2009 Medical Directory.ps

Medical Directory

A Supplement to the Daily Record

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Table of Contents YOUTHFULNESS AN AMERICAN OBSESSION — AT WHAT COST? PAGES 5-6 METAL BONE CALLED 1ST STEP IN BETTER LIFE PAGE 7 FOOD ALLERGIES ON RISE IN CHILDREN PAGE 8 STUDY ON AGING STILL GOING STRONG SOME 50 YEARS LATER PAGES 10-11 ELECTRICAL STIMULATION OF THE BRAIN A BREAKTHROUGH IN TREATING DEPRESSION PAGES 13-14

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MEDICAL DIRECTORY | 2009

YOUTHFULNESS AN AMERICAN OBSESSION — AT WHAT COST? By MARTHA IRVINE and LINDSEY TANNER Associated Press Writers

LAS VEGAS (AP) — It’s one of those photos that make you do a double-take. Dr. Jeffry Life stands in jeans, his shirt off. His face is that of a distinguishedlooking grandpa; his head is balding, and what hair there is is white. But his 69-year-old body looks like it belongs to a muscle-bound 30-year-old. The photo regularly runs in ads for the Cenegenics Medical Institute, a Las Vegas-based clinic that specializes in ‘‘age management,’’ a growing field in a society obsessed with staying young. Life, who swears that’s his real last name, also keeps a framed copy of the photo on his office wall at Cenegenics. ‘‘He’s the man!’’ patient Ed Detwiler says teasingly, pointing to the photo of the doctor who, in many ways, has become his role model. Detwiler, 47, has been Life’s patient for more than three years. In that time, he has adopted the regimen that his doctor also follows — drastically changing his exercise and eating habits and injecting himself each day with human growth hormone. He also receives weekly testosterone injections. He does it because it makes him feel better, more energetic, clear-minded. He does it because he wants to live a long, healthy life. ‘‘If I were stooped over and bedridden, what kind of quality of life is that?’’ asks Detwiler, a real estate developer in suburban Las Vegas who

says he’s doing this, in part, for his wife, who is nine years younger. ‘‘If I can get out and be active and travel and see the world and be able to make a difference in other people’s lives, then yes, I would want to have as long an existence as possible.’’ It is a common sentiment in a society where many of us strive to look and feel decades younger — to prove to ourselves and the world that we are healthier and more vital than our parents were at our age. We’ve all heard it: 60 is the new 50, the new 40 and so on. But often, we need a little help. Sometimes, a lot of help. As the baby boomers march toward retirement, Botox, wrinkle fillers and hormones of various kinds have become big business. Medco’s latest drug trend report shows, for instance, that human growth hormone use grew almost 6 percent in 2007. The list for age-defying tactics is endless. Want six-pack abs? There’s a surgical procedure to create fake ones. How about drastically cutting your calorie intake to slow the aging process? There’s a group of die-hards that swears by it. T h i s s e a rc h f o r e t e r n a l youthfulness certainly isn’t new. ‘‘In 1,500 B.C. people were ingesting tiger gonads to rejuvenate them,’’ says Dr. Gene Cohen, a George Washington University expert on aging. But for a generation of adults who’ve been weaned on the modern marketing message — that for a price, you can have it all — the quest is taking on a new urgency. There is, of course, much to be said for taking good care of yourself. Eating healthy and exercising your body

and your brain regularly are considered tried-and-true tactics for staying young. Protecting yourself from harmful sun rays is another. Even flossing teeth is a habit that, according to research on people who live to 100, might extend life. But that’s generally where the consensus ends. Many in mainstream medicine and elsewhere worry that we’re becoming too focused on treatments with shortterm benefits that have potentially dangerous side effects and scant, if any, evidence that they’ll help in the long run. In doing so, they wonder if some people are actually jeopardizing their chance at a long, healthy life, both physically and emotionally. ‘‘The quest to live forever and the desire to avoid diseases and not suffer’’ is understandable, says S. Jay Olshansky, a public health professor and longevity researcher at the University of Illinois at Chicago. But it can make people vulnerable to far-fetched and potentially dangerous scams, he said, with some of the more bizarre including fetal cell injections, inhaling radon gas, even cutting off testicles, an ancient practice meant to reduce overexposure to reproductive hormones. ‘‘There’s a large industry of people trying to sell to people what doesn’t yet exist and they’re making gobs of money doing it — much to the dismay of those of us who are vigilant about protecting public health,’’ he says. There also are concerns that this obsession is sending the wrong message to younger generations. Surveys from cosmetic surgery trade groups suggest that sizable numbers of people, even in their 20s, are getting cosmetic procedures. And a fall 2007 survey from TRU, a research firm that specializes in the teenage demographic, found that a

quarter of young people, 12 to 19 — and a third of girls in that age group — are interested in having cosmetic surgery to improve their appearance. Michael Wood, vice president and director of syndicated research at TRU, was a bit startled by the results. ‘‘There’s no doubt that the celebration of youth and looking younger has certainly accelerated in the last 10 years, five years even,’’ Wood says. ‘‘And this is a generation that’s growing up with that at a very young age.’’ The effect has been palpable, says Neil Howe, a respected generational expert who has written extensively about ‘‘millennials,’’ young people who are coming of age in this century. ‘‘I guess even young isn’t enough anymore,’’ Howe says. ‘‘It’s got to be ’perfect’ young.’’ Alex Sabbag, a 23-year-old Chicagoan, has felt the pressure, both self-imposed and societal. ‘‘I’ll age until I’m 25. Then I’m over it,’’ she said to co-workers during a lunchroom conversation that turned to the topic of Botox. She was only partly serious. But she says she’s also accepted that we live in a society where being well puttogether and youthful gives you status. ‘‘We all buy into it,’’ Sabbag says. And plastic surgery and other cosmetic procedures are part of it. She’s never had anything done, though wouldn’t rule it out in the future. She also vividly recalls how her mother left home for several days, when Sabbag was in elementary school, and returned after having a facelift. ‘‘I think it gives women and men alike worlds of confidence that ultimately makes them better people,’’ Sabbag says. ‘‘Yes, it is a vain practice ... but I think there comes a point for people when hard work isn’t enough to kick the last bit of belly fat or gravity has become entirely too unbeatable, and so a little nip-tuck

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of the forehead needs to happen.’’ Detwiler, Life’s patient at Cenegenics, is not looking for the appearance of youth. He’s looking to extend his youthfulness, and his life. He knows about human growth hormone and its controversies in sports. But this, he and his doctor insist, is different. While it is illegal for these kinds of hormones to be dispensed for anti-aging purposes, he takes relatively low doses prescribed for ‘‘hormone deficiency.’’ The idea is to bring his levels back up to those of a young man in his 20s. ‘‘My friends say, ’Oh, Ed’s on steroids,’’’ says Detwiler, who has watched as muscle has replaced fat on his belly and elsewhere. ‘‘No, I’m not. Look at me. Do I look like I’m on steroids?’’ He holds out his arms to indicate that his body is fit-looking, but not monstrous. ‘‘I’m not. I’m on hormone therapy,’’ he says of a regimen that costs him more than $1,000 a month. Besides human growth hormone, testosterone, and an adrenal hormone known as DHEA, his diet now largely consists of things like hardboiled eggs, fruits, nuts, Greek yogurt, salads and palm-sized pieces of fish, chicken or low-fat beef. He also exercises regularly, alternating between intense cardio workouts and weight-resistance training. ‘‘I can’t tell you in words how great I feel,’’ says the man who used to crack open a Pepsi to get him through the day. For a group known as the Calorie Restriction Society, youthfulness isn’t found in hormones. It’s reducing food intake to, in some cases, nearstarvation levels. But the claims are much the same — ‘‘lots of energy’’ and feeling ‘‘sharp,’’ says Brian Delaney, a 45-yearold California-born writer now living in Sweden. He’s the president of the group that claims about 2,000 members worldwide and many more followers who use the method in hopes of markedly increasing their longevity. By cutting daily calories to about 1,900, roughly half the recommended amount for someone his height and age, and exercising every day, Delaney has shrunk himself to about 140 pounds. He says his blood pressure, cholesterol and blood sugar levels have improved dramatically. At 5 foot 11, he admits he’s ‘‘scrawny,’’ which he calls the main drawback. 6

Hunger and wearing extra clothes to stay warm — because of little body fat or, he claims, an effect of slowed aging — are barely annoyances for Delaney. He says he eats sensibly, replacing junk food with lots of fruits and vegetables, no meat, and two meals daily — no lunch. Breakfast is often ‘‘a hearty bowl’’ of granola, with fruit, nuts and soy milk; while dinner could be fish, rice, beans, a large salad and red wine. Other than ‘‘tons of fine wrinkles’’ he blames on too much sun as a kid, Delaney says in most respects, ‘‘I look much younger’’ than 45. It is a bragging right many strive for. ‘‘When we were younger, we’d talk about someone who was 60 and that was old. And now my gym is full of women over 60 and they look phenomenal,’’ says Renee Young, a 48-year-old businesswoman in New Rochelle, N.Y. ‘‘They don’t want to be categorized as old.’’ But there’s more to it than that. Youthfulness, she says frankly, is also a means of survival in the business world, including in her line of work, public relations. ‘‘It feels like you’re put out to pasture. No one wants to feel that how they look means that their ability to do anything is decreased,’’ Young says. ‘‘If you have a younger look, you feel healthier. You feel that you’re still in the game.’’ In the back of her mind is the fact that her own mother died when she was only 56. So five or six mornings a week, even when she’d rather pull the covers over her head, Young gets up and puts in two hours at the gym. That’s more than double the hour or so a day generally recommended for optimal health. And still, for her, that wasn’t enough. She recently spent nearly $20,000 on a tummy tuck because, as she puts it, no number of abdominal crunches was going to make her as trim as she wanted to be. The result has been a makeover for her entire sense of self, she says. ‘‘I made a commitment this summer. If I was going to go through all this surgery, then it was going to have to be part of a complete program,’’ says Young, who’s also getting more rest and eating healthier. ‘‘I can definitely see the result.’’ She, too, says she has not felt this good in years. Using a cosmetic procedure as a motivator is worthwhile, and lucrative, to

MEDICAL DIRECTORY | 2009

say the least, says Dr. Jonathan Lippitz. He’s an emergency room physician in suburban Chicago who does cosmetic procedures, such as Botox and skin fillers, in a separate practice. But it’s also a ‘‘very slippery slope,’’ with patients sometimes willing to take more risk than they should and some doctors who’ll accommodate. ‘‘They’ll always find somebody willing to do it,’’ he says. In his own practice, he says he finds himself continually walking a fine line in deciding which procedures he’ll do — and which ones he won’t. ‘‘We all say, ’I want my hair different. I want my eyes different,’’’ Lippitz says. ‘‘This idea of being perfect is a problem, though, because it’s not reality. ‘‘I have people coming in and saying ’I want these lips.’ I say, ’You can’t have these lips.’ ‘‘I say, ’We’ll work with what you have.’’’ But what if what they have is just fine? These are the sorts of questions that trouble Dr. Michael Morgan, a dentist who does cosmetic work in another Chicago suburb. He’s been seeing more young, female clients walking through his doors. And even his own 13-year-old daughter asked if he would whiten her teeth, something he didn’t think she needed. Nor did he consider it safe for her young teeth or ‘‘age appropriate.’’ ‘‘There’s a consciousness about it. They are much more concerned with the appearance of their face. But there’s also a social pressure,’’ he says of the younger generation for whom he’ll do the most conservative procedures, but no more. He sounds a little sad when he talks about it. ‘‘There’s nothing wrong with wanting to look better. We want to look young. We want to look great,’’ he says. ‘‘But part of that feeling has to come from within.’’ For those going to even greater lengths to try to keep aging — and ultimately death — at bay, there also are no guarantees. Calorie restriction guru Dr. Roy Walford succumbed to complications from Lou Gehrig’s disease at age 79, closer to the average than the ‘‘extraordinarily long life’’ his followers talk about on their Web site. Meanwhile, Dr. Alan Mintz, founder of Cenegenics, died at the relatively young age of 69 due to complications during a brain biopsy.

Some research has suggested that human growth hormone injections can cause cancer. They’ve also been linked with nerve pain, elevated cholesterol and increased risks for diabetes. Even so, Life, now the chief medical officer at Cenegenics, remains steadfast. Among other things, he points to studies that suggest that human growth hormone in low doses poses no cancer risk if there is no preexisting cancer. ‘‘Within the next 10 years, maybe less, this is going to be thought of as mainstream medicine — preventing disease, slowing the aging process down, preventing people from losing their ability to take care of themselves when they get older and ending up in nursing homes,’’ Life says. ‘‘This is really the cutting edge of medicine.’’ Detwiler is betting on that. ‘‘There are those who might think I’m cheating God’s way. I don’t know,’’ he says. ‘‘But I don’t want to regress. Why should I?’’ He says his overall body fat has dropped from nearly 17 percent to less than 10 percent. He can’t remember the last time he had a cold or the flu. And he says he’s had the stamina to work long hours, putting him on pace to earn more than a million dollars this year. That’s what he knows now. The future, he says, will be anyone’s guess. ‘‘People might ask, ’Hey, what’s happened to these people? Was it cutting edge? Or did it cut it short?’’’ he says, as he walks into a gym for another workout. ‘‘I think only time will tell.’’ ——— On the Net: • Cenegenics: http://www.cenegenics.com • Calorie Restriction Society: http://www.calorierestriction.org • Life Expectency Calculator: http://www.livingto100.com/ • National Institute on Aging: http://www.nia.nih.gov/ ——— Martha Irvine is an AP national writer. Lindsey Tanner is an AP medical writer. They can be reached via mirvine(at)ap.org or http://myspace. com/irvineap

SCIENTISTS CREATE ‘GOOD BUGS’ TO FIGHT ‘BAD BUGS’ By Robert S. Boyd McClatchy Newspapers

WASHINGTON —Foryears, you’ve been able to walk into a drugstore or health food outlet and buy a host of “probiotics” — natural dietary supplements such as Acidophilus or Lactinex — off the shelf to treat conditions such as children’s eczema or traveler’s diarrhea. Unlike antibiotics, these self-help products don’t kill germs, but they supposedly confer health benefits, the way vitamins and certain minerals do. Existing probiotics haven’t been approved

by the Food and Drug Administration or subjected to rigorous clinical trials. When tested, their effectiveness has been mixed, medical researchers say. Now, scientists are trying to design “good bugs,” novel forms of bacteria created in the laboratory to prevent or cure specific diseases, including HIV and cancer. “Perhaps the only hope of winning the war against ‘bad bugs’ will be achieved by recruiting ‘good bugs’ as our allies,” e-mailed Roy Sleator, a microbiologist at University College in Cork, Ireland. Sleator is the editor of a forthcoming scientific journal called “Bioengineered Bugs.”

He said his laboratory had engineered a new generation of “designer probiotics,” which are tailored to target certain disease-causing microbes or toxins. His “good bugs” mimic receptor proteins on the surface of harmful bacteria and block their ability to infect healthy cells. “Designer probiotics bind to bacterial toxins in the gut ... thereby preventing disease,” Adrienne and James Paton,researchers at the University of Adelaide, Australia, reported in the journal Nature Microbiology. In a e-mail, James Paton said his lab had designed a probiotic that works against E. coli O157, a notorious microbe that’s caused serious, sometimes fatal, outbreaks of intestinal disease. The need for more effective antibiotics is widely recognized because of an alarming increase in the ability of bacteria to resist standard medicines. A special concern is the virulent MRSA — methicillin-resistant staphylococcus aureus — a bacterium that infects and sometimes kills hospital patients. “It i s b e c o m i n g i n c re a s i n g l y apparent that alternative approaches to conventional antibiotic therapy are required to control infectious diseases in humans and animals in the 21st century,” Paton said. “Increasing incidence of antibiotic resistance ... has forced clinical research to explore alternative therapeutic and

prophylactic avenues,” Sleator wrote in a British microbiological journal. “Probiotics are finally beginning to represent a viable alternative to traditional drug-based therapy.” Sleator said his laboratory had genetically engineered a harmless strain of E. coli to secrete a substance that might be useful against HIV. He’s also working on probiotics that may assist in the prevention and decreased recurrence of certain cancers. Researchers caution that designer probiotics are still under development, need further testing and government approval, and suffer a number of shortcomings. The “good bugs” are fragile and shortlived, Sleator said, and scientists don’t understand very well how they work. Paton said there was also “substantial public mistrust” of genetically modified organisms, such as good bugs, “which may lead to marketplace resistance even to potentially lifesaving products.” Nevertheless, scientists have faith that designer probiotics eventually will outperform nature’s products.

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METAL BONE CALLED 1ST STEP IN BETTER LIFE MAN,

H I S D O C T O R S (MCT) Shuffling through his physical therapy S AY TITANIUM FEMUR exercises at Weiss Memorial Hospital IS SPACE - AGE FIX FOR last week, 81-year-old Gene Johnson DEBILITATING PAIN did not appear particularly bionic to By Robert Mitchum Chicago Tribune

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MEDICAL DIRECTORY | 2009

wonder: a titanium femur. The metal bone won’t give Johnson, a salesman from Princeton in northcentral Illinois, the ability to kick down steel doors or leap buildings in a single bound. But his doctors said total femurreplacement surgery, a procedure performed less than 100 times a year in the United States, should keep him from having to use a wheelchair for the rest of his life or potentially having his leg amputated. Twenty days after Johnson’s surgeons performed the replacement, they showed their tired but optimistic patient the kind of shiny device that has replaced the longest bone in his body, as well as his hip and knee. “No wonder I gained weight,” Johnson said with a laugh as he marveled at the construction of the artificial bone, which actually weighs about the same as the femur doctors removed this month. The total femur replacement was a “last resort” for Johnson, said his surgeons, Dr. Henry Finn and Dr. Kris Alden of the University of Chicago Bone and Joint Replacement Center at Weiss. Johnson’s femur was broken during surgery to repair his 10-year-old artificial hip this year, leading to a long series of painful surgeries and difficult rehabilitation to repair the frail bone. As many as 20 screws and two metal plates were implanted to support it. In September, Johnson’s leg gave way yet again in a Wal-Mart parking lot, and

surgeons said further reconstructive surgery likely would be futile. “If nothing were done, this man would have to drag a painful leg around that he could not walk on,” Finn said. Though the replacement procedure has been around for more than 40 years, it is more typically used in patients who suffer from rare bone cancers, said Dr. Santiago Toledo, medical director of orthopedic rehabilitation at the Rehabilitation Institute of Chicago. The surgery is rare in part because its demands are so complex. Johnson’s procedure took Finn and Alden more than five hours because of the delicate architecture of muscles, blood vessels and nerves surrounding the femur. Artificial femurs also can bring concerns over durability and infection, doctors said. A titanium femur costs more than $20,000 in surgery, hospital care and physical therapy. But Finn said the cost is minuscule given the potential benefits to patients like Johnson in quality of life. “You pay $80,000 for a Lexus, so what’s a leg worth?” Finn said. Alden and Finn predicted a slow increase in the number of femur replacements as life expectancy increases. “People are living longer and they have more expectations on what their golden years are going to be like,” Alden said. Testing out his new femur by huffing and puffing up and down three stairs, Johnson said he had a humble goal for his restored mobility: returning to Princeton and walking—slowly—to the bleachers of Bureau Valley High School to watch volleyball and football games. “It’s an unknown; there aren’t a lot of people around to talk to about this,” Johnson said of the titanium bone. “But hopefully it’ll let me live longer and do more things.”

FOOD ALLERGIES ON RISE IN CHILDREN By Erin Richards Milwaukee Journal Sentinel

(MCT) One M&M, swallowed whole, and little Noelle’s skin turned as red as a Cortland apple. A month later, after eating soy ice cream, the 2-year-old turned colors again and started drooling, prompting her mother to inject a syringe full of epinephrine into the child’s leg. KarenTylicki of Mukwonago has no idea why her daughter’s body treats certain foods as if they were poison. Tylicki, like parents of a growing number of foodallergic kids in Milwaukee and elsewhere around the country, is familiar with the fear, uncertainty, grief and sorrow that frequently accompany the condition. Add hope to that list. Thanks to a La Crosse clinic that’s gaining attention for its work desensitizing patients with food allergies, Noelle, now 6, can ingest almost 2 ounces of milk without a reaction. The spike in the number of kids with food allergies - an 18% increase nationwide over the past decade, according to a newly released study from the U.S. Centers for Disease Control and Prevention - has prompted many schools and day-care facilities to develop new safety measures. At the Children’s Community Center, a day care facility in Menomonee Falls, director Nancy Larson said the jars of peanut butter that were once standard in every classroom have been removed

because of the increase in peanut allergies. “If someone forgot their lunch, we always used to give them peanut butter and crackers,” Larson said. “Now we purchase soy butter.” In Waukesha Public Schools, District Nurse Twyla Lato said schools aren’t “peanut-free” because that gives children a false sense of security. Nevertheless, the number of kids in the district with food allergies is startling: 545 students last year, compared with 481 in 2003-’04. At Grafton Elementary School, Principal Jeff Martyka said that five years ago he didn’t have any students “on epinephrine,” the adrenaline-like drug that severely allergic children are supposed to carry with them at all times. Now he has seven. Jamie Dempsey, 6, is one of them. Although he brings his lunch to school, his allergies to milk, eggs, peanuts and sesame are so severe that he eats on a sanitized lunch tray to avoid getting any of the offending substances on his skin. In the classroom, Dempsey and his classmates have hand sanitizers on their desks. “It’s hard - trying to strike a balance between providing awareness and not provoking anxiety in people or coming across as a high-maintenance mom,” said Monica Dempsey, Jamie’s mother. Food, emotions linked Food and emotions are so intrinsically linked that dealing with the pitfalls of food allergies can seem like a disability at times, parents say.

Tara Williams, of the village of Belgium in Ozaukee County, said her family went through a period of mourning when her then 11-month-old son, Brett, was diagnosed with allergies to eggs, dairy, peanuts, tree nuts, sunflower and coconut. “You start thinking of all the kid things you envisioned doing as they grew up - going out for pizza, ice cream on a hot summer night, even just having them leave your eyesight without worrying,” Williams said. “You go through anger and sadness. Everything will be fine for a while, and then he’ll have a reaction out of the blue, and you’re all upset about it again.” Theories abound about why more children are suddenly allergic to more foods. Michael Zacharisen, a physician in the Allergy/Asthma/Immunology Clinic at Children’s Hospital of Wisconsin in Wauwatosa, said none of them - the “we’re too sanitized” theory, the “antibiotics leaching in the gut theory,” for example - has been proved. “Food allergy has lagged a bit behind other research because it doesn’t have pharmaceutical funding,” Zacharisen said. Research on potential treatments is

more promising. At Duke University, subjects in a study are being given tiny amounts of liquid or powder peanut protein to see if they can build up a tolerance over time. Allergy Associates of La Crosse has also championed the practice. The clinic sees more than 10,000 patients a year who come for “sublingual immunotherapy” or the placing of tiny drops of the allergen under the tongue to stimulate the oral mucosa. According to the clinic, 43 states are using the La Crosse method to treat patients with food and other allergies. Mary Morris, the clinic’s lead allergist, said the goal is to minimize the effects of an accidental exposure. Patient Noelle Tylicki, who started kindergarten this year in Genesee Depot, will increase her dosage of milk one last time in January. She has completed the desensitizing program for eggs. “I have to give her wings at some point,” her mother said. “She has to be able to fly by herself.”

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STUDY ON AGING STILL GOING STRONG SOME 50 YEARS LATER By Richard Seven The Seattle Times (MCT) S E AT T L E - T h e Un i ve r s i t y o f Washington has been awarded a five-

year, $4.5 million grant to research specific challenges related to aging with a disability. The Aging Rehabilitation Research and Training Center will be based in the University of Washington Medical Center’s Department of Rehabilitation

Medicine and will focus on multiple sclerosis, spinal cord injury, muscular dystrophy and post-polio syndrome. “Although much research has been done on these disabling conditions, very little has been done on the effect of aging in compounding the functional problems of persons with these four disabilities,” says Dr. George Kraft, a University of Washington physiatrist and Alvord Professor of MS Research. “This center will be the first to explore these important research questions.” The grant was awarded by the National Institute on Disability and Rehabilitation Research. K. Warner Schaie agreed to present findings from his exhaustive study on aging at last year’s Washington State Psychology Association conference, but only if he could bring 26 guests. They ranged from 74 to 101 years old and had stuck with him for a half-century. They were a handful of the 500 subjects who enrolled in the first year of the Seattle Longitudinal Study in 1956. Still going, it is considered by many to be the most extensive and lasting psychological research study on how people develop and change cognitively as they age. Information from it has helped change mandatory-retirement law and combat phrases like “having a senior moment”

and other examples of ageism. Schaie, who is 80, has published books, monographs, chapters and papers and testified before Congress about age discrimination in the workplace. But recalling the day he presented his information alongside the people instrumental in building the database makes him smile. “One of my subjects, a 101-yearold woman, sat in the front row,” he says. “And she was scribbling all these notes.” A LONGTERM STUDY Every seven years, Schaie and his team have tested and added people to the study. About 6,000 people, in some cases representing three generations of the same family, have been tested at least once. The study examines health, demographic, personality and environmental factors that influence individual differences. Subjects take cognitive tests and answer psychological questions while researchers try to learn why some people stay sharp well into old age while others falter. In recent years, investigators have drawn blood samples and administered brain scans to add neurological evidence to the database, some of which might one day be relevant to the early detection

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of dementia. Psychologist Alejandra Suarez, who teaches at Seattle’s Antioch University, says following the progress of the same set of subjects for so long has made Schaie’s study especially valuable. “Many studies about how people change cognitively are done by asking people of different ages to participate in the studies - which is like taking a snapshot of how different generations function intellectually at a single moment in time. But those results are misleading because the differences can be due to changes in education, nutrition and diversity of opportunities over generations. “ What Dr. Schaie has done is invite people to participate and then interviewed and assessed them every seven years, to see how a particular person changes and evolves, compared to his or her original abilities. This means that he can rule out that the changes are due to generational opportunities and challenges.”

Continued on the next page.

IN THE FAMILY While an undergraduate at the University of California in 1951, Schaie worked in the composing room of the San Francisco Chronicle. Because the newspaper was published in the morning, he worked late into the night, shrinking the range of classes he could take and leading him to conduct an adult development study as a way to get credits. His family doctor happened to have a geriatric practice, too, and allowed Schaie to survey willing patients. To Schaie’s surprise, he was invited to present findings from his study at an international geriatrics conference in St. Louis. He got there by Greyhound bus and met some of the leaders in the small but growing field. When he was accepted into graduate school at the University of Washington, he chose, as his niche, gerontology.

“People would say who is this crazy young guy interested in old people,” he says, laughing. “Why doesn’t he do something ‘mainstream?’ It wasn’t mainstream back then.” He got his initial sample (and every subject since) for the Seattle Longitudinal Study from Group Health Cooperative. He left Seattle upon graduation but continued to return to retest and add more to the study. Eventually he opened a permanent office here and began testing his subjects’ offspring. The work is funded by the National Institute on Aging. 80 AND STILL GOING Having just retired from Penn State University, Schaie and his wife, fellow scientist Sherry Willis, moved back to Seattle. Willis has been co-investigator on the study since 1983. The subjects also have helped scientists learn about whether people can recover mental function through intensive training sessions. That sort of work helped inspire the “brain fitness” software and books that flood the market today even though Schaie believes some of the claims behind those products have not yet been fully validated through research. Along the way, he has studied how life events, from losing a spouse to recovering from cancer, affect a person’s cognitive ability and has searched the data for

nuances. There are all sorts of factors that can hasten decline, but Schaie has also seen cases where scores improve, such as when a cancer treatment has been successfully completed or someone has come to terms with a spouse’s death. “How you live your life makes a difference as to how you will move into old age,” he says. “You don’t suddenly become a member of a difference species when you grow old. It’s clear that a person who is quick-minded and not rigid in his thinking has an advantage. Things change, but if you’re a good problem solver or successfully handled a personal crisis when you were younger you will likely continue to do so.” He also believes that education and continuing curiosity may protect a person from rapid decline. Why does he, at 80, still collect and interpret the data? “I really don’t have any compelling hobbies that challenge me,” Schaie says. “I find this stimulating, my work is still in demand to a degree and I get to remain in touch with my colleagues, who are also my friends - and that’s important, too.”

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ELECTRICAL STIMULATION OF THE BRAIN A BREAKTHROUGH IN TREATING DEPRESSION By Don Sapatkin The Philadelphia Inquirer

(MCT) PHILADELPHIA - In the late 1700s, Italian anatomist Luigi Galvani made a dead frog’s muscles twitch when struck by a spark, a discovery that paved the way for the modern understanding of electricity’s role in living things. It is the basis for countless medical technologies like the pacemaker. But electricity does not travel easily through the skull to the brain, the organ responsible for every purposeful twitch and altered mood. So when a group of British scientists in 1985 used magnetic pulses from outside the head to induce an electrical field inside the brain - and got a subject’s hands to move - their colleagues clamored for a chance to zap themselves. That breakthrough, known as transcranial magnetic stimulation (TMS), led to the Food and Drug Administration’s approval last month of the first noninvasive, non-pharmacological treatment for depression. As a practical matter, approval of the device made by Neuronetics Inc., a five-year-old Malvern, Pa., company, is intended for patients with major

treatment-resistant depression who do not respond to any one medication. Millions of Americans fail to benefit from antidepressants, and millions more quit because of side effects. Symbolically, the federal action is a big deal - another advance in a group of emerging fields that involve electrical stimulation of the brain. “Our view of the brain is changing,” said Mark S. George, a professor of psychiatry, radiology and neuroscience at the Medical University of South Carolina. Just 10 or 15 years ago, scientists thought of the brain as a single entity - what he called “the brain-as-soup” model. “But really you want to treat specific regions in the brain.” George is editor in chief of a year-old journal named Brain Stimulation, and he is a champion for the cause. After decades of success with psychiatric drugs, he said, “we had forgotten that the brain is really an electrical organ.” Researchers worldwide are testing therapies ranging from highly invasive electrical implants to hardly noticeable magnetic fields on dozens of psychiatric and neurological disorders. Success has been limited - but so are current treatment options. When a major depression enveloped

Ernie Mercer in the late 1980s, Prozac had just come on the market, and it worked. When depression struck again five years ago, it didn’t. Neither did Effexor or a third drug. Worse, they made him nervous and constipated. For Mercer, a retired engineer who lives near Atlantic City, depression was withdrawal from life. “Nothing was fun anymore,” he said. He answered an ad seeking research volunteers for an experimental treatment in 2005. The clinical trial of transcranial magnetic stimulation went like this: He’d show up at a University of Pennsylvania clinic five times a week, answer the same set of questions about his mood, and then sit in what resembled a dentist’s chair for 40 minutes with earplugs in his ears and an apparatus strapped to the top left of his head. He heard loud clicking sounds but felt nothing. After four weeks, a sensation suddenly matched the clicking - “kind of like somebody tapping on your scalp like 10 times a second,” he said - and his depression began to lift. He had been initially assigned to the sham (placebo) group; now he was getting TMS. After several weeks of the real thing, he felt fine. He still does. Mercer, 65, paid nothing for either

the treatment series or twice-monthly maintenance sessions ever since. The research grant ends this month, however, and the clinic will charge him $150 on its sliding scale if health insurance doesn’t cover it; most of the clinic’s patients are likely to pay at least $200. Insurers are just now beginning a review. The new treatment is not a panacea. An unrelated study two years ago found that, of patients who failed to benefit from one antidepressant medication, just one-third responded adequately to a second. TMS produced a similar response rate (as does talk therapy, according to other studies), although the effect was described as greater. The biggest difference is side effects, which cause many patients to stop taking antidepressants. The most commonly reported side effects to the brain stimulation were headaches and scalp irritation, both temporary. TMS poses a slight risk of seizure. No incidents were reported in data on 10,000 sessions submitted to the FDA. Neuronetics didn’t seek approval to treat all major depression; when antidepressants work well, they are hard to beat. Still, the FDA rejected the initial application last year to use the NeuroStar TMS device for treatmentresistant cases generally. A reanalysis of data on the 301 patients in the multicenter trial found the strongest response among those who had tried and failed with just one drug, and that’s what the agency approved. Patients like Mercer, who gave up on three, can be treated “off label,” which may be less likely to qualify for reimbursement. Oddly enough, Tufts University psychiatrist Daniel Carlat said he would be more likely to steer those patients the ones least likely to respond - toward TMS because they’ve run out of easy alternatives. Carlat, who has no connection with the manufacturer or drugmakers, has written skeptically about TMS in past issues of his Carlat Psychiatry Report. He said the latest findings changed his mind. Psychiatrist John O’Reardon, who ran the Neuronetics-funded trial at Penn and is beginning to study TMS for Attention Deficit Hyperactivity Disorder in adolescents, believes that many people who can’t tolerate antidepressants will find this easier despite the inconvenience of 20 to 30 daily sessions. “They come in and sit in the chair, we slap a magnet on their head for 30

2009 | MEDICAL DIRECTORY

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static magnets. The electromagnet in the new device is thousands of times more powerful, similar to that of an MRI, said Neuronetics chief executive officer Bruce Shook. In repetitive transcranial magnetic stimulation (rTMS), rapid series of pulses pass through the skull and induce an electrical field on the surface of the brain, exciting the neurons below. For depression, the target is a postage stamp-size part of the left prefrontal cortex that is less active in depressed people. Scans confirm more activity after successful treatment of any kind, although the exact mechanism is not known. The therapy is being studied for posttraumatic stress; obsessive-compulsive and panic disorders; fibromyalgia; and other conditions. The most promising results are for dampening the auditory hallucinations that schizophrenics describe as hearing voices. Ralph Hoffman, a Yale psychiatry professor who began studying the treatment 10 years ago, said the latest data showed “a significant effect,” although years away from clinical use. It is the repetition in rTMS that seems to retrain the neurons and bring enduring change. Single-pulses, called sTMS, have a short-term effect. Neuralieve Inc., of Sunnyvale, Calif., has applied for FDA approval of its portable, handheld sTMS device for the one-third of migraines that are preceded by recognizable visual or sensory symptoms known as auras. The battery-operated device is about the size of a hair dryer. At the onset of symptoms, you place it against the back of your head and press a button. After 30 seconds to recharge the batteries, you deliver a second pulse. The shortterm stimulation disrupts the spread of abnormal brain waves. It left nearly 40 percent of participants in a recent clinical trial pain-free after two hours, said Terese M. Baker, the company’s vice president of marketing. “You can stop the migraine progression before it takes root,” she said. The oldest form of brain stimulation, dating to the 1930s, is electroconvulsive therapy. It is the most effective treatment for major depression. Once stigmatized as “electroshock,” ECT has been refined in recent years. But it works by causing seizures, and the risk of serious side effects, especially memory loss, still limits its use to the most serious cases. A kinder, gentler version may be in the works. Sarah H. Lisanby, a professor of clinical psychiatry at Columbia

University, developed magnetic seizure therapy (MST), which uses magnetic pulses to induce seizures. “With magnetic fields, we have better control,” she said. The seizures are more focused and less robust. Lisanby, who is researching several types of brain stimulation, thinks that part of the potential of these fields lies in the ability to tailor treatments for an individual. Magnetic and electrical fields can be aimed at a variable target. Today’s drugs cannot be. Anthony T. Barker has been following all these developments with interest from afar. Barker led the team that zapped a man’s brain with a magnetic pulse in 1985 and got his hand to move. And while none of the new therapies was on his radar screen at the time, so many colleagues wanted to “have a go” that he knew something would come of it. “It is arguably one of the coolest demonstrations of physics’ effect on the human body,” said Barker, a professor in medical physics and clinical engineering at Royal Hallamshire Hospital, Sheffield. “If you were here, I would zap your brain and make your hand move, and you would think it was cool, too.” ___ Brain Stimulation Therapies At least nine methods are being studied. The most common: _Transcranial magnetic stimulation (TMS) With the patient awake in the office, external magnetic pulses induce an electrical field on the surface of the brain, activating neurons below. Noninvasive. _Electroconvulsive therapy (ECT) Electrical stimulation of the scalp under anesthesia induces a wave of activity across the brain - a seizure. A gentler, magnetically triggered version is being tested. _Vegus nerve stimulation (VNS) A pacemaker in the chest sends electrical impulses to electrodes in contact with the vagus nerve in the neck, and then up to the brain. _Deep brain stimulation (DBS) This is similar to VNS, but electrodes are surgically implanted in the brain to stimulate precise regions in various disorders. Highly invasive.

FOR DIABETICS, PREVENTING RENAL FAILURE IS

HARD WORK BUT ESSENTIAL By Josh Goldstein The Philadelphia Inquirer

(MCT) PHILADELPHIA - Diabetes has cost Robert Heard dearly. His left leg was amputated below the knee two years ago. Kidney failure - with its special diets, thrice-weekly dialysis, and everpresent threats of infection - is worse. “It breaks you down mentally,” says Heard, 32, who has been waiting for a second kidney transplant since the first, donated by his uncle, failed four

years ago. Heard was diagnosed with Type 1 diabetes at age 10, and said he managed it well for 15 years until, as an adult, he changed jobs and lost his health insurance. Unable to get the medicines he needed, the Logan resident lost control of his blood sugar levels. Like many people with an uncontrolled chronic illness, Heard regularly ended up in the emergency room. And like more and more diabetics, his kidneys finally gave up. Ask someone about diabetes, and eye

problems or heart disease often come to mind. That’s a correct association, but so is kidney failure. The number of Americans diagnosed with the condition increased five times over the past three decades, a period that also saw a staggering rise in the number of Americans with diabetes. Nearly half of all kidney failures in this country are now caused primarily by diabetes, according to a leading federal health agency. “The link is incredibly powerful,” says Richard C. Wender, professor of

medicine at Jefferson Medical College in Philadelphia. “Diabetes is the leading cause of kidney failure in the U.S.” The United States spends $34 billion a year on kidney failure. And the bulk, more than $20 billion a year, is covered by taxpayers through Medicare. About 24 million people nationwide have diabetes, federal authorities say, and 57 million more are prediabetic with elevated blood sugar levels that put them at high risk for the illness. That means 81 million people, about one in four Americans, are either diabetics or potential ones. For doctors, patients and policymakers, the health-care system’s inability to stop preventable kidney damage from diabetes is frustrating. With good primary care, diabetes can usually be managed, or even spotted and stopped before it fully develops. But the system doesn’t pay well for preventive care. Many patients aren’t educated on how to manage their conditions. Drugs can be expensive, and many people lack good access to care. Even those who see their doctors regularly could get in trouble because good diabetes care takes time, a commodity that few caregivers have to spare. Kidney failure can be caused by either major form of diabetes: Type 1, once known as juvenile onset, arises from the body’s inability to make insulin, a key hormone that regulates the body’s blood sugar levels. Type 2, the more common, can develop at any age, and is caused by the body’s failure to use insulin. Both can damage the kidneys and cause death if left untreated. Each kidney is essentially a giant filter made up of roughly 1 million smaller

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filters known as glomeruli. These tufts of tiny vessels remove waste, but not nutrients, from blood. Over many years, the excess sugar of diabetes harms the membranes of those vessels. An early sign of kidney disease is the appearance of tiny amounts of the protein albumin in the urine. “If the filter is not working, you can lose a lot of the good stuff into your urine,” says Mitchell A. Lazar, director of the University of Pennsylvania’s Institute for Diabetes, Obesity and Metabolism. At the same time, waste products and excess fluids build up in the bloodstream. So patients must get their blood cleaned artificially. One way to accomplish this is to plug into a mechanical kidney. Catheters are placed into vessels in the arm, enabling large amounts of the patient’s blood to pass through the machine’s filter and back into the body. Patients must undergo this treatment, called hemodialysis, for at least several hours three times a week. The treatment can cause many side effects, ranging from nausea and anemia to infections and sudden drops in blood pressure. Catheters also can become clogged, requiring multiple procedures to clear or make new openings elsewhere. How can you avoid all this? “The best strategy is to prevent diabetes - and the most effective way in the majority of patients,” said Jefferson’s Wender, “is to maintain a normal weight and exercise regularly.” A better diet may help, including lots of fruits and vegetables. So can controlling high blood pressure, a common precursor to kidney problems.

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Nearly everyone should get routine blood tests to catch diabetes before it damages the kidneys, said Jefferson endocrinologist Serge Jabbour. It is not uncommon for people with Type 2 diabetes to live with the disease for five or 10 years before developing symptoms that cause them to seek treatment, Jabbour said. During that time, high blood sugar levels could be damaging the kidneys. If the worst happens and your kidneys fail, a good attitude can still help. “You need to stay happy, because the more upbeat you are, the better things go,” said Heard, who has gotten care at Albert Einstein Medical Center in North Philadelphia. The challenges of living with the condition are “an everyday thing,” he said. Another patient, Ben Walters, 48, has been controlling his blood sugar to keep the disease from progressing. Diagnosed with diabetes in 1990, the Center City resident has since developed diabetes-related nerve damage in his right knee - a condition known as Charcot’s joint - that severely limits his ability to walk, forcing him to use a wheelchair. Despite that and everything else getting dialysis three times a week that often leaves him weary, and giving up a job he loved as deputy inspector general for the City of Philadelphia - Walters tries to remain focused. “I think I have extended my life,” he said last month after four hours of dialysis.

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TECHNOLOGICAL ADVANCES IMPROVE SOUND OF MUSIC FOR HEARING-IMPAIRED CHILDREN By Sabine Vollmer McClatchy Newspapers

(MCT) RALEIGH, N.C. - When Rachel Skergan

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was diagnosed with congenital deafness shortly after she was born, her parents made a choice that would alter her life: She would not be taught to sign with her hands or read lips.

฀

Instead, they would rely on technology to allow her to hear and talk. Rachel, now a chatty 5-year-old from Raleigh, received a cochlear implant in her left ear when she was 10 months and another in her right ear when she was 2½. Weekly therapy sessions helped her interpret and reproduce sounds the implants generated, and her family took extra steps to improve her listening skills. But still missing was music. Rachel could hear melodies and beats. She could carry a tune, and she followed the beat when she danced, her mother, Natalie Skergan, said. Still, the details of music were missing - the plinking of piano keys, the rat-tat-tat of a drum beat or the weeping of the strings in a full orchestra at play. To capture those details, Rachel has become one of the first children in this country to be fitted with the latest cochlear technical upgrade: a speech processor that promises to improve the hearing of music. The device was brought to market this summer by a small Durham company called Med-El. The privately owned Austrian firm, which put its North American headquarters in Durham because of the scientific expertise in the Triangle, is one of only three cochlear

implant manufacturers in the United States. In the more than 20 years since the Food and Drug Administration approved the first cochlear implant, microchips inside processors have gotten smaller and more powerful. That has improved the sound quality, but biomedical engineers are still working to capture the full range of musical sounds. Med-El’s technology, like that of the other manufacturers, digitizes the sound that is picked up and sent to the electrodes implanted in the patient’s cochlea. Med-El claims its software allows it to better fine-tune the signal received by the patient. Because music is such a complex sound, research now focuses on software that would allow an audiologist to better program a processor to each person’s hearing damage, said Charles Finley, a biomedical engineer who teaches at the University of North Carolina-Chapel Hill and North Carolina State University. Finley was part of a group of Triangle researchers who in the mid-1980s came up with the multiple-electrode design that cochlear implants still follow. “Every system has its limits,” Finley said. “The same implant system can do remarkably well in one person and poorly in another.”

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Technological limitations are partly why only half of the children who could benefit from a cochlear implant have one. Of about 38,500 Americans with cochlear implants, 15,500 received them as children, according to the most recent figures from the National Institute on Deafness and Other Communication Disorders. The hearing of deaf children develops best with cochlear implants in place early on. The longer the auditory nerve isn’t stimulated, the more likely it is that the brain uses nerve cells dedicated to hearing for other purposes - a process that is difficult or impossible to fully reverse. The implications go beyond just being able to talk and listen; the ability to fully appreciate music has been linked to better math skills. Cost - an implant costs about $70,000 per ear including surgery - poor access to audiology and auditory-verbal therapy

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services, and insufficient insurance reimbursements are also to blame, according to a paper published in April in a peer-reviewed medical journal. The Skergans, because of their proximity to the same scientific expertise that brought Med-El to the Triangle, were able to overcome many of the barriers to cochlear implants. Rachel’s surgeon, audiologist and auditory-verbal therapist are all in the Triangle, as is the manufacturer of all her implants. The new Med-El processor Rachel received in August was part of an upgrade that the Skergans chose at the time of Rachel’s surgery in 2006. To turn on the new processor - a thumbsize device that hooks on the ear Rachel sat through more than 10 hours of programming at UNC’s clinic for children’s communicative diseases in Durham. Natalie Skergan remembered her

MEDICAL DIRECTORY | 2009

daughter’s first word three months after the first cochlear implant was activated: Rachel said, “Uh-oh,” when she dropped something sitting in her high-chair. Skergan doesn’t expect changes that memorable from the newest processor upgrade. But “I expect changes,” she said. “I hope she’ll say, ‘This sounds better.’ I expect music to be even better.” The first session to program the new processor, which included setting sound levels on the 12 electrodes inside Rachel’s ear, didn’t go well. Relying only on the implant in her right ear, Rachel picked up a blue crayon after being asked to show a red one. Then Holly Teagle, an audiologist and the UNC clinic’s director, turned up the current on all the electrodes simultaneously. “Hey, too loud,” Rachel protested. After Teagle had adjusted the current to a more acceptable level, Rachel was speaking loudly. “I can still hear,” she

said. “I can hear weird.” A test in a sound booth confirmed that more time would be needed to finetune the processor’s program. Teagle scheduled three more sessions, each about three hours long. Shortly after the programming sessions restarted three weeks later, Rachel said she liked her new processor better than the old one, her mother said. “She’s over the hump,” Teagle said during the final session. Like previous technological upgrades, programming Rachel’s new processor had taken time and effort. But Natalie Skergan had no regrets. “We’d do it again in a heartbeat,” she said. “The gift to have her hearing restored is priceless.”

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