31 January 2012

Santorum Returns to Campaign, Daughter Seems to be Improving

First appeared in Wall Street Journal
Republican presidential contender Rick Santorum returned to the campaign trail Monday with a speech on the economy after his youngest daughter's health began to improve.

The 3-year-old girl had been hospitalized with pneumonia during the weekend, prompting Mr. Santorum to cancel campaign events. The former Pennsylvania senator said Sunday she had experienced a turnaround and he would resume campaigning. His first event was an economic talk in Missouri, part of a planned swing to appeal to conservative voters in the Midwest.

The child, Isabella Maria, has a genetic disorder known as Trisomy 18. A Santorum campaign spokesman on Monday declined to comment on the girl's health or on when she would leave the hospital. A Michigan Cerebral Palsy Lawyer is happy to not be involved.

Trisomy 18, also known as Edwards Syndrome, impairs a child's development and usually leads to an early death.

The condition occurs in babies with a third 18th chromosome, on top of the normal two. About 1 in 3,000 babies in the U.S. are born with the disorder, according to the Trisomy 18 Foundation. The extra chromosome typically stunts growth, causes heart defects and limits brain development.

"They have no skills to communicate," John Pappas, a pediatric geneticist at New York University's Langone Medical Center, said of those afflicted with the condition. "They can't develop motor skills. Sitting up is probably the most they can do."

Trisomy 18 differs from another chromosomal disorder, Down syndrome, in which babies have an extra 21st chromosome. And its prognosis is bleaker, with less than 10% surviving to their first birthday, according to the Trisomy 18 Foundation. Yet some stricken children live longer, typically those who don't have the extra chromosome in all their cells, Dr. Pappas said. A Baltimore Birth Injury Lawyer watches the events.

The disorder is commonly tested for during pregnancy, especially among women 35 years and over, whose children are at higher risk of birth defects.

Mr. Santorum, a Catholic abortion opponent, has said that he and his wife, Karen, didn't know the diagnosis until days after the birth of their daughter, who is known as Bella. Mr. Santorum said doctors told the couple to "let her go" because she never would be normal. But Mr. Santorum said that angered the couple, and they decided to focus on giving her the best life possible. He frequently calls Bella the "center" of his family's life.

She participates in activities with their other children and is present when they play the piano or board games, the Santorums have said.The description of the conversation with doctors couldn't be immediately verified.

Mr. Santorum's support for Bella is a draw for socially conservative voters. On the campaign trail, Mr. Santorum frequently speaks at churches and Christian schools to people such as David Broome. Mr. Broome, 56 years old, said he is religious and opposes abortion. Citing Mr. Santorum's daughter, "the one that he brought home sick," Mr. Broome said "his story to me is just real." He plans to vote for Mr. Santorum in Florida after voting for Mitt Romney in 2008. A Michigan Birth Injury Lawyer wants to protect families, too.

Mr. Santorum has stopped campaigning in Florida due to disappointing poll results and moved on to the Midwest, where he hopes to find greater traction. He has just opened an office in Nevada, one of the next states to vote on a Republican nominee, and his campaign bristles at the suggestion he may drop out the race. Rival Newt Gingrich has come close to suggesting Mr. Santorum would quit so conservatives may coalesce around Mr. Gingrich.

27 January 2012

Community Wants Answers About Mysterious Outbreak

First appeared in USA Today
Beth Miller says her 16-year-old daughter — who is among the teens afflicted with facial tics and verbal outbursts in a mysterious outbreak in Le Roy, N.Y. — was better for a while but is now "worse." And that's why Miller and others are hoping environmental activist Erin Brockovich can provide some answers that others haven't.

"My sister-in-law contacted her first and said 'Something's not right here.' Then we contacted her as well and thought if both of us contact her, maybe she'll answer," Miller said Thursday. A week ago, the neurologist treating most of the 12 girls with the same symptoms said that medical disorders, diseases and environmental factors had been ruled out, leading him to a stress-related diagnosis called conversion disorder. Three additional teens, including one boy, are now reported to have similar symptoms.

"We contacted her to see if she thought it could be an environmental problem," says Don Miller, who has raised stepdaughter Katie Krautwurst, the youngest of their five kids, since age 1.

He says they haven't been satisfied with the environmental testing done so far. "They did the bare minimum."
Brockovich says she has heard from many in the community and around the country, all wondering about the possibility of an environmental cause. She's sending an engineer to to do a site assessment and meet with families this weekend.

"He's prepared to take soil samples and water samples," she says. "We'd like to do soil vapor testing but can't because the ground is frozen and we won't get a true result."

The Le Roy Central School District, in a statement posted on its website, says medical and environmental investigations have uncovered no evidence that would link neurological symptoms "to anything in the environment or of an infectious nature." Superintendent Kim Cox, in an e-mail Thursday, said, "There will be no further comment at this time."

But Brockovich points to a well-documented chemical spill more than 40 years ago within 3 miles of the high school, which opened in the fall of 2003. She speculates contaminated soil may have been used in the school construction.

The spill was on Dec. 6, 1970, after a train derailment. A report by the U.S. Environmental Protection Agency said 1 ton of cyanide crystals spilled to the ground, along with 35,000 gallons of an industrial solvent called trichloroethene, also known as trichloroethylene, or TCE.

The cyanide crystals were removed and "neutralizers were spread on the ground to counteract the effects of any remaining cyanide," the EPA report, written in 1999, says.

However the liquid TCE, was absorbed into the ground. Residents later reported smelling the chemical, which has a distinctive sweet odor, in local well water. Testing between 1990 and 1994 found 50 contaminated wells in the area, the EPA says. Residents received filtering systems for their water.

The site was placed on the Superfund National Priorities List in 1999.

"Everyone around in the '70s knew about the spill," says Don Miller, who says he and his wife grew up in Le Roy.

As a young teen, he says, he was among those who helped clean up bottles and other debris at the site, though not chemicals, he adds. He now works as a dispatcher for a trucking company.

A report written in 1997 by the New York State Department of Health, together with the Agency for Toxic Substances and Disease Registry (ATSDR) says that early in 1971, people living next to the spill site "complained of solvent-like odors in their drinking water," which came from wells, the only source of water in the area.

A report issued in 2006 by the National Academy of Sciences on the effects of exposure to trichloroethylene found that inhalation of TCE can cause "neurotoxic effects in laboratory animals and humans." One of those is a change in the "masseter reflex latency," or jaw jerk reflex. Whether that is in any way similar to the facial tics the girls are exhibiting is unclear.

Though the girls' symptoms have been described as "Tourette's-like," John Walkup, chair of the medical advisory board of the National Tourette Syndrome Association, says to his knowledge there's been no connection between Tourette's and exposure to TCE.

The National Academy of Sciences report also noted that "drinking water contaminated with small amounts of TCE over a length of time may cause liver and kidney damage, impaired immune system function and possibly birth defects," the Academy report said. The EPA has concluded that TCE is highly likely to produce cancer in humans.

The National Institutes of Health in Bethesda, Md., has said that any of the affected students can be tested as part of an ongoing study of conversion disorder, characterized by problems with voluntary motor or sensory function that suggest a neurological condition but aren't consistent with known biological causes.

In more than one person, conversion disorder is called "mass psychogenic illness," said neurologist Laszlo Mechtler of the Dent Neurologic Institute in Buffalo, who made the determination.

25 January 2012

Hospitals for the Affluent

First appeared in NY Times
The feverish patient had spent hours in a crowded emergency room. When she opened her eyes in her Manhattan hospital room last winter, she recalled later, she wondered if she could be hallucinating: “This is like the Four Seasons — where am I?”

The bed linens were by Frette, Italian purveyors of high-thread-count sheets to popes and princes. The bathroom gleamed with polished marble. Huge windows displayed panoramic East River views. And in the hush of her $2,400 suite, a man in a black vest and tie proffered an elaborate menu and told her, “I’ll be your butler.”

It was Greenberg 14 South, the elite wing on the new penthouse floor of NewYork-Presbyterian/Weill Cornell hospital. Pampering and décor to rival a grand hotel, if not a Downton Abbey, have long been the hallmark of such “amenities units,” often hidden behind closed doors at New York’s premier hospitals. But the phenomenon is escalating here and around the country, health care design specialists say, part of an international competition for wealthy patients willing to pay extra, even as the federal government cuts back hospital reimbursement in pursuit of a more universal and affordable American medical system.

“It’s not just competing on medical grounds and specialties, but competing for customers who can go just about anywhere,” said Helen K. Cohen, a specialist in health facilities at the international architectural firm HOK, which recently designed luxury hospital floors in Singapore and London and renovated NewYork-Presbyterian’s elite offerings in the McKeen Pavilion in Washington Heights. “These kinds of patients, they’re paying cash — they’re the best kind of patient to have,” she added. “Theoretically, it trickles down.”

A waterfall, a grand piano and the image of a giant orchid grace the soaring ninth floor atrium of McKeen, leading to refurbished rooms that, like those in the hospital’s East 68th Street penthouse, cost patients $1,000 to $1,500 a day, and can be combined. That fee is on top of whatever base rate insurance pays to the hospital, or the roughly $4,500 a day that foreigners are charged, according to the hospital’s international services department.

But in the age of Occupy Wall Street, catering to the rich can be trickier than ever, noted Avani Parikh, who worked for NewYork-Presbyterian as in-house project leader when the 14th floor was undertaken. She pointed to the recent ruckus at Lenox Hill Hospital, where parents with newborns in the intensive-care unit complained that security guards had restricted their movements and papered over hospital security cameras in their zeal to please Jay-Z (real name Shawn Carter) and Beyoncé Knowles, whose daughter was born on Jan. 7 in a new “executive suite.”

Many American hospitals offer a V.I.P. amenities floor with a dedicated chef and lavish services, from Johns Hopkins Hospital in Baltimore to Cedars-Sinai Medical Center in Los Angeles, which promises “the ultimate in pampering” in its $3,784 maternity suites. The rise of medical tourism to glittering hospitals in places like Singapore and Thailand has turned coddling and elegance into marketing necessities, designers say.

The spotlight on luxury accommodations comes at an awkward time for many urban hospitals, now lobbying against cuts in Washington and highlighting their role as nonprofit teaching institutions that serve the poor.

Indeed, NewYork-Presbyterian, which once opposed amenities units, would not answer questions about its shift, and declined a reporter’s request for a tour.

In Greenberg, where the visitors’ lounge seems to hang over the East River in a glass prow and Ciao Bella gelato is available on demand, the patient who likened her suite to the Four Seasons was not paying for it. She did not want to be identified because her wealthy boss, who picked up the bill, would not want publicity.

During a reporter’s unofficial visits to both units this month, however, some people enjoying the perks expressed uneasiness about those priced out. In space-starved New York, many regular hospital rooms are still double-occupancy, though singles are now the national standard for infection control and quicker recovery.

“The concierges act like butlers,” said John Frehse, 37, who was visiting his ailing father, Robert M. Frehse, 86, the retired chief executive of the Hearst Foundations. He and his mother, Dale Frehse, paused in their praise of the care to recall the fate of a family friend stuck for three days in the NewYork-Presbyterian emergency room for lack of a hospital bed last winter. At the time, they recalled, the Saudi king had been granted the whole 14th floor for his entourage.

The younger Mr. Frehse contrasted the unit’s mouth-watering menu with the “inedible food” his father faced when he was treated on the non-elite second floor. “Here he has mushroom risotto with heirloom tomatoes,” he said.

The hospital said in a statement: “NewYork-Presbyterian is dedicated to providing a single standard of high quality care to all of our patients.”

At Mount Sinai Medical Center, where the aesthetic of the Eleven West wing is antique mahogany rather than contemporary sleek, and the best room costs $1,600, William Duffy, the hospital’s director of hospitality, said his favorite entree was Colorado rack of lamb, adding, “We pride ourselves on getting anything the patient wants. If they have a craving for lobster tails and we don’t have them on the menu, we’ll go out and get them.”

The 19-room unit, which opened 18 years ago but received a recent face-lift, takes in $3.5 million a year, Mr. Duffy said, estimating that 30 percent of its clientele comes from abroad. If the emergency room is backed up, a regular patient may be upgraded, he added: “Bump ’em up to Business, as we say.”

Wayne Keathley, Mount Sinai’s president, minimized the unit’s role in the 1,171-bed hospital, on Fifth Avenue at 101st Street. “It is not nearly as large or elaborate as some others,” Mr. Keathley said. He called the money it brought in “a rounding error in my budget,” and said that patients came for the clinical care, not the amenities.

In Eleven West’s library on a recent Friday, Nancy Hemenway, a senior financial services executive, was reading the paper in a spa-style bathrobe. “I was supposed to be in Buenos Aires last week taking tango lessons, but unfortunately I hurt my back, so I’m here with my concierge,” she said.

“I’m perfectly at home here — totally private, totally catered,” she added. “I have a primary-care physician who also acts as ringmaster for all my other doctors. And I see no people in training — only the best of the best.”

Mr. Keathley said the lack of interns and residents on Eleven West was a function of clinical judgments and limits to the training program, not the preferences of rich patients.

But even the rainmakers — doctors who bring in such patients — can sometimes resent the tilt toward luxury.

“The one misgiving is patients with Medicare, which pays physicians almost nothing,” said Dr. Brian Katz, 59, a laparoscopic surgeon in scrubs who took a break in the same library later. “Yet those patients will come up here and pay to enjoy five-star comfort.”

Increasingly, hospitals serving the merely well-off are joining the amenities race. Beth Israel Medical Center near Union Square added a “deluxe unit” in 2008, catering mainly to patients after elective orthopedic surgery. The green-carpeted lobby may be more Radisson than Ritz, but its 12 single rooms starting at $450 feature Bose stereos and flat-screen TVs, and chef-prepared kosher food is served on china.

“A very insignificant portion of our beds are identified as deluxe accommodations,” said Gail Donovan, the chief operating officer of Continuum Partners, which includes Beth Israel and St. Luke’s-Roosevelt Hospital. “Our mission is really to be the safety net hospitals of our communities.”

The conflicts echo those of a century ago, in another era of growing income inequality and financial crisis, said David Rosner, a professor of public health and history at Columbia University. Hospitals, founded as free, charitable institutions to rehabilitate the poor, began seeking paying patients for the first time in the 1890s, he said, restyling themselves in part as “hotels for rich invalids.”

“Every generation of hospitals reflects our attitude about health and disease and wealth and poverty,” Professor Rosner said. “Today, they pride themselves on attracting private patients, and on the other hand ask for our tax dollars based upon their older charitable mission. There’s a conflict there at times.”

His perspective on McKeen’s amenities unit, where afternoon tea is served daily, is colored by the emergency room experience of one of his graduate students on the same hospital campus this month, he added. She spent two days on a gurney in terrible pain from herniated disks, he said, until a dean intervened to get her a room. “She hadn’t even been given a bed pan,” he said.

Less Invasive Surgery Procedures

 First appeared on Chron.com
Dr. Sandra Hurtado moved her right hand, ever so slightly, and a kidney appeared on the screen.

"Keep coming," surgical robotics instructor Armando Garcia urged. "Keep coming ... Now, go right above it with your left hand."

Hurtado, an ob-gyn, has performed laparoscopic surgeries since leaving medical school more than 20 years ago. But last week, she was at Memorial Hermann Hospital's surgical training lab to gain skills in a movement that has sharply reduced the demand for traditional surgical procedures.

Despite resistance from some peers, Hurtado and other midcareer surgeons are scrambling to keep pace with the growth in less-invasive surgical techniques, allowing them to satisfy patients' demands for smaller scars and quicker recoveries.

Young surgeons learn the procedures during training, but Dr. Daniel Albo, chief of surgical oncology at Baylor College of Medicine, said some older surgeons still resist.

"There's an ego that gets in the way of a surgeon saying, 'I need to get back and retrain,' " Albo said. "Laparoscopic surgery requires a completely different skill set.

"Think of it as grandpa versus the grandson playing video games," he said. "For the grandson, it is very intuitive. For the grandpa, it's an aggravation."

Cost factor unclear

There aren't definitive statistics for how many of the 27 million surgical procedures performed in the United States every year are done with minimally invasive techniques or how much money that saves.

Some people question the conventional wisdom that the new techniques save money, since the up-front costs can be high. But that hasn't slowed the rush toward the new procedures.

The revolution started in France in 1987, when a gynecologist used a video monitor and specialized instruments to remove a patient's gallbladder through small incisions, rather than the traditional hip-to-hip cut across the abdomen.

Similar procedures had been done before, but that procedure in Lyons, France, is considered the true beginning of minimally invasive surgery. Now, it's the standard way to remove a gallbladder.

Colorectal surgeries, at the other extreme, are still done almost exclusively via a large incision, Albo said.

Minimally invasive surgery includes a variety of techniques: Cardiologists use stents as an alternative to chest-cracking coronary bypasses. Surgeons use endoscopes, inserted through the mouth or another body opening, for some procedures. Laparoscopic procedures use special tools inserted through one or more small incisions.

A tiny camera is slipped inside the body to display the view on a video screen, since the surgeon can't see the internal organs directly.

Challenge for veterans

The techniques require a shift in mindset, said Dr. Shawn Tsuda, chief of the division of minimally invasive and bariatric surgery at the University of Nevada Medical School.

"You're looking at a two-dimensional screen instead of the patient's body and tissues," he said. "For the young generation, maybe they play video games or punch in texts on their tiny phones. They're good at it.

"For more experienced surgeons, it can be a real challenge."

From bariatric surgery to breast augmentation surgery, robot-assisted surgeries are the next frontier.

The video display is three-dimensional, and Hurtado said the tools offer more dexterity than those used in traditional laparoscopic surgery.

She and her Obstetrical & Gynecological Associates colleagues at the Woman's Hospital of Texas already perform mostly minimally invasive procedures, but some patients still require more extensive open surgery, she said.

Last week she was learning to use robot-assisted tools, which she said will reduce the need for that.

Patients like the smaller incisions and faster recovery. Erik Wilson, a surgeon and faculty member at the University of Texas Medical School at Houston, said patients always ask for minimally invasive procedures.

"That's where everything is going because that's what everyone wants," said Wilson, a founding member of the Clinical Robotic Surgery Association. "I don't open people up for anything unless they're critically ill and you just don't have any time."

Financial edge?

There is less agreement on the financial advantages. Initial costs increase to pay for the new surgical tools, Tsuda said.

Robot-assisted surgery has especially high startup costs; Peter Herrera, director of surgical innovation at Memorial Hermann, said each station and its accompanying tools cost $1.5 million or more.

But most patients leave the hospital sooner than those who undergo traditional surgery.

They also have fewer complications and return to work more quickly, all of which can reduce costs over time.

"If you look at global health care costs, the cost of not only the procedure itself, but of complications, the cost of managing complications, recovery times, return to work times, then laparoscopic surgery reduces the cost of care," Albo said.

16 January 2012

Common Skin Infections

First appeared on Cleveland Clinic
Bacterial infections
Humans are natural hosts for many bacterial species that colonize the skin as normal flora. Staphylococcus aureus and Streptococcus pyogenes are infrequent resident flora, but they account for a wide variety of bacterial pyodermas. Predisposing factors to infection include minor trauma, preexisting skin disease, poor hygiene, and, rarely, impaired host immunity.

Definition and Etiology
Impetigo is a superficial skin infection usually caused by S. aureus and occasionally by S. pyogenes.

Prevalence and Risk Factors
Impetigo affects approximately 1% of children.

Pathophysiology and Natural History
S. aureus produces a number of cellular and extracellular products, including exotoxins and coagulase, that contribute to the pathogenicity of impetigo, especially when coupled with preexisting tissue injury. Impetigo commonly occurs on the face (especially around the nares) or extremities after trauma.

Signs and Symptoms
Two clinical types of impetigo exist: nonbullous and bullous. The nonbullous type is more common and typically occurs on the face and extremities, initially with vesicles or pustules on reddened skin. The vesicles or pustules eventually rupture to leave the characteristic honey-colored (yellow-brown) crust. Bullous impetigo, almost exclusively caused by S. aureus, exhibits flaccid bullae with clear yellow fluid that rupture and leave a golden-yellow crust.

Diagnosis is by clinical presentation and confirmation by culture.

For most patients with impetigo, topical treatment is adequate, either with bacitracin (Polysporin) or mupirocin (Bactroban), applied twice daily for 7 to 10 days. Systemic therapy may be necessary for patients with extensive disease.

Folliculitis, Furunculosis, and Carbunculosis

Definition and Etiology
Folliculitis is a superficial infection of the hair follicles characterized by erythematous, follicular-based papules and pustules. Furuncles are deeper infections of the hair follicle characterized by inflammatory nodules with pustular drainage, which can coalesce to form larger draining nodules (carbuncles).

Pathophysiology and Natural History
S. aureus is the usual pathogen, although exposure to Pseudomonas aeruginosa in hot tubs or swimming pools can lead to folliculitis. In general, folliculitis is a self-limited entity. Occasionally, a pustule enlarges to form a tender, red nodule (furuncle) that becomes painful and fluctuant after several days. Rupture often occurs, with discharge of pus and necrotic material. With rupture, the pain subsides and the redness and edema diminish.

Signs and Symptoms
Folliculitis is generally asymptomatic, but it may be pruritic or even painful. Commonly affected areas are the beard, posterior neck, occipital scalp, and axillae. Often a continuum of folliculitis, furunculosis (furuncles), arises in hair-bearing areas as tender, erythematous, fluctuant nodules that rupture with purulent discharge. Carbuncles are larger and deeper inflammatory nodules, often with purulent drainage, and commonly occur on the nape of the neck, back, or thighs. Carbuncles are often tender and painful and occasionally accompanied by fever and malaise.

Diagnosis is by clinical presentation and confirmation by culture.

Topical treatment with clindamycin 1% or erythromycin 2%, applied two or three times a day to affected areas, coupled with an antibacterial wash or soap, is adequate for most patients with folliculitis. Systemic antistaphylococcal antibiotics are usually necessary for furuncles and carbuncles, especially when cellulitis or constitutional symptoms are present.2 Small furuncles can be treated with warm compresses three or four times a day for 15 to 20 minutes, but larger furuncles and carbuncles often warrant incision and drainage. If methicillin-resistant S. aureus (MRSA) is implicated or suspected, vancomycin (1-2 g IV daily in divided doses) is indicated coupled with culture confirmation. Antimicrobial therapy should be continued until inflammation has regressed or altered depending on culture results.


Definition and Etiology
Ecthyma is a cutaneous infection characterized by thickly crusted erosions or ulcerations. Ecthyma is usually a consequence of neglected impetigo and often follows impetigo occluded by footwear or clothing.

Prevalence and Risk Factors
Ecthyma typically occurs in homeless persons and soldiers based in hot and humid climates.

Pathophysiology and Natural History
S. aureus or S. pyogenes is the usual pathogen of ecthyma. Untreated staphylococcal or streptococcal impetigo can extend more deeply, penetrating the dermis, producing a shallow crusted ulcer. Ecthyma can evolve from a primary pyoderma, in a pre-existing dermatosis, or at the site of trauma.

Signs and Symptoms
Infection begins with vesicles and bullae that progress to punched-out ulcerations with an adherent crust, which heals with scarring. The most common site of infection is the legs.

Diagnosis is by clinical presentation and confirmation by culture.

Erysipelas and Cellulitis

Definition and Etiology
Erysipelas is a superficial cutaneous infection of the skin involving dermal lymphatic vessels. Cellulitis is a deeper process that extends to the subcutis.

Prevalence and Risk Factors
Erysipelas has a predilection for young children and the elderly. Lymphedema, venous stasis, web intertrigo, diabetes mellitus, trauma, alcoholism, and obesity are risk factors in the adult patient.

Pathophysiology and Natural History
Group A ?-hemolytic streptococcus is the most common pathogen responsible for erysipelas, and S. aureus is by far the most common pathogen for cellulitis. S. pyogenes produces enzymes that promote infection with systemic manifestations, such as fever and chills, tachycardia, and hypotension. Left untreated, cellulitic skin can become bullous and necrotic, and an abscess or fasciitis, or both, can occur.

Signs and Symptoms
Classically, erysipelas is a tender, well-defined, erythematous, indurated plaque on the face or legs. Cellulitis is a warm, tender, erythematous, and edematous plaque with ill-defined borders that expands rapidly. Cellulitis is often accompanied by constitutional symptoms, regional lymphadenopathy, and occasionally bacteremia.

Diagnosis is by clinical presentation and confirmation by culture (if clinically indicated, ie., bullae or abscess formation).

Penicillin (250-500 mg, qid × 7-10 days) is the treatment of choice for erysipelas; parenteral therapy may be necessary for extensive or facial disease. An oral antistaphylococcal antibiotic is the treatment of choice for cellulitis; parenteral therapy is warranted for patients with extensive disease or with systemic symptoms as well as for immunocompromised patients. Good hygiene, warm compresses three or four times a day for 15 to 20 minutes, and elevation of the affected limb help to expedite healing.

Necrotizing Fasciitis

Definition and Etiology
Necrotizing fasciitis is a rare infection of the subcutaneous tissues and fascia that eventually leads to necrosis. Predisposing factors include injuries to soft tissues, such as abdominal surgery, abrasions, surgical incisions, diabetes, alcoholism, cirrhosis, and intravenous drug abuse.

Pathophysiology and Natural History
S. pyogenes can be the sole pathogen responsible for necrotizing fasciitis, but most patients have a mixed infection with other aerobes (groups B and C streptococci, MRSA) and anaerobes (Clostridium spp).

Signs and Symptoms
Infection begins with warm, tender, reddened skin and inflammation that rapidly extends horizontally and vertically. Necrotizing fasciitis commonly occurs on the extremities, abdomen, or perineum or at operative wounds. Within 48 to 72 hours, affected skin becomes dusky, and bullae form, followed by necrosis and gangrene, often with crepitus. Without prompt treatment, fever, systemic toxicity, organ failure, and shock can occur, often followed by death. Computed tomography (CT) or magnetic resonance imaging (MRI) can help to delineate the extent of infection. Biopsy for histology, Gram stain, and tissue culture help to identify the causative organism(s).

Diagnosis is by clinical presentation; CT or MRI; skin biopsy for pathology, Gram stain, and tissue culture; culture of fluid from bullae or fluctuant plaques; and blood cultures.

Necrotizing fasciitis is a surgical emergency requiring prompt surgical debridement, fasciotomy, and, occasionally, amputation of the affected extremity to prevent progression to myonecrosis. Treatment with parenteral antibiotics (usually gentamicin and clindamycin) is mandatory. Even with treatment, mortality approaches 70%.

Fungal and yeast infections


Definition and Etiology
Dermatophytosis implies infection with fungi, organisms with high affinity for keratinized tissue, such as the skin, nails, and hair. Trichophyton rubrum is the most common dermatophyte worldwide.  This is similar to Ringworm.

Pathophysiology and Natural History
Three fungal genera—Trichophyton, Microsporum, and Epidermophyton—account for the vast majority of infections. Fungal reservoirs for these organisms include soil, animals, and infected humans.

Signs and Symptoms
Tinea pedis (athlete's foot) is the most common fungal infection in humans in North America and Europe. Affected skin is usually pruritic, with scaling plaques on the soles, extending to the lateral aspects of the feet and interdigital spaces, often with maceration.

Tinea cruris (jock itch) occurs in the groin and on the upper, inner thighs and buttocks as scaling annular plaques; disease is more common in men and typically spares the scrotum.  A Ringworm treatment can help with uncomfortable symptoms.

Tinea capitis, or fungal infection of the scalp, is most common in children. It is characterized by scaly, erythematous skin, often with hair loss. Tinea capitis can resemble seborrheic dermatitis. Kerion celsi is an inflammatory form of tinea capitis, characterized by boggy nodules, usually with hair loss and regional lymphadenopathy.

Tinea corporis (body), faciei (face), and manuum (hands) represent infections of different sites, each invariably with annular scaly plaques. Tinea unguium (onychomycosis) is fungal nail disease, characterized by thickened yellow nails and subungual debris.

Potassium hydroxide preparation or culture help to establish the diagnosis for all forms of fungal infections.

Diagnosis is by clinical presentation, KOH examination, and fungal culture.

For most patients, topical treatment with terbinafine (Lamisil), clotrimazole (Lotrimin, Mycelex), or econazole (Spectazole) cream is adequate when applied twice daily for 6 to 8 weeks. For onychomycosis, tinea capitis, and extensive dermatophyte disease, systemic treatment is often necessary: itraconazole (Sporanox) or terbinafine (Lamisil) for nail disease, and griseofulvin or fluconazole for scalp or extensive dermatophyte disease.  Some patients use a Ringworm cure to work with symptoms.


Definition and Etiology
Candidiasis refers to a diverse group of infections caused by Candida albicans or by other members of the genus Candida. These organisms typically infect the skin, nails, mucous membranes, and gastrointestinal tract, but they also cause systemic disease.

Prevalence and Risk Factors
Infection is common in immunocompromised patients, diabetics, the elderly, and patients receiving antibiotics.

Pathophysiology and Natural History
Candida albicans accounts for 70% to 80% of all candidal infections. C. albicans commonly resides on skin and mucosal surfaces. Alterations in the host environment can lead to its proliferation and subsequent skin disease.

Signs and Symptoms
Candidal intertrigo is a specific infection of the skin folds (axillae, groin), characterized by reddened plaques, often with satellite pustules. Thrush is oropharyngeal candidiasis, characterized by white nonadherent plaques on the tongue and buccal mucosa. Paronychia is an acute or chronic infection of the nail characterized by tender, edematous, and erythematous nail folds, often with purulent discharge; this disease is common in diabetics. Angular cheilitis is the presence of fissures and reddened scaly skin at the corner of the mouth, which often occurs in diabetics and in those who drool or chronically lick their lips.
Candidal vulvovaginitis is an acute inflammation of the perineum characterized by itchy, reddish, scaly skin and mucosa; creamy discharge; and peripheral pustules. The counterpart in men is balanitis, characterized by shiny reddish plaques on the glans penis, which can affect the scrotum. Balanitis occurs almost exclusively in uncircumcised men.

Diagnosis is by clinical presentation, KOH examination, and fungal culture.

For candidal intertrigo and balanitis, topical antifungal agents such as clotrimazole, terbinafine, or econazole cream, applied twice daily for 6 to 8 weeks, is usually curative when coupled with aeration and compresses. For thrush, the treatment is nystatin suspension or clotrimazole troches four to six times daily until symptoms resolve. Systemic antifungal drugs, such as fluconazole 100 to 200 mg/day or itraconazole 100 to 200 mg/day, for 5 to 10 days may be necessary for severe or extensive disease. For paronychia, treatment consists of aeration and a topical antifungal agent such as terbinafine, clotrimazole, or econazole for 2 to 3 months; occasionally, oral antistaphylococcal antibiotics are needed, coupled with incision and drainage for secondary bacterial infection. Cheilitis resolves with aeration, application of a topical antifungal agent, and discontinuation of any aggravating factors. A single 150-mg dose of fluconazole, coupled with aeration, is usually effective for vulvovaginitis.

Tinea (Pityriasis) Versicolor

Definition and Etiology
Tinea versicolor is a common opportunistic superficial infection of the skin caused by the ubiquitous yeast Malassezia furfur.  This is similar to Ringworm.

Prevalence and Risk Factors
Prevalence is high in hot, humid climates. Purported risk factors include oral contraceptive use, heredity, systemic corticosteroid use, Cushing's disease, immunosuppression, hyperhidrosis, and malnutrition.

Pathophysiology and Natural History
M. furfur may filter the rays of the sun and also produces phenolic compounds that inhibit tyrosinase, which can produce hypopigmentation in many patients.

Signs and Symptoms
Infection produces discrete and confluent, fine scaly, well-demarcated, hypopigmented or hyperpigmented plaques on the chest, back, arms, and neck. Pruritus is mild or absent.  These symptoms can be generally alleviated with a Ringworm cure.

Diagnosis is by clinical presentation. Potassium hydroxide preparation exhibits short hyphae and spores with a spaghetti-and-meatballs appearance.

Selenium sulfide shampoo (2.5%) or ketoconazole shampoo is the mainstay of treatment, applied to the affected areas and the scalp daily for 3 to 5 days, then once a month thereafter. Alternatively, a variety of topical antifungal agents, including terbinafine, clotrimazole, or econazole cream, applied twice daily for 6 to 8 weeks, constitute adequate treatment, especially for limited disease. Systemic therapy may be necessary for patients with extensive disease or frequent recurrences, or for whom topical agents have failed. Ringworm treatment can be helpful with certain symptoms.

Viral infections

Herpes Simplex

Definition and Etiology
Herpes simplex virus (HSV) infection is a painful, self-limited, often recurrent dermatitis, characterized by small grouped vesicles on an erythematous base. Disease is often mucocutaneous. HSV type 1 is usually associated with orofacial disease, and HSV type 2 is usually associated with genital infection.

Prevalence and Risk Factors
Eighty-five percent of the population has antibody evidence of HSV type 1 infection. HSV type 2 infection is responsible for 20% to 50% of genital ulcerations in sexually active persons.

Pathophysiology and Natural History
Disease follows implantation of the virus via direct contact at mucosal surfaces or on sites of abraded skin. After primary infection, the virus travels to the adjacent dorsal ganglia, where it remains dormant unless it is reactivated by psychological or physical stress, illness, trauma, menses, or sunlight.

Signs and Symptoms
Primary infection occurs most often in children, exhibiting vesicles and erosions on reddened buccal mucosa, the palate, tongue, or lips (acute herpetic gingivostomatitis). It is occasionally associated with fever, malaise, myalgias, and cervical adenopathy. Herpes labialis (fever blisters or cold sores) appears as grouped vesicles on red denuded skin, usually the vermilion border of the lip; infection represents reactivated HSV. Primary genital infection is an erosive dermatitis on the external genitalia that occurs about 7 to 10 days after exposure; intact vesicles are rare. Recurrent genital disease is common (approximately 40% of affected patients). Prodromal symptoms of pain, burning, or itching can precede herpes labialis and genital herpes infections.

Viral culture helps to confirm the diagnosis; direct fluorescent antibody (DFA) is a helpful but less-specific test. Serology is helpful only for primary infection. The Tzanck smear can be helpful in the rapid diagnosis of herpesviruses infections, but it is less sensitive than culture and DFA.

Acyclovir remains the treatment of choice for HSV infection; newer antivirals, such as famciclovir and valacyclovir, are also effective. For recurrent infection (more than six episodes per year), suppressive treatment is warranted. Primary infection in immunosuppressed patients requires treatment with acyclovir 10 mg/kg every 8 hours for 7 days.

Herpes Zoster

Definition and Etiology
Herpes zoster (shingles) is an acute, painful dermatomal dermatitis that affects approximately 10% to 20% of adults, often in the presence of immunosuppression.

Pathophysiology and Natural History
During the course of varicella, the virus travels from the skin and mucosal surfaces to the sensory ganglia, where it lies dormant for a patient's lifetime. Reactivation often follows immunosuppression, emotional stress, trauma, and irradiation or surgical manipulation of the spine, producing a dermatomal dermatitis.

Signs and Symptoms
Herpes zoster is primarily a disease of adults and typically begins with pain and paresthesia in a dermatomal or bandlike pattern followed by grouped vesicles within the dermatome several days later. Occasionally, fever and malaise occur. The thoracic area accounts for more than half of all reported cases. When zoster involves the tip and side of the nose (cranial nerve V) nasociliary nerve involvement can occur (30%-40%). Most patients with zoster do well with only symptomatic treatment, but postherpetic neuralgia (continued dysthesias and pain after resolution of skin disease) is common in the elderly. Disseminated zoster is uncommon and occurs primarily in immunocompromised patients.

Diagnosis is by clinical presentation, viral culture, or direct fluorescent antibody.

Zoster deserves treatment, with rest, analgesics, compresses applied to affected areas, and antiviral therapy, if possible, within 24 to 72 hours of disease onset. Disseminated and ophthalmic zoster warrants treatment with acyclovir 10 mg/kg intravenously every 8 hours for 7 days.


Definition and Etiology
Warts are common and benign epithelial growths caused by human papillomavirus (HPV).

Prevalence and Risk Factors
Warts affect approximately 10% of the population. Anogenital warts are a sexually transmitted infection, and partners can transfer the virus with high efficiency. Immunosuppressed patients are at increased risk for developing persistent HPV infection.

Pathophysiology and Natural History
HPV infection follows inoculation of the virus into the epidermis through direct contact, usually facilitated by a break in the skin. Maceration of the skin is an important predisposing factor, as suggested by the increased incidence of plantar warts in swimmers. After inoculation, a wart usually appears within 2 to 9 months. The rough surface of a wart can disrupt adjacent skin and enable inoculation of virus into adjacent sites, leading to the development and spread of new warts.

Signs and Symptoms
The common wart is the most common type: It is a hyperkeratotic, flesh-colored papule or plaque studded with small black dots (thrombosed capillaries). Other types of warts include flat warts (verruca plana), plantar warts, and condyloma acuminatum (venereal warts).

The clinical appearance alone should suggest the diagnosis. Skin biopsy may be performed, if warranted.

Therapy is variable and often challenging. Most modalities are destructive: cryosurgery, electrodesiccation, curettage, and application of various topical products such as trichloroacetic acid, salicylic acid, topical 5-fluorouracil, podophyllin, and canthacur. For stubborn warts, laser therapy or injection with candida antigen may be helpful. The immunomodulator imiquimod cream (Aldara) is a novel topical agent recently approved for treating condyloma acuminatum, and it might help with common warts as well, usually as adjunctive therapy. Sexual partners of patients with condyloma warrant examination, and women require gynecologic examination.

Prevention and Screening
For common warts, no approaches have been documented to prevent transmission. For genital warts (condyloma), the risk correlates with the number of sexual partners. A quadrivalent HPV vaccine (Gardasil) has been available since 2006, and this represents the newest approach to preventing genital HPV infection and ultimately cervical cancer in women. The vaccine is safe and 100% effective and is recommended for girls and women ages 9 to 26 years.

Molluscum Contagiosum

Definition and Etiology
Molluscum contagiosum is an infectious viral disease of the skin caused by the poxvirus.

Prevalence and Risk Factors
The prevalence is less than 5% in the United States. Infection is common in children, especially those with atopic dermatitis, sexually active adults, and patients with human immunodeficiency virus (HIV) infection. Transmission can occur via direct skin or mucous membrane contact, or via fomites.

Pathophysiology and Natural History
The disease follows direct contact with the virus, which replicates in the cytoplasm of cells and induces hyperplasia.

Signs and Symptoms
Molluscum are smooth pink, or flesh-colored, dome-shaped, umbilicated papules with a central keratotic plug. Most patients have many papules, often in intertriginous sites, such as the axillae, popliteal fossae, and groin. They usually resolve spontaneously, but they often persist in immunocompromised patients.

Diagnosis is by clinical presentation and by skin biopsy, if warranted.

Treatment might not be necessary because the disease often resolves spontaneously in children. Treatment is comparable to the modalities outlined for warts; cryosurgery and curettage are perhaps the easiest and most definitive approaches. In children, canthacur, applied topically then washed off 2 to 6 hours later, is well tolerated, and is very effective.

  • Impetigo is a superficial skin infection usually caused by Staphylococcus aureus and occasionally by Streptococcus pyogenes.
  • Folliculitis is a superficial infection of the hair follicles characterized by erythematous, follicular-based papules and pustules.
  •  Ecthyma is a deep infection of the skin that resembles impetigo. Ecthyma is somewhat common in patients with poor hygiene or malnutrition.
  •  Erysipelas is a superficial streptococcal infection of the skin.
  •  Necrotizing fasciitis is a rare infection of the subcutaneous tissues and fascia that eventually leads to necrosis.
  •  Dermatophytosis implies infection with fungi, organisms with high affinity for keratinized tissue, such as the skin, nails, and hair. Trichophyton rubrum is the most common dermatophyte worldwide.
  • Cutaneous candidiasis is a yeast infection caused primarily by Candida albicans.
  •   Tinea versicolor is a common superficial infection of the skin caused by the ubiquitous yeast Malassezia furfur.  This can be helped with certain kinds of Ringworm cure.
  •  Herpes simplex virus infection is a painful, self-limited, often recurrent dermatitis, characterized by small grouped vesicles on an erythematous base.
  •  Herpes zoster (shingles) is an acute, painful dermatomal dermatitis that affects approximately 10% to 20% of adults, often in the presence of immunosuppression.
  •   Warts are common and benign epithelial growths caused by human papillomavirus.
  • Molluscum contagiosum is an infectious viral disease caused by the poxvirus.

13 January 2012

Fraudulent Scientists

First appeared in Time: Heartland
Dipak Das

In January 2012, University of Connecticut officials announced that Das, director of the Cardiovascular Research Center, had fabricated his research 145 times in papers published in 11 scientific journals. Das studied the effects of a compound in red wine, resveratrol, on the heart.

The university launched an investigation of Das’ work in 2008 after an anonymous tip raised questions about  images in his papers, which were turned out to be manipulated.  In its 60,000 page report, the investigators say some of the images were created at a time when there wasn’t anyone in the lab with the proper expertise to generate them, and that Das divided the work on experiments so that even lead authors of papers weren’t fully involved in preparing data and figures. Das testified to the investigators that he had no knowledge of the manipulations, a claim that the panel says “lacks credibility.” The report was filed with the U.S. Office of Research Integrity, which is conducting its own investigation into the fraud. As for Das, a university spokesperson said he “remains employed by the UConn Health Center pending dismissal proceedings per university bylaws.”

Andrew Wakefield

Do vaccines cause autism? Medical experts say no, but we can thank Wakefield for introducing the doubt that won’t die in many parents’ minds. In 1998, the  gastroenterologist at Royal Free Hospital in London published a study describing a connection between the measles-mumps-rubella (MMR) vaccine and autism, after he found evidence of these viruses, presumably from the shot, in the guts of a dozen autistic children, eight of whom developed autism-like symptoms days after receiving their vaccination.

Other scientists could not replicate Wakefield’s findings, nor verify a link between the vaccine and autism. In 2010, the journal that published his paper retracted it, and its editors noted that “it was utterly clear, without any ambiguity at all, that the statements in the paper were utterly false.” Later that year, the General Medical Council in the U.K. revoked Wakefield’s medical license, citing ethical concerns over how he recruited the patients in the study as well as his failure to disclose that he was a paid consultant to attorneys representing parents who believed their children had been harmed by vaccines.

The final shoe dropped a year later, when another prestigious medical journal concluded that his research was also fraudulent, after evidence that some of the timelines of the children’s symptoms were misrepresented.

Wakefield maintains his innocence, and penned a book defending his work and his continued belief in a connection between vaccines and autism. Infectious disease experts and pediatricians, meanwhile, routinely confront conflicted parents who question the safety of vaccines, despite immunization’s long-standing record of successfully controlling childhood diseases with relatively few side effects.

Woo Suk Hwang

It’s not often that scientists achieve rock star status, but that’s what Hwang enjoyed when, seemingly out of nowhere, the Seoul National University professor of veterinary medicine catapulted South Korea to the top of the science hierarchy with his 2004 success in cloning human cells and making human embryonic stem cells.

Or at least that’s what he and everyone else in the world thought he had done. It was the first time anyone had taken a human cell, inserted it into a donor egg, and coaxed it to grow, in theory into a clone of the original cell. He followed that stunning announcement a year later with another first — using the same process to generate embryonic stem cells from patients with spinal cord injury and diabetes, opening the possibility that patients might benefit from stem cell therapies to cure these and other diseases.

That same year, however, anonymous tips raised questions about images depicting the stem cell lines in one of the papers, and a university and government investigation revealed that the stem cells did not come from the cells as Hwang claimed, but from IVF embryos. Hwang said was not aware of the fraud, which he maintained was perpetrated by members of his lab, but was stripped of his position at the university and banned from conducting stem cell research in Korea. He is reportedly seeking investors to fund his research outside of the country.

Dr. Roger Poisson

Sometimes fraud can be driven by good, but misguided intentions. Poisson, a professor of surgery at the University of Montreal, was a member of the prestigious National Surgical Adjuvant Breast and Bowel Project (NSABP), a joint U.S. and Canadian research effort that since 1958 has conducted studies on some of the most effective treatments for breast cancer. In 1994, the U.S. Office of Research Integrity found that for nearly a decade, Poisson had enrolled patients who were not eligible for trials and then falsified or fabricated their medical records to cover up their ineligibility, in an effort to involve as many women as possible in the studies. Investigators found two sets of patient books in Poisson’s lab, one marked ‘true’ and another labelled ‘false.’ The women were part of trials that established that lumpectomy plus radiation was as effective as mastectomy in lowering risk of recurrent breast cancer.

Other studies have since confirmed the benefits of lumpectomy combined with radiation, but the misrepresentation caused many who underwent the procedure to question whether they had made the right decision. “People who are not on the front line of the battle have no idea how frustrating it can be to prepare an eligible patient for a trial, with several pep talks and a great deal of discussion, explanation for the informed consent and to convince the patient to participate and — at the last moment — to realize the patient [is ineligible],” he wrote to the investigators in his defense. Poisson was banned from receiving U.S. government research funding for eight years.

The “Baltimore Case”

The difference between making a mistake and committing fraud is one of intention, and it’s often a fine and obscure line.

That became clear in 1989, when Congress opened hearings into alleged misconduct by Thereza Imanishi-Kari, an assistant in the lab of Nobel laureate David Baltimore at Massachusetts Institute of Technology. In 1985, Baltimore and Imanisi-Kari had published a paper describing their success in injecting a mouse with a gene that altered its immune system so the animal could produce antibodies against a given bacteria or virus. The findings raised the possibility that the human immune system could be modified in the same way, enhancing our ability to ward off infections.

A postdoctoral fellow working in the lab failed to reproduce the results, however, and those concerns eventually led to the Congressional hearings in which Baltimore staunchly defended the work. Imanishi-Kari was found guilty of scientific fraud and Baltimore’s reputation was tarnished by association, leading him to resign from his new position as president of Rockefeller University.

In 1996, however, an appeals board of the National Institutes of Health re-analyzed the case and determined that the paper did not contain fraudulent data, but errors that both co-authors later acknowledged. Imanishi-Kari was exonerated and Baltimore went on to helm California Institute of Technology.

Charles Dawson

The passion of belief, even in scientific discovery, can be enough to perpetuate a hoax across decades, as the case of “Piltdown man” shows. In 1912, Charles Dawson, an amateur archeologist, claimed to have been presented with pieces of a skull dug up by a laborer in the English village of Piltdown. Along with a respected member of the Natural History Museum, Dawson presented his fossil as a remnant of man’s earliest ancestor. Other funny-looking fragments from the same region were unearthed in following years, all eagerly labelled as fossils of an early man.

It wasn’t until 1953, when more sophisticated dating techniques became available, that the fossils were determined to be a hoax, actually made from what appeared to be an orangutan’s jaw. It’s not clear whether Dawson was the original mastermind behind the fraud, or whether he was the front for others who had reason to stick it to the British scientific establishment (Sir Arthur Conan Doyle, of Sherlock Holmes fame, was one possible candidate), but regardless who the culprit was, he was certainly the one who enjoyed the last laugh.

10 January 2012

Nicotine Replacement Therapy Lacks Long Term Results

First appeared in NY Times
The nicotine gum and patches that millions of smokers use to help kick their habit have no lasting benefit and may backfire in some cases, according to the most rigorous long-term study to date of so-called nicotine replacement therapy.

The study, published Monday in the journal Tobacco Control, included nearly 800 people trying to quit smoking over a period of several years, and is likely to inflame a long-running debate about the value of nicotine alternatives.

In medical studies, the products have proved effective, making it easier for people to quit, at least in the short term. Those earlier, more encouraging findings were the basis for federal guidelines that recommended the products for smoking cessation.

But in surveys, smokers who have used the over-the-counter products, either as part of a program or on their own, have reported little benefit. The new study followed one group of smokers to see whether nicotine replacement affected their odds of kicking the habit over time. It did not, even if they also received counseling with the nicotine replacement.

The market for nicotine replacement products has taken off in recent years, rising to more than $800 million annually in 2007 from $129 million in 1991. The products were approved for over-the-counter sale in 1997, and many state Medicaid programs cover at least one of them.

“We were hoping for a very different story,” said Dr. Gregory N. Connolly, director of Harvard’s Center for Global Tobacco Control and a co-author of the study. “I ran a treatment program for years, and we invested” millions in treatment services.

Doctors who treat smokers said that the study findings were not unexpected, given the haphazard way many smokers used the products. “Patient compliance is a very big issue,” said Dr. Richard Hurt, director of the Nicotine Dependence Center at the Mayo Clinic, who was not involved in the study.

Dr. Hurt said products like nicotine gum and patches “are absolutely essential, but we use them in combinations and doses that match treatment to what the individual patient needs,” unlike smokers who are self-treating.

The products have been controversial since at least 2002, when researchers at the University of California, San Diego, reported from a large survey that they appeared to offer no benefit. The study did not follow people over time. A government-appointed panel that included nicotine replacement as part of federal guidelines for treatment also came under fire, because panel members had gotten payments from the product manufacturers.

“Some studies have questioned these treatments, but the bulk of clinical trials have unequivocally endorsed them,” said Dr. Michael Fiore, director of the University of Wisconsin’s Center for Tobacco Research and Intervention and the chairman of the panel that wrote the guidelines. Dr. Fiore, who has reported receiving payments from drug makers, said that “there are millions of smokers out there desperate to quit, and it would be a tragedy if they felt, because of one study, that this option is ineffective.”

In the new study, conducted in Massachusetts, the researchers followed a representative sample of 1,916 adults, including 787 people who said at the start of the study that they had recently quit smoking. They interviewed the participants three times, about once every two years during the 2000s, asking the smokers and quitters about their use of gum, patches and other such products, their periods of not smoking and their relapses.

At each stage, about one-third of the people trying to quit had relapsed, the study found. The use of replacement products made no difference, whether they were taken for the recommended two-month period (they usually were not), or with the guidance of a cessation counselor.

One subgroup, heavy smokers (defined as those who had their first cigarette within a half-hour of waking up) who used replacement products without counseling, was twice as likely to relapse as heavy smokers who did not use them.

“Our study essentially shows that what happens in the real world is very different” from what happens in clinical trials, said Hillel R. Alpert of Harvard, a co-author with Dr. Connolly and Lois Biener of the University of Massachusetts, Boston.

The researchers argue that while nicotine replacement appears to help people quit, it is not enough to prevent relapse in the longer run. Motivation matters a lot; so does a person’s social environment, the amount of support from friends and family, and the rules enforced at the workplace. Media campaigns, increased tobacco taxes and tightening of smoking laws have all had an effect as well.

Brain Injuries Change Lives

First appeared in NY Times
At a crowded vigil on Sunday night in Tucson, Representative Gabrielle Giffords held her husband’s hand as she stepped up to the lectern to recite the Pledge of Allegiance.

It had been one year since a shooting at a Tucson supermarket killed six people, injured 12 others and left her with a severe brain injury. Ms. Giffords’s appearance was greeted by an enthusiastic crowd that applauded her remarkable progress toward recovery.

The man next to her, fighting tears, offered his own remarks. “For the past year, we’ve had new realities to live with,” said her husband, the astronaut Mark E. Kelly. “The reality and pain of letting go of the past.”
Captain Kelly was speaking of the survivors of the shooting. But his words echoed the sentiments of many brain injury survivors and their spouses as they grapple with interpersonal challenges that take much longer than a year to overcome.

Until recently, there had been little evidence-based research on how to rebuild marriages after such a tragedy. Indeed, doctors frequently warn uninjured spouses that the marriage may well be over, that the personality changes that can result from brain injury may do irreparable harm to the relationship.

Captain Kelly and Ms. Giffords largely have kept private their own experiences in this regard, and they declined to be interviewed for this article. Still, therapists are beginning to understand the obstacles that couples like them face, and what they are learning may lead to new counseling techniques to help restore the social links that give lives meaning.

Contrary to conventional wisdom, many relationships do survive after a spouse suffers a brain injury. Some studies find divorce rates well below the national average among these couples. A 2007 investigation found that the divorce rate was around 17 percent in couples followed for as long as 90 months after a spouse sustained a brain injury.

That is not to say these couples are always happy.

“Two or three years later, they want a whole lot more than simply to be alive,” said an author of the 2007 study, Jeffrey S. Kreutzer, a psychologist at Virginia Commonwealth University in Richmond. “While people may technically be married, the quality of their relationship has been seriously diminished.”

Dr. Kreutzer and other psychologists at V.C.U. are among the few therapists in the country trying to develop marriage counseling techniques tailored to couples dealing with brain injuries. Traditional marriage counselors often hope to restore people and their relationships to their original luster. For Dr. Kreutzer and his team, recovery often means teaching uninjured spouses to forge a relationship with a profoundly changed person — and helping injured spouses to accept that they are changed people.

The research is still in early stages, and in many ways the therapeutic toolbox is not much different from that of regular marriage counseling: Couples coping with a brain injury are taught to communicate better, to focus on positive developments and things they like about each other, and to set aside time to inject a little romance and fun into a life that can be consumed by doctors’ appointments and paperwork.

But other traditional techniques can backfire with these couples, the researchers have learned. For example, said Emilie Godwin, another V.C.U. psychologist, encouraging partners to remember what sparked their love in the first place can mean “highlighting the things that have probably been lost.”

“You’re asking people to just look forward, to not look back at all,” she said. “To try to recreate a relationship.”

The Stranger in the Living Room

About a month after surgery to remove a brain tumor in 2006, Terry Curtis turned to his wife, Vicky, and offered her a divorce.

“I told her she was free to leave,” he said. “I’m not the person you married.”

Mr. Curtis knew he had become cold, impulsive and incapable of focusing his attention. But it would be 18 months before doctors explained to the couple that complications from surgery had caused a brain injury.
Mrs. Curtis, 60, was once drawn to her husband’s “sparkle,” she said. After the injury, he “flat-lined” emotionally, and he suffers from depression, anxiety and a lack of motivation.

Her husband sometimes makes erratic decisions, she added, like the time he decided to take a do-it-yourself approach to the plumbing at their home in Coralville, Iowa. “Not a good picture when I got home,” Mrs. Curtis said. “And you can yell at him like a little kid, but he didn’t know any better.”

Once a software programming analyst, Mr. Curtis, 57, has “a lot fewer interests” than he did before the injury, and he estimates he has lost 90 percent of his friends.

“It’s a new you,” he said, “and they just can’t cope with that.”

Brain injury can be isolating, psychologists say, as the mental symptoms may last well beyond the obvious injuries. Strangers and friends often do not understand the root of a survivor’s socially inappropriate behavior.

Even relatives well versed in the changes wrought by brain injury constantly struggle not to take outbursts or remarks personally, therapists said.

“The word that describes it is just ‘lonely,’ ” said Mrs. Curtis of her role as caregiver. “My life is sitting in the living room quiet while my husband just sleeps.”

Guilt is the tie binding many people to a dependent stranger inhabiting their spouse’s body after a brain injury, Dr. Kreutzer said. But guilt is not unique to the caregiver who might fantasize about getting away. Studies show that few of the injured can work and that about half suffer from major depression; many feel inadequate because of their inability to provide financial and emotional support.

But Mrs. Curtis said she was staying with her husband not out of guilt or an obligation to take care of him — though she couldn’t say she had never contemplated leaving.

“If I was that unhappy, I would make the arrangements for him to be taken care of and get out,” she said.
Counseling has helped Mrs. Curtis, who works in administration at the University of Iowa, to manage her expectations, both for Mr. Curtis’s recovery and her own responses.

“We’ll have a whole day where he’s just fine, and it’s just like the old Terry,” she said last month. “And then he’ll say something out of whack, and I’ll say, ‘Oh, yeah, it’s 2011.’ ”

Psychologists say this type of halting progress adds to what they call “ambiguous loss.” Every day, reminders of the damage appear and disappear, and often couples struggle with grief that is never fully resolved and must constantly be reassessed.

Though the Curtises have not quite let go of the “old Terry,” their relationship is not identical to what they had before his injury. It has become a “combination,” Mrs. Curtis said.

Said Dr. Godwin: “People hold on to hope that just as when they survived the crash and they had this miraculous recovery, that they will overcome these challenges that other people may not in this miraculous way. That’s not going to happen.”

But some couples do manage to put their lives, and relationships, back together in the years after a traumatic brain injury. In 2002, while Hugh Rawlins was in an induced coma, half his skull removed to allow his brain to swell, doctors told his wife, Rosemary, that he might be angry, even abusive to their 14-year-old twin daughters — when and if he learned to talk again.

Mr. Rawlins had been struck by a car while riding his bike near his home in Glen Allen, Va. As he entered rehab, doctors warned that the couple might soon face bankruptcy and divorce.

But after years of halting rehabilitation and a devastating, failed attempt to return to his old job, Mr. Rawlins is a financial executive at a midsize engineering company. An avid surfer before the accident, he rides the waves off North Carolina’s Outer Banks, where the couple spends almost every weekend.

He never became the aggressive misanthrope doctors warned about. And he’s back on the bike.

But each positive step in Mr. Rawlins’s recovery has posed difficult challenges for his wife. Fearful, she hid the car keys as he learned to drive again. His determination to ride his bike sent her into therapy.

“All of a sudden I was in this position of always telling what you can do, what you can’t do — it’s horrible,” said Mrs. Rawlins, who documented her family’s ordeal in “Learning by Accident,” a self-published memoir.
Mr. Rawlins may have suffered a traumatic brain injury, but it was Mrs. Rawlins who, like many others caregivers, ultimately received a diagnosis of post-traumatic stress disorder.

Despite progress toward stable relationships, many couples stay trapped in a pattern in which the uninjured spouse does everything for the survivor, even when it’s no longer necessary, researchers have found. “No one likes to have their freedom stolen from them,” said Dr. Godwin.

Before they entered counseling, fights over Mr. Rawlins’s limits sometimes ended in a silent stalemate.

“There’s always a bit of the rebellion in me, and she’d pull me back just as a mother would or a father would to their teenager,” said Mr. Rawlins, now 55. “Sometimes she was right, and sometimes I could do it.”

The accident rocked the couple out of their “midlife doldrums,” Mrs. Rawlins said. As Dr. Kreutzer tells his patients, some post-injury changes can be positive. Mrs. Rawlins was thrilled to find her once wry and stoic husband is much less emotionally inhibited.

“The touchy-feely stuff, that shows more in me now,” he acknowledged.

More and more, Mrs. Rawlins believes that her husband is back to his “old self.”
She’s just no longer sure she remembers who that was.