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Vital Signs


Among the people and programs coming in for prominent media coverage in recent months was neurologist James Bernat, M.D. The former chair of the American Academy of Neurology's ethics committee, he was asked to comment on the high-profile Florida right-to-die case of Terri Schiavo. The 39-year-old Schiavo has been in a persistent vegetative state since she suffered a heart attack 13 years ago. National Public Radio's Richard Knox reported that "Dr. James Bernat of Dartmouth . . . says that a persistent vegetative state can be a subtle diagnosis to make." The Chicago Tribune described the difficulty in such patients of distinguishing between conscious movements and reflexive reactions: "'The human body has a repertoire of reflexes that respond to things like noxious stimuli,' said Dr. James Bernat of Dartmouth. 'It's very difficult to determine the level of awareness in a case like this. There is no laboratory test.'" He was also quoted in the New York Times as saying that "assuming she is in a vegetative state, I can say with medical certainty that there is no realistic hope that she'll recover."

Health services researcher Elliott Fisher, M.D., has also been much in the media eye. The New York Times turned to him for commentary on the fact that South Florida patients "have more office visits, see more specialists, and have more diagnostic tests than almost anywhere else in the country. . . . But there is no apparent medical benefit, Dr. Fisher said." Money magazine, in a feature on "the world's most expensive health care," wrote: "'Across hospitals that are very similar in quality, people can be treated in very different ways,' explains Dr. Elliott Fisher of . . . Dartmouth's Center for the Evaluative Clinical Sciences, which during the past 14 years has been studying weird regional variations in how doctors in the U.S. decide what care their patients need." Finally, Fisher wrote an editorial for the New England Journal of Medicine on a study showing better outcomes from cutting hospitalization rates in half within the VA system—and once again reporters came knocking on his door. "At a time when the rest of the country has been going to unfettered access to specialists and little actual management of care . . . the VA is going in the opposite direction," he told the New York Times. And in USA Today, he explained that "hospitals can be dangerous places if you don't need to be there."

"The DES Legacy" was the headline on a Washington Post feature about a hormone given to pregnant women from 1938 to 1971, under the belief that it would prevent miscarriages. Instead, DES led "to a host of health problems for mother and child. . . . Questions about DES and its possible link to sexual orientation and transgender characteristics have also emerged in the last few years. 'It's a very interesting question and frustrating for us,' said Linda Titus-Ernstoff, a professor at Dartmouth who authored a paper this year on the psychosocial characteristics of men and women exposed to DES in the womb. As for 'transgender mix-ups,' she said, evidence has been 'extremely rare, so we can't study it in a scientific way.'"

When a U.S. soldier was charged with cowardice after he "experienced a strong physical reaction— sweating, vomiting, headaches" upon seeing the dismembered body of an Iraqi soldier, the Palm Beach Post reported on the event: "'In the military, this is called combat stress reaction. It's also called battle fatigue,' says Dr. Matthew Friedman, executive director of the VA's National Center for Post- Traumatic Stress Disorder and a professor of psychiatry at Dartmouth. . . . 'In my opinion,' Friedman said, 'an acute stress reaction is powerful and involuntary.' . . . Experts say it is wrong to confuse a stress reaction with cowardice."

A recent report from a commission headed by a DMS faculty member got national media attention. "Environment not only influences children but can alter their biology" was the way the Wall Street Journal put the report's conclusion. According to the Washington Post, the report said "it is the weakening of the connections between children and their extended families and communities that is causing a virtual epidemic of emotional and behavioral problems." And the report's principal author, Kathleen Kovner Kline, told Good Morning America's Diane Sawyer: "What we need is a particular form of engagement [with children] that is both warm and loving and also has expectations and limits." (See page 10 in this issue for more on the report.)

The Infinite Mind, a program on National Public Radio, had DMS family physician Allen Dietrich, M.D., as a guest recently. The topic was mental health treatment in primary-care settings. "Primary-care doctors," said the show's host, "often misdiagnose mentalhealth problems or provide inadequate treatment and follow-up." One reason, noted Dietrich, is that "the doctor may not have enough time in a standard office visit to uncover the underlying emotional or psychological issues."

The unconventional pastime of competitive eating—downing as many hot dogs as possible in 12 minutes, for example—was the subject of a recent feature in the New York Times Magazine. The story explained that the stomach signals the brain when a person is hungry and then "sends a second signal— 'I'm full'—to the brain. It is a signal that successful competitive eaters are able, it seems, to disregard. 'It may be that they are eating so fast that those signals don't have time to register,' says Dr. Brian Lacy, a gastroenterologist at Dartmouth. 'It's also possible that they've taught themselves to ignore them. . . . It's probably not the best eating behavior,' Lacy concedes."

"Disrespect and bad manners have risen to new heights" among American children, said a recent column in the Washington Post. It suggested some reasons for the trend and some commonsense advice for parents eager to buck it: "Experts partially blame the media. 'Television plays a huge role in instructing children how they should act,' says Steven Atkins, an associate professor of child and adolescent psychiatry at Dartmouth. Atkins contends that much of the behavior portrayed on TV is rude."

A Dartmouth psychiatrist, noted the Washington Post, is a national spokesperson for "people of a certain age who suffer mental illness. . . . 'It's easy for the informed physician or family member to say, "If I had all these problems, I would want to die,'" said psychiatrist Stephen Bartels of Dartmouth. The individual internalizes that message, too. 'All these things come together so that older adults get less access to mental health care than any other age group.' " Bartels cochaired a recent panel that issued national geriatric psychiatry recommendations.

The effect of volume on surgical outcomes was the subject of a study that was widely covered. "Lead researcher John Birkmeyer, chief of general surgery at Dartmouth, said the study shows that patients 'need to be mindful of picking a surgeon that does a procedure often,'" said the Wall Street Journal. "The preponderance of the evidence says that volume counts," Birkmeyer told ABC. And Time said the researchers had "reviewed the charts of nearly 475,000 Medicare patients, all of whom had undergone one of eight high-risk operations."

There has been a recent surge in the banking of stem-cell-rich blood from newborns' umbilical cords. The controversial and expensive practice was the subject of a Houston Chronicle article that cited a cord-blood expert at DMS. The first successful cord-blood transplant was in 1988. "Since then, between 2,500 and 3,000 umbilical-cord stem-cell transplants have been done worldwide, said Zbigniew Szczepiorkowski, chair of a committee on cord-blood-bank standards for the American Association of Blood Banks. . . . The Food and Drug Administration is working on guidelines to govern cord-blood banks Szczepiorkowski said. But for now, no one oversees them."

The impact of smoking in the movies on teens' smoking behavior continues to make headlines. The Chicago Tribune recently quoted "Madeline Dalton, a cancer-prevention researcher at Dartmouth. 'The tobacco industry has known for years that celebrities and movies can persuade kids to start smoking. The images of cinema are more powerful than any advertising or marketing campaign.' She and colleagues . . . discovered that kids who watch the most smoking scenes are 2.7 times more likely to start a smoking habit within two years than children who watch the fewest smoking scenes."

In a story on the national blood supply, the Baltimore Sun quoted some experts who say stringent new regulations have made donor blood safer. "But others say the AIDS disaster has made regulators and blood banks too skittish. 'The FDA is still feeling the sting from HIV,' said Dartmouth pathologist James AuBuchon, M.D. He argues that by reducing the number of donors, the deferrals are likely doing more harm than good. 'The blood supply is very tenuous. Shortages we used to see only during certain holidays are becoming more frequent,' said AuBuchon."

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