Brigham & Women’s Hospital

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What’s A ‘Natural Cesarean’ And How Natural Is It?

That was my reaction when I read a recent post by my friend Ananda Lowe who writes a blog, thedoulaguide, about childbirth issues of all sorts. (Disclosure: she is also my co-author on a book we wrote on how to have a fulfilling and fully-informed birth experience.)

Ananda explains that a new “natural cesarean technique” is being developed here in Boston at Brigham and Women’s Hospital:

While talking with my friend Dr. William Camann, director of obstetric anesthesiology at Brigham and Women’s hospital in Boston, I was surprised and excited to learn that he recently helped the hospital adopt components of what is being called “the natural cesarean” technique. Bill is co-author of the book “Easy Labor: Every Woman’s Guide to Choosing Less Pain and More Joy During Childbirth,” and the Brigham is Boston’s largest maternity hospital, so its adoption of these methods is good news. In the past, some mothers reported feeling “a disconnection from their cesarean baby because they did not actually see or feel the baby born,” according to the International Cesarean Awareness Network (ICAN). The natural cesarean technique offers parents the option of viewing the emergence of the baby if they wish. (For years, ICAN has been a pioneer in proposing guidelines for family-centered cesareans, as well as advocating for other reforms related to the use of cesarean sections—I encourage everyone to support their work!)

I spoke with Camann today and he said the preferred term for the new technique is “family-centered Cesarean,” or “gentle Cesarean.” The concept has been evolving for several years, he said, with some elements of it — like early skin-to-skin contact between mom and baby in the operating room — becoming more standard. The newest element — a clear surgical drape that allows the mom to actually see the birth — just started a few months ago. “To my knowledge, the Brigham is the only hospital doing that,” Camann says. “It was my idea; the patients love it.”

A "natural" or "family-centered" Cesarean section. (Photo courtesy Dr. Bill Camann)

A “natural” or “family-centered” Cesarean section. (Photo courtesy Dr. Bill Camann)

But a bird’s eye view of a surgical birth isn’t for everyone, he added, and some new moms don’t want to see anything. “You pick up cues from the patients and other providers,” Camann says. “It’s very much a judgement call.”

Here, Camann offers more details on the technique:

A growing movement is attempting to make the cesarean delivery a more natural, or family-centered, event.

Modifications of the standard technique include:
· Early skin-to-skin contact in the operating room (with either mom or dad)
· A slow delivery (with intent to mimic the “vaginal squeeze”) Continue reading

How Being Obese May Hinder Pregnancy: Eggs Gone Awry

Human egg

A human egg being injected with sperm (Eugene Ermolovich on Wikimedia Commons)

The more obese you are, the harder it is to get pregnant, and a study just out in the journal Human Reproduction offers some new insight into why. For the 1/3 of American women of childbearing age who are obese, its concrete images of eggs gone awry may also offer a bit of added incentive to lose weight before trying to get pregnant.

The study, led by Dr. Catherine Racowsky of Brigham and Women’s Hospital, found that in severely obese women who underwent fertility treatments, the eggs that failed to fertilize were more likely to have abnormal structures and disorganized chromsomes than the eggs in normal-weight women.

In particular, the eggs in the obese women were roughly twice as likely to have double “spindles.” The spindle is something like the axis around which the gene-bearing chromosomes organize themselves; for an egg to fertilize normally, it must have a single spindle. (See the image below.)

spindles

Normal and abnormal spindles in human eggs (Courtesy of BWH)

How, I asked Dr. Racowsky, might all this work? How might obesity lead to double spindles and other egg malformations?

‘The egg, of course, develops in the ovary,” she replied, ” and the immediate environment in which the egg develops is called the follicle. And we know from other studies that there are various abnormalities in the follicles of women who are obese. A lot more work needs to be done to understand how these abnormalities in the follicles relate to abnormalities in the eggs, but we do know that the relationship between the health of the follicle and the health of the egg is of paramount importance.”

In the paper, I said, I caught hints of a couple of familiar elements that may go wrong in the follicles of obese women. There were mentions of leptin, an obesity-related hormone involved in appetite and metabolism, and of inflammation, which has also been found to increase in obesity. Continue reading

First Total Artificial Heart Implant In New England: The Video

http://vimeo.com/44387011

Brigham and Women’s Hospital announced this morning that surgeons implanted the first total artificial heart in New England.

The Boston Globe reports:

The first total artificial heart implant in New England was performed last February on a 66-year-old retired high school teacher and track and field coach from the South Shore, who was diagnosed last year with a rapidly deteriorating condition that would have caused total heart failure.

The artificial heart that James Carelli received at Brigham and Women’s Hospital is intended as a bridge to a human heart transplant. Doctors diagnosed Carelli with cardiac senile amyloidosis, and they determined that his only option for survival was to receive the artificial heart while he awaits the transplant, according to an e-mail the hospital’s president, Betsy Nabel, sent Thursday morning to staff. He is on the waiting list for a heart transplant, as well as a kidney transplant.

Brain Decline Seen ‘As Early As Age 45,’ But Not To Worry (Yet)

“I knew it — I’m getting stupider,” was my first response when I saw the major new study on “cognitive decline” just out in the BMJ (formerly known as the British Medical Journal.)

“Cognitive decline can begin as early as age 45, warn experts,” was the headline of the press release. It began: “The brain’s capacity for memory, reasoning and comprehension skills (cognitive function) can start to deteriorate from age 45, finds research published on bmj.com today. Previous research suggests that cognitive decline does not begin before the age of 60, but this view is not universally accepted.”

Not a pleasant prospect — early senility. But I feel much better now that I’ve spoken with Dr. Francine Grodstein, an associate professor of medicine at Brigham and Women’s Hospital who studies aging. She wrote a BMJ editorial that accompanied the study, and I turned to her for a reality check. Tell me it ain’t so, I begged; is there real cognitive decline in our forties?

‘The translation in a day-to-day message for people in their forties is, ‘Start living healthy now, because if you put it off for 40 years, it may be too late.’

“It depends on what ‘real’ means,” she replied. “They did demonstrate in this study that there was ‘measurable’ cognitive decline in people in their mid-40s. So ‘measurable’ is probably a better word than real. But it still was quite a small amount and though it’s not data-driven, I would say those 40-year-olds who had measurable cognitive decline aren’t feeling anything. So it’s probably a small enough amount that in terms of their day-to-day life, it does not mean very much in the present.

The bigger question is really whether a small amount of measurable decline that the [BMJ] Whitehall study could see in the forties does predict dementia 20-30-40 years down the line. And if it does, then the translation in a day-to-day message for people in their forties is, ‘Start living healthy now, because if you put it off for 40 years, it may be too late.'”

It’s good to hear the early decline is slight, but I still find it depressing…

It’s not depressing! The amount of decline that was measured here was tiny. It doesn’t mean you’re demented when you’re 50. This is a long, long way from anything that has clinical relevance. People are more sensitive about memory, but it’s no different from other things: cancer, cardiovascular disease — the same thing is true: These are very long-term processes and the fact that you have some early signs of it in mid-life shouldn’t be something that depresses you, it should be something that inspires you. It should get you to say, ‘If I want to prevent something bad from happening in 30 years, I need to start doing more healthy things today.’ These findings in no way mean that at 50, there are more people with dementia than we previously thought.”

But doesn’t it imply that we’re getting stupider? Continue reading

Breast Tumors, Like Guns In Luggage, Missed Because They're Rare

A mammogram image, with arrow in upper left pointing to cancer

We already knew this about guns and knives hidden in baggage. Now it seems the same important insight applies to cancers hidden in breasts: When the target of a visual search — like a weapon or a tumor — occurs only rarely, we’re far likelier to miss it than if it were much more common.

Jeremy Wolfe, director of the Visual Attention Lab at Brigham and Women’s Hospital, uses this pithy phrase for the problem: “If you don’t find it often, you often don’t find it.”

And a problem it is, from airport security to pap smears. Growing research suggests that because some of the perils we most want to seek and destroy are extremely rare, we’re naturally ill-suited to the task.

A cognitive scientist and vision expert, Wolfe began applying his lab’s work to airport security in the years after 9/11. Now he has just presented real-world findings on breast cancer at the annual convention of the Radiological Society of North America, a gathering of tens of thousands of medical scanning professionals.

Typically, mammography turns up three or four cases of breast cancer for every 1,000 scans, but misses 20-30% of tumors, Wolfe said. His central finding: As many as half of those misses could be the result of the “behavioral effects of searching for something very rare.”

First, to clarify the point, using an example from Wolfe’s convention talk based on lab experiments:

Imagine you have X-rays of 20 bags with guns and knives in them. Mix them into a stack of 40 X-rays in total, so the “prevalence” of weapons is 50%, one in two. If you were a typical scan-checker in Wolfe’s experiment, you would fail to catch only four or so of those 20 hidden weapons.

Now imagine those same weapon-laden 20 suitcases are mixed in a pile of 1,000 bags, so the prevalence of weapons is a mere 2%. It’s the same 20 bags, but your “miss” rate more than doubles, from missing perhaps four weapons to perhaps eight or nine.

Why? These searches are hard tasks, exhausting for our fallible human eyes and brains. Plus, we have a built-in hesitancy about saying we have found something rare. And when targets are rare, we tend to give up more quickly.

Go look for a zebra

Say I tell you to go out to the streets of Boston and look for a zebra, Wolfe said. Continue reading

Breathing Easier: Asthma And The Placebo Effect

Asthmatics report improvement in symptoms after taking placebo medications

Asthma can be terrifying. One minute you’re breathing, the next, you’re gasping for air. I’ll never forget my little brother, chest heaving, rushed to the emergency room during middle-of-the-night attacks.

But despite its dramatic and objectively physical nature, asthma is also a disease with an element of subjectivity.

That point is elegantly underscored in a new study just published in The New England Journal of Medicine. Harvard Medical School investigators found that when asthma patients were treated with the medication albuterol, their lung function improved significantly compared to those given placebo, or fake, treatments. However, and here’s the rub, when the same patients were asked to report how they were feeling — a subjective measure — placebo treatments turned out to be as effective as real medicine in helping to relieve asthma symptoms and alleviate patients’ discomfort.

Indeed, the placebo effect seemed to be on full display here: whether patients were on albuterol, the placebo inhaler or undergoing sham acupuncture (which feels real, but in fact uses trick needles that don’t penetrate the skin) they all reported significant symptomatic improvement compared to little improvement among patients who got no treatment at all.

The takeaway, researchers agree, is that there’s something therapeutic about the act of treatment itself, the ritual of care and the reassuring bond between doctor and patient that makes people feel better, whether or not their treatment includes pills or drugs with an active ingredient. Continue reading

The Ethics Of Boston Med: 6 Facts You Probably Didn’t Know

I went to an interesting panel at Harvard Medical School yesterday on the ethics of the reality medical TV series Boston Med. The show, which aired last summer, featured high drama involving patients and their families — race-against-time transplants, sudden death, a cop shot in the face, a major surgical error on an infant — and a glimpse into the harried lives of doctors from three Boston teaching hospitals: Massachusetts General, the Brigham & Women’s and Children’s.

What I learned at the panel was this: Everyone involved with the series had an agenda. ABC wanted heart-tugging stories of life and death; the hospitals wanted great PR and a chance to showcase their extraordinary talent; patients wanted, what, a little extra attention, a fraught moment captured on film, a chance to help other patients and possibly ease their suffering. “I want to thank the producers of Boston Med for capturing cherished moments on film,” said Jeannette Pollet, widow of Marvin, who died on camera in one of the episodes.

Not everyone was so happy: several nurses, particularly one from Children’s who stood up before the crowd, said she was disappointed that the program didn’t sufficiently highlight the tough, often thankless work that nurses do every day. Terence Wrong, executive producer of the series at ABC News blamed “the brutal narrative regime,” that required each of the eight episodes to include cohesive, gripping stories with a beginning, middle and end. There was much discussion about how the ABC crew seamlessly inserted themselves into the patient’s and doctor’s daily routines, to the point that many at the hospitals simply forgot the cameras were rolling. This raised the question: was the process so seductive it became exploitative, or was it empowering?

You can watch it here and judge for yourself.

In the meantime, here are six facts about the series you probably didn’t know:

1. The ratio of film shot to film actually used was 400 to 1.

2. Doctors, nurses and patients (even those who consented to be filmed for the show) could ask the cameras to stop — in real time — at any time. And they did.

3. The surgeon who allowed a camera crew to accompany her on a date doesn’t regret it.

4. One doctor at Children’s said in an email that the show was a bad idea and wrote that the “hospital sold out for free advertising on a national stage.”

5. Of the patients who were asked to participate in the show, 99 percent of the transplant patients said “Yes.”

6. The hospitals were not allowed to view the episodes before they aired.

And, the bonus fact, the producers tended to choose stories that had happy endings.