Twenty-Nine, Male, and Dangerously Ill

A young man with fevers and groin pain leads E.R. doctors on a race to find the cause. by Tony Dajer

“I’m sending you a patient.” The voice on the phone belonged to Fabio Giron, a critical-care specialist and one of the smartest doctors I know. “Twenty-nine-year-old guy, headache, photophobia, fevers off and on for two weeks. Trouble urinating. Ataxic gait.”

“Bizarre,” I replied. “Start with a head CT and spinal tap?”

“Definitely. I can’t figure out if it’s viral meningitis or maybe a brain abscess,” Fabio said.

The signs were not good. Photophobia —light bothering the eyes—is a classic symptom of infection or inflammation of the meninges, the lining of the brain. Ataxic gait—inability to walk a straight line—suggests damage to the cerebellum, the brain’s coordination center. Most odd and worrisome was the difficulty urinating. That suggested a tumor or infection in the spinal cord.

The symptoms were all over the neurological map. I got off the phone and found the charge nurse. “Jeannie, Dr. Giron is sending a patient down. Possible meningitis. We need an isolation room.”

I called over my two medical students, Anne and John, to relay the story. Taking notes, they both nodded gravely.

“Your job,” I said, “is diagnosis.”

Twenty minutes later they were back.

“Well,” Anne said, pursing her lips. “We’re not sure.”

John jumped in. “He’s under a lot of stress. Three hours’ sleep a night. Taking a slew of cold remedies and stimulants to stay awake. Two weeks ago he was running somewhere, really had to urinate. When he finally went, he felt he had ‘done some harm’ to his bladder. Since then he’s had a weak stream.”

“That makes no sense.” I eyed the ceiling tiles. “You can rupture a bladder, but how can you ‘harm’ it?”

John shrugged. “As for the headaches, they come and go.”

“Any migraine history?”

Anne picked up the thread. “No. Very healthy guy. And then the fevers. They come every three days. Drench the sheets.”

In two weeks bacterial meningitis would have killed him. “Could be lymphoma. Any enlarged lymph nodes?”

“No,” John replied, “but that doesn’t rule it out, does it?”

“No.”

“Plus, he has this lower abdominal pain,” Anne added, “but there’s no tenderness when you press. Temp is 102, but the rest of the exam is normal.”

“Boy, lots going on. Let’s see if we can sort the real clues from the red herrings.”

Entering the isolation room, John and Anne donned their masks again. One look at the muscular, smiling young man sitting on the stretcher told me that he did not have meningitis.

“Masks off,” I told them. “Hi,” I said to their patient. “I’m Dr. Dajer. I’m the boss.”

He gave me a hearty handshake. “I’m Kevin. I’m the patient.”

Chuckling, I said, “I heard all about the cold remedies. Any other meds?”

Kevin ducked his head. “I know it was a bad idea, but I took some flu medication a week ago. A friend gave it to me. I figured I had the flu.”

“Don’t ever do that again,” I said mock sternly. “Seriously, those things can cause a lot of side effects. Did you have trouble walking afterward?”

Kevin thought a moment. “Not really. Just kept feeling crummy.”

“Any alcohol lately?”

“Some over the weekend.”

“How much is ‘some’?”

“I was stupid. Vodka shots.”

“Enough to get drunk?”

He winced. “Yup.”

The clues were lining up: Stress plus no sleep plus a lingering hangover-cum-migraine plus the effects of flu meds would make anyone batty.

I walked my students through the neurological exam. Kevin’s neck was supple in every direction. No sign of meningeal irritation, making meningitis even less likely.

“Now let’s see you walk heel to toe,” I told him.

He shrugged an apology. “I really scared Dr. Giron with this one. But I can do it better now.” A brief wobble, then he got heel and toe to line up.

“This urinating problem, does it burn or hurt when you pee?”

“No, but something happened when I was running that time. And that pain is back.”

+++

He pointed to his lower right groin. The spot didn’t match appendicitis. Through Kevin’s boxer shorts, I pressed across the lower belly and the upper thigh.

“Does this hurt?”

“No. When I’m lying down it’s OK.”

“Benign abdomen,” I muttered to Anne and John. “Nothing there. Let’s go think.”

As we were walking out, the brown checker­board pattern on Kevin’s shorts caught my eye. His exam was not complete.

“Why don’t you guys wait outside?” I told my duo.

Turning back to Kevin, I said, “Let’s take a look. Just pull them down and stand up here, OK?”

Kevin hopped off the bed and faced me. Sitting, I felt his groin for hernias, then gently examined the testicles. As my fingers moved behind the left one, he jerked back.

“Ow. That hurts. Up here, between my legs.”

Suddenly, clarity. Anatomists call that nether region of our bodies the perineum. Pain there equals prostatitis.

“We need to do a rectal, Kevin. Sorry.”

Inserting a gloved and lubricated finger into his rectum, I felt the contour of the prostate. It was swollen and boggy.

“Wow, that really hurts, Doc.”

Everything snapped into place: the fevers, the abdominal pain, and the difficulty urinating all stemmed from an infection of the prostate. Tucked away in such a private spot, an infected prostate can cause symptoms so vague that patients think, as Kevin did, that they have the flu. Doctors, in turn, often miss the diagnosis. At the other extreme, an infected prostate may trigger life-threatening bacterial sepsis.

The size of a walnut, the prostate gland sits between bladder and rectum, encasing—and discharging its secretions into—the urethra as it exits the bladder. It lies so close to the rectal lining that prostate biopsies can be taken right through it. As to function, it’s all about reproduction: Without secretions from the prostate, sperm would never complete their dash to the ovum. Unfortunately, the prostate is hardly the pinnacle of evolutionary design. As men age, some 80 percent develop an enlarged prostate, which can press on the hollow urethra and throttle urination. More dangerous, it can turn malignant. Prostate cancer is a leading cause of cancer death in men (almost 29,000 per year). Say “prostate” and most people, doctors included, think “old man.”

Turns out, it is not old men who most often get prostatitis, the infection or inflammation of the gland. The numbers are surprising: In one large Canadian study, 20 percent of men under 60 complained of symptoms attributable to chronic prostatitis. Let’s face it, the gland lives in a dirty neighborhood. Bacteria can sneak in through the rectal wall or be sexually transmitted through the penis (chlamydiae are not uncommon visitors). Because the gland is honeycomb-like and filled with secretions, bacteria can rapidly infect it. Yet most antibiotics penetrate it weakly, so treatment for bacterial prostatitis must last four to six weeks. Misery results when small pockets of infection remain, causing persistent, frustratingly broad symptoms. In some cases, it takes repeated, painstaking milking of the gland (via a rectal exam) and meticulous culturing to identify the culprit. It might also require a patient to repeat a long-term course of antibiotics.

For Kevin, at least, we now knew where to begin. I rang up Fabio. “You owe me a dollar.”

“OK, but it better be good.”

“Prostatitis.”

“Shoot, he was complaining about the urination as I walked him down to the ER. I missed it.”

“Want me to write his prescriptions?”

“No. I’ll be right down.”

Minutes later Fabio was writing a prescription for four weeks of antibiotics. Kevin pressed an arm across his lower belly. “Boy, after that rectal exam this whole part hurts,” he said.

Fabio pointed at me.

“His fault.”

“Sorry about that,” I said. John and Anne followed me out of the room.

“Not that sorry,” I whispered. “That complaint just clinched the diagnosis.”

Tony Dajer is the chairman of the department of emergency medicine at New York Downtown Hospital in Manhattan. The cases described in Vital Signs are real, but names and certain details have been changed.

Can Vitamin C Cure Colds?

When the sniffles strike, many of us reach for a glass of orange juice or a vitamin C supplement. But are they really effective?

Sarah Kliff

Newsweek Web Exclusive

Nov 15, 2007 | Updated: 4:59 p.m. ET Nov 15, 2007

Oranges, grapefruits and other vitamin C-loaded foods have many health benefits. But study after study has shown that the vitamin does little—if anything—to cure, prevent or even shorten the duration of the common cold.

The most recent roundup of vitamin C research, published this spring in the Cochrane Database of Systematic Reviews, evaluated several decades of studies that included more than 11,000 subjects taking 200 or more milligrams of vitamin C each day. (The government's recommended daily allowance is 60 milligrams.) The research found that vitamin C did little to reduce either the length or severity of colds among the general population. However, studies have found that it may lower the risk of catching a cold among people whose bodies are under high physical stress—think marathon runners or soldiers on subarctic exercises. They were 50 percent less likely to catch a cold if they took a daily dose of vitamin C.

For the rest of us, however, that extra glass of orange juice is not going to do much. "The presumption of the millions of people who are taking vast amounts of vitamin C that they're preventing a cold has no foundation," says Robert Douglas, lead author of the study and former president of the Public Health Association of Australia.

So where did the vitamin C-cold connection start? It all stems from Linus Pauling, a Nobel Prize-winning chemist who lived from 1901 to 1994. In 1970 he wrote the book "Vitamin C and the Common Cold," which popularized the notion that this particular vitamin could prevent one of the most common ailments on earth. But the book came with little scientific backing and was largely devoid of evidence, says Pauling biographer Thomas Hager. "He published this very influential health book without writing a single scientific paper on the subject," he says. "He seemed to be prescribing a major change in dietary habits without much evidence." Nonetheless, the book's message stuck.

While the cold-killing effect may not exist, doctors have little incentive to correct the notion that it does, since consumption of vitamin C is not considered a public threat. (In fact, some studies have associated vitamin C's antioxidant properties with a decreased incidence of some cancers.) "Is it worth trying to dissuade people?" asks Arnold Monto, a professor of epidemiology at the University of Michigan's School of Public Health. "You've got to choose your battles in public health. Having an extra glass of orange juice may do some good, and it certainly isn't going to do a lot of harm."

In short, if you like the taste of orange juice, then drink up. But keep the tissues handy.

URL: http://www.newsweek.com/id/70628

Climbing the Academic Ladder

Nancy Andrews, dean of Duke Medical School, on the challenges facing women in science.

Nancy Andrews

NEWSWEEK

From the magazine issue dated Oct 13, 2008

I got interested in science in high school and went to Yale thinking that I was going to become a scientist and probably a professor. But in my senior year, some friends from Yale Medical School persuaded me to apply to a combined M.D./Ph.D. program so that I could work in areas of science that wouldn't be as open to me with only a Ph.D. This was in the late 1970s, and it never occurred to me that being a woman might be a problem. That was probably a good thing.

As part of the M.D./Ph.D. program, I did a year and a half of medical school at Harvard, went to MIT for three and a half years, and then returned to Harvard for my final two years of medical school. I never felt at a disadvantage, but there were moments in my training when I would suddenly become aware that there weren't a lot of other women in my position. I remember being on rounds with an all-male team and hearing the residents and doctors talk about women patients and nurses and women faculty in ways that shocked me.

After medical school, I became a pediatrics resident. I didn't do it because it was what was expected of women. I did it because it was the direction of my research and interests. I think that people were expecting me to head toward a clinical career, which was more common for women. But I just kept moving forward and didn't really pay any attention. I wanted to do research because I liked the idea that I could be my own intellectual boss. In clinical medicine, it's a different kind of reward. I enjoyed working with kids and with their families. But it was always responding to something, rather than creating something.

I deliberately chose to wait to have my children until after I was finished with my formal training. As soon as I could see my way to my first faculty position, I got pregnant with my daughter. I was lucky because it happened basically when I wanted it to. My son was born three years later. In retrospect, I was probably pretty naive about trying to do all those things at once, but it worked out. I think the most important thing is to have your partner sharing in the responsibilities. I had that.

I spent most of my career at Harvard and was a dean at the medical school when I decided to move to Duke. I wanted to do something new.

I was surprised that there was so much publicity about my move, but I understand why: there are still very few women running top medical schools. Even the word "dean" conjures up a male image for many people. I saw that firsthand when my husband and my children and I visited a school where Duke staff members had made an appointment for the new dean of the medical school—but neglected to provide the principal with a vital piece of information. The principal, a man, held out his hand to my husband and said, "Ah, you must be the man of the moment." And my husband just said, "No, it's actually her." The principal recovered quickly, and said, "Well, all the better," which was a great response.

My goal is pretty simple: to convince our students and faculty that they can go out and do whatever they want to do. People hear so much advice, including a lot of bad advice, about what they can or cannot do. I worry a lot when people come in and say, "I was told I can't do both science and medicine," or "I was told I can't do medicine and be very involved with my family." When young people hear those things, they can become self-fulfilling prophecies.

If there are unwritten rules that don't make sense to me, I challenge them and see if I can change them.

URL: http://www.newsweek.com/id/162356

Mental health coverage to see boost as long-sought parity law is enacted

The law does not apply to small employers or the individual insurance market. But it leaves stronger state parity laws intact.

By Doug Trapp, AMNews staff. Oct. 27, 2008.

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Washington -- The $700 billion economic recovery bill signed into law on Oct. 3 was designed to improve the nation's economic health. But a provision in the law also should serve to improve the mental health of many by requiring parity between mental health benefits and physical health benefits.

The mental health parity law, more than a decade in the making, "is one of the most dramatic improvements in the health care available for people who have mental illness and substance use problems in my lifetime," said Jeremy A. Lazarus, MD, 65, a psychiatrist and speaker of the AMA House of Delegates.

Coverage requirements go into effect in January 2010 for most plans. Doctors who have had difficulty referring patients to psychiatrists and other mental health professionals should find significantly fewer obstacles, Dr. Lazarus said.

Physicians sometimes struggle with current coverage limitations in the mental health portions of insurance plans, said Nada Stotland, MD, MPH, president of the American Psychiatric Assn. Many plans, for example, require more prior authorizations or higher patient cost-sharing for mental health benefits than they do for medical or surgical benefits.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 became law on the back of the economic recovery act. The law bans most group health plans that offer mental health and substance abuse benefits from restricting them -- through higher cost-sharing or treatment limits -- more than they do medical or surgical benefits. It also requires plans to cover any out-of-network mental health benefits if they cover out-of-network medical and surgical benefits.

The mental health parity law will affect health coverage for more than 113 million Americans.

The parity law is expected to apply to more than 113 million Americans' health coverage, including 82 million enrolled in self-funded group plans, which aren't regulated by state mental parity laws, according to the measure's authors. Nearly every state has at least a limited mental parity law.

The federal law exempts employers with 50 or fewer workers. It also exempts for one year any group plans that see a 2% increase in the cost of benefits during the first year the law takes effect or a 1% increase in any subsequent year. The law does not apply to the individual health insurance market.

Patient advocates have been trying to broaden mental health coverage since the Mental Health Parity Act of 1996 was enacted. That law prohibits insurers only from imposing stricter lifetime or annual caps on mental health benefits than they do for physical health benefits.

"This is a civil rights issue," said Sen. Edward Kennedy (D, Mass.). "With passage of this bill, fundamental justice arrives for millions of our fellow Americans who deal with mental illness."

Representatives of hospitals and health plans also praised the measure.

It "marks a turning point for mental health in this country," said Chip Kahn, the Federation of American Hospitals' president.

America's Health Insurance Plans hailed the law for allowing health plans to continue to manage benefits based on valid medical evidence. "Millions of Americans will now be assured greater access to mental and behavioral health coverage while continuing to benefit from the innovative programs health plans have developed to promote high-quality, evidence-based care," said Karen Ignagni, AHIP president and CEO.

A long-sought balance

The final version, breaking a more-than-decade-old stalemate, is a compromise between parity bills adopted in September 2007 by the Senate and in March 2008 by the House.

Sens. Mike Enzi (R, Wyo.), Pete Domenici (R, N.M.) and Kennedy took the lead on the Senate version. Reps. Patrick Kennedy (D, R.I.) and Jim Ramstad (R, Minn.) authored the House measure.

Businesses with 50 or fewer employees are exempt from the mental health parity law.

For the compromise version, the senators agreed to drop a provision to preempt all state parity laws, not just the weaker ones. The House members agreed to drop a requirement that plans with mental health benefits cover all conditions in the Diagnostic and Statistical Manual of Mental Disorders version four.

The AMA, as part of the Coalition for Fairness in Mental Illness Coverage, a group of mental health advocates, supported the passage of the final mental health parity bill.

Business leaders fought mental health parity in the late 1990s but changed their perspectives after embracing wellness and preventive health care, said Neil Trautwein, National Retail Federation vice president and employee benefits policy counsel. "We want to be able to identify and manage chronic conditions. We want to prevent them when we best can."

Trautwein chaired an ad-hoc coalition of business and insurance representatives that participated in the negotiations and helped shape the final compromise between the more sweeping House bill and the more limited Senate measure.

Dr. Lazarus is hopeful that the parity law's benefit mandate won't lead employers to drop mental health coverage. "There's adequate evidence that when people get appropriate mental health treatment they're actually more productive workers."

The Government Accountability Office will report to Congress by October 2011 on the parity law's impact on coverage, costs and care. By 2012, the Dept. of Labor will report to Congress on group health plans' compliance.

A shortage of mental health care professionals could continue to hamper access to care, said the APA's Dr. Stotland. Although the law should encourage people who need care to seek it in part by destigmatizing many of the treatments, patients may have trouble finding an available professional. Health plans' networks sometimes include psychiatrists who are retired or who can't see new patients for weeks, she said.

Workers at businesses with 50 or fewer employees won't be affected by the law and could continue to have inferior mental health and substance abuse coverage, Dr. Stotland said. "When people go to [interview for] a job, that's not something they're going to make a fuss about."

Dr. Lazarus and Trautwein said it's too soon to tell if another mental health parity expansion will be needed down the road.

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ADDITIONAL INFORMATION:

Principles of parity law

Employer-based group health plans that have more than 50 members and cover medical and surgical plus mental health or substance abuse must:

• Set equal financial requirements for the benefits, such as deductibles, co-payments, coinsurance and out-of-pocket expenses.
• Set equal treatment limitations, such as caps on frequency of care, number of visits and days of coverage.
• Offer out-of-network coverage for mental health and substance abuse benefits if out-of-network coverage is offered for medical and surgical benefits.

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Years in the making

The Mental Health Parity Act of 1996 prohibited group plans from offering mental health and substance abuse coverage with more restrictive annual and lifetime limits than for medical and surgical coverage. Lawmakers tried for more than a decade to strengthen the law.

105th Congress (1997-98): Two mental health parity bills are introduced in the House, including one that would require plans offering mental health benefits to offer equivalent coverage for all conditions in the DSM-IV. No hearings are held, but lawmakers extend the 1996 parity law to all State Children's Health Insurance Program and Medicaid managed care plans.

106th Congress (1999-2000): Four mental health parity bills are introduced, but none receives a vote. President Clinton extends full mental health and substance abuse parity to federal employees' health plans.

107th Congress (2001-02): Sens. Mike Enzi (R, Wyo.) and Paul Wellstone (D, Minn.) introduce a bill that would provide full parity for all DSM-IV diagnoses, but the House rejects it. Instead, lawmakers extend the 1996 parity law through 2003. Wellstone dies in a plane crash in October 2002.

108th Congress (2003-04): Lawmakers extend the 1996 parity law through 2005 but hold no hearings on three new parity bills.

109th Congress (2005-06): Lawmakers extend the 1996 parity law through 2007. Reps. Patrick Kennedy (D, R.I.) and Jim Ramstad (R, Minn.) reintroduce a parity bill named after Wellstone that would provide full parity for all DSM-IV diagnoses, but no hearings are held.

110th Congress (2007-08): Kennedy and Ramstad reintroduce the Wellstone parity bill. Sens. Enzi, Edward Kennedy (D, Mass.) and Pete Domenici (R, N.M.) introduce a more limited parity bill based on negotiations with stakeholders. The House and Senate easily adopt their respective versions. Lawmakers include a compromise parity bill in an economic recovery act President Bush signs into law on Oct. 6.

Source: Congressional Research Service

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Copyright 2008 American Medical Association. All rights reserved.

RELATED CONTENT You may also be interested in:
House passes mental health parity bill March 24/31
Parity, genetic privacy bills face snags Feb. 25
Senate passes bill to bolster parity for mental health benefits Oct. 8, 2007
Bill aims for mental health parity in Medicare April 23/30, 2007
Momentum grows in Congress for mental health parity bill March 5, 2007
New York, Ohio adopt limited mental health parity coverage Jan. 22, 2007

VM Oct 4: Jumping to Premature Conclusions

The goals of fertility specialists oftentimes conflict with those of neonatologists, and regulatory agencies should intervene to reduce the number of preterm babies.

Annie Janvier, BSc, MD, PhD

In the United States, one in eight babies is born prematurely, accounting for more than 500,000 births each year. Before the 1970s, babies that were even mildly premature often died, but recent scientific developments have led to a decrease in their mortality. Contemporary with the birth of the neonatology field was the birth of modern bio ethics. Ethical questions posed as a result of improved treatment of prematurity have been numerous—one prominent concern being the tiny baby at the "limits of viability." To assume that extreme prematurity is the main ethical problem in neonatology, however, is to jump to premature conclusions. The large majority of preterm infants are between 32 and 36 weeks' gestation, and these "late preterm" births impose the largest emotional and financial burdens on families and society.

Learning Objective Understand how the goals of fertility specialists can conflict with those of neonatologists and how regulatory agencies might intervene to reduce the number of preterm babies.

This article will discuss prematurity, the recent technological advances that led to increased neonatal survival, and the complexity of decision making for treatment of these infants. I will focus on a neglected ethical issue of great importance: the rising number of premature births. As a consequence of lax governmental investment in the prevention of preterm birth, society, babies, and families continue to pay more every year—financially, physically and emotionally—for avoidable burdens of prematurity.

Neonatology is a recent subspecialty of pediatrics that focuses on the medical care of newborn infants who require intensive monitoring and treatment. The majority of patients in neonatal intensive care units (NICUs) are born prematurely. A normal gestation lasts 40 weeks after the mother's last menstrual period, and prematurity is defined as a gestation lasting fewer than 37 weeks. In 1963, Patrick Bouvier Kennedy, son of the late President John F. Kennedy, was born at a gestational age of 35 weeks and died 2 days later. At that time, to be born 5 weeks early was a substantial risk. Three recent developments in neonatology—respirators, antenatal corticosteroids, and surfactant replacement therapy—have given babies born at 35 weeks' gestation mortality rates only slightly higher than those of full-term infants.

Babies born in the last 20 years are more likely to survive and less apt to develop a disability than those at the same gestational age born before 1980. Even so, the number of premature babies with disabilities or significant morbidity as a result of prematurity has remained relatively unchanged because, even though a lower percentage of survivors have impairments, more babies survive. And prematurity rates are continuing to rise. Although all developed countries have rising rates of preterm births, the United States retains the highest rate among industrialized countries with 12.5 percent in 2004 [1], and most of these preterm babies in NICUs are late preterm, with gestational ages between 32 and 36 weeks. Babies that are extremely preterm, with a gestation of fewer than 28 weeks or a weight of less than 1,000 grams (also called extremely low-birth-weight babies), comprise 0.8 percent of all deliveries and about 10 percent of NICU admissions. Currently, infants weighing 1,000 grams or born at 27 weeks' gestation have an approximately 90 percent chance of survival, with the majority having normal neurological development [2].

The earlier in its gestation that a baby is delivered, the greater the risks of complications, mainly developmental delay, cerebral palsy, chronic pulmonary disease, learning disability, hyperactivity, and, much less frequently, deafness and blindness. Babies of less than 26 weeks' gestation, as noted, form a minority of babies in the NICU. Of the survivors, about half are without disability at 3 years of age, and 25 percent have a major impairment such as cerebral palsy (10 percent), blindness (2 to 5 percent), deafness (2 to 5 percent), and developmental delay. These are the babies that make the headlines in newspapers and receive much attention from bioethicists regarding the decision-making dilemmas they pose.

The questions are of three main types: (1) whether to intervene medically, (2) whether a medical intervention should be stopped once it has started, and (3) who should be primarily responsible for these decisions and how. The decisions are critical; failure to provide the medical care in question often leads to death, whereas intervening often brings a chance of survival, either with or without serious impairments. Dilemmas arise on a case-by-case basis, raising one of the most profound questions regarding human life: which life with disability is worse than death?

Thankfully decision making for the majority of preterm infants is much simpler; more than 80 percent of NICU preterm admissions are babies born after 30 weeks' gestational age. Mortality in these babies is extremely low, and individual outcomes are generally excellent. On a population basis, however, the implications of the large numbers of late preterm infants are more important. About 10 percent of babies are born late preterm in the United States, and the frequency of long-term disabilities such as cerebral palsy, although low, is higher in these babies than in those born at term. More babies with disabilities originate each year from this group of patients than from extremely preterm or full-term infants. Half the patients in cerebral palsy registries were not admitted to a NICU at birth. For the remaining half, most were of a gestation greater than 28 weeks at birth. In general, there would be no ethical question about whether to admit these babies to the NICU. In order to substantially decrease disability rates from late prematurity in the population and the NICU costs, one would have to let patients of 28 to 36 weeks' gestation die, which would of course be morally unacceptable.

Preventing Prematurity

A major issue in neonatal ethics is how to prevent babies from being born preterm in the first place. Because of advances in obstetric surveillance, the number of medically induced preterm births for fetal or maternal reasons has grown, accompanied by a decrease in the stillbirth rate. About 25 percent of preterm deliveries are medically induced because of risk to the fetus or mother [3]. Limiting this source of prematurity may be neither feasible nor desirable.

Today, multiple pregnancies (twins, triplets, or more) and delayed childbearing account for a significant, and potentially reducible portion in the rate of prematurity. The substantial increase in multiple births over the last 2 decades [1, 4, 5, 6] is attributable, in large part, to artificial reproductive technologies (ART). Multiple gestations can occur following ovarian stimulation or when more than one embryo is transferred during in vitro fertilization (IVF). In the United States, 32 percent of live births following IVF are multiple pregnancies. Multiple births increase the risks of fetal, maternal, and neonatal morbidities. Fifty percent of twins and more than 90 percent of triplets are born preterm and admitted to the NICU.

Also contributing to growing numbers of preterm babies is the fact that the average maternal age is increasing; women who deliver after 40 years of age have a greater than 16 percent risk of delivering preterm [1]. As women age, their fertility declines and more employ ART to get pregnant, which places them at even greater risk for premature delivery because now they may have twins or triplets.

Given these biological realities and their consequences for newborns, our society should inform women about the risks of delayed child bearing and encourage them to have children earlier. On average, women in their early twenties have fewer financial resources than those over 35. When a woman decides to have children in early adulthood, does the government provide generous maternity leave, social and economic support for their education, and subsidized, universal childcare services when the child is young? The answer, unfortunately, is no. Society rewards performance, work, and wealth, creating an incentive to delay childbearing. The same women who would receive very limited financial incentives were they to become pregnant at an earlier age when the risks of prematurity were lower end up paying for expensive ART services years later and increasing their risks.

Conflicts between Goals of ART and Best Interest of Newborns

Infertility is a health problem that ART can help treat. There are some alternatives to ART, mainly adoption (local and international) and surrogacy, but these alternatives can be complicated and costly, and are unacceptable to some. ART services are neither reimbursed nor regulated by the Canadian and U.S. governments, which creates discrimination in access to treatment due to the cost of services. Physicians who provide ART are vulnerable to conflicts of interest. ARTs are effective—the rate of conception for fertile couples trying to conceive a baby naturally is about 25 percent per cycle. Some IVF providers, on the other hand, state a success rate per cycle as high as 60 percent [7]. This efficacy comes with a cost: an epidemic of multiple births created by physicians and governments that oftentimes produces complications for babies, their families, and society.

Infertile couples are emotionally vulnerable, which can mean they are willing to take greater health risks to acquire a baby. Because patients pay per cycle of IVF, a "two- or three-for-one" deal is an appealing alternative. But having twins is a lottery; 50 percent of IVF twins are preterm, some extremely preterm. It is also a gamble for women, inasmuch as every risk associated with pregnancy increases when a woman carries more than one fetus. In one study, despite being adequately informed of the risks, patients in fertility clinics still wanted twins: 85 percent of childless women in one study had the goal of getting pregnant with twins [8]. In fertility literature, success of a cycle of infertility treatment is counted as a live birth after 20 weeks' gestation. By implanting more than one embryo and impregnating patients with fewer treatment cycles, the success rate of a fertility clinic improves, which attracts more clients and improves financial competitiveness: multiple pregnancies can therefore also be seen as beneficial for the fertility physician. These conflicts of interest are largely responsible for the tremendous increase in multiple pregnancies in the United States and Canada. Hence, in a society where the patient pays for IVF, there is a perverse economic incentive for both patients and physicians to increase the risk of complications for mothers and disabilities in babies.

While the ethics hot topics in the reproductive world are pre-implantation genetic diagnosis, selection of various performance genes, and pregnancy in woman over 60, the numbers involved in those endeavors are very small, or even theoretical. In contrast, we calculated that 17 percent of NICU admissions were multiple gestations following ART [9]. Most of these could have been avoided by rigorously controlling the clinical practices relating to the treatment of infertility. It's easy to envision a public policy to decrease multiple births. Unlike Canada and the United States, some countries—Sweden, Belgium, Finland, and Denmark, for example—regulate and reimburse ART services. In these countries, single-embryo transfer during IVF is the norm. Where financial conflicts of interest related to ART are avoided, patients and physicians seem far less willing to take the unnecessary risk of multiple births in order to become pregnant as quickly as possible. Having children with the least risk for the mother and infant seems to be the morally responsible position.

The cost of IVF treatment goes beyond fees for the procedure itself; it includes the cost of health care to women and their children born from such techniques. Reimbursement for ART should be contingent upon regulating IVF and ovarian stimulation. Exceptions to single-embryo transfer could be considered only for mothers over 38, where the transfer of two embryos can be acceptable to achieve a singleton pregnancy. Medical societies and health-system regulations in the United States and Canada have a moral responsibility to reduce the frequency of multiple gestations following IVF to a level similar to that found in countries where single-embryo transfer is the norm, for example to 6 percent in Sweden (compared to about 32 percent in the United States). Restricting embryo transfers without including reimbursement will likely lead to "reproductive tourism"—women traveling abroad to find unregulated fertility centers where they can continue to have multiple-embryo transfers and hope for multiple gestations with the attendant risks and costs.

Do U.S. hospitals want to decrease NICU stay? While in most areas of pediatrics, frequency and duration of hospitalization have decreased over several years, NICU admissions have gone up mainly because of the increase in prematurity. According to pediatrician and ethicist John Lantos, "NICUs have become the economic engine that keeps children's hospitals running [10]." Lantos adds, "It almost seems as if society, by some mechanism, is working against health to produce more and more low-birth-weight babies, and that medicine is then working against society, desperately trying to patch the wounds caused by some nameless thing that is forcing our babies from the womb too soon [11]." Countries that have made single-embryo transfer the norm have drastically reduced the rate of multiple births without affecting the pregnancy rate. These countries have lower prematurity rates. Why do we see the epidemic of multiple births as an immutable social and political phenomenon when so many countries have demonstrated that this epidemic is controllable? Do our institutions also have conflicts of interest?

Canada and the United States are successful in developing specialists who have the skills to make preterm babies survive with a good prognosis. NICUs are the most efficient and cost-effective ICUs in modern medicine, but they should not be seen as the only solution to prematurity. In my NICU, physicians and our government are responsible for a preventable 17 percent of the admissions and for significant avoidable mortality and morbidity, which produce unacceptable financial and emotional costs [9]..Medical developments have changed the way physicians and society respond to diseases of neonates, to their illnesses, and to the pain and suffering of their parents. We have to question whether we are responding adequately to these new challenges. Rising prematurity rates and the continued unchecked epidemic of multiple births are a sign of political and moral failure.

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References

1. Born too soon and too small in Arizona. March of Dimes Birth Defects Foundation 2008. PeriStats. http://www.marchofdimes.com/Peristats/pdflib/195/04.pdf.
2. Lemons JA, Bauer CR, Oh W, et al. Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1995 through December 1996. NICHD Neonatal Research Network. Pediatrics. 2001;107(1):E1.
3. Goldenberg RL, Iams JD, Mercer BM, et al. The preterm prediction study: the value of new vs standard risk factors in predicting early and all spontaneous preterm births. NICHD MFMU Network. Am J Public Health. 1998;88(2):233-238.
4. Meis PJ, Michielutte R, Peters TJ, et al. Factors associated with preterm birth in Cardiff, Wales. II. Indicated and spontaneous preterm birth. Am J Obstet Gynecol. 1995;173(2):597-602.
5. Meis PJ, Goldenberg RL, Mercer BM, et al. The preterm prediction study: risk factors for indicated preterm births. Maternal-Fetal Medicine Units Network of the National Institute of Child Health and Human Development. Am J Obstet Gynecol. 1998;178(3):562-567.
6. Bartholomew S, Crain J, Dzakpasu S, et al. Canadian Perinatal Health Report 2003. http://www.phac-aspc.gc.ca/publicat/cphr-rspc03/pdf/cphr-rspc03_e.pdf.
7. McGill Reproductive Center. http://www.mcgillivf.com. Updated August 15, 2008. Accessed August 10, 2008.
8. Pinborg A, Loft A, Schmidt L, Andersen AN. Attitudes of IVF/ICSI-twin mothers towards twins and single embryo transfer. Hum Reprod. 2003;18(3):621-627.
9. Spelke B, Janvier A, Brown R, Vallerand D, Barrington KJ. The cost of irresponsibility. Platform presentation, clinical bioethics, at: Society for Pediatric Research 2008, Honolulu.
10. Lantos JD. Hooked on neonatology. Health Aff (Millwood). 2001;20(5):236.
11. Lantos, 237.

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Annie Janvier, BSc, MD, PhD, is an assistant professor of pediatrics at McGill University in Montreal. She has a doctorate in bioethics and is a clinical ethicist. Her main interests are decision making for neonates and other incompetent patients, end-of-life issues, and decision making in the face of uncertainty.

Drop That Corn Dog, Doctor

If doctors aren't making wise choices about their health, what kind of message are they sending their patients?

Claudia Kalb

NEWSWEEK

From the magazine issue dated Oct 13, 2008

I'm not naive when it comes to doctors' diets. I've seen M.D.s eat cookies in hospital cafeterias and gulp down sodas at medical conferences. One of my doctor friends sneaks corn dogs and fried dough at the beach. But even I was surprised when I sat down to dinner with a couple of physicians one night and watched them order the biggest steak platters on the menu. Here were two guys who presumably recognized the ills of dietary fat and clogged arteries, eating an overly rich, wildly caloric meal. Shouldn't they have known better?

On the whole, America's physicians are healthier than the people they take care of. Twenty-one percent of the population smokes; only 4 percent of docs do. And M.D.s are leaner, too. Forty-four percent of male doctors are overweight and 6 percent are obese, according to Harvard's Physicians' Health Study. The rest of America: 65 and 32 percent, respectively. We can all do better.

But doctors are the people we look to for guidance and advice about our health. If they're not making wise choices, what kind of message are they sending us? Studies show that physicians are more likely to counsel patients about good health habits when they're also following the rules. "You can't look a patient in the eye and talk to them about exercising, diet and weight loss if you yourself aren't a role model," says Dr. Ted Epperly, president of the American Academy of Family Physicians.

Dr. David Eisenberg, director of the Osher Research Center at Harvard Medical School, came up with a novel idea: teach doctors how to create "nutritious, yet delicious" meals so that they can, in turn, teach their patients. With diabetes, heart disease and cancer plaguing this nation, a nutritious diet is "as essential as any prescription drug or surgery," says Eisenberg, who developed a passion for cooking as a child when he spent weekends in his father's bakery. Last month some 300 health-care professionals, most of them physicians, gathered in Napa Valley to attend Eisenberg's brainchild, Healthy Kitchens, Healthy Lives, a collaboration between Harvard and the Culinary Institute of America. They listened to scientists talk about healthy carbs and phyto-nutrients. They received guidance on the basics—how to hold a knife, how to measure portion size. And they learned how to eat mindfully, savoring flavor, texture and taste.

Dr. Rajani LaRocca attended an earlier session in April and went home inspired. Plenty of LaRocca's patients at a community health center in Charlestown, Mass., want to lose weight, but too often they look for an easy out. "People come in and ask, 'Is there a pill?' " she says. A couple of weeks ago, LaRocca and her colleagues put on a healthy-cooking demonstration for their patients, teaching them that olive and canola oils are "good" fats—something many doctors still don't know, according to a survey of physicians published in Nutrition Journal. "You have to change the basic way you think about food," says LaRocca.

Medical professionals must change the way they think about themselves, too—and early on. Dr. Jo Marie Reilly, of the Keck School of Medicine of the University of Southern California, has seen the negative impact that doughnut-eating, sedentary young M.D.s can have on their clinic population. Patients will say, "This doctor is telling me to lose weight and exercise more, but look how he looks," Reilly says. Reilly's first-year med students must fill out a "physician wellness contract" stating their personal health goals. Yohualli Balderas-Medina, 23, committed to running regularly and maintaining close ties with friends and family, which can reduce stress and lead to better health outcomes. She's done both, and says she feels "healthy and motivated." A great beginning for a future doc and her patients.

URL: http://www.newsweek.com/id/162334

VM Oct 3: Resuscitating the Extremely Low-Birth-Weight Infant: Humanitarianism or Hubris?

Pressure exists to resuscitate younger and smaller preterm babies, but ability to predict how the earliest and tiniest will fare if they survive is limited.

Patrick M. Jones, MD, MA, and Brian S. Carter, MD

In any complex, controversial topic, attempts at open dialogue run the risk of shipwrecking on the shore of preconceived, deeply held opinion. For example, walk into a room that contains people at opposite ends of the political spectrum and toss out the phrase "universal health care." If we had the ability to project their initial reactions onto a screen, they would range from a Technicolor utopian society, dancing hand-in-hand with their health care providers to a stark, gray picture of huddled masses in long outdoor lines awaiting their catheterization for emergent cardiac failure. In a similar way, reactions vary when the phase "resuscitation of a 24-weeker" is uttered in mixed health-professional company. On one side of the spectrum a person will see the advances in neonatal care that allow a disease (respiratory distress syndrome) that killed President Kennedy's son only 45 years ago to be consistently and successfully treated today in a premature child born to the least advantaged of our society. Others, should they include pediatric and family physicians, will harken back to their residency days and recall the former premature infant who lived all 6 months of its life on a ventilator in the hospital's neonatal intensive care unit.

Learning Objective Identify sources of the pressure to resuscitate ever-younger and smaller preterm babies and the limits to medicine’s ability to predict how the earliest and tiniest will fare if they survive.

Providing intensive care to extremely low-birth-weight infants (birth weight of less than 1 kilogram) and extremely premature infants (infants born between 22 and 25 weeks' gestation) raises many questions: (1) Who benefits, and when do these benefits cease? (2) Does survival come at any and all costs to the patients, their families, and the health care staff? (3) And is a technology-dependent child truly reaping what is in his or her best interest?

With the birth, growth, and development of the bioethics community during the last 60 years, these questions have entered the public forum, and neonatology has at times found itself to be the perceived "poster-child" for medical hubris—aggressively treating any newborn, ethical concerns be damned. No doubt, parts of the complex technical, sociopolitical, and ethical history of neonatology moved clinical innovation, research, and practice in this direction [1], but we would argue that this history is neither unparalleled nor limited to neonatology. Indeed, all realms of critical care medicine have struggled with these and similar questions, yet a cloud of prejudice lingers over neonatology, casting its life-saving work into shadow and hiding the complexity of decisions made on behalf of extremely premature infants by families and physicians. The brevity of this article prohibits an in-depth discussion of the history and literature on resuscitation of increasingly smaller and younger premature infants. Nevertheless, it is our hope that we can guide the reader through some commonly held notions about neonatology that will serve as an impetus for identifying preconceived notions or biases, reflecting on the matter in a more informed manner, and considering a reexamination of this topic's complexities.

Neonatology Constantly Pushes the Line of Viability Downwards

Not really. In fact, the results of neonatologists' ability to save infants as young as 23 weeks' gestational age has been facilitated by a few major advances in applied technology, pharmaceuticals and procedures—not a gradual and persistent push toward saving younger and younger babies. These advances have occurred in a manner described by the evolutionary concept of punctuated equilibrium—large shifts in the evolution of a species followed by small incremental improvements until the next big shift. For neonatology, those shifts have been the advances in thermal regulation; modification of mechanical ventilators developed for adults for use with newborns (improved initially by the addition of end-expiratory pressure, and later—with the advent of microcircuit technology—by the capability to synchronize respirations with the neonatal patient); discovery and utilization of prenatal steroids on fetal lung development (so that this obstetrical intervention contributes largely to improved neonatal outcomes); and the development of exogenous surfactant for the treatment of respiratory distress syndrome.

Presently, we are limited in sustaining life for fetal neonates by the developmental biology of the lung and its circulation. This limit will most likely persist inasmuch as further ability to support cardiopulmonary function in the smallest and youngest newborns is not foreseeable without disrupting vital organ development. Since the advent of surfactant therapy 18 years ago, clinical research has not for the most part resulted in the ability to save ever-younger babies. The very real limits of fetal biological development force neonatologists and others to question the appropriateness of attempting to sustain extra-uterine life when the costs borne by the patient (organ system maldevelopment or failure) argue for considering not simply survival but the quality of the life saved. Hence, the bulk of research in recent years has been directed towards producing better long-term outcomes for newborns who survive prematurity.

Neonatologists Compete to Save the Smallest Premature Infant

Media attention garnered by certain medical centers upon graduating another in a series of "tiniest babies" saved, makes one wonder whether each NICU has a plaque with a revolving set of numbers that change to announce the weight of its smallest baby saved. The senior author on this paper (BC) has failed to interact with any colleague over the past 20 years at four major medical centers who boasted of saving the smallest baby. Nor has the neonatal fellow (PJ), who has trained at three separate institutions in the past 10 years, had any such interaction. In other words, it is not neonatologists who promote such feats.

The greatest pressure to resuscitate extremely premature infants often comes from outside NICUs. In our health care system, NICUs are substantial revenue generators for hospitals and academic medical centers. As a result, there is a tendency to market women's and infant services in hospitals that have NICUs. The marketing can be done discreetly and with evidence-based local outcomes, or blatantly with large billboards strategically placed on main thoroughfares in a community or in newspaper, television, or Internet advertisements—replete with the seemingly obligatory photo of a tiny baby held in the palm of someone's hand. Considering that health care dollars expended in neonatal services reap more long-term rewards than those spent at any other time in life and with the lowest cost-per-year of life gained [2], the idea for marketing neonatal services comes from offices other than those of neonatologists. The result, however, is that families understandably come to us with the expectation that their premature infant will be as advertised: tiny, cute, and healthy.

Neonatologists Know the Abysmal Outcomes for these Infants, but Push on Regardless

Outcome data is available, but the field is still developing. Making use of follow-up data, investigators are gradually adding to the knowledge base of outcomes for extremely low-birth-weight and early gestation infants [3-6]. The absolute number of these patients is very small (less than 0.5 percent of all U.S. births), and a large number (up to 50 percent, depending upon gestational age) of them die prior to discharge from the NICU. As a result, few infants remain to be tracked in neonatal follow-up clinics that collect information and perform longitudinal neurodevelopmental testing (generally over no more than 2 to 7 years). The follow-up is poorly organized and underfunded in the United States, and, because of this, the existing extremely low-birth-weight outcome literature is based on relatively few numbers. The neonatologist's capacity to prognosticate the outcome for a premature infant, then, is not generally comparable to that of his or her adult medicine colleague who addresses more common, thoroughly studied diseases in larger populations.

Predicting the individual outcome for most extremely low-birth-weight infants remains elusive. Patient information is at times difficult to discover. Depending on a mother's access to and utilization of prenatal care services, estimates of an infant's gestational age can be unreliable. Furthermore, birth weight can vary due to factors other than developmental maturity, allowing children of the same weight to have markedly different chances for survival. But even when all of the desired patient information is available, clinicians are left with the fact that population-based predictions only provide an estimate of outcomes that may or may not accurately reflect the morbidity and mortality risk for any extremely low-birth-weight infant [7].

Two bodies of work that reveal this difficulty are Ambalavanan's attempt to use multiple logistic regression and neural network models to predict extremely low-birth-weight death [8] and Meadow's research on caregiver intuition regarding an individual patient's survival to discharge [7, 9]. While neonatologists may be able to tell prospective parents that, in general, the 22-week gestational age infant will almost certainly die and the 26-week infant will likely do well, they are not good at predicting the individual outcomes of those who fall in between these age brackets.

Even if our predictive abilities were excellent, there would still be limitations to its use.Parents have an understandable habit of hoping. Should a clinician's ability to predict death or severe disability for an individual patient be so accurate that he or she was wrong only 10 percent of the time, it would still mean to the family that its child had a 1-in-10 chance of living or not being severely disabled. What risk threshold is acceptable and who decides? Do clinicians—as both members of society and the community of health care professionals—stand ready to refuse intensive care to a patient, regardless of the family's wishes? And does giving outcome data to families facilitate their decision-making capabilities [10]?

Conclusion

The dilemmas over resuscitation of extremely low-birth-weight infants reach far beyond the medical profession's obsession with technology (no more present in neonatology than elsewhere in modern medicine), misleading media stories of the tiniest survivor, and forgoing the best interest of the patient to satisfy a family's or physician's agenda. These issues cut to the heart of the human questions that permeate medicine: (1) Who decides best-interest? (2) Who speaks for patients when they cannot speak for themselves? (3) What constitutes futile care? (4) And can we even define the word "futile" in the same manner for persons of different age or religious, educational, socioeconomic, and cultural backgrounds?

Recognizing this complexity allows us to approach the question of infant resucitation with less hubris and more humanitarianism, humility, and compassion—appreciating why physicians and families continue to struggle to make resuscitation decisions for extremely low-birth-weight infants.

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References

1. Lantos JD, Meadow WL. Neonatal Bioethics: The Moral Challenges of Medical Innovation. Baltimore: Johns Hopkins University Press; 2006.
2. Cutler DM, Rosen AB, Vijan S. The value of medical spending in the United States, 1960-2000. N Engl J Med. 2006;355(9):920-927.
3. Costeloe K, Hennessy E, Gibson AT, Marlow N, Wilkerson AR. The EPIcure study: outcomes to discharge from hospital for infants born at the threshold of viability. Pediatrics. 2000;106(4):659-671.
4. Marlow N, Wolke D, Bracewell MA, Samara M ; EPICure Study Group. Neurologic and developmental disability at six years of age after extremely preterm birth. N Engl J Med. 2005; 352(1):9-19.
5. Wood NS, Marlow N, Costeloe K, Gibson AT, Wilkinson AR. Neurologic and developmental disability after extremely preterm birth. EPICure Study Group. N Engl J Med. 2000;343(6):378-384.
6. Tyson JE, Parikh NA, Langer J, Green C, Higgins RD ; National Institute of Child Health and Human Development Neonatal Research Network. Intensive care for extreme prematurity—moving beyond gestational age. N Engl J Med. 2008;358(16):1672-1681.
7. Meadow W, Frain L, Ren Y, Lee G, Soneji S, Lantos J. Serial assessment of mortality in the neonatal intensive care unit by algorithm and intuition: certainty, uncertainty, and informed consent. Pediatrics. 2002;109(5):878-886.
8. Ambalavanan N, Carlo WA, Bobashev G, et al. Prediction of death for extremely low birth weight neonates. Pediatrics. 2005;116(6):1367-1373.
9. Meadow W, Lagatta J, Andrews B, et al. Just, in time: ethical implications of serial predictions of death and morbidity for ventilated premature infants. Pediatrics. 2008;121(4):732-740.
10. Boss RD, Hutton N, Sulpar LJ, West AM, Donohue PK. Values parents apply to decision-making regarding delivery room resuscitation for high-risk newborns. Pediatrics. 2008;122(3):583-589.

Additional Suggested Reading

• Carter BS, Stahlman M. Reflections on neonatal intensive care in the U.S.: limited success or success with limits? J Clin Ethics. 2001;12(3):215-222.
• Singh J, Faranoff J, andrews B, et al. Resuscitation in the "gray zone" of viability: determining physician preferences and predicting infant outcomes. Pediatrics. 2007;120(3):519-526.

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Patrick M. Jones, MD, MA, is a clinical fellow in neonatology at Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center. He has a medical degree from Baylor College of Medicine and a master’s degree in bioethics from the University of Virginia. His research interests include end-of-life decision making and the provision of health care to children with life-threatening or life-limiting disease.

Brian S. Carter, MD, is a professor of pediatrics (neonatology) at Vanderbilt University Medical Center and sees patients at the Monroe Carell, Jr. Children’s Hospital at Vanderbilt in Nashville, Tennessee. He serves on the VUMC Ethics Committee and has long been involved in bioethics and palliative care education.