It seems so intuitively right. You’re facing the risk of delivering your baby early and the doctor prescribes bed rest. What could be more cozy and safe? Why wouldn’t you endure a little extra annoyance (you’re pregnant, after all) if it would help keep your tiny, oh-so-vulnerable fetus floating inside the fortress of your womb as long as possible? Even the words “bed” and “rest” feel so inherently soothing and therapeutic.

Think again.

Bed rest, a growing body of research suggests, may be bad for you.  And for physicians to blithely prescribe it is, in a word, “unethical,” argue a trio of doctors from the University of North Carolina School of Medicine.

In a paper called “‘Therapeutic’ Bed Rest in Pregnancy: Unethical and Unsupported by Data” recently published in the journal Obstetrics and Gynecology, Dr. Christina A. McCall and her colleagues make a powerful case against the practice many perceive as cuddly and innocuous.

They cite the medical paradox in which bed rest remains widely used despite no evidence of benefits and, on the contrary, “known harms.” They further suggest that in its current form, strict bed rest should either be discontinued or else viewed as a “risky and unproven intervention” requiring rigorous testing through formal clinical trials.

In an email exchange, Dr. McCall clarifies that she is talking about strict bed rest here and adds:

“If a woman feels that increasing her daily rest lessens anxiety or improves symptoms (whatever they may be), then we are not suggesting this should be discontinued. We are merely suggesting that every woman receive INFORMED CONSENT regarding the literature on bed rest and the autonomy to make her own decision.”

Research suggests that the potential harms for women on bed rest (a broad term that can include everything from total inactivity to limits on strenuous endeavors like household chores, exercise and sex) can be significant. They range from potentially dangerous blood clots and bone demineralization to muscle and weight loss, financial harship due to restrictions on working and a range of psychological suffering, notably depression. A report earlier this month, for instance, found high rates of depression and anxiety among hospitalized pregnant women on bed rest and suggested that all women facing this type of confinement undergo mental health screening.

No Benefits

Dr. McCall’s conclusions are based on a broad review of the medical literature that found bed rest offers no benefit for the most common conditions it’s prescribed for: threatened abortion, hypertension, preeclampsia, pre-term birth, multiple gestations or impaired fetal growth.  (Another study published in the same issue of Obstetrics & Gynecology found that activity restriction did not reduce the rate of pre-term birth in women with a short cervix.)

Even beyond these physiological considerations, Dr. McCall asserts that prescribing bed rest is morally questionable and “inconsistent with the ethical principles of autonomy, beneficence, and justice.”

Still, the practice remains deeply ingrained. Here are the numbers, according to an accompanying editorial:

As many as 95% of obstetricians report recommending activity restriction or bed rest, in some form, in their practices. Nearly 20% of gravid women in the United States — approximately 800,000 per year — will be placed on bed rest between 20 weeks of gestation and delivery.

Questioning the wisdom of bed rest — which has been used for centuries and viewed mostly as an inconvenient, potentially beneficial and essentially harmless cost of pregnancy — isn’t new. For years, data has been mounting on the negative effects of prolonged activity restriction in other medical arenas. Last year the influential American College Of Obstetricians and Gynecologists issued a practice bulletin challenging — but not fully condemning — the practice:

Although bed rest and hydration have been recommended to women with symptoms of preterm labor to prevent preterm delivery, these measures have not been shown to be effective for the prevention of preterm birth and should not be routinely recommended. Furthermore, the potential harm, including venous thromboembolism, bone demineralization, and deconditioning, and the negative effects, such as loss of employment, should not be underestimated.”

What About Maternal Harm?

But Dr. McCall and her colleagues go further, suggesting that bed rest should be limited to formal clinical trials, with written protocols, approval from an institutional review boards and informed consent. As it’s currently used, she writes, the practice undermines the spirit of the physician’s premier commandment — “do no harm” — in several ways:

“…bed rest conflicts with the ethical principle of justice. Justice requires that clinicians treat individuals fairly and that the provision of care not be discriminatory. Numerous Cochrane reviews regarding pregnancy and childbirth are available, yet the evidence frequently is ignored or interpreted selectively in a way that disregards maternal interests. For example, findings of fetal harm often lead to immediate prohibitions (such as caffeine or various medications), whereas findings of maternal harm or relative fetal safety are overlooked or slowly integrated into practice.”

Online Shopping, No Husband

For Kristen Rathjen, pregnant with twins and currently hospitalized and on bed rest at Beth Israel Deaconess Medical Center in Boston, the reasons for staying put are simple: she’s already about 2.5 centimeters dilated at 30 weeks pregnant, and she doesn’t want to give birth to a premature infant in an ambulance rushing from Mashpee, on Cape Cod, where she lives, into the city.

“I’m just doing what’s in the best interest of my child,” says Rathjen, a 32-year-old marine biologist. “Sure there’s stress, I’m not at home, I don’t have my husband or my pets and I’ve definitely gotten weaker. But the big stress of ‘How am I going to get here?’ is off my shoulders.”

So, for the next few weeks, Rathjen is resigned to forgoing work, accepting boredom and generally following her doctor’s advice. “I’ve got books, my laptop, crafts and really bad TV,” she said. “Plus, it’s given me time to research baby products and do some online shopping.”

Dr. Adam Wolfberg, a maternal-fetal specialist with Boston Maternal-Fetal Medicine, says despite the lack of evidence to support bed rest, there is something real, almost a kind of placebo effect, to women feeling like they are doing something to protect their babies, as opposed to doing nothing.

“Obstetrics is a field in which we have a very limited number of tricks up our sleeve when it comes to preventing preterm delivery,” he said. “So to say, ‘I’m sorry ma’am, there is nothing we can do,’ is harder then saying, ‘Well, there’s no evidence bed rest helps, but it is something we can try…The idea that there’s something they can do that’s proactive — that can be meaningful.”

In a recent post called “The Truth About Bed Rest” on the Isis blog Parenting Starts Here, Dr. Wolfberg lays out some other reasons why doctors — himself included — continue this “nutty” practice:

Why is it that most obstetricians I know still recommend bed rest, when peer-reviewed literature and the American College of Obstetricians and Gynecologists suggest the practice doesn’t work and might even be dangerous? Here are some possible explanations:

•Bed rest seems logical: the reclining posture theoretically reduces the force of gravity on the cervix – another theory entirely lacking evidence.
•It feels better to prescribe bed rest than to tell a patient, “we really don’t have anything to offer you to reduce the chance that you will deliver early.”
•Women on bed rest are doing something, which feels a whole lot better than doing nothing.
•If bed rest isn’t recommended, and the patient delivers prematurely, they and their doctor will always wonder whether bed rest would have changed the outcome.

Dr. Wolfberg says despite his skepticism, he would not go so far as to brand bed rest as ethically unsound. “There are so many things in medicine we do without evidence, I really don’t think bed rest is unethical. In many ways, medicine isn’t just about evidence, it’s evidence plus — it’s experience and skill and intuition — not to say those are replacements for evidence. But evidence isn’t all there is.”

This may sound good, says ob/gyn Dr. David. A Grimes, co-author on the bed rest article, but doctors should be wary of relying too heavily on instinct alone. “If we have anything to learn from the history of medicine,” Dr. Grimes says via email. “It is that instincts and good intentions are a highly fallible compass without the check of scientific controls.”

And course, every woman is different and the complications of pregnancy vary, notes Angela Davids, who moderates an online forum, keepemcookin.com for women who have been prescribed bed rest. She tells me in an email that 76 percent of her forum participants deliver at 36 weeks or later:

Any one of them will tell you that bed rest helped to prolong their pregnancies, and I think that is what researchers need to look at. Instead of looking at 37 weeks of gestation as a measure of success, look at how many days of gestation there were following the diagnosis of a specific complication. Every additional day in the womb counts toward the health of a baby…

So, what’s an expectant mom to do?

Dr. Wolfberg offers this advice:

•Patients who are worried about pre-term labor, short cervix, or vaginal bleeding should consult their midwife or physician.

•In his own practice, Wolfberg says he works hard to identify patients who would benefit from progesterone and get them on that medication when appropriate.

•He says it is reasonable for women at high risk for pre-term delivery to limit strenuous activities or exercises.

•He says he’s never had a patient suffer long term consequences of bed rest, and notes that since he’s never met a mother who delivered prematurely who didn’t – irrationally – blame herself, he prescribes activity reduction because it’s something patients can do.

•If bed rest is going to interfere with a patient’s need to earn a living, hold down a job, or take care of her family, he says he support her decision to remain active (and cites the evidence that bed rest doesn’t help).

Beyond that, Dr. Wolfberg said, “if they do bed rest and fail, at least they feel like they did everything they could…we all need a little bit of magical thinking to get through the day.”

Oftentimes, what helps or hurts a pregnancy is in the eye of the beholder. A friend offers this memory of her six weeks on bed rest:

I started bleeding and the baby seemed like it was low, plus I’d had two prior miscarriages, so the doctor prescribed “modified bed rest,” meaning I could get up to eat, go to the bathroom, or recline on the sofa. It wasn’t fun — I spent alot of time reading and looking at the clouds…One day I wandered downstairs to rest on the sofa, and saw the 9/11 airplanes hit the twin towers. I think it was the stress that brought on the delivery — a late miscarriage at 19 weeks — and that was that.

Angelina Jolie’s decision to undergo a prophylactic double mastectomy to limit her genetic risk for breast cancer demonstrated a lot of courage. It also demonstrates that genetic testing is a real part of disease prevention. But though the discussion she has prompted is helpful, it is not going far enough.

Although the “BRCA” type of gene she inherited is named for BReast CAncer, mutations in those genes also affect other organs, particularly the ovaries. Your lifetime risk for ovarian cancer increases from about 1.5% to Jolie’s estimated risk of about 50%.

But nobody is talking about the increased risk of other cancers that BRCA mutations cause, such as the “silent killer,” pancreatic cancer.

They should. Sharon, who is BRCA2-positive, was diagnosed with it a year ago, and we believe more BRCA-positive women can — and should — be screened for pancreatic cancer.

Sharon has a strong family history for ovarian cancer: Her great grandmother, grandmother and aunt died young from it. Sharon grew up with the belief that she would suffer a similar fate.

Until she read an article over ten years ago discussing the BRCA1 and 2 genes. It was the first study reporting that women with BRCA1 and BRCA2 genes could reduce their risk of breast and ovary cancer by 75% by having their tubes and ovaries removed. We arranged for genetic testing, and Sharon tested positive for BRCA2.

While the positive results brought on a sinking feeling initially, relief followed, because there was something that could be done to potentially alter destiny and avoid ovarian cancer. A month later, Sharon underwent surgery to have her tubes and ovaries removed.

Sharon also contacted the rest of her extended family and urged them to get tested. Because of the association of BRCA2 with breast cancer, Sharon began breast cancer screening every six months with a breast MRI alternating with mammograms.

It seemed everything was covered; the tubes and ovaries were surgically removed and breast testing was being done regularly. But then came the elephant in the room: pancreatic cancer.

It was absolutely unanticipated. Although we’d been told pancreatic cancer was associated with BRCA1 and 2, most doctors who talked with us and most lecturers at meetings minimized the risk and were more focused on breasts and ovaries than on the pancreas.

The party line has been that there’s no good way to screen for pancreatic cancer anyway. But when the “minimal risk” (4 – 8% over a lifetime according to Endocrinology and Metabolism Clinics of North America) became 100 percent, it did not seem so minimal.

Pancreatic cancer is potentially a more lethal disease than breast cancer. After all the breast screening and prophylactic surgery, it just seemed impossible,

It’s now a year later, and having successfully gone through proton beam radiation, surgery and chemotherapy, we want others with the BRCA genes to at least know that there is a real possibility of pancreatic cancer.

There is ever-evolving scientific evidence surrounding screening for it. Testing is now available with ultrasound-guided endoscopy and radiology scans.

If caught early, pancreatic cancer can be treated successfully. Although one doctor Mache spoke with recently said that she sends all her BRCA patients for pancreatic screening, another prominent expert thought the risk/reward ratio for screening did not warrant it at this time.

This differing opinion means many women are not being given the option to be screened for a silent killer.

This philosophy needs to change. Angelina Jolie has done a great service by increasing awareness for BRCA genetic testing if there is a strong family history of breast and/or ovarian cancer.

Our goal it to take it one step further and raise awareness for pancreatic cancer screening in those who test positive for BRCA1 or 2. The risk is real and the testing is now available in selected centers.

Dr. Mache Seibel is editor and Dr. Sharon Seibel is assistant editor of My Menopause Magazine, based in Newton, Mass. Dr. Mache Seibel is a professor at the University of Massachusetts Medical School with a focus on menopause and mental health.

[Posted by Carey Goldberg]

Yet as that prevalence increases, treatment options are decreasing, writes Lisa Lambert, executive director of the Parent/Professional Advocacy League, which advocates for Massachusetts families with mentally ill children. Below, she discusses one particular pending loss, of Cambridge Hospital children’s psychiatric beds long especially valued by families. The hospital announced last month that it would consolidate two units with 27 beds into just one with 16 beds. It cited tight budgets, declining utilization and cyclical demand. The details are still in play.

By Lisa Lambert
Guest contributor

When Aiden was seven, it seemed like he would never be safe.

At home and in his second-grade classroom, he repeatedly talked about killing himself. He barely slept, raced from one spot to another and threatened to harm his younger sister. His parents stayed glued to his side, barely taking time to eat, shower or sleep.

One day, his mother caught him lighting a fire in his bedroom. Aiden ended up in the emergency room, and later in a bed in Cambridge Hospital. The staff had seen young patients like him before and they knew what treatment would work and what kind of follow-up care a seven-year-old needs. Without that hospital stay, his mother says, ”We don’t know where our family would be.”

No one likes the idea of admitting a young child to an inpatient psychiatric program. It is a last resort, something to be avoided at all costs. Parents will tell you, however, that when they’ve exhausted all the options, Cambridge Hospital has provided the best possible care. Now, it seems that a major piece of that care is coming to a close, unless a miracle happens.

Last week, the Department of Public Health held a hearing to receive comments about closing the Cambridge Hospital child psychiatric unit and eliminating beds. Nurses stood shoulder to shoulder to tell stories of families they’ve helped and of their pride in the wonderful care they’ve given. Parents came to say that this place was a lifesaver and without it, their children would never have improved.

The Child Assessment Unit is one of a kind, they all said, where parents can visit anytime and even stay overnight. Since PPAL is a grassroots organization, we surveyed families about this and want their voices to be part of the public conversation.

Three years ago, there were 310 inpatient beds for children and teens in Massachusetts. Today there are 252. If those 11 beds at Cambridge Hospital close, that number will be even smaller.

Each spring there is a surge in children with mental health crises and each spring there are waits of hours, even days, for the beds we do have. One mother reported that her very unsafe daughter spent “several days in a locked local emergency room” last fall and again this spring waiting for a bed to become available. Others tell stories of how their child was sent two hours away for inpatient treatment and worry this will become more common.

What they aren’t saying, but needs to be clearly pointed out, is that an additional burden will fall on families who are already overtaxed. Families whose children have mental health needs already have enormous responsibility for their child’s safety and care. When they cannot find a needed hospital bed, parents run a hospital-unit-for-one in their home at great cost to themselves and their other children.

As one parent pointed out, closing beds has a “major long-term impact on the immediate family, the community and society as a whole. We have to stop removing help while we pile responsibility and blame on the families.”

And then there’s the lack of parity for mental health. Besides their worries about shrinking services, nearly all parents felt this trend in closing beds was a form of discrimination. One wrote, “What would people say or do if they were closing a pediatric cancer center or burn unit? Isn’t anyone outraged that pediatric psychiatric beds are being closed?”

It’s well documented that medical beds for children are filled throughout the year, while psychiatric beds are in demand in the winter and spring and often empty in the summer. But inpatient care is not like a product from Apple or the Gap that doesn’t sell well. If this care becomes scarce, children with suicidal or risk-taking behavior can’t find a substitute product.

Everyone agrees we should find a way to provide good care to children who need inpatient care. And we all seem to agree that Cambridge Hospital has long provided that care because of their dedicated staff and wonderful, innovative practices.

Massachusetts is the place where the telephone, chocolate chip cookie and zipcar were all invented. It seems like we have the ingenuity and dedication to create a solution. Many parents sure hope so.

[Posted by Carey Goldberg]

In the inimitably dry language of the nation’s public health authorities: “A study of public pools done during last summer’s swim season found that feces are frequently introduced into pool water by swimmers.”

Moreover, the study found:

“Fifty-eight percent of the pool filter samples tested were positive for E. coli, bacteria normally found in the human gut and feces. The E. coli is a marker for fecal contamination. Finding a high percentage of E. coli-positive filters indicates swimmers frequently contaminate pool water when they have a fecal incident in the water or when feces rinse off of their bodies because they do not shower thoroughly before getting into the water.”

(Be honest, does anyone really shower before getting into the pool? Maybe it’s time to start.)

So, what’s a swimmer to do?

The CDC offers these tips:

–Keep feces and other contaminants out of the water.
–Do not swim when you have diarrhea.
–Shower with soap before you start swimming.
–Take a rinse shower before you get back into the water.
–Take bathroom breaks every 60 minutes.
–Wash your hands with soap after using the toilet or changing diapers.
–Check the chlorine level and pH before getting into the water.

Here’s my desperate attempt at a silver lining: Germs are on the upswing (see, for instance, foodie Michael Pollan’s take in this Sunday’s New York Times) and a ton of new research finds that bacteria of all sorts can boost your immune system, and so fecal contamination may be just what the doctor ordered, right?

Here’s more from the CDC news release:

Through the study, released today by the Centers for Disease Control and Prevention (CDC), researchers found germs in samples of pool filter water collected from public pools.
CDC collected samples of water from pool filters from public pools and tested the samples for genetic material (for example, DNA) of multiple microbes. The study found that 58 percent of the pool filter samples tested were positive for E. coli, bacteria normally found in the human gut and feces… No samples tested positive for E. coli O157:H7, a toxin-producing E. coli strain that causes illness.

Pseudomonas aeruginosa, which can cause skin rashes and ear infections, was detected in 59 percent of samples. Finding Pseudomonas aeruginosa in the water indicates natural environmental contamination or contamination introduced by swimmers. Cryptosporidium and Giardia, germs that are spread through feces and cause diarrhea, were found in less than 2 percent of samples.

The tests used in the study do not indicate whether the detected germs were alive or able to cause infections. Indoor and outdoor public pools were sampled.

The study did not address water parks, residential pools or other types of recreational water. The study does not allow CDC to make conclusions about all pools in the United States. However, it is unlikely that swimmer-introduced contamination, or swimmer hygiene practices, differ between pools in the study and those in the rest of the country.

“Swimming is an excellent way to get the physical activity needed to stay healthy,” said Michele Hlavsa, chief of CDC’s Healthy Swimming Program. “However, pool users should be aware of how to prevent infections while swimming. Remember, chlorine and other disinfectants don’t kill germs instantly. That’s why it’s important for swimmers to protect themselves by not swallowing the water they swim in and to protect others by keeping feces and germs out of the pool by taking a pre-swim shower and not swimming when ill with diarrhea.”

In addition to the precautions listed above, the CDC offers this guidance to the parents of young children:

–Take children on bathroom breaks every 60 minutes or check diapers every 30–60 minutes.
–Change diapers in the bathroom or diaper-changing area and not at poolside where germs can rinse into the water.

“You had a C-section, right?”

“Are they natural?”

Questions that may seem odd—even offensive — to some new mothers. Unless you are the mother of twins. Then you’re used to them.

The “babyrazzi” can be relentless, and the appearance of multiples in public can create an instantaneous barrage of questions. Earlier this year, I was in line at the Mothers of Twins sale (a huge biannual event in Winchester that is akin to the running of the bulls) comparing notes with other moms. Some of the more seasoned moms were used to the forward questioning, while the rest of us were still adjusting to the public’s keen interest in our multiples and our pregnancies.

Here’s my favorite. Upon seeing my boy and girl twins, “Are they identical?”

So when the hilarious cartoon above appeared in my Facebook feed on Mother’s Day, I didn’t mind the peering grandmothers at Costco later that afternoon. It captures just about every inquiry I’ve ever received and somehow it was validating to know that I’m not alone. I must say, all in all it’s a pretty special club.

Readers, any other cringe-worthy twin questions or comments you’d like to share?  

I’ve thought about that exchange as I’ve read commentaries weighing in this week on the meaning of Angelina Jolie’s decision to undergo prophylactic mastectomies and to go public with the details. Most have focused on the impact of Jolie’s decisions on her film career and on women’s assessment of cancer risks.  They have missed an important point:  Jolie’s revelation is ultimately as much about her brain as her body.

There’s a reason Jolie has been the highest paid actress in Hollywood, earning up to $30 million a year.  Sure, she’s got bee-stung lips, big boobs, a tiny waist and comely hips. But she’s not just beautiful.  She’s brainy.  Jolie has cannily put her physical assets to work in roles that have allowed her to link sex and power: as video-game heroine Lara Croft, a super spy in Mr. and Mrs. Smith, and as a daring CIA agent in the film Salt. Jolie has taken her body to the bank by choosing to be seen as active and able.

Jolie consciously continues in her role as action/adventure hero in the way she shapes her decisions to undergo genetic testing and surgery.

Here’s how:

• She remains powerful because she controls the flow of information.  She managed to keep her mastectomies private until she was ready to share.  And when she chose to share, she “bared all” on the opinion page of what is arguably the most respected newspaper in the world.

• Jolie holds onto her brawn and brain by controlling her own ending.  By electing to have her breasts removed, she won’t let her enemy — in this case, cancer — get the best of her.

• She exercises power and brains by advocating for the most vulnerable.  In the past, she’s brought attention to the plight of orphaned refugees as a Goodwill Ambassador for the United Nations High Commission for Refugees.  Now, for the first time, she is announcing her own vulnerability and taking steps on her own behalf.

Jolie may now have a harder time selling herself as a sex symbol onscreen with the revelation of her surgeries. I hope not.  In any case, I hope she’ll continue to use her best asset — her brain — off screen to fulfill my own personal fantasy.

I’d love to see brilliant Angelina Jolie gobbling up stock in Myriad Pharmaceuticals, the Utah-based company currently awaiting a decision from the U.S. Supreme Court as to whether it may continue to claim ownership of the BRCA genes – the mutations that put Jolie and the rest of us BRCA carriers at such a high risk of developing reproductive cancers.

Myriad is the reason the tests of the BRCA genes can cost over $3,000, and it refuses to let other companies or labs test for or perform research on the mutations.  In a move worthy of one of her action/adventure heroines, Jolie would do an end-run around Myriad, becoming majority stockholder and policy director.  She’d fight off the enemy, steal the treasure and escape (in a tight outfit) as the walls of the business came down around her.  Then she would be Lara Croft, Tomb Raider, indeed.

Cathy Corman teaches history and makes radio in Boston. She wrote about the Myriad case here: Opinion: Why Our Genes Should Not Be Patented.

[Posted by Rachel Zimmerman]

This week, longtime New York Times reporter and popular “Dot Earth” blogger Andrew Revkin vividly describes his 2011 stroke in the first-person piece “My Lucky Stroke.” He includes these “prime take-home points”: “Take your body seriously. Time (wasted) is brain (lost). Question authority, but not too much. Old habits die hard.”

Dr. Lee Schwamm, chief of Massachusetts General Hospital’s stroke service and medical director of Mass General TeleHealth, would suggest that readers take away some rather different stroke lessons from Andy Revkin’s story. He shares them here.

By Dr. Lee H. Schwamm
Guest contributor

I congratulate the journalist and blogger Andy Revkin for courageously sharing the story of his stroke and his subsequent recovery. I also thank him for taking the time to share his personal experience for the benefit of his readers, and for the opportunity it presents to highlight some key learning points for patients, as we dissect his journey through the health-care system.

Mr. Revkin was relatively young and healthy, out for a run with his son, when he experienced stroke symptoms. All too often, when we think of stroke, we envision an older patient clutching their chest and being unable to move or speak. This stereotype is dangerous, both for patients and health-care providers, because it lowers our sensitivity to stroke-like symptoms in patients of any age.

Mr. Revkin and his son were concerned enough about his symptoms that he went home, but they didn’t appreciate the immediate seriousness of his condition and he took a shower, hoping his symptoms would resolve. Watch the video clip above showing a young news reporter having stroke-like symptoms, and ask yourself, would you have called 911 if you’d been present? You should have.

Then Mr. Revkin did what generations of doctors have advised us to do for a heart attack; namely, take some aspirin and call your doctor’s office. Unfortunately, when it comes to stroke, there are two types: those caused by blocked arteries (ischemic) and those caused by rupture of blood vessels (hemorrhagic). It’s not possible to tell just from symptoms if a stroke is ischemic or hemorrhagic; only a CAT scan or MRI can distinguish them.

Obviously, you don’t want to take an aspirin if you’re having bleeding in your brain, as it will make the bleeding worse. But it’s also not a great idea to take aspirin if it’s an ischemic stroke, especially not six aspirin, as Mr. Revkin did, because there are powerful clot-busting drugs that can be given to reverse the disability caused by ischemic stroke. These drugs — the main one is known as tPA — are only effective if they are given within the first 4.5 hours after the start of symptoms, and aspirin might increase the risk that the drugs could convert an ischemic stroke into a giant hemorrhage that could be fatal.

It’s also really important to realize, as Mr. Revkin mentions, that “time is brain.” This expression reflects the fact that without treatment to restore the blocked blood flow to the brain, 2 million nerve cells are dying every minute of continued stroke.

So what’s the best way to act fast and to get help fast? First you need to know the warning signs so you can recognize stroke. A simple memory tool is the acronym FAST, which stands for Face, Arm, Speech, Time: Is the Face drooping or uneven? Does one Arm drift down when held outstretched? Is there trouble with Speech or understanding?

If any of these are present, then it’s Time to call 911. The terrific animated public service message below helps reinforce this critical message and has been shown in studies to improve detection and recall of stroke symptoms.

The next issue is how to get help, and many studies have shown that if you arrive by ambulance, your odds of being seen rapidly and getting the right treatment are dramatically increased, because arriving by ambulance already signals this may be an emergency.

When EMS responds to your call for help, they need to decide where to take you, and there are many different methods they might choose to make that decision.

If you can’t breathe, they will take you to the nearest hospital; if your vital signs are stable, in many states they will take you to the nearest stroke center. Different organizations certify these stroke centers and not all stroke centers are alike. In many cities, there may be more than one nearby stroke center. So if you’ve done your homework as detailed below, you may want to weigh in on where you or your loved one is taken.

To see a map of stroke centers near you, click here and enter your zip code. There, you can select centers certified by the Joint Commission, which accredits and certifies American health care facilities, as having the processes in place that lead to quality, or by the American Heart Association Get With the Guidelines Stroke program that have demonstrated high rates of actually providing evidence-based treatments for stroke, including rates of tPA use greater than 85% of all eligible patients.

A recent editorial highlights the differences in these certification programs and explores how the different factors motivating certification might determine the quality of care that can be provided. It’s hard to tell why a center near you has chosen to become a stroke center, but as always, look for the other signs of excellence such as local reputation, service to the community, the presence of their doctors and educators serving as leaders in their fields.

As Mr. Revkin notes, telemedicine-enabled stroke care is revolutionizing the field of stroke, and programs and centers from across the country now provide this service to increase access to care and mitigate disparities in acute stroke care.

A recent survey documents programs across the United States, based at leading academic medical centers like Partners Healthcare and the Mayo Clinic as well as for-profit companies, all working to bring stroke care to the bedside wherever it is needed.

This is critical, since not every hospital has the skills and the staffing to treat acute stroke properly and safely. So look on the map cited above, ask around, and find out why the hospital near you isn’t certified, or if it is certified, why it hasnt won any awards for its care. Be an advocate for having the highest quality of stroke care in your community, since you never know when you or someone you love might need it.

Sadly, Mr. Revkin’s story is all too common, that a patient has to be the one to raise the question of whether stroke might be the diagnosis, and all too often, the chance for treatment has evaporated before the diagnosis is made.

Fortunately, it sounds like he made a substantial recovery. The good news is that most stroke patients experience some recovery, and many have a complete recovery and return to their lives, their homes and their work.

I will end by sharing with you the take-home points I give all my patients: Be prepared. Know the warning signs. Know how to activate EMS and say the word “stroke” when you call. Act FAST if you suspect a stroke. Know where the nearest stroke center is located. And know that getting to the hospital quickly is your best shot at a full recovery.

[Posted by Carey Goldberg]

Well, where Massachusetts feared to tread, neighboring Vermont has now trodden, and the state is about to become the fourth to legalize physician-assisted suicide for terminally ill people, after Oregon, Washington and Montana. It is the first to do so through its lawmakers rather than a popular referendum or court.

The “end-of-life choices” bill rode a wild political roller-coaster before it was finally passed this Monday evening, and it’s now on its way to a supportive Gov. Peter Shumlin and expected to be signed soon.

Vermont Public Radio’s John Dillon has covered the bill all along the way, and I asked him for his insights into the political dynamics behind the action. But first, a brief note for us flatlanders: What will our neighbor to the north’s decision mean for us? Will we be able to drive with our doctors up to Brattleboro or Burlington if we’re fatally ill and want help taking control of our final days?

I sent a query to Patient Choices Vermont, the group that spearheaded the state’s “end-of-life choices” bill, and heard back from Jessica Oski of Sirotkin & Necrason, a government relations firm that has represented Patient Choices Vermont for a decade. She writes:

1. To be qualified to use the assistance of the Vermont Patient Choice at End of Life Bill, a person must be “18 years of age or older, a resident of Vermont, and under the care of a physician.” There is no specific guidance under the law as to who qualifies as a Vermont resident.

2. In order for a physician to benefit from the immunity under the law the physician must be “licensed to practice medicine under 26 V.S.A chapter 23 or 33.” In other words, licensed in Vermont.

Now for the politics. The tale I heard from VPR’s John Dillon suggests three possible lessons for the backers of physician-assisted suicide in Massachusetts: Stick with it. Compromise quickly when the right moment strikes. And you may fare better in a legislature than in a popular referendum.

The Vermont House had considered a “death with dignity” bill in 2007, John said, but it didn’t pass. Last year, a similar measure failed to pass in the state Senate. This year was different. 

The legislative action first heated up in February. The 30-member Senate narrowly voted down a bill that proposed an assisted-suicide model much like Oregon’s, with extensive reporting and protections aimed at preventing possible coercion. The measure appeared dead for this session.

But then, John said, proponents of the bill came up with an alternative measure “on the fly — they wrote it on the Senate floor, a bill that basically says that doctors can’t be prosecuted for murder if they prescribe drugs that patients then use to kill themselves. It was a three-paragraph piece of legislation and it passed. The proponents supported it just to get it to the House, and then rewrote it.”

That renewed bill’s passage was still far from assured, however. Earlier this month, the House sent its rewritten measure, now very Oregon-like again, back to the Senate.

It was then, John said, that the Senate came up with a pivotal compromise: a “hybrid” bill that included extensive, Oregon-style protections against coercion but also was scheduled to “sunset” in three years to assuage dissent.

That hybrid was the key to gaining the support of two swing senators, John said.

After three years of Oregon-style protections, he explained, the hybrid bill reverts to a version in which the terminally ill patients must still be mentally competent to request help with suicide, “but basically the government regulation goes away. And it was kind of ingenious. There were people who said, ‘We don’t want a government role in suicide at all. It should just be between patient and doctor.’ And other people said, ‘You really need all these protections, because you don’t want people to be coerced, be told they’re a drain on family resources, be nudged into it.’”

“So they kind of tried to bridge it by having these two versions with the sunset in the middle. And of course, a legislature can always elect not to sunset a bill. They can come back in two or three years and say, ‘That provision goes away, and we have an Oregon law,’ which is what the backers hope.”

In any case, the hybrid bill managed to pass in the Senate last week. Then it went back to the House, John said, for “a replay of arguments: ‘You’re going to kill Grandma!’ or ‘It makes sense for people to have the means to relieve their suffering.’ And everyone had to tell their story. It’s been the culmination of 10 years of this ‘end-of-life choices’ group in Vermont, Patient Choices Vermont, trying to get it done. They hired some really skilled lobbyists, and the real genius was this hybrid bill.”

It does seem easier to win a campaign in a legislature of a couple of hundred people than in a popular referendum, John said. Though the battle spilled beyond the State House: The sides bought Web and TV ads; those in favor of the bill showed “people staring into the camera saying ‘This is my story,’ including one really compelling one by the wife of a former house speaker, Richard Mallary. He killed himself a year ago December, and he was in favor of the bill, and his wife is on TV saying, ‘I wish I could have been there with my husband, Dick Mallary, but he had to die alone.’” (Read John’s 2012 report on Mallary’s suicide: Family Says Mallary Followed Convictions On Death With Dignity.)

This Monday night, the House took up the Senate version of the bill, and if it had passed any amendments, that would have killed the bill for the year, because the Senate would not have had time left to consider them, John said. But the measure passed unamended Monday evening.

Listening to John made me nostalgic for the days way back in 2000 when I covered the Vermont legislative debate around “civil unions” — so revolutionary at the time, so quaint now that gay marriage is legal in a dozen states. I admit to brazen bias in my admiration for Vermonters as leaders on social change, and mark my words, this Vermont move will likely find its reflection sometime soon in Massachusetts as well.

“As with same-sex marriage or other social issues, the passage of time changes attitudes,” John observed. “The years also brought in a new generation of lawmakers, who were probably more open to this idea.”

Readers, predictions?

Further reading:

Vermont Public Radio: House Approves End Of Life Bill

The New York Times: Vermont Passes ‘Aid In Dying’ Measure

Northeastern Dean of Health Sciences Terry Fulmer says going smoke-free will save student’s lives.

“If you smoke when you’re younger, you’re more likely to be addicted for life,” Fulmer said. “So now is our opportunity to help them not get in a habit that will potentially be fatal.”

Northeastern will use peer pressure and a campus education campaign — as opposed to penalties — to enforce the new policy. There’s a free smoking cessation program for students and most faculty and staff can enroll through their insurance plan. Dean Fulmer says she does expect the ban on smoking to affect admissions.

Here’s more on new smoke-free policy from Northeastern:

The deci­sion to go smoke-​​free dove­tails with Northeastern’s focus on solving global chal­lenges in health. According to the Cen­ters for Dis­ease Con­trol and Pre­ven­tion, some 443,000 people die each year from smoking or expo­sure to second-​​hand smoke. What’s more, tobacco use is the single most pre­ventable cause of dis­ease, dis­ability, and death in the United States.

“This new policy reflects Northeastern’s long-​​standing com­mit­ment to pro­moting a healthy and safe envi­ron­ment,” said Terry Fulmer, dean of the Bouvé Col­lege of Health Sci­ences, in a cam­puswide memo on Monday. Fulmer is co-​​chair of the com­mittee along with John Auer­bach, director of the Insti­tute on Urban Health Research and Dis­tin­guished Pro­fessor of Prac­tice in Bouvé’s Depart­ment of Health Sci­ences. “We look for­ward to updating the campus com­mu­nity in the coming months and working with stu­dents, fac­ulty, and staff as we join the more than 1,100 col­leges and uni­ver­si­ties across the nation—and among the first in the Boston area—that have taken this impor­tant step to pro­mote the health of uni­ver­sity campuses.”

 “Sometimes it is necessary to reteach a thing its loveliness” – Galway Kinnell

After years and tears spent treating girls with eating disorders, I found myself pregnant — in my 40s — with a daughter.

Penelope is now 10, and suddenly, everything I’d preached and chiseled and chipped and interpreted in my office is getting put to the test. How was I going to try to prevent my own child from having an eating disorder?  How would I prevail against a culture of young girls in short shorts, strappy tops and frankly lewd fashion, where my 4th grader must choose between “boyfriend jeans” and “skinny jeans”?  As I had told my patients:  “Many girls entertain diets — not everyone gets an eating disorder.”

Still, I reviewed the early dangers for developing such a disorder — flipping through my own brain for knowledge.

1. Genetics
We had some family history of mood disorders but nothing that seemed so severe it couldn’t be tempered by attentive parenting.

2. Home obsession with foods

I made absolutely sure that nothing in my house was low-fat, low-calorie and insisted that dessert was part of the meal if you ate your ‘growing foods” a useful phrase I learned from her pre-school teacher.

3. Range of affect (or, enough feelings)

Yup, no problem there. My house was never one where feelings were suppressed. In fact, I might have spent too much time inquiring what my child thought or felt. I was politely interrupted. “Mom,” she said, “I’m watching the cars outside” or “Making a friendship bracelet” or “Telling myself a story.”

4. Too much affect

Yes, I wanted to tone this down. She neded to learn resilience — that horrible feelings, the dementors of loneliness, sadness and intense anger can be survived. She needed to endure them and learn to soothe herself. I reminded myself of this as I clenched my nails into my hand while she hurled about in her crib.

5. Too much talk about appearance
I failed on this. I could not even try to stop my outpouring of sheer joy at her natural beauty. I was, as C.S. Lewis said, “surprised by joy” in this department. I craved her attention like a jilted suitor. But it amuses both of us — and possibly helped her — that I would joke about my “separation issues.” I believe I gave her the freedom to express those same feelings and a good many more.

6. A sense of purpose  

We are currently working on this. The most effective cure for the most recalcitrant eating disorders is — surprisingly — community service.  Like people in a nursing home who thrive when they care for a plant, children do better when they feel their effect on the world is real. I ramped up on chores, folding laundry, carrying grocery bags. A child who danced for hours could use her legs to help me.

7. Perfectionism

When my daughter was three, I saw a child in her nursery school crumple up a drawing, burst into tears and throw it away. I vowed I would do my best to melt perfectionist thinking. We practiced making mess-ups into other shapes. We practiced turning pages over and writing on the backs of things. I told her often, purposefully, about my own mess-ups, what caused them and how I still was growing. I learned to ask her if she felt proud of something — not to tell her that I was instead.

8. Culture

This huge piece of influence is almost indescribable. Culture is written across the bottom of shorts, the straps of shirts, the piercings and tattoos called body art. Wherever you stand on particular trends, it’s hard to deny that a new, frankly lewd look is popular. Somehow feminism has been replaced by exhibitionism.  Reality TV and instagram make looks all that matters. Sexting seems a natural outcome from this atmosphere.

All I could do on this front is to hold my ship fast at home. I batten down the hatches. I encourage critical commentary about dolls that are too thin, pictures of girls who were too thin. Movies which demean fatties. I censure TV and books about mean girls.

What I cannot plan for is my daughter; her own self. She dances (at a studio she feels is like a second home). All I did was steer her toward the one that has the most diverse group of girls’ strong bodies I’ve seen.

But she is at a liminal age and it terrifies me.  She is a perfectionist at times and it drives me nuts. I never want her to look at herself with loathing, to pinch a part of her skin with disgust and wish it gone. I detest the bonding that begins — very soon — when girls turn to each other and say: “I’m fat.” And the response — rather than saying “Don’t be ridiculous” or “How boring,” the only scripted response is: “Are you kidding, I’m fat. You’re thin.”

A few days ago we went to buy jeans — she’d grown again. I was sick to see that our choices were reduced to two categories: “Skinny jeans” or “Boyfriend jeans.’ Those are her choices.

Is she skinny or does she have a boyfriend whose clothes she borrows? She’s 10. Why can’t the pants simply be called straight or baggy?

I don’t know how we can hold back this enormous wave surging toward our girls. But we must keep trying. I hope I will not be reteaching Penelope her loveliness as I do, here, in my office, every day at work.

Katy Aisenberg is a psychologist in private practice in Cambridge