medical evidence has repeatedly shown that as soon as a person quits smoking the body begins to repair the damage done by tobacco-smoke-related chemicals, and it's been theorized that continued smoking can influence the behavior of lung tumors. But until now it was not clear if ending the smoking habit after being diagnosed with lung cancer had any impact on a patient's survival.

Researchers at the University of Birmingham in England reviewed the results of 10 studies that evaluated how smoking cessation after lung cancer diagnosis affected a patient's prognosis. The review included patients with both non-small-cell and small-cell forms of lung cancer.

Among their findings:

    * Patients with early-stage lung cancer who continued to smoke had a "substantially higher risk of death" than those who quit after their diagnosis. The increased death risk appeared to be due to the cancer spreading.
    * The five-year survival rate for the quitters was 64%-70% compared with 29%-33% for those who continued to smoke.
    * The continued smokers were also more likely to have their cancer return than those who quit.

The researchers say their findings suggest that smoking-cessation programs may benefit patients with early-stage lung cancer, but they add that more research is needed.

25 January 2010

Salami Recalled Over Salmonella Concern

USA Today

Pepper, a spice historically used to preserve food, could be the cause of a 1.24 million-pound salami recall, some food safety experts say.

Daniele Inc., of Pascoag, R.I., recalled ready-to-eat pepper-coated salami, sausage and other cured meats Saturday, saying they may be contaminated with salmonella.

The outbreak began in July. So far it has sickened 184 people in 38 states, leading to at least 35 hospitalizations but no deaths, according to the federal Centers for Disease Control and Prevention.

To date, health officials have not found this salmonella strain in any Daniele products. But 11 people who recently ate "Daniele Italian Brand Gourmet Pack" were infected, said the company's Davide Dukcevich, in a statement on its website.

The one thing all the recalled products have in common is that they were rolled in pepper, or packaged with a product that was.

The answers won't be known until the factory investigation is finished. "I don't think that other possibilities have been ruled out yet," said William Keene, a senior epidemiologist with Oregon's Dept. of Public Health.

Uncooked pepper has been known to carry salmonella, said David Theno, formerly head of food safety at Jack in the Box and now a consultant. "Frankly, if you're using pepper and you're not doing some sort of sterilization process on it, you're rolling the dice."

Some suppliers sell irradiated pepper, but "there is no federal requirement that pepper be sterilized," Daniele spokesman Jason Maloni said Sunday. "However, we will begin only using irradiated pepper next week for all our products."

Last April, at least 42 people were sickened with salmonella linked to pepper.

Salmonella can cause diarrhea, fever and stomach cramps; in infants, elderly and those with weak immune systems, illness can be severe.

23 January 2010

FDA Approves MS Drug


The second-to-last time EJ Levy was at Disney World, she used a scooter to navigate the enormous park. Her legs were weak and she suffered from foot drop caused by multiple sclerosis. That was 4½ years ago. On her most recent trip, a few months ago, Levy walked the entire time, thanks in part to a drug approved by the FDA on Friday.

The FDA says the drug, Ampyra (generic name dalfampridine, formerly known as fampridine), is the first MS therapy that is taken orally and the first of its kind to receive FDA approval. It is designed help people with any type of MS improve their walking speed.

The prime of her life

In 2002, Levy was in her 30s and an active hiker and skier with a job on Wall Street and later in San Francisco, California. But her life took a turn when she started stumbling, falling down and dragging her right leg. Her doctor's diagnosis? Secondary Progressive Multiple Sclerosis, a less common form of MS and, as the name implies, one that usually plagues people with the disease after its initial course.

The National Multiple Sclerosis Society defines MS as a "chronic, often disabling disease that attacks the central nervous system, which is made up of the brain, spinal cord and optic nerves." Symptoms of MS include extreme fatigue, difficulty walking, problems with memory and heat sensitivity.

The most common form of MS is relapsing-remitting, in which people have acute attacks followed by periods of remission. In secondary progressive, however, the disease worsens steadily and there are no acute flare-ups. People with relapsing-remitting may later develop secondary progressive MS.

Levy says she lived in the same building as her parents at one point because she needed them to help take care of her. She says she mostly stayed at home, and when she did venture out she usually walked only a block or two with a cane. She relied on a wheelchair for longer distances.

She says she realized she would eventually be unable to walk. "I was scared of being in a wheelchair. I was scared of getting worse and worse. I had traveled around the world before I got sick, I was super independent," Levy says.

Trying things out

After exhausting the usual MS treatments -- and developing intolerable side effects -- Levy also became frustrated that the treatments were primarily designed for people with the more common course of the disease, and not the secondary progressive course.

Levy's neurologist then discussed the possibility of trying 4-aminopyradine -- a version of the same drug the FDA approved Friday that was available only through compounding pharmacies. Just three days after taking the drug, Levy was able to walk unassisted.

"I never thought I could put my cane away for good," she said.

Now she hopes the same drug that helped her will be able to help other people. She addressed an FDA advisory panel late last year and recommended approval of it.

"It's about quality of life," Levy says.

How it works

Two phase III clinical trials of Ampyra showed 35 and 43 percent of patients experienced, on average, a consistent improvement in their walking speed, increasing it by about 25 percent.

According to the National Multiple Sclerosis Society, even a modest improvement in walking ability could mean that thousands of people could benefit from the drug.

Dr. John Richert, executive vice president of Research & Clinical Programs at the National Multiple Sclerosis Society, says the drug can be used by most people with MS. However, the drug is not for people with a history of seizures or people who have moderate to severe kidney disease.

Richert says approval means patients can now skip the compounding pharmacy and get a consistent, exact dosage in a guaranteed time-released formula, which would lower the risk of getting a toxic dose instead of a therapeutic dose.

"It's likely that further study and clinical practice may help to determine the extent to which the drug may impact other functions, and may also provide hints as to which patients are most likely to respond positively to the therapy," Richert said.

He added that the drug would not help nerves that have been destroyed and emphasized that people should try the drug to see if it works for them.

Ampyra may not work for everyone. "Like any medication, people will have different responses, so they should talk to their doctors about whether it's appropriate to start therapy on Ampyra," according to a spokesperson from Acorda, Ampyra's manufacturer.

Moving with MS

Today, Levy is doing well. She established the not-for-profit organization MS Hope for a Cure, and in three years the organization has raised $1.8 million for research and programs to help people living with MS.

She has also completed several five-mile hikes. But she says she is always conscious of where she steps. She says she occasionally has some weakness in her leg, but that she is thankful for every day: "I don't ever take jumping out of bed for granted."

22 January 2010

High Cholesterol Puts 1 of 5 Teens at Risk for Heart Disease

The Washington Post

One out of every five U.S. teenagers has a cholesterol level that increases the risk of heart disease, federal health officials reported Thursday, providing striking new evidence that obesity is making more children prone to illnesses once primarily limited to adults.

A nationally representative survey of blood test results in American teenagers found that more than 20 percent of those ages 12 to 19 had at least one abnormal level of fat. The rate jumped to 43 percent among those adolescents who were obese.

Previous studies had indicated that unhealthy cholesterol levels, once a condition thought isolated to the middle-aged and elderly, were increasingly becoming a problem among the young, but the new data document the scope of the threat on a national level.

"This is the future of America," said Linda Van Horn, a professor of preventive medicine at Northwestern University who heads the American Heart Association's Nutrition Committee. "These data really confirm the seriousness of our obesity epidemic. This really is an urgent call for health-care providers and families to take this issue seriously."

Earlier research found that the obesity epidemic has been accompanied by an increase in a host of health problems in youths that were previously found mostly among adults, including high blood pressure, diabetes and arthritis. The new data detail the obesity's effect on cholesterol levels, which can increase the risk for a variety of illnesses, including diabetes and heart disease.

"The current epidemic of childhood obesity makes this a matter of significant and urgent concern," said Ashleigh May, an epidemic intelligence service officer with the federal Centers for Disease Control and Prevention's division for heart disease and stroke prevention, who led the analysis.

Although the latest government data suggest that the obesity epidemic might be leveling off after increasing for decades, at least one-third of youths are overweight or obese, and the heaviest boys continue to get heavier.

"People are worried that this generation is going to grow up to have more cardiovascular disease than the current generation," said Denise Simons-Morton of the National Heart, Lung and Blood Institute. "This problem is poised to negate all of the advances we've made in cardiovascular health."

In the new study, published in the CDC's Morbidity and Mortality Weekly Report, researchers analyzed data collected from 3,125 youths through the National Health and Nutrition Examination Survey, which is conducted every two years.

According to data from surveys conducted between 1999 and 2006, 20.3 percent had abnormal "blood lipid" levels, which includes low levels of high-density lipoprotein (HDL), or the "good cholesterol"; high levels of low-density lipoprotein (LDL), the "bad cholesterol"; and high levels of triglycerides, which can also clog arteries.

The percentage of teens with an abnormal blood lipid level varied by weight, ranging from 14.2 percent of those whose weight was normal to 22.3 percent among those who were overweight to 42.9 percent among those who were obese.

The findings support a 2008 recommendation by the American Academy of Pediatrics that children and adolescents get blood tests to see whether they need to be treated for abnormal lipid levels if they are at risk for heart disease because of a family history of high blood cholesterol or early heart disease or if they are at risk because they smoke, have high blood pressure or diabetes or are overweight.

21 January 2010

Study Shows Benefits of Cutting Salt Intake

The Wall Street Journal

A national program to reduce dietary salt could prevent tens of thousands of heart attacks, strokes and deaths and trim as much as $24 billion from the U.S. health-care tab, according to a study published Wednesday in the New England Journal of Medicine.

The study, a computer simulation, suggests the impact would be similar to prevention strategies such as quitting smoking, lowering cholesterol or modest weight-loss.

But significant cuts in salt from the diet could be challenging for individuals without action from food manufacturers. Some 75% of dietary salt intake comes from processed foods, according to the researchers.

Their findings add to a growing body of research suggesting that lowering dietary salt could be an effective weapon against high blood pressure and cardiovascular disease. "The time is right now to consider efforts to…achieve population wide reduction in salt" intake, says Kirsten Bibbins-Domingo, first author of the study and an associate professor of medicine and epidemiology at the University of California, San Francisco.

Last week, the New York City Health Department said it would encourage packaged food makers and restaurants to cut salt by 25% over five years. Many food manufacturers have long sold "low sodium" versions of products, but generally they haven't been popular with consumers. Some companies have recently begun cutting sodium content without highlighting it on product labels.

Morton Satin, technical director of the Salt Institute, a nonprofit group of salt producers, says few data exist linking salt intake and disease. He is skeptical that reducing salt will yield important health benefits.

Americans consume far more than the recommended daily salt intake. The average adult male consumes more than 10 grams of salt a day, according to the U.S. National Health and Nutrition Examination Survey. On Wednesday, the American Heart Association published new guidelines calling for all Americans to reduce their daily intake of sodium—a key component of salt—to 1,500 milligrams, equivalent to 3.8 grams of salt. Previously, that was the recommended limit for higher risk individuals; the regular limit had been 2,300 milligrams of sodium, or 5.8 grams of salt.

A typical sandwich, with two slices of bread and meat or peanut butter, has about half the daily recommended amount of salt, Dr. Bibbins-Domingo says.

In the computer simulation, which included data from the U.S. Census, the Centers for Disease Control and Prevention and other national studies, Dr. Bibbins-Domingo and her colleagues estimated the effect of lowering salt in the daily American diet by a small amount—up to three grams a day—in adults age 35 and older.

Based on other research, they assumed a three-gram reduction in salt would lower systolic blood pressure by 3.6 to 5.6 millimeters of mercury; a one-gram reduction would reduce the level by 1.2 to 1.9 millimeters. (Systolic is the higher number in a blood-pressure reading. People whose level is 140/90 or more are considered to have high blood pressure.) Such modest blood-pressure reductions are associated, in other studies, with significant lowering of risk of death, heart attack and stroke.

In the current study, researchers found that lowering salt intake by three grams a day would cut new cases of heart disease annually by a third—an estimated 60,000 to 120,000 cases per year—heart attacks by 54,000 to 99,000 cases and strokes by 32,000 to 66,000 cases. It would reduce about 100,000 deaths a year in the U.S.

Based on a cost of $1 a person for salt-reduction strategies projected by the World Health Organization, researchers estimated a U.S. program could save from $10 billion to $24 billion in annual health costs. Such projections can be imprecise because they are based on assumptions that may differ from disease that would develop in real life.

But even if these numbers are off, the results still indicate that sodium reduction is important, said Clyde Yancy, president of the American Heart Association and medical director of the Baylor Heart and Vascular Institute in Dallas. "We can go beyond saying that too much salt is a bad thing," said Dr. Yancy. "We can say, yes, too much sodium is related to disease. By reducing sodium we can reduce disease."

18 January 2010

Federal Panel Urges Obesity Screening for Kids Ages 6 and Up

Business Week

A federal panel of health experts has issued new recommendations encouraging U.S. doctors to screen children aged 6 and older for obesity, and to offer them a referral to intensive weight management programs when necessary.

The recommendations from the U.S. Preventive Services Task Force (USPSTF) update those issued in 2005. At that time, the group said there was insufficient evidence to recommend routine obesity screening in children.

However, "since 2005, a series of randomized clinical trials have demonstrated that there is effective therapy, so we felt compelled to change the recommendations," said the UPSTF panel chair Dr. Ned Calonge, chief medical officer of the Colorado Department of Public Health in Denver.

"This is an encouraging message. There's hope for successful treatment, and we hope that parents will ask their pediatrician if their child needs intervention," said Calonge.

He said it's better to address the problem as early as possible in childhood instead of waiting until your child is grown.

"Once you become an overweight adult, it's more difficult to change your behavior," Colange said. "We do believe that childhood behaviors can be changed, and investing in changing these behaviors in kids is an investment that can pay off lifelong."

The new recommendations will be published in the February issue of Pediatrics, and are available online on Jan. 18 on the Pediatrics Web site.

Although recent statistics suggest that the rate of childhood obesity may be leveling off, one out of every six U.S. children is still obese, according data from the U.S. National Center for Health Statistics released last Wednesday.

The new recommendations now urge doctors to screen all children between 6 and 18 years of age for obesity. Screening should be done using height and weight measurements used to calculate body mass index (BMI), and findings should be compared to other children of the same sex and age. Kids whose BMI is over the 95th percentile for their gender and age are considered obese.

For children or teens who meet the definition of obesity, the task force recommends that doctors refer children and teens to intensive weight-management programs. Such programs should include more than 25 hours of contact with the child or teen over the first six months, and include three components:

    * Counseling for weight loss
    * A physical activity program or counseling on physical activity
    * Behavioral management counseling, such as teaching goal-setting and self-monitoring behaviors

In an editorial in the same issue of the journal, Dr. Sandra Hassink, a member of the American Academy of Pediatrics' board of directors, wrote that the current USPSTF report is "significant because it provides evidence that obesity treatment can be effective and beyond the immediate intervention." However, she also wrote that the recommendation fell short because it should have included younger children, from age 2 and up.

Another concern is that there may not be enough weight-management treatment programs available for all the children who meet the task force's threshold for obesity.

"The recommendation is that any program for children should be at least 25 hours over six months, and it's not easy to find programs that are 25 hours in duration," explained Dr. Goutham Rao, clinical director of the Weight Management and Wellness Center at Children's Hospital of Pittsburgh.

"Very intense programs like this are usually very expensive and private-pay, and they may take in few kids," he said.

Calonge said that at least for now, there may be a shortage of programs. But, he said, as more children are referred, and more insurers start reimbursing for the treatment, more programs should become available. He pointed out that when mammograms were first recommended, few centers were available to address this need, but that hospitals and private companies quickly filled the gap.

Rao agreed that more programs will likely become available, and said that new ways to help children change their behaviors may be developed. At his own center, they've recently developed on online weight-loss program where children keep daily food logs and have email contact with a dietician.

And, despite the potential shortage of treatment programs, Rao said, these recommendations "are a major step in the right direction. The longer you wait to address obesity, the more habits are entrenched. The younger children are, the easier it is to make changes."

15 January 2010

A Doctor's Case For Legal Cannibis

The Wall Street Journal / Dr. David L. Nathan

Most Americans are paying too much for marijuana. I'm not referring to people who smoke it—using the drug generally costs about as much as using alcohol. Marijuana is unaffordable for the rest of America because billions are wasted on misdirected drug education and distracted law enforcement, and we also fail to tax the large underground economy that supplies cannabis.

On Monday, the New Jersey legislature passed a bill legalizing marijuana for a short list of medical uses. Outgoing Democratic Gov. Jon Corzine says he will sign it into law. This is a positive step, as cannabis has several unique medical applications. But the debate over medical marijuana has obscured the larger issue of pot prohibition.

As a psychiatrist, I treat individuals who often suffer from devastating substance abuse. Over many years of dealing with my patients' problems, I have come to realize that we are wasting precious resources on the fight against marijuana, which more closely resembles legal recreational drugs than illegal ones. My conscience compels me to support a comprehensive and nationwide decriminalization of marijuana.

Prohibition did decrease alcoholism and alcohol consumption in the 1920s. However, the resulting rise of violent organized crime and the loss of tax revenue were untenable and led to the repeal of Prohibition. By analogy, while the broad decriminalization of marijuana will likely reduce the societal and economic costs of pot prohibition, it could lead to more use and abuse.

The risks of marijuana use are mild compared to those of heroin, ecstasy and other illegal drugs, but the drug is not harmless. A small number of my patients cannot tolerate any use without serious impact on underlying disorders. Others become daily, heavy smokers, manifesting psychological if not physiological dependence. While most of my patients appear to suffer no ill effects from occasional use, the drug makes my work more difficult with certain individuals.

So why do I support decriminalization? First, marijuana prohibition doesn't prevent widespread use of the drug, although it does clog our legal system with a small percentage of users and dealers unlucky enough to be prosecuted. More to the point, legal cannabis would never become the societal problem that alcohol already is.

In most of my substance-abuse patients, I am far more concerned about their consumption of booze than pot. Alcohol frequently induces violent or dangerous behavior and often-irreversible physiological dependence; marijuana does neither. Chronic use of cannabis raises the risk of lung cancer, weight gain, and lingering cognitive changes—but chronic use of alcohol can cause pancreatitis, cirrhosis and permanent dementia. In healthy but reckless teens and young adults, it is frighteningly easy to consume a lethal dose of alcohol, but it is almost impossible to do so with marijuana. Further, compared with cannabis, alcohol can cause severe impairment of judgment, which results in greater concurrent use of hard drugs.

Many believe marijuana is a gateway drug—perhaps not so harmful in itself but one that leads to the use of more serious drugs. That is not borne out in practice, except that the illegal purchase of cannabis often exposes consumers to profit-minded dealers who push the hard stuff. In this way, the gateway argument is one in favor of decriminalization. If marijuana were purchased at liquor stores rather than on street corners where heroin and crack are also sold, there would likely be a decrease in the use of more serious drugs.

The nation badly needs the revenue of a "sin tax" on marijuana, akin to alcohol and tobacco taxes. Our government could also save money by ending its battle against marijuana in the drug war and redirecting funds to proactive drug education and substance-abuse treatment. Hyperbolic rants about the evils of marijuana could give way to realistic public education about the drug's true risks, such as driving under the influence.

Our nation can acknowledge the dangers of cigarettes, alcohol and marijuana while still permitting their use. The only logically and morally consistent argument for marijuana prohibition necessitates the criminalization of all harmful recreational drugs, including alcohol, nicotine and caffeine. We can agree that such an infringement on personal freedoms is as impractical as it is un-American. The time has come to accept that our nation's attitude toward marijuana has been misguided for generations and that the only rational approach to cannabis is to legalize, regulate and tax it.

13 January 2010

Exercise Improves Memory For Older Women

Guardian UK

Exercise might improve mental sharpness for older people starting to suffer from memory loss, researchers say. However, the benefits were seen mainly in women, and required an intensive, six-month exercise programme.
What do we know already?
Researchers have hoped for some time that exercise might have positive effects for the brain, perhaps by improving blood flow. If the benefits were proven, exercise would be used as a way for older people to prevent memory loss, or even Alzheimer's disease.

So far, research shows that older people who are more active are less likely to have memory problems, but it may just be that healthier, mentally sharper people find it easier to get out and exercise. There have also been some promising animal studies.

In a new trial, researchers asked older adults with slight memory problems to complete a six-month, high-intensity aerobic exercise programme. People exercised for up to an hour, supervised by a trainer, four times a week. They were compared with a second group, who did a more relaxed set of stretching exercises. The average age was 70.
What does the new study say?
Women who exercised intensively improved more in tests looking at things like memory and verbal fluency, compared with women who just did stretching. The researchers don't say whether the improvements were large enough to make a difference in day-to-day life.

For men, there was no clear improvement in most of the tests, despite the fact that men's fitness levels had improved the same amount as the women.
How reliable are the findings?
The main problem with the study is that it's very small. It started with just 33 people in total, and four dropped out before the end. Studies with fewer people tend to be less reliable, especially when you're looking at treatments that only have a small effect.

Where does the study come from?
Several of the researchers were based at the University of Washington, in Seattle. The study appeared in Archives of Neurology, published by the American Medical Association.

Funding came from the US Department of Veterans Affairs, and from the Alzheimer's Association.

What does this mean for me?
The exercise programme used in the trial was quite strenuous. People had been carefully selected to be able to cope, but even so, four of the 23 people doing the intensive programme dropped out because of problems like chest or joint pain. So, it might be that not all older people would be able to complete this type of exercise programme.

The people in the study were aged between 55 and 85, and all had mild problems with their memory. So, we don't know if the results apply to healthy people, or to people with serious memory problems because of Alzheimer's disease.

What should I do now?
It's still too early to say what effects exercise has on how mentally sharp you are. But we know that exercise can protect your health and help keep you fit generally, so it makes sense to stay as active as your health allows. Government guidelines recommend about 30 minutes' exercise, five days a week.
Baker LD, Frank LL, Foster-Schubert K, et al. Effects of aerobic exercise on mild cognitive impairment: a controlled trial. Archives of Neurology.

There's No Good Time For A Stroke, But There May Be A Better Time

LA Times

You might think that the weekend is a particularly bad time to suffer a stroke. Hospitals have smaller staffs, and academic medical centers are more likely to rely on interns, residents and fellows.

A Canadian study from a few years back found that stroke patients who were admitted to the hospital on weekends were 14% more likely to die than patients who were admitted on weekdays, after adjusting for age, sex, complications and other factors.

American researchers have also found that patients who suffered heart attacks on the weekend were less likely to get aggressive cardiac treatment; as a result, mortality is higher on the weekends than on weekdays.

But it turns out that stroke treatment in the U.S. is actually more aggressive on the weekends, according to a new study in the January issue of Archives of Neurology.

Researchers at the Medical University of South Carolina in Charleston analyzed the records of nearly 80,000 patients who were treated for acute ischemic stroke – which occurs when a blood clot or other obstruction cuts off blood supply to the brain – in Virginia between 1998 and 2006.  Patients who were admitted on the weekend were 20% more likely to receive the clot-busting drug tissue plasminogen activator, also known as tPA, than were patients who suffered strokes on weekdays.

The researchers aren’t exactly sure why treatment would be more aggressive on Saturdays and Sundays, but they speculate that the slower pace of the weekend actually benefits stroke patients. There’s less traffic to contend with on the way to the hospital. Diagnostic equipment isn’t tied up by people having elective surgical procedures. And doctors who are staffing weekend shifts may be less busy. Perhaps all of that adds up to a situation in which stroke patients get to doctors within the 3-hour window required for administration of tPA, they wrote.

But it didn’t seem to result in a lower mortality rate on weekends. In fact, the study found that the death rate was about 7% throughout the week.

12 January 2010

Doctor Shortage for Severely Ill Children

The Wall Street Journal

A growing shortage of pediatricians trained in specialties such as neurology, gastroenterology, and developmental and behavioral medicine is threatening timely access to care for children, according to pediatric medical groups.

As the House and Senate intensify the process of melding their two health bills, pediatric groups are lobbying to secure more funding for training and higher reimbursement for pediatric sub-specialties, in the hope of encouraging more doctors-in-training to enter the field. Specialization typically requires up to three years of training beyond a general pediatrics residency and can pay salaries less than half the rate of adult specialty medicine. At present, 17 states lack at least one physician in one of 13 sub-specialties.

Wednesday, in a briefing for members of a congressional caucus on children's health, the National Association of Children's Hospitals and Related Institutions, known as Nachri, will present results of a December survey. In it, members said that shortages of doctors across a multitude of pediatric sub-specialties are forcing 90% of hospitals to delay appointments, lose patients or refer them elsewhere.

Of particular concern, given the rise in autism-related disorders, is a shortage of development-behavioral experts; half of hospitals in the survey reported that it takes more than three months to see a developmental pediatrics specialist, one of the longest wait times.

Jim Kaufman, Nachri's vice president for public policy, says its 200 members on average devote half their caseloads to children from low-income families who are covered by the federal Medicaid program, which reimburses pediatric sub-specialists on average at 30% below what the Medicare program reimburses adult specialists. The group is counting on a provision in the House bill that would require Medicaid to pay Medicare rates for office visits to most providers, which could boost subspecialist pay.

Thanks to advances in medicine such as better care of premature infants, many children are alive who may have died in the past. "We've done a good job of caring for kids with complex medical problems, but we've created a generation of kids who need ongoing and continuing care for serious issues," says Arthur Pickoff, chairman of pediatrics at Children's Medical Center of Dayton, Ohio. His hospital has struggled to fill jobs in gastroenterology, neurology and pediatric surgery and is looking at ways to raise more money for training, such as reducing spending on urgently needed capital projects.

Nachri says 44 hospitals employing 3,000 sub-specialists responded to the survey, representing about 40% the children's hospitals that train half of all pediatric sub-specialists. The hospitals also reported that jobs for the top specialties are going unfilled for a year or longer; nearly half reported vacancies in pediatric-rehabilitation medicine, hematology and oncology, and cardiology.

For families, that often means waiting for months to see a specialist and incurring heavy travel costs, often to another state. Three-year old Kenneth Jones, for example, was born in Alaska with a rare gastrointestinal disorder that made him unable to absorb protein. He had to travel three hours to see one pediatric GI specialist in the state—a doctor who left a year later. The family moved to Oregon for work-related reasons and found a clinic that could provide complete care for the disorder—in Ohio, at a Cincinnati Children's Hospital clinic where they had to wait seven months for Kenneth's first appointment.

"There are so few pediatric GIs out there and so many children that need to be seen that you just have to wait in line," says Kenneth's mother, Lauren Jones. "That's the hardest thing to endure for a parent with a sick child who needs help right away."

For example, nearly 300,000 children suffer rheumatic diseases such as rheumatoid arthritis, characterized by inflammation of joints, muscles or tendons. Pediatric rheumatologists have been trained to treat the complex and sometimes life-threatening diseases, but fewer than 200 are in practice in the U.S.; 13 states lack a pediatric rheumatologist, and children on average travel 57 miles to the nearest one, according to the federal Department of Health and Human Services. Pay for the specialists is even lower than other pediatric sub-specialists; in 2007, salaries averaged $115,022, compared with $144,000 for pediatric cardiology, neonatal medicine and pediatric critical care.

The Senate bill contains a measure that would fund a loan-forgiveness program for pediatric sub-specialists, easing the financial burden of medical-school costs. "While most of us are driven into this profession because we love kids, the vast majority leave training with huge debt and the prospect of not making very much money at the end," says John McBride, a pediatric pulmonologist at Children's Hospital Medical Center of Akron, Ohio, who cares for children with a number of diseases including cystic fibrosis.

The federal Medicare program funds training programs for adult medicine. Congress five years ago authorized funding for pediatric specialty training, but the funds must be re-authorized every year. Nachri is asking for $330 million for funding for fiscal 2011, up from the $317.5 million appropriated for fiscal 2010.

The American Board of Pediatrics currently certifies or jointly certifies 20 pediatric subspecialties, not including neurology and surgical subspecialties. In 2008, there were close to 19,000 certified pediatric sub-specialists, compared to about 15,000 five years earlier. But while there has been an increase in the number of pediatric residents choosing to enter sub-specialty programs, fewer are finishing the training, leading to an overall decline in the number of doctors who chose pediatric specialties. And while the pipeline of trainees is increasing in some specialty areas, large gaps still exist between demand and supply in many pediatric specialty areas, according to James Stockman, president and chief executive of the American Board of Pediatrics.

"We are really in a crisis mode" says Beth Pletcher, a professor at New Jersey Medical School who chairs a committee on work-force issues for the American Academy of Pediatrics. When Dr. Pletcher recently tried to refer a patient to a pediatric endocrinologist, she learned that there was a six-month waiting list—and the doctor wasn't taking any new patients.

One problem is that specialists tend to cluster close to large academic medical centers, in areas where there is a population large enough to sustain a practice. But in a survey of its members, to be published later this year, the American Academy of Pediatrics found that while the greatest shortages are in rural areas, the majority of general pediatricians in all geographic areas considered wait times to be excessive when referring patients to sub-specialists.

To cope with the problem, many hospitals are turning to strategies such as telemedicine—remote consultations using two-way video systems—and mobile vans that may drive hundreds of miles to set up clinics in under-served areas. Hospitals are also more often turning to adult specialists to treat children, though not all are willing to do so. Surgeons, for example, may refuse to operate on children, because they aren't trained to deal with the differences in their physiology.

"Children are not just small adults, they have unique characteristics and different responses to medications and side effects," says Dr. Pletcher. "Given the choice, you want your child to see a pediatric sub-specialist."

11 January 2010

Mayor Bloomberg Urges New Yorkers To Shake The Salt

ABC News

New York Mayor Michael Bloomberg — who is known to shake salt on his pizza — is focusing on sodium as the next unhealthy enemy in his crusade to coax people into eating better.

Bloomberg's health department has already banned trans fats in restaurant meals and forced chain eateries to post calorie counts on menus. On Monday, the city set guidelines recommending maximum amounts of salt for a variety of restaurant and store-bought foods, with the goal of cutting salt levels in food by a quarter overall in five years.

"I use a lot of salt," Bloomberg admitted Monday. Despite any personal eating habits he may have, the mayor is fixated on nutrition as a public health concern.

"We're trying to extend the lives and improve the lives of people who live in this city," he said.

Unlike the city's trans fat ban and calorie count rule, the salt initiative is voluntary.

The recommendations posted on the city health department's Web site call for substantial reductions in the salt content of many products, from a 20 percent drop in peanut butter to a 40 percent decline in canned vegetables.

The targets include a 40 percent reduction in breakfast cereals and flavored snack chips, and a 25 percent reduction for cold cuts, processed cheese and salsa.

Not even the mayor's favorite foods — popcorn and hot dogs — were spared: The city wants food manufacturers to work on reducing salt by 30 percent in popcorn and 20 percent in wieners.

Health officials say Americans now eat about twice the amount of salt they should. Too much sodium contributes to high blood pressure, which can cause heart attack and stroke.

New York City's program is modeled in part after a similar initiative in Britain that has been under way since 2003.

Seventeen national health organizations and 25 other city or state health agencies have endorsed New York City's effort, called the National Salt Reduction Initiative.

Food industry representatives reacted cautiously to the program Monday

"It's something I'm sure our members will be taking under consideration," said Nevin Montgomery, president and chief executive of the National Frozen & Refrigerated Foods Association.

The guidelines suggest that manufacturers lower salt content gradually over several years so consumers won't notice, and they aren't asking for big changes in every category.

For example, under the city's standards, by 2014 no restaurant hamburger should contain more than 1,200 milligrams of salt. Nearly every burger sold by McDonald's already meets that guideline, although there are exceptions like the double quarter pounder with cheese, which has 1,380 milligrams of salt.

ConAgra Foods Inc., which makes products including Chef Boyardee canned pasta meals, Healthy Choice frozen dinners and Swiss Miss hot chocolate, has pledged a 20 percent reduction of salt in its consumer food products by 2015, in part because of consumer demand. The company, based in Omaha, Neb., said its initiative would eliminate about 10 million pounds of salt per year from the American diet.

Even though there will be no penalties for companies that ignore the guidelines, health officials say they think some manufacturers may be motivated to make changes.

"They all fully recognize that sodium is a major health problem that they need to address," said the city's health commissioner, Dr. Thomas Farley.

10 January 2010

FDA Approves New Rheumatoid Arthritis Drug

Food Consumer
The Food and Drug Administration has approved Actemra for the treatment of rheumatoid arthritis (RA), biotechnology company Genentech, Inc. announced this week.

Actemra is indicated for the treatment of adult patients with moderately to severe RA who have had inadequate response to existing rheumatoid arthritis treatments.

"The FDA approval of Actemra marks a major step forward in the treatment of RA, providing a new option for patients with this very serious d isease," said Hal Barron, chief medical officer for Genentech and the parent company, the Roche Group, according to a company statement.

Rheumatoid arthritis is a chronic, progressive inflammatory disease of the joints and tissues resulting in intense pain, joint destruction and a variety of other complications.

The ailment is not the same as arthritis, according to WebMD, but is an auto-immune disease, meaning the body's immune system is mistakenly attacking the tissues it is supposed to protect.

Actemra blocks the effects of a protein, IL-6, which causes the inflammation of joints and tissues, according to study investigator Dr. Mark Genovese, Professor of Medicine at Stanford University Medical Center.

"For many RA patients, treatment with existing therapies does not resolve the painful and debilitating symptoms of the disease," said Genovese. "Data from the clinical development program clearly establish Actemra and its unique mechanism of action as an important new option for RA patients who experience continued disease symptoms despite treatment with existing therapies."

Actemra has been studied in five multi-national studies involving more than 4,000 participants, the largest clinical development program for RA to date, according to Genentech.

The rheumatoid arthritis medication has been approved for use in Japan, the European Union, India, Brazil, Switzerland and Australia.

Worldwide, it is estimated that 1 percent of the population has RA, with about 1.3 million people affected in the United States alone.  RA affects 5 to 6 percent of Native Americans, while people from the Caribbean or of African descent have very low incidence of the disease.

RA is most likely to strike people at the age of 35 to 50 years of age, but it can also occur in children, teenagers, and the elderly.

New, More Expensive Antiseptic Proves Its Value In The Surgical Theatre

Houston Chronicle

A study led by a Houston researcher has found that a less-popular, but more-expensive surgery-site antiseptic is more effective at reducing infections than the most commonly used product.

The research, led by Dr. Rabih Darouiche and published in today's edition of theNew England Journal of Medicine, is prompting a local hospital — one of six across the country to participate in the seven-year study — to change its pre-surgery skin cleanser.

The first-of-its-kind study compared two surgery-site antiseptics — including the one most widely used in the United States to cleanse patients' skin before surgery — and found that the more expensive, less popular product reduces infections about 40 percent more than the other product does.

Research sites included Ben Taub General Hospital and the Michael E. DeBakey VA Medical Center.

Every year in the United States, 300,000 to 500,000 patients have surgical-site infections. Twenty to 30 percent of those infections are caused by staph and more than half of those infections come from bacteria already on the patient's skin.

The more-effective antiseptic — chlorhexidine-alcohol — is used for about 10 percent of U.S. surgeries, but the slightly higher price pales in comparison to the savings for avoiding costly infections, Darouiche said.

Since 2002, the Centers for Disease Control and Prevention has recommended chlorhexidine-alcohol to reduce vascular catheter-association bloodstream infections. Studies have shown the antiseptic is more effective than povidone-iodine for cleaning the entry site for those tiny needles used to move fluids through patients.

“This is a very powerful, quick and practical approach to prevent surgical-site infections,” said Darouiche, who practices at the DeBakey VA Medical Center and teaches at Baylor College of Medicine.

The study included 849 patients.

Most VA hospitals continue to use povidone-iodine to cleanse surgical sites, but because of the study, the DeBakey VA Medical Center is in the process of switching to chlorhexidine-alcohol, Darouiche said.

“The reason they use it is not just because it has been used for decades, but they use it because it's essentially cheap,” he said. An average surgery would require a $12 chlorhexidine-alcohol product. A similar povidone-iodine skin preparation costs about $3.

“You can save anywhere from $10 to $400 (in infection treatment costs) for each extra dollar you spend,” said Darouiche, an internist whose specialties include infectious disease and spinal cord injury medicine.

Neither officials at the hospitals nor CareFusion — the company that makes both antiseptic products — knew about the study results until they were released Wednesday afternoon, Darouiche said.

The company supplied researchers with ChloraPrep, a chlorhexidine-alcohol preoperative skin preparation, along with another product that contained povidone-iodine. The study was almost entirely funded through grants and consulting fees to researchers from Cardinal Health, which recently spun off CareFusion.

08 January 2010

Pet Frogs Behind Salmonella Outbreak

Business Week

For the first time in the United States, doctors have spotted an outbreak of Salmonella linked to African dwarf frogs, typically kept in home aquariums.

According to the U.S. Centers for Disease Control and Prevention (CDC), the outbreak is ongoing, with 85 cases of Salmonella infection in 31 states identified by the end of December.

Salmonella outbreaks have previously been tied to other small pets, such as turtles, but "this is a unique investigation," said report coauthor and CDC epidemiologist Shauna Mettee. "This is the first known outbreak of Salmonella due to contact with frogs -- especially African dwarf frogs."

The infections are mostly in children, Mettee noted. "Half the cases were less than 5 [years of age] and almost 80 percent of all the cases were less than 10 years old. And we are continuing to see new cases," she said.

The report is published in the Jan. 8 issue of the CDC's journal Morbidity and Mortality Weekly Report.

The first signs of an outbreak occurred in April in Utah, where officials identified five cases of Salmonella infection in children. Cases were then found in other states, including Colorado, Ohio, New Mexico and California.

These frogs can be purchased at pet stores, small convenience stores, fairs and toy stores, among other outlets, according to Mettee. "You put them in your aquarium with other fish," she said.

However, like reptiles, such as turtles, frogs are known to carry Salmonella.

The disease is passed to humans not only by touching the frog itself, but from the water in the aquarium.

"Anything the frog comes into contact with is contaminated with Salmonella," Mettee explained. Even when you change the water in the aquarium, some Salmonella remains -- either in the water, the aquarium gravel or other surfaces within the tank.

Currently, the U.S. Food and Drug Administration prohibits the sale of turtles whose shells are less than four inches long, because of the high risk of Salmonella. There are no current regulations governing the sale of frogs, Mettee noted.

Mettee is not discouraging people from buying these frogs, but it is important to follow some simple guidelines to protect yourself and your children.

"If you have any contact with the frog, the water or their habitat, wash your hands with soap and water thoroughly," she said. "Adults should assist young children with the hand washing."

In addition, the aquarium should not be cleaned near where food is prepared, such as in the kitchen sink.

If the tank is cleaned in a bathtub, the tub should also be cleaned with bleach and water, she said.

"We are also recommending that the aquarium not be kept in a child's bedroom, especially for children less than 5," Mettee said.

Most people infected with Salmonella develop diarrhea, fever and abdominal cramps within 12 to 72 hours after contact with the germ. Infections typically clear up in five to seven days.

But, severe infections can occur, particularly in infants, the elderly and people with weakened immune systems. In severe cases, the Salmonella infection can spread from the intestines to the bloodstream and other parts of the body, causing death unless antibiotics are administered, according to the CDC.

Dr. Pascal James Imperato, dean and distinguished service professor of the School of Public Health at SUNY Downstate Medical Center in New York City, said, "It has long been demonstrated that frogs, turtles, snakes and other reptiles, as well as chicks and ducklings, can serve as healthy carriers of a variety of salmonella species which can cause serious illness in humans."

The current multi-state outbreak of salmonella again demonstrates the risks of contact with such pets and their excrement-contaminated environments, he said.

U.S. Backs Vaccines For Drug, Nicotine Addiction


Hooked on cocaine or cigarettes? The U.S. government wants drug companies to make a vaccine for that.

Convinced of the need for new and better treatments for addiction, the government is focusing its efforts on vaccine development as a new way to treat and possibly prevent addiction to a range of addictive substances.

"It's a perspective that is very different from what we've operated on in the past," Dr. Nora Volkow, director of the National Institute on Drug Abuse told reporters this week at the Society for Neuroscience meeting in Chicago.

Volkow said the agency intends to piggyback on the frenetic investment by drug companies in vaccine development, spurred by the need for new products and the runaway success of products like Merck's Gardasil vaccine to prevent the virus that causes cervical cancer.

"There is an enormous amount of research and development in vaccines for cancers and a wide variety of disorders," she said. "We can take advantage of those developments."

But first Volkow has to tempt drug companies to develop the vaccines by funding costly clinical trials.

Earlier this month, her agency, part of the National Institutes of Health, awarded Nabi Biopharmaceuticals a $10 million grant -- the agency's largest ever -- for a late-stage clinical trial of Nabi's vaccine for nicotine addiction called NicVAX.

Volkow said she did her homework before backing the Nabi vaccine to ensure it was significantly different from other products. "Nonetheless, when you are investing in something at this level, it can be very risky," she said.

The vaccine is meant to stimulate the immune system to make antibodies against nicotine, blocking its rewarding effects and helping to prevent relapse in smokers trying to quit.


A similar anti-smoking vaccine by Cytos Biotechnology and Swiss drugmaker Novartis last week missed its main goal in a midstage study, leading some analysts to question whether it can make it to market.

"They are still looking at it but it has been very problematic," said Robert Wasserman, director of investment research at the investment banking firm Dawson James in Florida.

"Vaccines are really tough," he said. "It's not for the faint of heart."

Still, if it works, a nicotine vaccine could have a huge impact, Volkow said. "It's an international problem that kills 5 million individuals every year across the world," she said.

The global market for smoking cessation is expected to reach $4.6 billion by 2016, and vaccines could account for $2 billion in sales, according to independent market research firm Datamonitor.

Volkow said the same methods for making a nicotine vaccine could be used for other illicit substances.

Her agency backed a study released this month of an anti-cocaine vaccine that helped block the high felt by 38 percent of addicts who took it.

The vaccine was developed by Dr. Thomas Kosten of Baylor College of Medicine in Houston, who used a similar approach to make a nicotine vaccine now being tested in Europe by private equity firm Celtic Pharma.

Volkow said drumming up drug company interest in vaccines for illicit drugs is a harder sell because of liability concerns, and the fact that drug abusers are stigmatized.

"Unfortunately, when it comes to cocaine addiction treatment ... most of the investment goes to the government," she said.

06 January 2010

Spreading Joy

Lubbock Online

Winner of contest at state children's hospital glad to share holiday spirit with others

The call came out of the blue. Someone on the other end of the line talking was about a Christmas card contest. For a moment, Tori Houston wasn't sure what this was all about.

"I didn't have a clue when they called me," she said.

As it turns out, this was no telemarketer. Instead, representatives from the Texas Scottish Rite Hospital for Children were calling to inform Tori that her 8-year-old daughter, Kimbree, had been named a winner in the hospital's annual holiday card contest.

"I had to think back for a minute about what contest," Tori said. "I thought to myself, 'What did she draw?' It was done back at the beginning of the summer."

Kimbree, a second-grader at Rush Elementary School, drew and painted a picture of a rocking horse before providing the caption "Have a rocking good Christmas!" Her artwork will be one of three designs used for the hospital's holiday cards.

"She was so excited when she found out," said Tori, who works as a teacher's assistant at Rush. "All the attention she has gotten has been unbelievable. The teachers at the school were excited, and her art teacher is so excited."

Tori said they learned of the contest early in the summer because Kimbree has been a patient at the hospital off and on since she was diagnosed with hip dysplasia. Tori said her daughter was born prematurely and weighed 1 pound at birth.

Following a stint in the neonatal intensive care unit, Kimbree was referred to the Scottish Rite facility, which was founded in 1921 and has become one of the nation's leading medical centers for the treatment of pediatric orthopedic conditions. She was diagnosed with pediatric scoliosis at age 1, and since has made regular visits to the facility in Dallas.

"Her entire life, since she was born, she has been in some kind of an apparatus," Tori said. "She has never yet been without anything. As soon as school let out this past summer, she went into having a halo (a device for immobilizing the head) and being put in a wheelchair. In October, she was back at Scottish Rite having growing rods put in her back."

Through it all, Kimbree has kept a smile and an optimistic outlook.

She may also have a bright future as an artist. In addition to the holiday card, Kimbree drew a horse and painted it for the PTA Reflections program. That effort has won first-place honors at the school and regional level, Tori said

"She doesn't let anything slow her down," Tori said. "To look at her, you would never guess she has been through anything like she's been through."

It was a summer trip to the hospital that opened the door to the holiday card contest, which has been held each year since 1987. The winning designs are sold to the public, with proceeds benefiting patients at the hospital. Kimbree's card was one of three selected from more than 50 entries.

"We happened to be at the hospital for a check-up, and the appointment was over and we were waiting for a taxi to take us back to the airport," Tori said. "A lady handed us a piece of paper and looked right at Kimbree and told her she might want to do this. I put the paper in my purse and didn't think about it until a few days after we got back home. It was the Christmas card contest, and Kimbree decided she wanted to draw a rocking horse."

Horses occupy a special place in Kimbree's heart. Her mother explained that Kimbree has enjoyed the benefits of horse therapy since she was 3.

"Kimbree has very much loved horses since she was a small kid," Tori said. "She does horse therapy, and that's where that love came from."

The dose of holiday cheer couldn't have come at a better time for her daughter, who is also a straight-A student, Tori said.

"This is exactly what she needed," she said. "Everything that she has gone through and had to deal with, with her medical history - She's said to me before, 'Mom, why can't I be like the other kids?' This said it all. This did it right here. She's just like all the other kids."