Author Archives: Rachel Zimmerman

Blogger, CommonHealth Rachel Zimmerman worked as a staff reporter for The Wall Street Journal for 10 years in Seattle, New York and in Boston as a health and medicine reporter. Rachel has also written for The New York Times, the (now-defunct) Seattle Post-Intelligencer and the alternative newspaper Willamette Week, in Portland, Ore., among other publications. Rachel co-wrote a book about birth, published by Bantam/Random House, and spent 2008 as a Knight Science Journalism Fellow at MIT. Rachel lives in Cambridge with her husband and two daughters.

More On ‘Sundowning,’ And The Agitation That Can Grip Seniors After Dark

(edward musiak/Flickr)

(edward musiak/Flickr)

Our post last week on “sundowning” — a syndrome in which seniors’ behavior changes dramatically after dark — generated an outpouring of stories from patients, caregivers and people working in hospitals, in hundreds of comments on Facebook.

Many brought up the fact that delirium and sundowning are related. While sundowning is thought to happen in elderly patients with advanced dementia, many people described seeing sundowning in others — like a relative after surgery. While experts aren’t sure how much sundown syndrome and delirium overlap, they agree that not everyone who gets confused at night is sundowning.

Delirium is very common and also gets worse at night. So the first time someone experiences delirium they should be checked for underlying and reversible causes like infections or mind-altering medications.

People also pointed out that sundowning can happen at home as well as in the hospital. For people with severe dementia like Alzheimer’s, this is especially true.

Some commenters referenced “The Visit,” a recently released horror movie where two children are visiting their elderly grandparents who exhibit erratic and violent behavior each night. I haven’t seen it myself, but it seems to be taking the concept to the extreme in the most frightening way possible.

Many of the stories on Facebook were particularly moving. We thought we’d share a few: Continue reading


Mass. Moves To Adjust Controversial Medical Marijuana Testing Standards

There are currently four medical marijuana dispensaries open in Massachusetts — in Salem, Brockton, Northampton and Ayer. But patients aren’t able to buy the full 10 ounces every 60 days that is allowed by state law because most of the marijuana grown by these facilities is not passing state testing standards, which dispensaries say are too strict and not realistic. Now the state is proposing a fix.

“With this new … approach, we’re able to specify the amount of exposure and the intended use, similar to what you’d see on a bottle of Tylenol.”

– Marc Nascarella, director of the environmental toxicology at DPH

Revised draft testing standards released Friday by the Department of Public Health (DPH) propose changing the amount of marijuana — and in turn possible contaminants — regulators expect heavy users to consume.

The current assumption is up to 1 ounce a day. That’s a lot of marijuana — in the range of 40 joints, depending on the size. If you smoke 40 joints a day you’re much more likely to inhale a dangerous amount of lead, mercury or arsenic than if you smoke 12 to 15 joints a day, which is what the state would assume (using a very rough ounce to joint translation) under the new proposed standards.

To be more precise, the state’s revised standards are based on the assumption that patients would inhale or ingest 0.35 ounces a day, or 10 grams.

“The department is shifting away from a worst case risk assessment style approach and more to a pharmaceutical industry based approach,” said Marc Nascarella, director of the environmental toxicology program at DPH.

Continue reading

Paleo And Vegan Can Be Friends: 11 Points Of Consensus On What We Should Eat

(J. Scott Applewhite/AP)

(J. Scott Applewhite/AP)

By Rebecca Sananes

For healthy eating fans, it was the All-Star Game. Pick your preferred diet — vegan, paleo, Mediterranean, you name it — and the scientist, clinician or academic behind it was at the table in Boston this week. Think Dean Ornish, S. Boyd Eaton and T. Colin Campbell.

They all gathered at the Finding Common Ground Conference, convened by the nonprofit Oldways, to hammer out a consensus on healthy eating — an antidote to what can seem like endless flip-flops on dietary research. And amazingly enough, they did.

What they found was that despite all the food fights, the prevailing theories of nutrition and healthy eating actually have more in common than you’d think. (Though it’s a bit more complex than Michael Pollan’s classic, “Eat food. Not too much. Mostly plants.”)

After two days of presentations on the latest research, debates over ethics and attempts to differentiate between nit-picky nuance and important distinctions, Harvard’s Walter Willett sums up the consensus like this in a press release: “The foods that define a healthy diet include abundant fruits, vegetables, nuts, whole grains, legumes and minimal amounts of refined starch, sugar and red meat, especially keeping processed red meat intake low.”

So there you have it. But for a more granular look, here’s my take on the 11 principles these top scientists and nutritionists agreed should be the guiding principles when thinking about what and how we eat:

1. Yes to the federal guidelines

From the consensus statement:

The Scientists of Oldways Common Ground lend strong, collective support to the food-based recommendations of the 2015 Dietary Guidelines Advisory Committee, and to the DGAC’s endorsement of healthy food patterns such as the Mediterranean Diet, Vegetarian Diet and Healthy American Diet.

The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meats; and low in sugar-sweetened foods and drinks and refined grains.

Additional strong evidence shows that it is not necessary to eliminate food groups or conform to a single dietary pattern to achieve healthy dietary patterns. Rather, individuals can combine foods in a variety of flexible ways to achieve healthy dietary patterns, and these strategies should be tailored to meet the individual’s health needs, dietary preferences and cultural traditions. Current research also strongly demonstrates that regular physical activity promotes health and reduces chronic disease risk.

The Dietary Guidelines Advisory Committee is a group of scientists handpicked by the government to create a report detailing nutritional and dietary guidelines. Every five years, their report is reviewed by the USDA and the Department of Human Health Services before being voted on by Congress and implemented as the American Dietary guideline — the public policy informing public school lunches, military food and food industry regulations. The official vetted guidelines are due out by the end of the year.

Along with endorsing that committee’s report, the Oldways Common Ground Committee also backed Mediterranean and vegetarian diets.

2. We have to think about the planet when we eat

Form the consensus:

We emphatically support the inclusion of sustainability in the 2015 DGAC report, and affirm the appropriateness and importance of this imperative in the Dietary Guidelines for Americans because food insecurity cannot be solved without sustainable food systems. Inattention to sustainability is willful disregard for the quality and quantity of food available to the next generation, i.e., our own children.

Background: The DGAC recommended to Congress, for the first time, that nutritional policy should take into account environmental impact. Continue reading

‘Sundowning’: Why Hospital Staffs Dread Nightfall, And How To Help Seniors Avoid It

By Dr. David Scales

The elderly woman had been normal all day, my colleague told me, tolerating it well when a tube was placed in her bladder to measure her urine. But that evening, she was found wandering the hospital halls yelling in Italian, carrying her urine bag under her arm thinking it was her purse, traumatized that hospital staff were trying to take it away.

Another night in the hospital, a female Sri Lankan colleague saw an elderly man who was convinced she was a Nazi soldier. Reassurances and even a plea from the doctor — “How could I be a Nazi? I have brown skin!” — could not persuade him otherwise. The next day the patient was back to normal, incredulous when told about what transpired the night before.

An 80-year-old man — I’ll call him Bill — came to our emergency room after a fall. He seemed fine and his tests were negative, but his family wanted him admitted over night for observation. That evening, he began shouting out, repeatedly wanting to get up and walk to the bathroom (forgetting he had just gone). Our calming efforts only riled him up more.

This erratic nighttime behavior is called “sundowning.” Staff in hospitals and nursing homes always worry what will happen as twilight approaches. As the sun sets, many elderly patients can change drastically: They can become extremely confused, agitated, not know where they are, and even hallucinate. In other words, they exhibit signs of delirium, a confused state that can lead them to do things they otherwise wouldn’t.

Ulrich Joho/Flickr

Ulrich Joho/Flickr

Thankfully, not every elderly patient sundowns, but when one does, it can be emotionally traumatizing for everyone. To be confused or hallucinate, or to see a relative acting out in irrational ways, is frightening and destabilizing. Yet, sundowning seems to be extremely common. So, what is it? Why do people sundown? And what can you do to minimize the risk of sundowning in yourself or a close friend or relative?

Experts agree that confusion and agitation are more common in the evening and at night. But there is surprisingly little scientific consensus on what sundowning actually is.

The debate is in how much sundowning and delirium are related. Some experts think they’re the same thing, others separate but related entities.

It’s hard to study sundowning without a clear definition and diagnostic criteria. Experts can’t even be sure how often it happens. A recent review found a rate of anywhere from 2.4 percent to 66 percent. Continue reading

Study: Risk Of Hidden Cancer In Gynecologic Surgery Higher Than Previously Thought

Undetected cancer among women undergoing a type of minimally invasive hysterectomy or fibroid removal surgery is more common than previously thought, a new study finds. Researchers at Boston Medical Center report that the risk of such hidden cancer is about 1 in 352 women.

The upshot: these women may have had the undetected cancer spread within their bodies inadvertently through a technique that has fallen out of favor called “power morcellation,” which was typically used in these types of surgeries. The technique involves cutting the woman’s uterus or fibroids into small pieces to make them easier to remove during the less invasive laparoscopic procedure.

The new findings (which looked at the cases of more than 19,000 women) support a 2014 estimate by the U.S. Food and Drug Administration that approximately 1 in 350 women undergoing this type of surgery face the risk of hidden cancer. But earlier conventional wisdom was that the risk of undetected cancer for women undergoing this kind of surgery was closer to 1 in nearly 5,000 or more.

“The take-home message of the study is that the true risk of an undetected cancer at the time of gynecologic surgery for what was assumed to be benign disease is about 1 in 352 women,” says Dr. Rebecca Perkins, a practicing gynecologist at BMC and lead author of the new study.

This kind of minimally invasive surgery had “increased greatly” over the past decade, researchers report, because the procedures involved less pain and shorter recoveries, among other benefits.

But power morcellation came under public and regulatory scrutiny a few years ago (in large part due to excellent reporting by Jennifer Levitz at The Wall Street Journal). In 2014, the FDA issued a series of warnings against the use of laparoscopic power morcellators in the majority of women undergoing these types of gynecologic surgeries because of the risk of spreading unsuspected cancer.

At that time, regulators estimated the risk of hidden cancer this way:

Based on an FDA analysis of currently available data, we estimate that approximately 1 in 350 women undergoing hysterectomy or myomectomy for the treatment of fibroids is found to have an unsuspected uterine sarcoma, a type of uterine cancer that includes leiomyosarcoma. At this time, there is no reliable method for predicting or testing whether a woman with fibroids may have a uterine sarcoma.

If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s long-term survival. While the specific estimate of this risk may not be known with certainty, the FDA believes that the risk is higher than previously understood.

Continue reading

Walsh Proposes 21 As Legal Age For Tobacco Sales In Boston

In this March 2013 file photo, cigarette packs are displayed at a convenience store in New York. Later in 2013, lawmakers in New York City voted to raise the cigarette-buying age from 18 to 21. Mayor Marty Walsh wants to do the same in Boston. (Mark Lennihan/AP, File)

In this March 2013 file photo, cigarette packs are displayed at a convenience store in New York. Later in 2013, lawmakers in New York City voted to raise the cigarette-buying age from 18 to 21. Mayor Marty Walsh wants to do the same in Boston. (Mark Lennihan/AP, File)

The age requirement for tobacco sales would rise from 18 to 21 in the city of Boston, under a proposal out Wednesday from Mayor Marty Walsh.

If the plan is approved by the city Board of Health, Boston would become the second major city in the United States, after New York City, to increase the legal age for tobacco sales. Continue reading


A Tale Of 2 Hospital Visits: How The Cost Of Care Can Vary Dramatically Depending On Where You’re Treated

After receiving almost the exact same care at two different hospitals, a patient we're calling Nancy was stunned when she received both bills on the same day. (AP file photo)

After receiving almost the exact same care at two different hospitals, a patient we’re calling Nancy was stunned when she received both bills on the same day. (AP file photo)

The stomach cramp and nausea began one hot Friday evening in August, midway through a vacation on Martha’s Vineyard. The next morning, nearly doubled over in pain, a patient who we’ll call “Nancy” walked gingerly into the emergency room at Martha’s Vineyard Hospital.

Nancy is a 55-year-old former nurse who would prefer not to use her real name because she works with the hospitals in this story.

Even Nancy, who spends hours every day focused on health care costs, would gasp when she saw the bill for this visit.

In the ER, a doctor poked at Nancy’s tender belly and took blood for tests and a urine sample. The doctor ordered a CT scan of Nancy’s abdomen and pelvis, using contrast. It showed bulges, inflammation and thickening in Nancy’s colon. The diagnosis: uncomplicated diverticulitis. Nancy filled a prescription for an antibiotic, took some Advil, and felt better after a few days on a clear liquid diet.

Five weeks later, the diverticulitis monster invaded Nancy’s intestines again. This time she went to an urgent care center closer to home, run by Beth Israel Deaconess Medical Center (BIDMC). A doctor there ordered the same single CT scan of the abdomen and pelvis, again with contrast.

Nancy says the care she received at both places was great. But a month later, when she received the bills and her insurance company’s explanation of benefits for both visits on the same day, she was stunned.

The explanation of benefits show Blue Cross had paid Martha’s Vineyard Hospital almost seven times what it paid BIDMC’s urgent care center for the same CT scan — $3,888.76 vs. $574.97. Continue reading

Clinicians Petition Boston Children’s Hospital To Preserve Prouty Garden

A 65-foot dawn redwood tree slated for removal if the plans to build on the site of Prouty Garden proceed. (Jesse Costa/WBUR)

A 65-foot dawn redwood tree slated for removal if the plans to build on the site of Prouty Garden proceed. (Jesse Costa/WBUR)

Seventy clinicians from Boston Children’s Hospital have sent hospital administrators a petition imploring them to “reverse course” on plans to demolish Prouty Garden, a healing garden that was gifted to the hospital 60 years ago.

The petition calls Prouty Garden a “precious asset,” an “enduring therapeutic resource” and a testament to the hospital’s commitment to compassionate care.

The doctors, nurses and nurse practitioners who signed the petition say they’ve been left out of the hospital’s decision to construct an 11-story clinical building on the site of the garden and build other smaller, green spaces throughout the property.

Dermatology program director Dr. Stephen Gellis helped organize the petition.

“You cannot replace [Prouty Garden] with indoor gardens or with the [outdoor] garden they’re planning,” Gellis told WBUR. “It’s just depressing. I think so many people have gotten joy from the garden and solace.”

Continue reading


Am I Safe? Psychiatrist’s Tips For Talking To Kids About The Paris Attacks

A victim outside the Bataclan theater in Paris (Jerome Delay/AP)

A victim outside the Bataclan theater in Paris (Jerome Delay/AP)

Advice columnist Steve Almond has a typically provocative piece on WBUR’s Cognoscenti today: “Why I’m Not Talking To My Kids About The Paris Attacks.” He and his wife decided, he writes, that “we have absolutely no interest in exposing our kids to the sort of panic-stricken coverage whose central aim is the profitable stoking of anxiety.”

But for parents whose children have been exposed to the news from Paris, here are some extensive and sage tips, broken down by age group, from child psychiatrist Gene Beresin, director of The Clay Center for Young Healthy Minds at Massachusetts General Hospital, re-posted with permission from The Clay Center’s website.

By Dr. Gene Beresin

Our hearts go out to the families of those who lost their lives or were injured in the recent terrorist acts in Paris.

At times like these, amid our shock, grief and fear, we need to be particularly attuned to the impact such events have on our children. Kids of all ages have questions and various emotional reactions — compounded all the more by the footage and commentary they may be seeing and experiencing. It is abundantly clear from sound research that children and teens can develop significant stress responses to what they are exposed to in the media.

While we want to shield our kids from the horrific images and stories of the terrorist attacks, it is increasingly hard to create an impervious shield. Full protection is impossible, and we should instead be prepared to help them in the wake of yet another mass killing.

While the world may feel to us increasingly unsafe, it’s our obligations as parents and caregivers to provide comfort, reassurance and guidance to our kids.

Here are some tips for all of us as we navigate this tragic time.

For Parents And Caregivers

Let’s face it: We’re all scared. These terrorist acts leave us feeling afraid, angry and insecure. However, we as adults need to find our own way of coping; after all, the more secure we feel, the better we are able to help our kids.

• We need, in times like these, to engage with others. Adults as well as kids require a sense of community to help us feel connected and protected. So, don’t worry alone; talk about what you are feeling with your partner, spouse and friends. It’s our relationships that hold us safely in this world.

• Make time for self-care through relaxing activities such as reading, listening to music or exercising.

• Pace yourself in terms of the amount of information you choose to consume. Sometimes, it’s best to just disconnect completely.

• If you have specific questions about your kids, call your pediatrician, primary care provider or mental health professional for advice.

Universal Impact On Children Of All Ages

Children need answers to three fundamental questions:

• Am I safe?

• Are you, the people who take care of me, safe?

• How will these events affect my daily life?

Parents should expect to answer these questions over and over again. For those with toddlers and preschool children who may not yet be able to express their concerns in words, it’s still important to reassure them that everyone is safe, and that life will continue in a normal fashion. Continue reading


For Depression, Computer-Assisted Therapy Offers Little Benefit, Study Finds

It’s unlikely that your therapist will be replaced by a computer program anytime soon.

That’s the takeaway of recent study out of Britain looking at the effectiveness of computer-assisted therapy for depression.

The bottom line: The computer programs offered little or no benefit compared to more typical primary care for adults with depression. That’s largely because the patients were generally “unwilling to engage” with the programs, and adherence faltered, researchers conclude, adding that the study “highlighted the difficulty in repeatedly logging on to computer systems when [patients] are clinically depressed.”

In an accompanying editorial, Christopher Dowrick, a professor of primary care medicine at the University of Liverpool, stated what may seem obvious: Many depressed patients, he wrote, don’t want to interact with computers; rather, “they prefer to interact with human beings.” He noted that the poor result “suggests that guided self help is not the panacea that busy [primary care doctors] and cost conscious clinical commissioning groups would wish for.”

(Lloyd Morgan/Flickr)

(Lloyd Morgan/Flickr)

As part of the study, published in the BMJ, 691 patients suffering from depression were randomly assigned to receive the usual primary care, including access to mental health care, or the usual care plus one of two computer-assisted options that offer cognitive behavior therapy (CBT), a form of therapy that encourages patients to reframe negative thoughts. Patients were assessed at four, 12 and 24 months; those using the computer programs (one called “Beating the Blues” and the other “MoodGYM“) were also contacted weekly by phone and offered encouragement and technical support.

The context of all this is that demand for mental health services generally exceeds supply around the globe, and health systems are seeking ways to bridge the gap. According to the new paper, demand for cognitive behavioral therapy, for instance, “cannot be met by existing therapist resources.” So, the thinking goes, maybe a computer can ease some of the caseload. And in some cases, it works. Indeed, Britain’s National Institute of Health and Care Excellence (NICE) guidelines recommend computerized CBT as an “initial lower intensity treatment for depression….” based on studies that showed it can be effective.

However, results of this latest study may nudge clinicians and policymakers to rethink the computer’s role in therapy.

Here are the results, summed up in BMJ news release:

Results showed that cCBT offered little or no benefit over usual GP care. By four months, 44% of patients in the usual care group, 50% of patients in the Beating the Blues group, and 49% in the MoodGYM group remained depressed…. Continue reading