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Why A U.S. Obstetrician Says Some Women May Be Better Off Having Baby In U.K.

Despite the fact that we all go through it, birth remains a fraught topic. Everyone, it seems, has an opinion on the ideal place, position and method of childbirth, and those views can be unshakable.

Into this prickly arena steps Dr. Neel Shah, an obstetrician at Beth Israel Deaconess Medical Center in Boston and assistant professor at Harvard Medical School. In a smart, nuanced and provocative opinion piece in the current New England Journal of Medicine on the cultural and systemic differences between giving birth in the United Kingdom compared to the United States, Shah suggests what might seem like heresy to some in his field: “The majority of women with straightforward pregnancies,” he writes, “may be better off in the United Kingdom.”

Dr. Neel Shah (Courtesy)

Dr. Neel Shah (Courtesy)

Why write about this now? The U.K.’s National Institute for Health and Care Excellence (NICE) recently issued new guidelines saying that healthy women with uncomplicated, low-risk pregnancies are “safer giving birth at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician.” When the recommendations came out, Shah notes, “eyebrows went up. The New York Times editorial board (and others) wondered ‘Are midwives safer than doctors.’ How can hospitals be safer than homes?”

Before you, too, reject Shah’s conclusion out of hand, consider the careful thinking behind it and the larger context, which is that one in three births are now carried out by cesarean section — major abdominal surgery — and that C-sections are the most commonly performed surgery on the planet. But Shah’s argument focuses more on the vastly different medical cultures involved: “At its core,” he writes, “this debate is not about the superiority of midwives over doctors or hospitals over homes. It is about treatment intensity and when enough is enough. Nearly all Americans are currently born in settings that are essentially intensive care units: labor floors have multi-paneled telemetry monitors, medications that require minute-by-minute titration, and some of the highest staffing ratios in the hospital. Most labor floors are more intensive than other ICUs in that they contain their own operating rooms. Surely, every birth does not require an ICU.”

I asked Shah to lay out the key points of his piece. Here they are, edited:

RZ: Why do you conclude that it may be safer for women to give birth in the U.K. rather than the U.S.?

NS: I think the biggest takeaway from this piece is that there are harms from doing too much just like there are harms from doing not enough and that’s a big paradigm shift in U.S. health care. Childbirth is one of the biggest illustrations of that: We err on the side of overdoing it and for the healthy majority, we end up causing a lot of harm from overdoing it in the interest of making it safe for the high-risk minority.

People think that C-sections are like a rip cord — they are if you are truly at risk. But if you are low-risk, C-sections have a lot of bad consequences. Major complications such as hemorrhage, severe infection and organ injury are three times as likely to occur with cesarean deliveries as they are with vaginal deliveries. But even more fundamentally: you could go home with a 12-centimeter incision with a newborn or you could go home without a 12-centimeter incision and a newborn….moms are resilient so they just deal with it but that has a major impact. Continue reading

Why We Need To Talk Now About The Brave New World Of Editing Genes

Screen shot 2015-05-21 at 7.48.44 PM

(Image: NIH)

It was standing room only in the Harvard Medical School auditorium last week, the atmosphere electric as an audience of hundreds hummed with anticipation — for a highly technical talk by a visiting scientist, Dr. Jennifer Doudna of Berkeley. Near the front sat the medical school’s dean, Dr. Jeffrey Flier.

Dr. Jennifer Doudna (Vimeo screenshot)

Dr. Jennifer Doudna (Vimeo screenshot)

“I don’t believe in my years at Harvard Medical School I’ve ever seen a crowd of this magnitude for a lecture of this kind,” he said.

The draw?

“The draw is, this is one of the most exciting topics in the scene of biology today.”

That buzzworthy biology topic is a revolutionary new method to “edit” DNA that has spread to thousands of labs around the world just in the last couple of years.

Suddenly, it’s no longer purely science fiction that humankind will have the ability to tinker with its own gene pool. But should it?

Learn This Acronym: CRISPR

The hot new gene-editing tool is known by the acronym CRISPR, for “clustered regularly interspaced palindromic repeats.” It acts as a sort of molecular scissors that can be easily targeted to cut and modify specific genes.

(Source: NIH)

(Source: NIH)

CRISPR occurs naturally in bacteria, but scientists are now learning to harness its power to alter DNA for research across the board — cancer, HIV, brain disease — even to make better potatoes. Just this week, the journal Science published a paper on possibly using CRISPR to try to stop female mosquitoes from spreading deadly diseases.

CRISPR looks particularly promising for human diseases that hinge on just one gene, like sickle-cell anemia or cystic fibrosis. Someday, the hope is, CRISPR and gene-editing tools like it will let us cure what are now lifelong diseases by simply deleting and replacing a baby’s “broken” gene. Continue reading

Visionaries: MIT Scientist Helps Blind Indian Children See, And Then Learns From Them

MIT neuroscience professor Pawan Sinha (Robin Lubbock/WBUR)

MIT neuroscience professor Pawan Sinha (Robin Lubbock/WBUR)

MIT neuroscience professor Pawan Sinha still gets goosebumps when he thinks about it, he says: “Things just happened so perfectly, so well-timed.”

Back in 2002, Sinha was grappling with a deep scientific question: How do we learn to recognize the objects we see? How do our brains know, “That’s a face”? Or “That’s a table”?

A fateful taxi ride set his research — and his life — onto a new road.

He was back visiting New Delhi, where he grew up on the elite campus of the Indian Institute of Technology before coming to America for graduate school. He was on his way to see a friend one evening, when the taxi he was riding in stopped at a traffic light.

“I noticed, by the side of the road was this little family, a mother and her two children,” he says. “And it felt really terrible to see these two children, who were barely wearing any clothes, very young children on this cold winter day. So I called over the mother to give her a little bit of change.”

When she approached, Sinha noticed that both of the children holding on to her sari had cataracts clouding their eyes.

It was the first time that he had seen children with cataracts. When he looked into childhood blindness in India, he learned that it is a widespread problem, often caused by rubella during the mother’s pregnancy. Blind children in the developing world suffer so much abuse and neglect that more than half don’t survive to age 5, he says.

Sinha wanted to help, but he figured that what he could contribute on his academic salary would be just a drop in the ocean.

“And that’s when the realization struck me that in providing treatment to those children, I would have exactly the approach that I had been looking for in my scientific work,” he says.

“If you have a child, say, a 10-year-old child who has not seen from birth, has only seen light and dark, and in a matter of half an hour you’re able to initiate sight in this child, then from the very next day, when the bandages are removed, you have a ringside seat into the process of visual development.”

Sinha applied for a federal grant to pay for cataract operations, which are relatively simple, and for studying the children who got them. Usually, American research money stays in America, “but I took a chance because I completely, honestly believed, and believe, that in providing that surgery, we are benefiting science that belongs to all of mankind, it’s not just specifically India.”

That grant eventually came though and to continue the work, Sinha founded a nonprofit based in New Delhi. He named it Project Prakash; Prakash means “light” in Sanskrit. Since 2005, he says, nearly 500 Indian children have gained sight through the project.

Now, at 48, Sinha is planning a major expansion of Project Prakash, to create a center that includes a hospital, a school and a research facility. The goal is to serve many more children than the current 40 to 50 a year. Continue reading

Related:

The Science Of Suicide: Researchers Work To Determine Who’s Most At Risk

Harvard psychology professor Matt Nock and research assistant Nicole Murman demonstrate the Implicit Association Test related to suicide risk. (Robin Lubbock/WBUR)

Harvard psychology professor Matt Nock and research assistant Nicole Murman demonstrate the Implicit Association Test related to suicide risk. (Robin Lubbock/WBUR)

Part of an occasional series we’re calling “Suicide: A Crisis In The Shadows

BOSTON — Up on the 12th floor of a nondescript concrete building in Cambridge, about a dozen Harvard University researchers spend their days trying to crack the code on something that’s eluded scientists for decades.

“We’re really lacking in our ability to accurately predict suicidal behavior and to prevent it,” says psychology professor Matt Nock, who runs the so-called Nock Lab, which is focused entirely on suicide and self-harm. “We are really struggling with identifying which people who think about suicide go on to act on their suicidal thoughts and which ones don’t.”

Nock demonstrates a computer-based exercise he’s using in his research, known as the Implicit Association Test, or IAT. The test asks patients to quickly classify words related to life or death — such as “thriving” or “suicide” — as being like them or like other people.

“For suicidal people, they’re faster responding when ‘death’ and ‘me’ are paired on the same side of the screen. People who are non-suicidal are faster responding when ‘death’ and ‘not me’ are paired on the same side of the screen,” Nock explains.

He and his team are evaluating the test by trying it out with patients in the psychiatric emergency room at Massachusetts General Hospital. The study participants do one other word classification exercise called Stroop and answer questions about addiction, mental illness and suicidal thoughts or behavior. Continue reading

How Art Can Re-Order A Harsh, ‘Deformed’ Childhood

Artist Evelyn Berde was born with congenital scoliosis in 1950 and spent many years in and out of Massachusetts General Hospital, confined to a bed for months at a time.

Her art, she says, is informed by her experience living with her “deformity,” as it was referred to back then, and her childhood growing up in the old West End of Boston, a low-income neighborhood near MGH and the Charles River, which was razed in the late 1950s, displacing many residents.

It wasn’t an easy childhood: Alcoholism ran in the family and Evelyn’s brother drowned in the Charles River when he was nine and she was just six. Evelyn was subjected to numerous surgeries and procedures for her scoliosis — some that now seem barbaric.

But art, she says, “has the ability to lift us out of one place and take us to another.”

Here, you can listen to Evelyn talk about five of her paintings and tell the stories that helped shape them.

Artist Evelyn Berde's "Shame" (Courtesy Berde)

Artist Evelyn Berde’s “Shame” (Courtesy Berde)

Artist Evelyn Berde's "July 12, 1956" (Courtesy Berde)

Artist Evelyn Berde’s “July 12, 1956” (Courtesy Berde)

Continue reading

Pediatric Politics: How Dire Warnings Against Infant Bed Sharing ‘Backfired’

sundaykofax/flickr

sundaykofax/flickr

By Dr. Melissa Bartick
Guest Contributor

Every new parent has heard the dire warning: Never sleep with your baby.

State and local health departments in Massachusetts and around the U.S. have prioritized this message. Millions of dollars have been invested in promoting it, and millions more spent on giving away cribs to poor families. It all comes from the official recommendations of the influential American Academy of Pediatrics published in 2011.

Some localities have even backed this message up with scary ads: a baby in an adult bed with a meat cleaver, stating “Your baby sleeping with you can be just as dangerous,” and another ad that says “Your baby belongs in a crib, not a casket.”

Studies Misrepresented

The problem with this widespread advice is that the AAP’s statement from which it comes is based on just four papers. Two of the studies are misrepresented, and actually show little or no risk of sharing a bed when parents do not smoke, and two of the studies do not collect data on maternal alcohol use, a known and powerful risk factor.

In addition, the AAP statement ignores many other more recent excellent papers that are not even mentioned or cited. My colleague, Linda J. Smith, and I recently published an analysis of all AAP’s statement and all the literature to date, “Speaking out on Safe Sleep: Evidence-Based Sleep Recommendations.” Along with this dissection of the AAP statement, we found that that any risk of death from a parent sharing a bed with an infant is greatly overshadowed by other risks that get far less attention.

Dangerous Sofas

We concluded that the only evidence-based universal advice to date is that sofas are hazardous places for adults to sleep with infants; that exposure to smoke, both prenatal and postnatal, increases the risk of death; and that sleeping next to an impaired caregiver increases the risk of death.

Formula feeding increases the risk of Sudden Infant Death Syndrome. No sleep environment is completely safe. But public health efforts must address the reality that tired parents must feed their infants at night somewhere and that sofas are highly risky places for parents to fall asleep with their infants.

The fact is, across the United States and the world, across all social strata and all ethnic groups, most mothers sleep with their infants at least some of the time, despite all advice to the contrary, and this is particularly true for breastfeeding mothers.

When You Avoid Bed Sharing

Unfortunately, we also know that parents who try to avoid bed sharing with their infants are far more likely to feed their babies at night on chairs and couches in futile attempts to stay awake, which actually markedly increases their infants’ risk of suffocation. Continue reading

The Bionic Mind: Building Brain Implants To Fight Depression, PTSD

Liss Murphy this summer, with husband Brian, son Owen and sheepdog Ned. (Courtesy)

Liss Murphy, who had surgery to implant Deep Brain Stimulation for depression in 2006 and got much better, on Cape Cod in summer, 2014, with husband Scott, son Owen and sheepdog Ned. (Courtesy)

Ten years ago, with little warning, Liss Murphy fell victim to paralyzing depression, a “complete shutdown.”

She was 31, living in Chicago and working in public relations. The morning of Aug. 13, 2004, she had gone in to the office as usual. “It was Tuesday, and I remember the day so clearly,” she says. “The sun — everything — and I walked out — it was about 11 o’clock — and I never went back. The only time I left the house was to see my psychiatrist, who I saw three times a week.

“I have a hard time believing it was depression, in a way, because it was so pervasive and powerful,” she says. “It invaded every aspect of my life. It took so much away from me. And it happened so fast, and it was so degrading — it took everything from me.”

Murphy came home to Boston, and she tried everything — medications, talk therapy, even repeated rounds of electroshock. But she was barely able to get out of bed for months — then years. Her husband and family and top-flight doctors cared for her, but she sank so low she tried twice to commit suicide.

Finally, a psychiatrist told her about a cutting-edge trial to implant stimulation devices deep in the brains of patients with severe depression. She signed up. In June of 2006, she had the operation.

“My greatest hope that day was to have something go horribly wrong and die on the table,” she says. “I didn’t care.”

She didn’t die. Over the next few months, she got better. These days, eight years after the surgery, if you saw Liss Murphy walking her Old English Sheepdog, Ned, or playing with her 3-year-old son, Owen, only the faint silver scars on her clavicles would hint at anything unusual: That’s where the batteries that power her brain stimulator are implanted.

“We’re taking a wall of computers, basically, and putting it into something that would easily fit inside a box of Tic-Tacs.”

– Jim Moran, Draper Laboratory

But though the surgery changed Murphy’s life, “the trial, on average, didn’t work,” says Dr. Emad Eskandar, the Massachusetts General Hospital neurosurgeon who operated on her. “When you pooled everyone together it didn’t work. But there were like five people out of the 10 we did that had remarkable benefits and went into complete remission. We couldn’t continue with the study because on the average it failed, but for those people in whom it worked, boy did it work.”

Now, as part of a $70-million project funded by the military, researchers are aiming to take brain implants for psychiatric disorders to the next level.

Over the next five years, they aim to build a device that can sit inside a patient’s head, pick up the onset of depression or post-traumatic stress disorder, and head it off before it hits. One implant researcher calls it “a moonshot for the mind.” Continue reading

Mass. Becomes First State To Require Price Tags For Health Care

CLICK TO ENLARGE: Massachusetts residents can now shop for their health care online, seeing prices for procedures and visits. (screenshot)

CLICK TO ENLARGE: Massachusetts residents can now shop for their health care online, seeing prices for procedures and visits. (screenshot)

Massachusetts has launched a new era of shopping. It began last week. Did you notice?

Right this minute, if you have private health insurance, you can go to your health insurer’s website and find the price of everything from an office visit to an MRI to a Cesarean section. For the first time, health care prices are public.

It’s a seismic event. Ten years ago, I filed Freedom of Information Act requests to get cost information — nothing. Occasionally over the years, I’d receive manila envelopes with no return address, or secure .zip files with pricing spreadsheets from one hospital or another.

Then two years ago Massachusetts passed a law that pushed health insurers and hospitals to start making this once-vigorously guarded information more public. Now as of Oct. 1, Massachusetts is the first state to require that insurers offer real-time prices.

“This is a very big deal,” said Undersecretary for Consumer Affairs and Business Regulation Barbara Anthony. “Let the light shine in on health care prices.”

There are caveats.
Continue reading

Making Peace With My Abnormal Brain

(Andrew Ostrovsky)

(Andrew Ostrovsky)

By Dr. Annie Brewster
Guest Contributor

What you never want to hear from the radiologist: “I wouldn’t mistake it for a normal brain.”

Yet this is what I recently heard from my radiologist friend who kindly took a look at an MRI of my brain. Let me repeat: it was my abnormal brain under discussion here, and I’ll tell you, his assessment was tough to hear.

The state of my brain isn’t exactly news to me. I have had Multiple Sclerosis since 2001, and I have frequent MRIs. Moreover, as a physician at the hospital where I get my treatment, I have the dubious privilege of having complete and immediate access to my medical chart. As such, I often see the MRI images and read the reports before my neurologist does, and fortunately or unfortunately, I understand “medicalese.” (And I have radiologist friends.)

Every time I get an MRI, I devour these reports as soon as they become available on the computer, scanning optimistically for words like “stable.” I even hold onto the absurdly magical hope that old lesions will have disappeared, and that this whole diagnosis of MS has been a big mistake. Instead, I find mention of new “hyperintense foci of white matter signal abnormality” and “enhancing” lesions, “consistent with actively demyelinating MS plaques.” I fixate on words like “volume loss” and “atrophy” and in one preliminary report generated by a resident, I think I saw the word “diminutive.” Did I imagine this?

Despite the sting of these words, I am able to remain somewhat detached. As a doctor, I spend my days looking at radiology images and reading such reports.

Often — due to the formal and impersonal language that is used — it’s hard to remember that the body part being referred to is actually part of a human being. It is even harder to remember that it is part of me!

“I wouldn’t mistake it for a normal brain” penetrates deeper. I understand. My brain is under attack, and is irreparably damaged.

My first response is to mount a defense. I feel the need to tell you that my brain is still a good brain. It just has a few small blemishes. It still works! I recently passed the required ten year recertification medical boards (apparently I will never escape bubble tests), and I feel smarter than ever. I am the mother of four and the primary logistical organizer in my
household, and my (short term) memory is at least ten times better than my husband’s (no offense, honey). Furthermore, research has clearly shown that MRI findings do not necessarily correlate with clinical symptoms in Multiple Sclerosis. So there is no cause for alarm.

Also, the research is promising. Exhibit A is this massive MS conference currently underway in Boston with many great minds focusing their attention on new approaches, such as potential remyelinating therapies, to tackle the disease. (MS damages the myelin, the sheath around nerve cells, and remyelination would restore it.)

My neurologist, Eric Klawiter, at Massachusetts General Hospital, writes me this:

As a research community, we have gained a great deal of knowledge on the mechanism of remyelination and how that process can go awry in MS. There are several candidate compounds demonstrated to promote the body’s ability to differentiate precursor cells into cells that lay down new myelin (oligodendrocytes). It is yet to be established whether these candidate therapies will work best to promote immediate recovery from relapses or whether they will also be effective in the setting of remote demyelination.

Of course, any potential new therapies are years or more away and don’t do much for me right now.

So, underneath my bravado, there is vulnerability. Continue reading

From Pimples To Desire, What Might Happen When You Ditch The Pill

(Becca Schmidt/Flickr via Compfight)

(Becca Schmidt/Flickr via Compfight)

By Veronica Thomas
Guest Contributor

So you’re thinking about going off the pill. Maybe you’ve been feeling depressed, getting headaches, or keep forgetting to pop the tiny tablet. Perhaps you’ve been experiencing some really strange stuff that didn’t happen before you started the pill—like inflamed, bleeding gums or cringing at another person’s touch.

Both personal anecdotes and research studies have linked these and other side effects, such as breast tenderness and nausea, to the pill. (One study suggested it might even make you pick the “wrong” partner by altering your chemical attraction to a man’s scent.)

Most randomized control trials haven’t actually found any real difference in the frequency of side effects among women taking the pill versus those taking a placebo.

“It’s an interesting phenomenon,” says Dr. Alisa Goldberg, director of clinical research and training at the Planned Parenthood League of Massachusetts. “Clearly some women are sensitive to the pill and experience these things, but when you try to study it scientifically on a population basis, there’s really no difference.”

Still, while four out of five American women have used the pill at some point, 30 percent have discontinued its use due to dissatisfaction—most commonly because of its side effects. The latest federal statistics on contraception use are due this fall, and experts expect trends from recent years to continue: IUD use will continue to rise, while pill use seems to have plateaued.

I tried five different formulations of the pill, but never managed to escape all the annoying symptoms.

The issues a woman experiences—or whether she has any at all—vary greatly based on the specific dosage of hormones and the unique individual swallowing them every day. Personally, along with bloating and mood swings, I got migraines with an aura, or what felt like a laser light show in my left eyeball. Twice I had to retreat to my office’s “Pump and Pray Room”—reserved for new mothers and religious employees—to lie down and recover. (What I did not know at the time was that, because of this symptom, I should not have been on an estrogen-containing pill in the first place. Women with aura migraines, along with other conditions that put them at risk for strokes, blood clots, heart disease or some cancers, should not take combination pills.)

Finally, I gave up on the pill—only to be blindsided by a whole new challenge: the unexpected side effects of going off the pill. To help others avoid similar unpleasant surprises, I spoke with three experts about what to expect when you ditch the pill for another birth control method.

Of course, just as each woman has a unique reaction to the pill, she’ll also have a unique reaction to going off. According to the feminist women’s health organization Our Bodies, Ourselves, there is “enormous variability in any individual’s response to her own hormones or any synthetic hormones she takes.” One woman’s skin may break out in pimples, while another’s clears up completely.

With this disclaimer in mind, here are eight possibly unexpected changes you might experience when you cancel your monthly refill of that crinkly foil packet:

1. Most of the side effects should disappear in a few days.

First off, while many women decide to have their period before pitching the pack, it’s safe to stop taking the pill at any point. However, you should stop immediately if experiencing any serious side effects, like headaches or high blood pressure, says Dr. Jennifer Moore Kickham, the medical director of a Massachusetts General Hospital outpatient gynecology clinic. Continue reading