New England Journal: 200 years of medical history

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EMBARGOED FOR RELEASE AT WEDNESDAY, JAN. 4, 2012 AT 5 P.M. EST - This illustration made available by the New England Journal of Medicine shows a diagram of a human heart in the article "Cases of Organic Diseases of the Heart and Lungs" by John C. Warren in the April 1, 1812, Issue of the journal. Unhappy with today's health care? Think of what it was like to be sick 200 years ago. No stethoscopes, antibiotics, X-rays or vaccines. Bloodletting was a common treatment. If you had a heart attack or a stroke, doctors put you in bed and hoped for the best. Into this medical dark age, two Boston doctors brought a beacon of light. Two centuries ago, they started what is now the New England Journal of Medicine with the idea that science should guide care medical treatment. (AP Photo/New England Journal of Medicine) EMBARGOED FOR RELEASE AT WEDNESDAY, JAN. 4, 2012 AT 5 P.M. EST - This illustration made available by the New England Journal of Medicine shows a diagram of a human heart in the article "Cases of Organic Diseases of the Heart and Lungs" by John C. Warren in the April 1, 1812, Issue of the journal. Unhappy with today's health care? Think of what it was like to be sick 200 years ago. No stethoscopes, antibiotics, X-rays or vaccines. Bloodletting was a common treatment. If you had a heart attack or a stroke, doctors put you in bed and hoped for the best. Into this medical dark age, two Boston doctors brought a beacon of light. Two centuries ago, they started what is now the New England Journal of Medicine with the idea that science should guide care medical treatment. (AP Photo/New England Journal of Medicine)eval("var currentItemd57851005a80479aaeeb90a12c70b9ff = 1;");eval("var nextd57851005a80479aaeeb90a12c70b9ff = 0;");eval("var previousd57851005a80479aaeeb90a12c70b9ff = 0;"); Unhappy with today's health care? Think of what it was like to be sick 200 years ago.

No stethoscopes, antibiotics, X-rays or vaccines. Bloodletting was a common treatment. If you had a heart attack or a stroke, doctors put you in bed and hoped for the best. If you needed surgery, you got a few shots of whiskey and a bullet to bite.

Into this medical dark age, two Boston doctors brought a beacon of light. They started what is now the New England Journal of Medicine with the idea that science should guide care — not whoever argued loudest or had the most persuasive theory.

The first 100 copies in January 1812 were delivered by horseback. Today, 2 million people read the journal online every month. It is the oldest continuously publishing medical journal in the world, and it has touched lives in more ways than you may know. Some examples:

—Stroke victims now get clot-busting medicine, not dark rooms to ride out their brain trauma, because a 1995 study in the journal proved its benefit.

—Heart attack patients have arteries unclogged without surgery, then go home on medicines that studies in the journal showed could prevent future attacks.

—Women with early stage breast cancer can have just the lump removed followed by radiation instead of losing the whole breast, thanks to a 1985 study that found the lesser surgery just as good.

—Bone marrow and organ transplants — radical ideas when first tried half a century ago — are now routine. Even face transplants are becoming more common: three were described in last week's issue.

—Rehydration is now recognized as the main treatment for many diarrheal diseases. A journal article warned against bloodletting in 1832 as cholera ravaged New York City.

—People no longer suffer surgery without anesthesia, a field that grew from Henry Jacob Bigelow's 1846 report on the first successful use of inhaled ether.

—Medicine is more ethical, and study participants have more protections, because of a 1966 report in the journal about researchers failing to get informed consent. Another top journal had rejected the article as too controversial.

The New England Journal started decades before the American Medical Association was founded in 1847 and is widely credited with promoting evidence-based care.

"It has been very good for society," said Pat Thibodeau, head librarian and associate dean for the Medical Center Library at Duke University. "When I go in, I'm hoping my doctor has read the New England Journal of Medicine or something similar and is following that information."

"It's the cream of the crop," said Dr. Barron Lerner, a Columbia University physician and medical historian.

"They get the best research submitted to them, and they do an extremely good job of peer reviewing" to make sure it is solid, he said.

That's what Boston surgeon John Collins Warren and James Jackson, who helped found Massachusetts General Hospital, hoped for the journal, which is now published weekly. It got its current name in 1928, seven years after it was bought by the Massachusetts Medical Society.

Warren's father, John Warren, surgeon to George Washington's troops, wrote the first article, on chest pain. Doctors had been debating whether it was caused by plaque — "the cement that builds up in arteries" — or blood clots, said Dr. Jeffrey Drazen, the journal's editor-in-chief since 2000. Both proved correct — the "cement" fractures and allows a clot to form that blocks an artery, he said.

Heart care has been a journal specialty, and two prominent doctors — Elizabeth Nabel and Eugene Braunwald of Brigham and Women's Hospital — trace its evolution in this week's issue. Nabel is former director of the National Heart, Lung and Blood Institute and now is president of the Boston hospital.

They describe the first human cardiac catheterization — now a common diagnostic procedure — that Werner Forssman performed on himself in 1929. Under local anesthesia, he put a catheter into his arm and maneuvered it into his own heart.

For a heart attack, "it used to be that all we did was put people to bed for five weeks," but studies in the journal showed "that that was the worst thing you could do," said Dr. Jerome Kassirer, its top editor from 1991 to 1999.

The journal also helped prove "germ theory" and the nature of infectious diseases.

"People didn't realize you could infect people when you were using your dirty gloves or not using gloves. People didn't realize tuberculosis was communicable. They thought it emanated from clouds they called miasma, clouds of dirty smoke in cities," said Lerner, the Columbia historian.

Not all was grand in the journal's history, though, as Allan Brandt, a Harvard University medical historian writes in this week's issue.

When Harvard Medical School debated admitting female students in 1878, the journal expressed concern about men and women mingling during surgeries normally witnessed only by one sex. The school didn't admit women until 1945, when World War II caused a shortage of men.

The journal also agreed with mandatory sterilization of "mental defectives" in the early 20th century. "Most alarming," Brandt writes, was its declaration in 1934 that "Germany is perhaps the most progressive nation in restricting fecundity among its unfit." The journal later condemned Nazi medicine.

In recent years, it has tracked health policy, from the Clinton health care plan and the advent of managed care to current debates about Medicare.

There were oddball reports along the way, like the 2007 account of a cat named Oscar that had a knack for predicting when patients at a Providence, R.I., nursing home were close to death by curling up to them in their final hours.

The journal has printed few studies on alternative medicine because so little good research has been done on it, Drazen said. Unlike some other journals that like controversial research, the New England Journal tries to avoid it.

"People think the cutting edge is sharp. The cutting edge is very dull. It's very foggy and you don't know what the right answer is," so editors try to pick studies that are definitive enough to affect care, Drazen said.

That's why it publishes very few observational studies, the kind that in the 1990s led to pronouncements like "margarine is better than butter" only to be reversed by the next such study.

"Some of those are papers that we've seen and turned back," Drazen said. "I'm looking for a higher evidence standard."

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Online:

Journal and medical timeline: http://nejm200.nejm.org

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Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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Doctors slap down claim Chavez to die in 2 years

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Venezuela's President Hugo Chavez talks to the media as he arrives at the La Fria airport in the state of Tachira October 20, 2011.

Credit: Reuters/Carlos Garcia Rawlins

By Enrique Andres Pretel and Daniel Bases

CARACAS | Sat Oct 22, 2011 3:22pm EDT

CARACAS (Reuters) - Physicians treating Venezuelan President Hugo Chavez disputed on Saturday claims made by a former doctor of the socialist leader that he would die within two years from his undisclosed cancer.

In the first official public comments on Chavez's health, three physicians dressed in laboratory coats at Venezuela's main military hospital said Salvador Navarrete was uninformed and had just minimal contact with the leader a decade ago.

"The President, from the standpoint of cancer has been diagnosed and treated early. Subject to the appropriate follow-up treatments, the current status is quite satisfactory with an excellent prognosis," Dr. Fidel Ramirez said in a televised midday press conference.

"Navarrete was not Chavez's physician, a trusted party or his family," Ramirez said, adding that Navarrete had no scientific evidence or understanding of Chavez's condition.

Navarrete, in an open letter published by local media on Friday, said he has since fled the country, fearing for his safety after an interview published a week ago quoted him saying Chavez would be dead in two years.

Navarrete attended to Chavez a decade ago and claims he is in touch with some relatives and members of his medical team.

In his letter, Navarrete said the interview with Mexico's Milenio Semanal magazine was intended to combat official secrecy over Chavez's condition. He stood by his original prognosis of Chavez, which caused an uproar.

Chavez's health is the all-consuming issue for the South American OPEC member nation of 29 million people, one year ahead of a presidential election where he wants to be re-elected.

Chavez, 57, returned on Thursday from Cuba where he has received cancer treatments, declaring himself cancer-free in an event that included an open-top caravan to a regional Catholic shrine where he prayed and gave thanks for his recovery.

The three doctors on Saturday still would not disclose the type of cancer Chavez has, four months after surgery to remove a malignant tumor from his pelvis. This was followed by four cycles of chemotherapy treatment.

Experts say it is possible for a patient to be considered cancer free at the time of testing if no cancer cells are found, but that typically no one is considered cured of the disease unless tests are negative for a number of years.

By common convention, oncologists say a person can be considered cured after two to five years of clean tests.

Dr. Earle Siso Garcia, director of the military hospital, disputed claims that Chavez was having kidney problems.

Navarrete mentioned again in his open letter Chavez has seen a psychiatrist. However, this claim was denied as well.

"The president never ever had psychiatric treatment. This is a total fallacy," said Dr. Rafael Vargas.

(Editing by Vicki Allen)

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IQ 'can change in teenage years'

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19 October 2011 Last updated at 17:05 GMT By David Shukman Environment & science correspondent, BBC News Intellectual performance can both improve and deteriorate in adolescence The mental ability of teenagers can improve or decline on a far greater scale than previously thought, according to new research.

Until now the assumption has been that intellectual capacity, as measured by IQ, stays quite static during life.

But tests conducted on teenagers at an average age of 14 and then repeated when their average age was nearly 18 found improvements - and deterioration.

The findings are published in the journal Nature.

They have implications for how pupils are assessed, and the age at which decisions about their futures are made.

This study involved 19 boys and 14 girls, all undergoing a combination of brain scans and verbal and non-verbal IQ tests in 2004 and then in 2008.

The results show that a change in verbal IQ was found in 39% of the teenagers, with 21% showing a change in "performance IQ" - a test of spatial reasoning.

The findings are seen to have greater validity because for the first time the variations in IQ correlated with changes in two particular areas of the teenagers' brains.

An increase in verbal IQ corresponded with a growth in the density of part of the left motor cortex - a region activated during speech.

And an increase in non-verbal IQ correlated with a rise in the density of the anterior cerebellum - an area associated with movements of the hand.

The work was led by Professor Cathy Price of the Wellcome Trust Centre for Neuroimaging at University College London and is published in the journal Nature.

The paper suggests that the results could be "encouraging to those whose intellectual potential may improve and… a warning that early achievers may not maintain their potential".

Professor Cathy Price explains how teenage brains and IQs can change over time

Professor Price said: "We have a tendency to assess children and determine the course of their education relatively early in life.

"But here we have shown that their intelligence is likely to be still developing.

"We have to be careful not to write off poorer performers at an early age when in fact their IQ may improve significantly given a few more years."

The research did not seek to understand the causes of the changes.

One explanation is that teenagers mature at relatively different ages - with "early" and "late" developers - while relative standards in education may play a part too.

One of the participants, Sebastian Friston, now aged 23, recorded a marked increase in IQ between the two tests - from average to one of the highest categories.

Educated in the state sector, he told me he had struggled in his early years, needing remedial maths tuition, but is now planning a doctorate in computer engineering.

"I think the change came in school I started doing subjects that really interested me, that I was engaged in, then I found it easier and far more interesting."

The research was funded by the Wellcome Trust, one of many projects supported under its programme of Understanding the Brain.

Future work may focus on how adaptable the brain may be beyond teenage years, and the implications for tackling mental diseases and other neurological conditions.

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HEALTH MANAGEMENT. American families only $ 95 off better in 10 years because of rising health care costs

A median-income American family is only $95 per month better off today than ten years ago because rising health care costs have eliminated virtually all their income gains, researchers from the RAND Corporation revealed in the journal Health Affairs. Had health care costs risen in line with other goods and services those families would have had an extra $545 disposable income per month in 2009.
Economist David Auerbach, the study's lead author, said:

"Accelerating health care costs are a primary reason that the so many American families feel like they are just treading water financially." "Unless we reverse the trend, Americans increasingly notice that health will costs compromise their other spending options."

Between 1999 and 2009 in the United States: health care spending rose from $1.3 trillion to $2.5 trillionHealth care spending per person rose from $4,600 to just over $8,000.13.8% of country's GNP (gross domestic product) was spent on health care in 1999. It rose to 17.6% in 2009.These numbers may be sobering, but they do not translate to the daily routine of typical American families easily, mainly because health care costs are not all clearly visible, the authors wrote.
To describe the hidden burden that ever increasing health care expenditure placed on a median-income family consisting of two parents with two children, with employer-sponsored insurance from 1999 to 2009, Auerback and Dr. Arthur L. Kellermann gathered various data together from several sources.
American families can see health care costs in two ways: through the amount they have to pay every month on their private health insurance premiumThrough out-of-pocket expenditure for deductibles, drugs, copayments and other itemsHowever, the researchers say there are other less visible costs: for an employer to be able to pay a share of the worker's premium, his/her wages and other compensation are usually reducedA proportion of the family's income goes towards paying for federal and state taxes which are devoted to such health programs as Medicaid, Medicare and the military health had on annual income of $76,000 in 1999, care system the median-income family in the United States this grew to $99,000 in 2009, on increase of 30%. However, health spending increased at a considerably greater rate. Monthly health insurance for families rose from $490 to $1,115 (128%), and out-of-pocket expenses from $135 to $240 (78%).
Public expenditure on health rose by 76% at state level and 140% at federal level.
As federal tax rates dropped during the ten-year period, the portion of family's tax bill that went towards health care costs – from $345 to $440 did not fully reflect this increase.
Therefore, families had much less money to spend because of rapidly rising healthcare costs.
A typical family's income rose by approximately $1,910 during the decade. Over 40% of that went on higher health care costs. Increases in the cost of consumer goods plus non-health care taxes absorbed a further 53%, leaving the average median-income family with a mere $95 extra money in their pockets at the end of each month.
Kellermann said:

"The complex way that the United States pays for health care often obscures the consequences of health care cost growth for most American families." "This makes the challenge of controlling health care costs that much harder."

The researchers worked out that if health care costs had risen by 1% more than the annual GDP rise, the median-income family would have had $335 extra cash at the end of the month at the end of the decade, and $545 if health care costs had risen the same as the overall inflation rate during that period.
The target set by the affordable care Act is a 1% higher increase in health care spending than the increase in GDP.

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