Methodist Healthcare Hospitals

Methodist Healthcare Hospitals
P 800.333.7333 (Toll Free)
www.sahealth.com

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Methodist Healthcare Hospitals Overview

As the region’s most preferred health care provider, Methodist Healthcare has a dynamic team of over 8,000 professionals and support staff devoted to fulfilling our mission of Serving Humanity to Honor God and providing exceptional and cost-effective health care accessible to all. More than 2,700 physicians in every field of specialization maintain credentials to practice at Methodist Healthcare Hospitals. In 1963, Methodist Hospital was the first hospital to open in the now world-renowned South Texas Medical Center. Methodist Hospital includes these additional campuses in the Medical Center: Methodist Heart Hospital, Methodist Children’s Hospital and Methodist Specialty and Transplant Hospital. Specialized services are provided through departments including the Texas Transplant Institute, Texas Neurosciences Institute, Gamma Knife® Center and Methodist Women’s Pavilion.

 

Chartered in 1955, Methodist Hospital became the first hospital built in the South Texas Medical Center. A group of businessmen known as the Five Oaks donated 40 acres for the development of a world-class medical hub. A groundbreaking ceremony was held in 1960 featuring a mock nuclear blast to showcase the design plans of the hospital: the world’s first nuclear-age hospital with two floors built completely underground to ensure vital services were available in the event of a nuclear attack. The hospital opened in 1963 and welcomed the first baby born in the Medical Center. Methodist Hospital now delivers more than 5,000 babies annually. In addition to its outstanding obstetrics program, Methodist Hospital is also known for its outstanding neurology and neurosurgical care as well as orthopedics, bone marrow transplants, emergency services and an oncology program which includes South Texas’ only Gamma Knife® Center. Methodist Hospital is accredited by the Joint Commission in stroke care and is one of two Texas hospitals to receive the highest quality award from the Texas medical Foundation Health Quality Institute: The Texas Medical Foundation Gold Award for Health Care Improvement.

 

As an accredited chest pain center, Methodist Heart Hospital is the area’s leader in cardiac care and recognized for an outstanding heart transplant program. Methodist Heart Hospital pioneered many firsts in cardiac care including the first balloon angioplasty, the first heart valve transplant and, the first hospital in San Antonio to offer a cardio-hospitalist program in which two cardiologists work in the hospital on rotating shifts, 24 hours a day, seven days a week, prepared to care for patients with signs and symptoms of a heart attack. Methodist Heart Hospital recently opened a Hybrid Operating Room, offering cardiology specialists and surgeons the opportunity to provide a wider range of services in a single room. Methodist Heart Hospital is the only private hospital in the area performing Transcatheter Aortic Valve Replacement, or TAVR.

 

Methodist Children’s Hospital is dedicated to providing outstanding pediatric care from children from all over Texas and beyond. Colorful images and artwork enhance every window and wall, creating a warm, welcoming environment that is focused on the health and well being of each child. Methodist Children’s Hospital has a spacious emergency department dedicated to pediatric cases with 32 individual treatment rooms, each equipped with a television and an activity center. The newborn intensive care unit is a regional center of excellence with 78 licensed beds over 19,000 square feet, caring for the most fragile premature and special needs babies. Methodist Children’s Hospital is among the nation’s largest providers of blood and marrow stem cell and cord blood transplants for children having preformed over 500 transplants since program inception.

 

 

Methodist Specialty and Transplant Hospital is a full-service facility that is widely acclaimed for its outstanding kidney, liver and pancreas transplant programs. Home to the Texas Transplant Institute, the center made medical history by performing the world’s first 16-way kidney donor exchange in three consecutive days in a single center. The kidney transplant program is the largest living donor program in the nation due to the success of its paired exchange kidney program. Other specialty areas include emergency care, psychiatry, bariatric surgery, inpatient rehabilitation and the latest treatments for cancer and incontinence. The facility houses a program with a specially trained team that works with law enforcement officers to provide forensic exams and emergency care for survivors of sexual assault.

MHS Featured Video

Neuroscience Articles

  • What makes hospital patients turn violent?

    By Shereen Lehman

    NEW YORK (Reuters Health) - It's common for patients to come into a hospital with injuries, but too often they're the ones inflicting injury on nurses, technicians and security guards, according to a new study.

    Researchers analyzed incident reports of patient violence to identify the situations most likely to lead to a physical conflict, in the hope of training hospital staff to avert the attacks.

    "This study is contributing to knowledge about how we can develop (patient violence) prevention," Judith Arnetz told Reuters Health. "This is a project that is very much in collaboration with hospital stakeholders and that means both labor and management," said Arnetz, a researcher with the Wayne State University School of Medicine in Detroit who led the new study.

    "Compared with workers in other industries, hospital workers have high rates of non-fatal workplace assault injuries," Arnetz and her colleagues write in the Journal of Advanced Nursing.

    Among hospital workers, nurses, mental health professionals and security staff are most at risk, they point out, but hospitals' efforts to reduce workplace violence are hampered by a lack of information about the reasons violence flares.

    To learn more about what triggers patient violence, Arnetz and her colleagues looked at electronic reports of patient-to-employee violence during a one-year period in a Midwestern hospital system that includes a pediatric hospital, a rehabilitation hospital and five specialty hospitals.

    The system has 15,000 employees, two of the hospitals are located in the suburbs and five are in cities. Employees are required to report details of all adverse incidents in a centralized computer reporting system.

    A total of 214 incidents of patient violence were entered over the year, with 90 percent involving physical violence directed toward employees. Nurses reported about 40 percent of the incidents. Another 16 percent were reported by security staff and 14 percent by nursing assistants called patient care associates.

    Incidents happened at all seven hospitals, "ranging from eight at a suburban specialty hospital to 64 at an inner city acute care hospital," according to the authors.

    "In order to know what's happening you really do have to look at incident reports," Arnetz said. "After reading and rereading all of these incidents we came up with what we saw as three main themes or categories."

    The study team further broke those patterns down into sub-themes, which were very specific types of situations that represented risk situations for violence.

    Within the first overall category of patient behavior and characteristics, which accounted for 40 percent of incidents, the researchers identified cognitive impairment (such as dementia or intoxication) and times when patients were demanding to leave as recurring sub-themes in the incident reports.

    For example, one registered nurse recounted, "I was sitting at bedside of a confused patient. She had been laying down, got up quickly and punched me in the left side of the face." A patient care associate also reported, "Was comforting confused patient and he put his hand around my neck and tried to choke me."

    A psychiatric social worker entered, "Patient was at the nurses' station demanding discharge, abruptly started striking at me, hitting and scratching my face and neck."

    A second category of incidents was related to delivering care and tended to happen when workers were in close proximity to patients, such as using needles and otherwise causing discomfort, or physically moving patients from one place to another.

    For example, a registered nurse wrote, "Patient needed lab work drawn and became very hostile, aggressive and violent with staff. He was verbally abusive with profanity and physically abusive by hitting, biting, scratching and pushing. Attempted to grab patient's arm to prevent him from hitting the ER (emergency room) tech who was drawing his blood and the patient hit me in the left side of my face . . . patient hit my eye, ear, cheek and head. Patient then tried to bite me, but could only get my clothing."

    And a patient care associate entered, "Employee was hooking up tube feeding, patient got agitated and kicked employee in the face."

    The third category, dubbed situational events, involved transitions such as admission or discharge, use of restraints, redirecting patients back to their beds or hospital rooms and intervening with a violent patient.

    A patient care associate wrote, "I was trying to keep the patient from leaving the room and going to the elevator by standing in front of her room door. She got mad and scratched my face. I grabbed her hands to keep her from scratching me again and then she bit my thumb."

    And a security guard's supervisor wrote, "Security officer was injured while attempting to control patient. Patient was disruptive and threatening medical staff. Security officer was kicked to the chest area by patient while attempting to place her in a wheelchair."

    "I think each of these subthemes are specific enough that it would be possible to educate staff to be aware of the risk situations," Arnetz said. "I think that is the importance of this study."

    Arnetz said another general theme that emerged from the analysis was that healthcare workers were often taken by surprise by the patient outbursts.

    "It may be that staff are missing signals, or they need to be educated so that they know that these things could happen," she said.

    SOURCE: http://bit.ly/1wg3mxD Journal of Advanced Nursing, online August 4, 2014.

  • Brain study hints at how fibromyalgia works

    By Kathryn Doyle

    NEW YORK (Reuters Health) - Brain scans show that people with the pain disorder fibromyalgia react differently to what others would consider non-painful sights and sounds, new research suggests.

    The small new study provides clues to what might be going wrong in the nervous system of people with fibromyalgia, along with possible new approaches to alleviating their pain.

    "If we understand the mechanism, we may come up with new and potentially better forms of treatment," said lead author Marina López-Solà of the department of Psychology and Neuroscience at the University of Colorado, Boulder.

    Fibromyalgia, which patients experience as widespread muscle pain and fatigue, affects as many as five million Americans, most commonly middle-aged women, according to the U.S. Department of Health and Human Services.

    Its cause is unknown and there is no cure, but medications can treat the symptoms.

    The new results suggest not only that fibromyalgia is related to greater processing of pain-related signals, but also potentially to a misprocessing of other types of non-painful sensory signals that may be important to address during treatment, Lopez-Sola told Reuters Health by email.

    She and her team used "functional magnetic resonance imaging," which measures blood flow changes in the brain, to assess brain responses among 35 women with fibromyalgia and 25 similar women without the disorder.

    The fibromyalgia patients were more sensitive to non-painful stimulation compared to people without the disorder, they report in Arthritis and Rheumatism.

    Researchers showed the subjects some colors, played some tones and asked subjects to perform very simple motor tasks at the same time, like touching the tip of the right thumb with another finger.

    Areas of the brain's cortex primarily responsible for processing visual, auditory and motor signals were significantly activated in the healthy comparison group, but not in the fibromyalgia group.

    However, other brain regions that are not relevant for primary processing were activated in fibromyalgia sufferers but not in healthy controls.

    What seems to be happening is that the brains of fibromyalgia patients are under-processing certain forms of sensory information at the first stages of processing, but are also amplifying the signal at a later level of sensory integration of multiple sensory inputs, Lopez-Sola said.

    "When you are in pain, it is probable that you are more concentrated on your own pain than on the tasks you have to pay attention to," said Dr. Pedro Montoya of the Research Institute on Health Sciences at the Universitat Illes Balears in Palma de Mallorca, Spain, who was not part of the new study.

    "For me, these findings provide further support for the idea that psychological strategies aimed at changing the focus of attention from the body to external cues could be useful for these patients," Montoya said.

    There were only a small number of people involved in the study, and the researchers did not account for other mental health conditions the participants may have had, both factors that limit the results, said Dr. Winfried Hauser, associate professor of Psychosomatic Medicine at Technische Universitat Munchen in Germany.

    People with fibromyalgia often also have conditions like depression, so some people believe the disorder has a mental basis, said Michael E. Geisser, professor in the department of physical medicine and rehabilitation at the University of Michigan in Ann Arbor.

    But evidence for a neuro-anatomical basis for fibromyalgia is growing, said Geisser, who was not part of the new study.

    "There is increasing evidence that fibromyalgia is not just a pain condition," he told Reuters Health by email. "More recent research done on persons with fibromyalgia, such as the research by Lopez-Sola and colleagues, suggests that persons with fibromyalgia suffer from a central processing deficit of multiple types of sensory stimuli, not just pain."

    "It's as if the volume control for sensation in persons with fibromyalgia is turned up, or louder, for many types of sensation compared to persons without the disorder," he said.

    That might help explain why many people with fibromyalgia also often suffer from fatigue, cognitive problems or mood disturbance, Geisser said.

    Currently, people with the disorder can take anticonvulsant medications, such as pregabalin (Lyrica), and antidepressants such as duloxetine (Cymbalta) and milnacipran (Savella), which have been FDA approved for treating fibromyalgia.

    Further research to improve understanding of where there are problems in the brain for people with the disorder could lead to the development of new treatments, Geisser said.

    For example, it would be interesting to see if a treatment targeted at dampening response in an area of the brain that "overreacted" in this study helped to treat fibromyalgia symptoms, he said.

    SOURCE: http://bit.ly/1mbOikg Arthritis and Rheumatism, online September 15, 2014.

  • Docs urge action to stop young drivers' texting

    By Janice Neumann

    NEW YORK (Reuters Health) - Texting while driving could be contributing to thousands of car crashes, especially among teens, and the American College of Preventive Medicine (ACPM) wants policy makers, doctors and parents to do something about it.

    Texting by novice drivers raises the chances of an accident almost four-fold, the authors of a new position statement point out. But they say new laws, combined with public education, could help eradicate this unnecessary risk on the roadways.

    "I was surprised that statistically the risks, given the little hard data we have, are comparable or worse than those of individuals who are driving under the influence," said Dr. Kevin Sherin, director of the Florida Department of Health in Orange County and lead author of the recommendations published in the American Journal of Preventive Medicine.

    The new recommendations focus on teens because they text or Internet browse nearly twice as much as adults. A recent study found that drivers with less than two years' experience are eight times more likely to crash if they use a cell phone, and seven times more likely if they reach for a cell phone (see Reuters Health story of January 1, 2014, here: http://bit.ly/19F1LID).

    Their risk of crashing increases 3.9 times by sending or receiving texts or using the Internet while driving, the same study found. Of drivers under 20 years old, 11 percent involved in fatal vehicle crashes said they were distracted and nearly one in five said those distractions came from using a cell phone.

    Distractions played a role in 17 percent of motor vehicle crashes in 2011 and 3,331 deaths, according to the National Highway Traffic Safety Administration. Cell phones were involved in 12 percent of the deaths.

    "I have personally observed my teens sending texts and admitting they were driving . . . despite my safety warnings and my own public health, preventive medicine and public safety awareness and special knowledge," said Sherin, whose children are now in their 20s.

    "It certainly did make me interested in effecting (change in) state and national policy," said Sherin, who also teaches at the Florida State University College of Medicine and the University of Central Florida College of Medicine in Tallahassee.

    The recommendations include state bans against texting and driving, public relations campaigns about the dangers, beefed up penalties for violations and educating future drivers when they apply for licenses. Primary care doctors and parents should also work at explaining the dangers of texting while driving to adolescents, starting at age 15, the authors say.

    They added that more research is needed on the role of texting in distracted driving, and on effective educational tools, ad campaigns and how best to counsel patients against it.

    According to the Governors Highway Safety Administration, 14 states have banned handheld cell phone use for all drivers, 38 states and Washington, D.C. prohibit cell phone use for new drivers, 20 states and D.C. prohibit cell phone use for school bus drivers and 44 states have banned texting while driving. Some states use primary enforcement laws for the infractions and others secondary enforcement laws.

    "I personally think the penalties for texting and driving should be as harsh as those for driving under the influence," Sherin said. "The risks are similar.

    Television ads in after-school time slots (like the ads against drugs and alcohol) could highlight the dangers of texting while driving for teens, the ACPM committee said.

    Dr. Linda Hill, clinical professor in the Department of Family and Preventive Medicine at the University of California, San Diego, told Reuters Health she agrees with the recommendations but thinks they should have also focused on the dangers of hands-free and hand-held cell phone use while driving. Hill was not involved in the recommendations, though she is a member of the ACPM.

    Employers also need to be involved since they often expect employees to answer their phones, even while driving, said Hill, who studies distracted driving and has launched several driver safety programs, including one for businesses.

    In a 2011-2012 survey of 5,000 college students in California, Hill found 90 percent were texting and 90 percent talking on the phone while driving. The survey also found that 50 percent sent texts while driving on the freeway.

    "We thought that was pretty scary," Hill said. "What shocked us was that 46 percent of the kids thought they were capable of distracted driving but thought only 8 percent of other drivers were."

    That unwarranted self-confidence in multitaskers is common, according to Zhen Joyce Wang at the Center for Cognitive and Brain Sciences, The Ohio State University. She told Reuters Health that texting while driving can be particularly dangerous.

    "It is because the capacities demanded by the tasks are more than what a person can typically afford," said Wang, who has published several studies on distracted driving. "We found both behavioral and eye movement (indicating visual attention) evidence that suggest texting and driving could be more dangerous than making phone calls while driving," Wang said in an email.

    SOURCE: http://bit.ly/1uHC58a American Journal of Preventive Medicine, published online Sept. 10, 2014.

  • REFILE-Falls indoors may signal frailty, linked to shorter survival

    (corrects third paragraph to say study was led by Bailly)

    By Shereen Lehman

    NEW YORK (Reuters Health) - Women in their eighties who fell indoors, rather than outdoors or from a height like a ladder, died sooner than their peers, a new French study finds.

    Indoor falls could be an indicator of frailty and a sign that protective measures should be taken, say the authors.

    The study was led by Sebastien Bailly, a researcher with Hospices Civils de Lyon in France. He and his coauthors write in the journal Maturitas, "The mean survival time of women with inside falls was nearly 1.6 years shorter than that of women with other falling profiles."

    Bailly and his colleagues studied 4,574 women who were over the age of 74 when they joined the study, could walk by themselves and were not living in institutional settings.

    The researchers called the women every four months for the first four years of the study to find out if they had fallen at some time during the previous week and where.

    The study team distinguished among falls by their location, whether they were due to inattention or to an environmental obstacle, and how serious the resulting injuries were.

    Along these lines, they classified the falls as environmental falls, such as slipping or tripping on something outdoors, falls from a height like a ladder or stairs, and inside or outside falls in general.

    Looking at information on 329 women who had fallen the week before the phone call follow-ups, the researchers found that 26 percent were so-called environmental falls, 19 percent were outside falls, 43 percent were inside falls and 12 percent were falls from height.

    The study team followed up again after another 13 years and found that 269 women had died. And those who had fallen indoors had an average survival time of 7.6 years, compared with 9.2 years for women who had any other type of fall.

    Separate from the type of falls women had, the researchers also found that women with advanced age, signs of frailty, slow walking speeds and comorbidities - that is, other health conditions - also had shorter survival times.

    However, women with frailties, for example, "who experienced outside falls or falls from height had no increased mortality despite more serious injuries," the researchers note.

    "Among community-dwelling women, some fall more frequently than others," the study team concludes. "These women should draw the caregivers' attention because their falls may be indicators of frailty. Non-injurious falls are also of concern because women experiencing this type of fall may suffer from unfavourable underlying conditions and be at risk of short survival."

    "The study is very well done," Dr. Kathleen Walsh told Reuters Health. "It has been shown in prior studies that for indoor falls the mortality tends to be worse, and longevity is diminished," said Walsh, who was not involved in the French research.

    Walsh, a geriatric and emergency medicine specialist at the University of Wisconsin Hospital in Madison, said there are different reasons that people fall inside and one of the questions that would be have been interesting to ask was how much time the patients were spending indoors or outdoors.

    "In general, people who fall inside have to stay inside for a reason and that's because of comorbidities - they're not super active and may not be active for different reasons," she said.

    But, Walsh said, family members shouldn't panic and tell their elderly loved ones that they need to move into assisted living after they've had a fall.

    "Because if you panic without having things evaluated by the physician that person will probably not tell you again when they have fallen," she said. "Staying calm is the number one thing."

    Walsh also said that physicians should ask their elderly patients if they have fallen within the previous year. If they have fallen, the doctors should find out what the patient remembers about the fall and if it was caused by certain movements, or if the patient could get up after the fall.

    "The red flags are, did they pass out before they fell," she said. "It's all in the history, if you take a good history you can usually figure things out."

    Walsh said that family members help to prevent falls by doing things like removing rugs and putting bars in bathrooms. In addition, she suggests elderly patients take classes to improve their balance and strength, such as the Stepping On class (http://www.steppingon.com).

    "Stepping is usually held at a local hospital or senior center and it's all about things that you can do while you're washing dishes or doing odds and ends around the house so you don't have to go to the physical therapist," she said.

    SOURCE: http://bit.ly/1oHXLKv Maturitas, online August 4, 2014.

  • REFILE-Falls indoors may signal frailty, linked to shorter survival

    (corrects third paragraph to say study was led by Bailly)

    By Shereen Lehman

    NEW YORK (Reuters Health) - Women in their eighties who fell indoors, rather than outdoors or from a height like a ladder, died sooner than their peers, a new French study finds.

    Indoor falls could be an indicator of frailty and a sign that protective measures should be taken, say the authors.

    The study was led by Sebastien Bailly, a researcher with Hospices Civils de Lyon in France. He and his coauthors write in the journal Maturitas, "The mean survival time of women with inside falls was nearly 1.6 years shorter than that of women with other falling profiles."

    Bailly and his colleagues studied 4,574 women who were over the age of 74 when they joined the study, could walk by themselves and were not living in institutional settings.

    The researchers called the women every four months for the first four years of the study to find out if they had fallen at some time during the previous week and where.

    The study team distinguished among falls by their location, whether they were due to inattention or to an environmental obstacle, and how serious the resulting injuries were.

    Along these lines, they classified the falls as environmental falls, such as slipping or tripping on something outdoors, falls from a height like a ladder or stairs, and inside or outside falls in general.

    Looking at information on 329 women who had fallen the week before the phone call follow-ups, the researchers found that 26 percent were so-called environmental falls, 19 percent were outside falls, 43 percent were inside falls and 12 percent were falls from height.

    The study team followed up again after another 13 years and found that 269 women had died. And those who had fallen indoors had an average survival time of 7.6 years, compared with 9.2 years for women who had any other type of fall.

    Separate from the type of falls women had, the researchers also found that women with advanced age, signs of frailty, slow walking speeds and comorbidities - that is, other health conditions - also had shorter survival times.

    However, women with frailties, for example, "who experienced outside falls or falls from height had no increased mortality despite more serious injuries," the researchers note.

    "Among community-dwelling women, some fall more frequently than others," the study team concludes. "These women should draw the caregivers' attention because their falls may be indicators of frailty. Non-injurious falls are also of concern because women experiencing this type of fall may suffer from unfavourable underlying conditions and be at risk of short survival."

    "The study is very well done," Dr. Kathleen Walsh told Reuters Health. "It has been shown in prior studies that for indoor falls the mortality tends to be worse, and longevity is diminished," said Walsh, who was not involved in the French research.

    Walsh, a geriatric and emergency medicine specialist at the University of Wisconsin Hospital in Madison, said there are different reasons that people fall inside and one of the questions that would be have been interesting to ask was how much time the patients were spending indoors or outdoors.

    "In general, people who fall inside have to stay inside for a reason and that's because of comorbidities - they're not super active and may not be active for different reasons," she said.

    But, Walsh said, family members shouldn't panic and tell their elderly loved ones that they need to move into assisted living after they've had a fall.

    "Because if you panic without having things evaluated by the physician that person will probably not tell you again when they have fallen," she said. "Staying calm is the number one thing."

    Walsh also said that physicians should ask their elderly patients if they have fallen within the previous year. If they have fallen, the doctors should find out what the patient remembers about the fall and if it was caused by certain movements, or if the patient could get up after the fall.

    "The red flags are, did they pass out before they fell," she said. "It's all in the history, if you take a good history you can usually figure things out."

    Walsh said that family members help to prevent falls by doing things like removing rugs and putting bars in bathrooms. In addition, she suggests elderly patients take classes to improve their balance and strength, such as the Stepping On class (http://www.steppingon.com).

    "Stepping is usually held at a local hospital or senior center and it's all about things that you can do while you're washing dishes or doing odds and ends around the house so you don't have to go to the physical therapist," she said.

    SOURCE: http://bit.ly/1oHXLKv Maturitas, online August 4, 2014.

Oncology Articles

  • More patients could wear regular clothing in hospital: study

    By Kathryn Doyle

    NEW YORK (Reuters Health) - Although doctors say many patients in hospitals could be wearing their own clothing below the waist, and most want to, a majority still don't, according to a small Canadian study.

    That could have an important effect on patient dignity, the authors suggest.

    Dr. Todd C. Lee, who participated in the research, said he was struck by how bizarre it was to see one of his patients leave the ward briefly to attend to business wearing a suit, and then return and don an undignified open-backed hospital gown again.

    "Clearly he was capable of wearing normal clothes - it was our system and its expectations (and perhaps his preconceived notion of them) that led to him awkwardly strutting down the hall in that fashion," Lee told Reuters Health in an email.

    "Since then, I have always believed that patients should be encouraged to wear their own clothing if it is appropriate," he said. "It is interesting in that most times I have ever suggested it to my patients, they usually take to the idea quite quickly."

    Lee is a doctor in the division of general internal medicine at McGill University Health Center in Montreal, Quebec.

    For the study, he and his colleagues noted whether or not patients entering six clinical teaching units at five hospitals in Canada on the same day were wearing any garments below the waist, other than underwear or a diaper.

    They also asked the attending doctors if each patient would be allowed to wear garments like pants if they wanted to.

    Of the 127 patients entering the units that day, doctors said that 57 would be eligible to wear pants, but only 14 of those were doing so, Lee and his team reported in a research letter in JAMA Internal Medicine.

    Some patients weren't eligible to wear regular clothes below the waist because they had wounds or catheters. In other cases, patients were too immobile, too incontinent, too confused, or too ill to wear such attire, given the available nursing resources.

    At one center, researchers also asked 17 patients who were eligible to wear pants but were not doing so if they would like to, and 13 said yes.

    "Our study, which was small, suggested that probably more than one in two patients could have been wearing their own clothing, but were not," Lee said. "On some units that proportion will be higher, on others lower."

    In certain circumstances, gowns do have practical advantages, making physical examinations easier for doctors, and making laundering and disinfecting easier for those caring for patients with frequent urinary or fecal incontinence, he said.

    But as others have suggested, taking away a patient's clothes and forcing them to adopt the familiar hospital gown may cause additional emotional trauma to some patients, he said.

    "I think all patients should therefore have the option to wear their own clothing if it is clinically reasonable to do so," Lee said. "Clothing worn needs to be hygienic, able to be laundered, and shouldn't preclude the examination of patients or the performing of medically necessary acts."

    Patients should be prepared to change into the hospital gown for procedures or examinations, which require them, he said.

    One way to address the problem would be for a Canadian or American company to design updated 'functional fashions' for the hospital that are easy to put on, easy to take off, easy to launder, and that facilitated examinations and tests, but preserve more dignity for the patient, he said. Until then, the base option may be for patients to ask for their own clothes and see if it would be an option.

    "Much as I think patients should politely ask all health care practitioners who see them in the hospital to wash their hands, I think they should also ask, if they are interested in doing so, if they can wear their own clothing," Lee said. "To my mind, there is no harm in asking politely."

    SOURCE: http://bit.ly/1emvR3n JAMA Internal Medicine, September 22, 2014.

  • Study of smoking cancer patients fuels e-cigarette debate

    By Kate Kelland

    LONDON (Reuters) - The fierce debate over whether e-cigarettes can help people quit smoking took another twist on Monday as a research paper on their use by cancer patients was criticized as flawed.

    The study of cancer patients who smoke found that those using e-cigarettes as well as tobacco cigarettes were more nicotine dependent and equally or less likely to have quit than those who didn't use e-cigarettes.

    The scientists behind the research, which was published online September 22 in Cancer, the journal of the American Cancer Society, said their results raised doubts about whether e-cigarettes had any benefit in helping cancer patients to give up smoking.

    But that conclusion was questioned by other tobacco and addiction researchers, who said the selection of patients for the study had given it an inherent bias.

    The uptake of e-cigarettes, which use battery-powered cartridges to produce a nicotine-laced vapour for the "smoker" to inhale, has rocketed in the past two years, but there is fierce debate about their potential risks and benefits.

    Because they are new, there is a lack of long-term scientific evidence on their safety. Some experts fear they could lead to nicotine addiction and be a gateway to tobacco smoking, while others say they have enormous potential to help millions of smokers around the world to quit.

    What few studies there are give a mixed picture, with some concluding that e-cigarettes can help people give up a deadly tobacco habit, while others suggest they may carry health risks of their own.

    A World Health Organization (WHO) report last month called for stiff regulation of e-cigarettes as well as bans on indoor use, advertising and sales to minors.

    But that report itself was also criticised by experts who said it contained errors, misinterpretations and misrepresentations.

    For the Cancer journal study, researchers led by Jamie Ostroff of the Memorial Sloan Kettering Cancer Center in New York City studied 1,074 cancer patients who smoked and who were enrolled between 2012 and 2013 in a tobacco treatment program at a cancer center.

    They found a three-fold increase in e-cigarette use from 2012 to 2013 - rising from 10.6 percent to 38.5 percent.

    At enrollment onto the program, the researchers' analysis found, the e-cigarette users were more nicotine dependent than non-users, had more prior quit attempts, and were more likely to be diagnosed with lung or head and neck cancers.

    By the end of the study period, the researchers said, e-cigarette users were just as likely as non-users of e-cigarettes to be smoking.

    But Robert West, director of tobacco research at University College London, said the study was not able to assess whether or not for cancer patients who smoke, using an e-cigarette to try and quit is beneficial, "because the sample could consist of e-cigarette users who had already failed in a quit attempt, so all those who would have succeeded already would be ruled out."

    Peter Hajek, director of the Tobacco Dependence Research Unit at Queen Mary, University of London, agreed that the study's data did not justify the conclusions.

    "The authors followed up smokers who tried e-cigarettes but did not stop smoking, and excluded smokers who tried e-cigarettes and stopped smoking," he said.

    "Like smokers who fail with any method, these were highly dependent smokers who found quitting difficult. The authors concluded that e-cigarette (use) was not helpful, but that would be true for any treatment however effective if only treatment failures were evaluated."

    SOURCE: http://bit.ly/1qntnWk

    Cancer 2014.

  • CORRECTED-Many think of dermatology as superficial: survey

    (Corrects affiliations of Dr. Armstrong in para 2 and Dr. Edison in para 10.)

    By Madeline Kennedy

    NEW YORK (Reuters Health) - The public has some misconceptions about what dermatologists actually do, according to a recent U.S. survey.

    "Overall, 46 percent of the participants thought that we spend the majority of our time managing skin cancer and 27 percent thought that we spend the majority of our time doing cosmetic procedures," said Dr. April Armstrong of the University of Colorado Denver in Aurora, Colorado, the study's senior author.

    The results show a lack of understanding of the day-to-day realities of dermatology, the researchers say, and that misperception could affect whether people get needed care for skin diseases or if adequate funding goes to dermatology research.

    According to a 2007 workforce survey, only 10 percent of a dermatologist's work involves cosmetic procedures and the remaining 90 percent is made up of surgery and managing medical conditions, Armstrong and her team point out in the Journal of the American Academy of Dermatology.

    For their own study, Armstrong and her colleagues asked a sample of more than 800 people across the United States what they think dermatologists spend most of their time doing.

    They also asked participants how important they consider dermatology to be, how much dermatologists earn and how many hours they work, as compared to other types of doctors.

    The respondents felt that cardiologists and primary care physicians have "more critical" professions than dermatologists and that plastic surgery is less important. Most people chose the same hierarchy when asked how difficult the job of a dermatologist was, with only plastic surgery rated as easier.

    The respondents were correct in certain of their perceptions, including the number of hours worked per week by different types of doctors and the average incomes in the various fields.

    Dermatologists tend to work fewer hours than the other specialties, though they report seeing a larger number of patients, according to the study team. Dermatologists also earn less than cardiologists and plastic surgeons but more than primary care physicians, the researchers say.

    Dr. Karen Edison, chair of the Department of Dermatology at the University of Missouri Heath Care in Columbia, Missouri, agreed that there are some misconceptions about her field. She told Reuters Health in a phone call that, "While we certainly have expertise and in fact pioneered many of the most popular cosmetic procedures, most of what we do is medical and surgical dermatology."

    According to the American Academy of Dermatology, dermatologists diagnose and treat over 3,000 diseases, ranging from skin cancer to eczema to bacterial infections.

    "In addition to the common dermatological conditions which are acne, rosacea, and psoriasis, dermatologists also manage a number of very complex medical dermatological conditions such as blistering diseases, pemphigus or pemphigoids, and a number of cutaneous infections that I think the public is not quite aware of," Armstrong said.

    "Misconceptions about dermatology may discourage patients with severe skin disease who need our expertise to seek care in settings that are not prepared to deliver high quality dermatology care and services," she added.

    "We also do quite a bit of primary care in dermatology," Edison said. "We talk to patients not only about the need for sun protection, but we talk to them about their smoking, about their diet and exercise, many of us look at a patient as an entire person because the general health of a patient really affects the health of their skin."

    Armstrong and her colleagues write that media emphasis on cosmetic innovations likely contributes to the public's confusion about what dermatologists really do.

    Edison places some of the responsibility with dermatologists as well. "We have also played a part, by in some areas not participating as fully as we perhaps should with the greater house of medicine or the wider medical community," she said.

    Armstrong emphasized that it's important for dermatologists to find ways to speak to the public about their profession.

    "The key message," Armstrong said, "is that there are gaps in the public understanding of the profession, of dermatologists' expertise and what we spend the majority of our time doing, and I think there can be educational efforts there to close the gap."

    SOURCE: http://bit.ly/1o6rpdq Journal of the American Academy of Dermatology, online August 28, 2014.

  • Angelina Jolie surgery sparks surge in female cancer tests-study

    By Laura Onita

    LONDON (Thomson Reuters Foundation) - Hollywood star Angelina Jolie's decision to make public her double mastectomy more than doubled the number of women in Britain seeking to have genetic breast cancer tests, according to a study released on Friday.

    Jolie, 39, who has become a high-profile human rights campaign, announced her surgery in May last year, saying she acted after testing positive for a mutation of the BRCA1 gene that significantly increases the risk of breast cancer.

    She said she was going public with news of her surgery as she hoped her story would inspire other women to fight the life-threatening disease.

    Researchers studied 21 clinics and regional genetic centers and found there were 4,847 referrals for testing in June and July last year compared to 1,981 in the same period of 2012.

    The study of the so-called "Angelina effect", published online in the journal Breast Cancer Research, credited Jolie's glamorous appearance and relationship with Hollywood actor Brad Pitt for helping to lessen women's fears about surgery.

    "Angelina Jolie ... is likely to have had a bigger impact than other celebrity announcements, possibly due to her image as glamorous and strong woman," researcher Gareth Evans of the charity Genesis Breast Cancer Prevention said in a statement.

    "This may have lessened patients' fears about a loss of sexual identity post-preventative surgery and encouraged those who had not previously engaged with health services to consider genetic testing."

    "These high-profile cases often mean that more women are inclined to contact centers such as Genesis - and other family history clinics - so that they can be tested for the mutation early and take the necessary steps to prevent themselves from developing the disease," he continued.

    "Of course, in some cases this may mean a risk-reducing mastectomy, however cancer preventing drugs, such as tamoxifen, and certain lifestyle changes like a healthy diet and more exercise, are also options which many women may consider."

    Breast cancer is the most common cancer in women worldwide. The World Health Organization estimated that more than 521,000 women died of breast cancer in 2012.

    Oscar-winning Jolie has in recent years drawn nearly as much attention for her globe-trotting work on behalf of refugees and victims of sexual violence in conflicts as for her acting.

    Jolie was named a Goodwill Ambassador for the UNHCR in 2001 and promoted to be Special Envoy to High Commissioner Antonio Guterres in 2012. Since 2012 she has also led a campaign against sexual violence in conflict zones.

    SOURCE: http://bit.ly/1u5z5nc Breast Cancer Research, September 18, 2014.

  • CORRECTED-Many think of dermatology as superficial: survey

    (Corrects affiliations of Dr. Armstrong in para 2 and Dr. Edison in para 10.)

    By Madeline Kennedy

    NEW YORK (Reuters Health) - The public has some misconceptions about what dermatologists actually do, according to a recent U.S. survey.

    "Overall, 46 percent of the participants thought that we spend the majority of our time managing skin cancer and 27 percent thought that we spend the majority of our time doing cosmetic procedures," said Dr. April Armstrong of the University of Colorado Denver in Aurora, Colorado, the study's senior author.

    The results show a lack of understanding of the day-to-day realities of dermatology, the researchers say, and that misperception could affect whether people get needed care for skin diseases or if adequate funding goes to dermatology research.

    According to a 2007 workforce survey, only 10 percent of a dermatologist's work involves cosmetic procedures and the remaining 90 percent is made up of surgery and managing medical conditions, Armstrong and her team point out in the Journal of the American Academy of Dermatology.

    For their own study, Armstrong and her colleagues asked a sample of more than 800 people across the United States what they think dermatologists spend most of their time doing.

    They also asked participants how important they consider dermatology to be, how much dermatologists earn and how many hours they work, as compared to other types of doctors.

    The respondents felt that cardiologists and primary care physicians have "more critical" professions than dermatologists and that plastic surgery is less important. Most people chose the same hierarchy when asked how difficult the job of a dermatologist was, with only plastic surgery rated as easier.

    The respondents were correct in certain of their perceptions, including the number of hours worked per week by different types of doctors and the average incomes in the various fields.

    Dermatologists tend to work fewer hours than the other specialties, though they report seeing a larger number of patients, according to the study team. Dermatologists also earn less than cardiologists and plastic surgeons but more than primary care physicians, the researchers say.

    Dr. Karen Edison, chair of the Department of Dermatology at the University of Missouri Heath Care in Columbia, Missouri, agreed that there are some misconceptions about her field. She told Reuters Health in a phone call that, "While we certainly have expertise and in fact pioneered many of the most popular cosmetic procedures, most of what we do is medical and surgical dermatology."

    According to the American Academy of Dermatology, dermatologists diagnose and treat over 3,000 diseases, ranging from skin cancer to eczema to bacterial infections.

    "In addition to the common dermatological conditions which are acne, rosacea, and psoriasis, dermatologists also manage a number of very complex medical dermatological conditions such as blistering diseases, pemphigus or pemphigoids, and a number of cutaneous infections that I think the public is not quite aware of," Armstrong said.

    "Misconceptions about dermatology may discourage patients with severe skin disease who need our expertise to seek care in settings that are not prepared to deliver high quality dermatology care and services," she added.

    "We also do quite a bit of primary care in dermatology," Edison said. "We talk to patients not only about the need for sun protection, but we talk to them about their smoking, about their diet and exercise, many of us look at a patient as an entire person because the general health of a patient really affects the health of their skin."

    Armstrong and her colleagues write that media emphasis on cosmetic innovations likely contributes to the public's confusion about what dermatologists really do.

    Edison places some of the responsibility with dermatologists as well. "We have also played a part, by in some areas not participating as fully as we perhaps should with the greater house of medicine or the wider medical community," she said.

    Armstrong emphasized that it's important for dermatologists to find ways to speak to the public about their profession.

    "The key message," Armstrong said, "is that there are gaps in the public understanding of the profession, of dermatologists' expertise and what we spend the majority of our time doing, and I think there can be educational efforts there to close the gap."

    SOURCE: http://bit.ly/1o6rpdq Journal of the American Academy of Dermatology, online August 28, 2014.

Orthopedic Articles

  • Brain study hints at how fibromyalgia works

    By Kathryn Doyle

    NEW YORK (Reuters Health) - Brain scans show that people with the pain disorder fibromyalgia react differently to what others would consider non-painful sights and sounds, new research suggests.

    The small new study provides clues to what might be going wrong in the nervous system of people with fibromyalgia, along with possible new approaches to alleviating their pain.

    "If we understand the mechanism, we may come up with new and potentially better forms of treatment," said lead author Marina López-Solà of the department of Psychology and Neuroscience at the University of Colorado, Boulder.

    Fibromyalgia, which patients experience as widespread muscle pain and fatigue, affects as many as five million Americans, most commonly middle-aged women, according to the U.S. Department of Health and Human Services.

    Its cause is unknown and there is no cure, but medications can treat the symptoms.

    The new results suggest not only that fibromyalgia is related to greater processing of pain-related signals, but also potentially to a misprocessing of other types of non-painful sensory signals that may be important to address during treatment, Lopez-Sola told Reuters Health by email.

    She and her team used "functional magnetic resonance imaging," which measures blood flow changes in the brain, to assess brain responses among 35 women with fibromyalgia and 25 similar women without the disorder.

    The fibromyalgia patients were more sensitive to non-painful stimulation compared to people without the disorder, they report in Arthritis and Rheumatism.

    Researchers showed the subjects some colors, played some tones and asked subjects to perform very simple motor tasks at the same time, like touching the tip of the right thumb with another finger.

    Areas of the brain's cortex primarily responsible for processing visual, auditory and motor signals were significantly activated in the healthy comparison group, but not in the fibromyalgia group.

    However, other brain regions that are not relevant for primary processing were activated in fibromyalgia sufferers but not in healthy controls.

    What seems to be happening is that the brains of fibromyalgia patients are under-processing certain forms of sensory information at the first stages of processing, but are also amplifying the signal at a later level of sensory integration of multiple sensory inputs, Lopez-Sola said.

    "When you are in pain, it is probable that you are more concentrated on your own pain than on the tasks you have to pay attention to," said Dr. Pedro Montoya of the Research Institute on Health Sciences at the Universitat Illes Balears in Palma de Mallorca, Spain, who was not part of the new study.

    "For me, these findings provide further support for the idea that psychological strategies aimed at changing the focus of attention from the body to external cues could be useful for these patients," Montoya said.

    There were only a small number of people involved in the study, and the researchers did not account for other mental health conditions the participants may have had, both factors that limit the results, said Dr. Winfried Hauser, associate professor of Psychosomatic Medicine at Technische Universitat Munchen in Germany.

    People with fibromyalgia often also have conditions like depression, so some people believe the disorder has a mental basis, said Michael E. Geisser, professor in the department of physical medicine and rehabilitation at the University of Michigan in Ann Arbor.

    But evidence for a neuro-anatomical basis for fibromyalgia is growing, said Geisser, who was not part of the new study.

    "There is increasing evidence that fibromyalgia is not just a pain condition," he told Reuters Health by email. "More recent research done on persons with fibromyalgia, such as the research by Lopez-Sola and colleagues, suggests that persons with fibromyalgia suffer from a central processing deficit of multiple types of sensory stimuli, not just pain."

    "It's as if the volume control for sensation in persons with fibromyalgia is turned up, or louder, for many types of sensation compared to persons without the disorder," he said.

    That might help explain why many people with fibromyalgia also often suffer from fatigue, cognitive problems or mood disturbance, Geisser said.

    Currently, people with the disorder can take anticonvulsant medications, such as pregabalin (Lyrica), and antidepressants such as duloxetine (Cymbalta) and milnacipran (Savella), which have been FDA approved for treating fibromyalgia.

    Further research to improve understanding of where there are problems in the brain for people with the disorder could lead to the development of new treatments, Geisser said.

    For example, it would be interesting to see if a treatment targeted at dampening response in an area of the brain that "overreacted" in this study helped to treat fibromyalgia symptoms, he said.

    SOURCE: http://bit.ly/1mbOikg Arthritis and Rheumatism, online September 15, 2014.

  • REFILE-Falls indoors may signal frailty, linked to shorter survival

    (corrects third paragraph to say study was led by Bailly)

    By Shereen Lehman

    NEW YORK (Reuters Health) - Women in their eighties who fell indoors, rather than outdoors or from a height like a ladder, died sooner than their peers, a new French study finds.

    Indoor falls could be an indicator of frailty and a sign that protective measures should be taken, say the authors.

    The study was led by Sebastien Bailly, a researcher with Hospices Civils de Lyon in France. He and his coauthors write in the journal Maturitas, "The mean survival time of women with inside falls was nearly 1.6 years shorter than that of women with other falling profiles."

    Bailly and his colleagues studied 4,574 women who were over the age of 74 when they joined the study, could walk by themselves and were not living in institutional settings.

    The researchers called the women every four months for the first four years of the study to find out if they had fallen at some time during the previous week and where.

    The study team distinguished among falls by their location, whether they were due to inattention or to an environmental obstacle, and how serious the resulting injuries were.

    Along these lines, they classified the falls as environmental falls, such as slipping or tripping on something outdoors, falls from a height like a ladder or stairs, and inside or outside falls in general.

    Looking at information on 329 women who had fallen the week before the phone call follow-ups, the researchers found that 26 percent were so-called environmental falls, 19 percent were outside falls, 43 percent were inside falls and 12 percent were falls from height.

    The study team followed up again after another 13 years and found that 269 women had died. And those who had fallen indoors had an average survival time of 7.6 years, compared with 9.2 years for women who had any other type of fall.

    Separate from the type of falls women had, the researchers also found that women with advanced age, signs of frailty, slow walking speeds and comorbidities - that is, other health conditions - also had shorter survival times.

    However, women with frailties, for example, "who experienced outside falls or falls from height had no increased mortality despite more serious injuries," the researchers note.

    "Among community-dwelling women, some fall more frequently than others," the study team concludes. "These women should draw the caregivers' attention because their falls may be indicators of frailty. Non-injurious falls are also of concern because women experiencing this type of fall may suffer from unfavourable underlying conditions and be at risk of short survival."

    "The study is very well done," Dr. Kathleen Walsh told Reuters Health. "It has been shown in prior studies that for indoor falls the mortality tends to be worse, and longevity is diminished," said Walsh, who was not involved in the French research.

    Walsh, a geriatric and emergency medicine specialist at the University of Wisconsin Hospital in Madison, said there are different reasons that people fall inside and one of the questions that would be have been interesting to ask was how much time the patients were spending indoors or outdoors.

    "In general, people who fall inside have to stay inside for a reason and that's because of comorbidities - they're not super active and may not be active for different reasons," she said.

    But, Walsh said, family members shouldn't panic and tell their elderly loved ones that they need to move into assisted living after they've had a fall.

    "Because if you panic without having things evaluated by the physician that person will probably not tell you again when they have fallen," she said. "Staying calm is the number one thing."

    Walsh also said that physicians should ask their elderly patients if they have fallen within the previous year. If they have fallen, the doctors should find out what the patient remembers about the fall and if it was caused by certain movements, or if the patient could get up after the fall.

    "The red flags are, did they pass out before they fell," she said. "It's all in the history, if you take a good history you can usually figure things out."

    Walsh said that family members help to prevent falls by doing things like removing rugs and putting bars in bathrooms. In addition, she suggests elderly patients take classes to improve their balance and strength, such as the Stepping On class (http://www.steppingon.com).

    "Stepping is usually held at a local hospital or senior center and it's all about things that you can do while you're washing dishes or doing odds and ends around the house so you don't have to go to the physical therapist," she said.

    SOURCE: http://bit.ly/1oHXLKv Maturitas, online August 4, 2014.

  • REFILE-Falls indoors may signal frailty, linked to shorter survival

    (corrects third paragraph to say study was led by Bailly)

    By Shereen Lehman

    NEW YORK (Reuters Health) - Women in their eighties who fell indoors, rather than outdoors or from a height like a ladder, died sooner than their peers, a new French study finds.

    Indoor falls could be an indicator of frailty and a sign that protective measures should be taken, say the authors.

    The study was led by Sebastien Bailly, a researcher with Hospices Civils de Lyon in France. He and his coauthors write in the journal Maturitas, "The mean survival time of women with inside falls was nearly 1.6 years shorter than that of women with other falling profiles."

    Bailly and his colleagues studied 4,574 women who were over the age of 74 when they joined the study, could walk by themselves and were not living in institutional settings.

    The researchers called the women every four months for the first four years of the study to find out if they had fallen at some time during the previous week and where.

    The study team distinguished among falls by their location, whether they were due to inattention or to an environmental obstacle, and how serious the resulting injuries were.

    Along these lines, they classified the falls as environmental falls, such as slipping or tripping on something outdoors, falls from a height like a ladder or stairs, and inside or outside falls in general.

    Looking at information on 329 women who had fallen the week before the phone call follow-ups, the researchers found that 26 percent were so-called environmental falls, 19 percent were outside falls, 43 percent were inside falls and 12 percent were falls from height.

    The study team followed up again after another 13 years and found that 269 women had died. And those who had fallen indoors had an average survival time of 7.6 years, compared with 9.2 years for women who had any other type of fall.

    Separate from the type of falls women had, the researchers also found that women with advanced age, signs of frailty, slow walking speeds and comorbidities - that is, other health conditions - also had shorter survival times.

    However, women with frailties, for example, "who experienced outside falls or falls from height had no increased mortality despite more serious injuries," the researchers note.

    "Among community-dwelling women, some fall more frequently than others," the study team concludes. "These women should draw the caregivers' attention because their falls may be indicators of frailty. Non-injurious falls are also of concern because women experiencing this type of fall may suffer from unfavourable underlying conditions and be at risk of short survival."

    "The study is very well done," Dr. Kathleen Walsh told Reuters Health. "It has been shown in prior studies that for indoor falls the mortality tends to be worse, and longevity is diminished," said Walsh, who was not involved in the French research.

    Walsh, a geriatric and emergency medicine specialist at the University of Wisconsin Hospital in Madison, said there are different reasons that people fall inside and one of the questions that would be have been interesting to ask was how much time the patients were spending indoors or outdoors.

    "In general, people who fall inside have to stay inside for a reason and that's because of comorbidities - they're not super active and may not be active for different reasons," she said.

    But, Walsh said, family members shouldn't panic and tell their elderly loved ones that they need to move into assisted living after they've had a fall.

    "Because if you panic without having things evaluated by the physician that person will probably not tell you again when they have fallen," she said. "Staying calm is the number one thing."

    Walsh also said that physicians should ask their elderly patients if they have fallen within the previous year. If they have fallen, the doctors should find out what the patient remembers about the fall and if it was caused by certain movements, or if the patient could get up after the fall.

    "The red flags are, did they pass out before they fell," she said. "It's all in the history, if you take a good history you can usually figure things out."

    Walsh said that family members help to prevent falls by doing things like removing rugs and putting bars in bathrooms. In addition, she suggests elderly patients take classes to improve their balance and strength, such as the Stepping On class (http://www.steppingon.com).

    "Stepping is usually held at a local hospital or senior center and it's all about things that you can do while you're washing dishes or doing odds and ends around the house so you don't have to go to the physical therapist," she said.

    SOURCE: http://bit.ly/1oHXLKv Maturitas, online August 4, 2014.

  • Salt and smoking may interact to raise RA risk

    By Shereen Lehman

    NEW YORK (Reuters Health) - Eating a diet high in salt may increase the risk of rheumatoid arthritis among smokers, according to a large study from Sweden.

    Researchers set out to see if a salty diet might be linked to the onset of RA, but found a connection only among smokers - who were more than twice as likely as anyone with a low-salt diet to develop the condition.

    "Although we could not confirm our original hypothesis, we were surprised by the large influence of sodium intake on smoking as a risk factor," Björn Sundström told Reuters Health in an email.

    "Smoking is a strong risk factor for developing rheumatoid arthritis, and this risk is further amplified by less than ideal food habits with high sodium intake," said Sundström, a researcher in the departments of public health and clinical medicine at Umea University who led the new study.

    Rheumatoid arthritis is a chronic disease that causes pain and swelling in the joints. About 1.5 million Americans, three-quarters of them women, have been diagnosed with the condition, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

    The cause of rheumatoid arthritis isn't known, but it results from a person's own immune system attacking joint tissues. Genetics and lifestyle factors, such as smoking, hormone and cholesterol levels and obesity, have all been identified as risk factors.

    Previous laboratory research on animals and human cells also suggests sodium may provoke inflammatory molecules that are often elevated in people several years before RA appears, the authors write in the journal Rheumatology.

    To see if there is a link between sodium in the diet and risk for developing RA, Sundström and colleagues looked at health records and lifestyle information for almost 100,000 participants in a screening and intervention program that began in 1991 in Vasterbotton County in northern Sweden.

    The study team identified 386 cases of people who developed rheumatoid arthritis by 2011. Then for each case, they identified five participants who were similar in age and sex, but did not develop disease, for comparison.

    The researchers accounted for dietary habits, education, cholesterol and triglyceride levels, weight and other factors for all the participants and found no significant associations between sodium in the diet and who went on to develop RA.

    But when they looked just at smokers, they found those who consumed the most sodium were 2.26 times as likely as smokers who consumed the least sodium to develop RA.

    Smokers who consumed the least sodium had similar risk to nonsmokers in the study, leading the researchers to conclude that smoking and heavy sodium intake interact somehow to promote RA.

    "Ideally, these results needs to be repeated in an independent population," Sundström, said.

    More research is also needed to identify the biological pathways through which sodium intake can affect smoking as a risk factor, he said.

    "The study provides the first evidence in rheumatoid arthritis that sodium intake may influence risk for onset of the disease," Dr. Lars Klareskog told Reuters Health in an email.

    Klareskog, a rheumatologist and researcher at the Karolinska Institute and Karolinska University Hospital in Stockholm, was not involved in the study.

    "In addition, the study demonstrates that the impact of high salt diet is restricted to individuals who smoke," he said.

    Klareskog noted that smoking is an important risk factor for rheumatoid arthritis.

    "The contribution of smoking to risk for rheumatoid arthritis overall is such that 25 percent of all rheumatoid arthritis in our country, Sweden, would not have happened without smoking," he said. One third of all cases with the more severe form of rheumatoid arthritis would not have happened without smoking, he added.

    The present study suggests that reducing salt intake may be added to this list of lifestyle advice for avoiding rheumatoid arthritis, Klareskog said.

    "Confirmatory studies are, however, needed before recommendations on salt intake can be made to the public as ways to protect against getting rheumatoid arthritis," he said.

    SOURCE: http://bit.ly/1piaEeE Rheumatology, online September 10, 2014.

Transplant Articles

  • Kidney patients know little about transplant benefits

    By Ronnie Cohen

    NEW YORK (Reuters Health) - In a new study, the vast majority of kidney failure patients told researchers they saw no need for a kidney transplant because they were doing fine on dialysis - but the researchers say these patients might not realize how much a transplant could help them.

    "Nobody is doing fine on dialysis to the point where a transplant wouldn't be better for them," senior author Dr. Dorry Segev told Reuters Health. "Transplantation is the better form of renal replacement."

    A kidney transplant doubles a recipient's life expectancy, said Segev, a transplant surgeon at the Johns Hopkins Hospital in Baltimore, Maryland.

    His group's study, published in the Clinical Journal of the American Society of Nephrology, showed a gap in dialysis patients' knowledge about the benefits of transplants over dialysis, Segev said.

    Researchers surveyed 348 patients being treated at 26 Baltimore-area freestanding dialysis centers, asking whether a dozen potential concerns constituted reasons they would not pursue a transplant. The average age was 56 and half the patients had been on dialysis for at least two months.

    Overall, more than 68 percent of the patients told researchers "I'm doing fine on dialysis."

    The older the patient, the more likely they were to report feeling fine on dialysis, the study found.

    Less educated patients were more likely to report being content with dialysis than those with higher degrees, the study found.

    Almost a quarter of patients had not seen a nephrologist (a doctor who specializes in kidney disease) before starting dialysis - and these people were almost twice as likely to report that no one had discussed a possible transplant with them.

    Nearly 30 percent of participants reported feeling uncomfortable asking a friend or relative to donate a kidney, the study found. The authors say such reluctance to ask friends and relatives to donate kidneys is consistent with prior studies.

    Also consistent with prior studies, the researchers found that women tended to be more fearful about transplants than men, with 26 percent of women saying they feared a transplant compared to less than eight percent of the men.

    Women do just as well after a transplant as men, if not better, Segev said. "That's another area where we need to work on education and assurance," he said.

    In sum, he said, the study points to a lack of education for renal-failure patients about the benefits of kidney transplants.

    "This is another set of evidence that we have a problem in how well we are educating people at the time of their kidney disease," he said. "We really need to find a better way to educate people about transplantation."

    Jesse Schold agreed. He has done similar research at the Cleveland Clinic but was not involved with the current study.

    "The preponderance of research shows that transplantation doubles life expectancy, improves quality of life and reduces healthcare costs," he told Reuters Health.

    "It's certainly interesting and to most people would be relatively startling" to realize how many patients aren't pursuing transplantation because they say they're doing fine, he said.

    "Given the overwhelming evidence that transplantation is a better treatment modality, it certainly suggests that more education may be appropriate."

    Schold stressed the need for patients suffering from renal failure to see nephrologists and learn about transplants soon after they are diagnosed with renal problems.

    Prior research found that kidney-disease patients who are African-American or lack private health insurance are less likely to be matched with donor organs before they need dialysis (see Reuters Health story of January 31, 2013 here: http://reut.rs/1tKdUU2).

    Almost 66 percent of the current study participants were African-American. Some 24 percent of them reported feeling uncomfortable asking someone to donate a kidney, compared to 41 percent of other participants.

    Americans who receive kidneys from unrelated live donors tend to be white, highly educated and live in wealthier neighborhoods, according to an earlier study (see Reuters Health story of April 9, 2012 here: http://reut.rs/ZoGvFw).

    A kidney is one of the few organs people can give away and go on to live a healthy life.

    Since the 1990s, advances in immune-suppression have made it safer to receive an organ from someone who's not a relative. Less-invasive surgical techniques also make it easier to donate.

    SOURCE: http://bit.ly/1uzgihR Clinical Journal of the American Society of Nephrology, online September 11, 2014.

  • British Ebola survivor flies to United States for blood donation

    By Reuters Staff

    (Reuters) - A British man who survived Ebola after being treated in London has flown to the United States to try to help another patient suffering from the virus, the Foreign Office in the United Kingdom said on Thursday.

    Media reports said William Pooley planned to donate his blood, which likely contains protective antibodies that could help fight the disease, for an emergency transfusion to an Ebola patient in Atlanta.

    An American doctor who worked for the World Health Organization is being treated at Emory University Hospital in Atlanta after he became infected with Ebola in Sierra Leone.

    A spokesman for the Emory hospital would not confirm on Thursday whether the doctor, who has not been named, will be getting blood donated from the British man, citing patient privacy laws.

    There are two Ebola patients being treated in the United States. A spokesman for the Nebraska hospital where another American is receiving care for the virus said the British man was not headed to that facility.

    Pooley, 29, contracted the disease while working as a volunteer nurse in Sierra Leone. He was discharged earlier this month from a special isolation unit at the Royal Free Hospital in London after 10 days of treatment with the experimental ZMapp drug.

    London's Evening Standard newspaper said Pooley and the doctor he is hoping to help were reported to be close friends after working together at the Ebola treatment center in Kenema, Sierra Leone.

    The pair has the same blood type, which made Pooley the perfect donor, the newspaper said.

    There is no proven cure for Ebola, a deadly virus that was discovered nearly 40 years ago in the forests of central Africa. The worst-ever outbreak on record of the virus, which has killed at least 2,630 people in West Africa, has triggered a scramble to develop the first drug or vaccine to treat it.

    Earlier this month at the University of Nebraska Medical Center in Omaha, Dr. Rick Sacra received a plasma infusion from another American Ebola survivor, Dr. Kent Brantly. Brantly's blood likely contained protective antibodies that doctors said could help buy Sacra some time while his body worked to fight off the infection.

    Brantly's blood type also turned out to be a match for his friend and fellow missionary Sacra.

Women’s Health Articles

  • More patients could wear regular clothing in hospital: study

    By Kathryn Doyle

    NEW YORK (Reuters Health) - Although doctors say many patients in hospitals could be wearing their own clothing below the waist, and most want to, a majority still don't, according to a small Canadian study.

    That could have an important effect on patient dignity, the authors suggest.

    Dr. Todd C. Lee, who participated in the research, said he was struck by how bizarre it was to see one of his patients leave the ward briefly to attend to business wearing a suit, and then return and don an undignified open-backed hospital gown again.

    "Clearly he was capable of wearing normal clothes - it was our system and its expectations (and perhaps his preconceived notion of them) that led to him awkwardly strutting down the hall in that fashion," Lee told Reuters Health in an email.

    "Since then, I have always believed that patients should be encouraged to wear their own clothing if it is appropriate," he said. "It is interesting in that most times I have ever suggested it to my patients, they usually take to the idea quite quickly."

    Lee is a doctor in the division of general internal medicine at McGill University Health Center in Montreal, Quebec.

    For the study, he and his colleagues noted whether or not patients entering six clinical teaching units at five hospitals in Canada on the same day were wearing any garments below the waist, other than underwear or a diaper.

    They also asked the attending doctors if each patient would be allowed to wear garments like pants if they wanted to.

    Of the 127 patients entering the units that day, doctors said that 57 would be eligible to wear pants, but only 14 of those were doing so, Lee and his team reported in a research letter in JAMA Internal Medicine.

    Some patients weren't eligible to wear regular clothes below the waist because they had wounds or catheters. In other cases, patients were too immobile, too incontinent, too confused, or too ill to wear such attire, given the available nursing resources.

    At one center, researchers also asked 17 patients who were eligible to wear pants but were not doing so if they would like to, and 13 said yes.

    "Our study, which was small, suggested that probably more than one in two patients could have been wearing their own clothing, but were not," Lee said. "On some units that proportion will be higher, on others lower."

    In certain circumstances, gowns do have practical advantages, making physical examinations easier for doctors, and making laundering and disinfecting easier for those caring for patients with frequent urinary or fecal incontinence, he said.

    But as others have suggested, taking away a patient's clothes and forcing them to adopt the familiar hospital gown may cause additional emotional trauma to some patients, he said.

    "I think all patients should therefore have the option to wear their own clothing if it is clinically reasonable to do so," Lee said. "Clothing worn needs to be hygienic, able to be laundered, and shouldn't preclude the examination of patients or the performing of medically necessary acts."

    Patients should be prepared to change into the hospital gown for procedures or examinations, which require them, he said.

    One way to address the problem would be for a Canadian or American company to design updated 'functional fashions' for the hospital that are easy to put on, easy to take off, easy to launder, and that facilitated examinations and tests, but preserve more dignity for the patient, he said. Until then, the base option may be for patients to ask for their own clothes and see if it would be an option.

    "Much as I think patients should politely ask all health care practitioners who see them in the hospital to wash their hands, I think they should also ask, if they are interested in doing so, if they can wear their own clothing," Lee said. "To my mind, there is no harm in asking politely."

    SOURCE: http://bit.ly/1emvR3n JAMA Internal Medicine, September 22, 2014.

  • Kidney patients know little about transplant benefits

    By Ronnie Cohen

    NEW YORK (Reuters Health) - In a new study, the vast majority of kidney failure patients told researchers they saw no need for a kidney transplant because they were doing fine on dialysis - but the researchers say these patients might not realize how much a transplant could help them.

    "Nobody is doing fine on dialysis to the point where a transplant wouldn't be better for them," senior author Dr. Dorry Segev told Reuters Health. "Transplantation is the better form of renal replacement."

    A kidney transplant doubles a recipient's life expectancy, said Segev, a transplant surgeon at the Johns Hopkins Hospital in Baltimore, Maryland.

    His group's study, published in the Clinical Journal of the American Society of Nephrology, showed a gap in dialysis patients' knowledge about the benefits of transplants over dialysis, Segev said.

    Researchers surveyed 348 patients being treated at 26 Baltimore-area freestanding dialysis centers, asking whether a dozen potential concerns constituted reasons they would not pursue a transplant. The average age was 56 and half the patients had been on dialysis for at least two months.

    Overall, more than 68 percent of the patients told researchers "I'm doing fine on dialysis."

    The older the patient, the more likely they were to report feeling fine on dialysis, the study found.

    Less educated patients were more likely to report being content with dialysis than those with higher degrees, the study found.

    Almost a quarter of patients had not seen a nephrologist (a doctor who specializes in kidney disease) before starting dialysis - and these people were almost twice as likely to report that no one had discussed a possible transplant with them.

    Nearly 30 percent of participants reported feeling uncomfortable asking a friend or relative to donate a kidney, the study found. The authors say such reluctance to ask friends and relatives to donate kidneys is consistent with prior studies.

    Also consistent with prior studies, the researchers found that women tended to be more fearful about transplants than men, with 26 percent of women saying they feared a transplant compared to less than eight percent of the men.

    Women do just as well after a transplant as men, if not better, Segev said. "That's another area where we need to work on education and assurance," he said.

    In sum, he said, the study points to a lack of education for renal-failure patients about the benefits of kidney transplants.

    "This is another set of evidence that we have a problem in how well we are educating people at the time of their kidney disease," he said. "We really need to find a better way to educate people about transplantation."

    Jesse Schold agreed. He has done similar research at the Cleveland Clinic but was not involved with the current study.

    "The preponderance of research shows that transplantation doubles life expectancy, improves quality of life and reduces healthcare costs," he told Reuters Health.

    "It's certainly interesting and to most people would be relatively startling" to realize how many patients aren't pursuing transplantation because they say they're doing fine, he said.

    "Given the overwhelming evidence that transplantation is a better treatment modality, it certainly suggests that more education may be appropriate."

    Schold stressed the need for patients suffering from renal failure to see nephrologists and learn about transplants soon after they are diagnosed with renal problems.

    Prior research found that kidney-disease patients who are African-American or lack private health insurance are less likely to be matched with donor organs before they need dialysis (see Reuters Health story of January 31, 2013 here: http://reut.rs/1tKdUU2).

    Almost 66 percent of the current study participants were African-American. Some 24 percent of them reported feeling uncomfortable asking someone to donate a kidney, compared to 41 percent of other participants.

    Americans who receive kidneys from unrelated live donors tend to be white, highly educated and live in wealthier neighborhoods, according to an earlier study (see Reuters Health story of April 9, 2012 here: http://reut.rs/ZoGvFw).

    A kidney is one of the few organs people can give away and go on to live a healthy life.

    Since the 1990s, advances in immune-suppression have made it safer to receive an organ from someone who's not a relative. Less-invasive surgical techniques also make it easier to donate.

    SOURCE: http://bit.ly/1uzgihR Clinical Journal of the American Society of Nephrology, online September 11, 2014.

  • Brain study hints at how fibromyalgia works

    By Kathryn Doyle

    NEW YORK (Reuters Health) - Brain scans show that people with the pain disorder fibromyalgia react differently to what others would consider non-painful sights and sounds, new research suggests.

    The small new study provides clues to what might be going wrong in the nervous system of people with fibromyalgia, along with possible new approaches to alleviating their pain.

    "If we understand the mechanism, we may come up with new and potentially better forms of treatment," said lead author Marina López-Solà of the department of Psychology and Neuroscience at the University of Colorado, Boulder.

    Fibromyalgia, which patients experience as widespread muscle pain and fatigue, affects as many as five million Americans, most commonly middle-aged women, according to the U.S. Department of Health and Human Services.

    Its cause is unknown and there is no cure, but medications can treat the symptoms.

    The new results suggest not only that fibromyalgia is related to greater processing of pain-related signals, but also potentially to a misprocessing of other types of non-painful sensory signals that may be important to address during treatment, Lopez-Sola told Reuters Health by email.

    She and her team used "functional magnetic resonance imaging," which measures blood flow changes in the brain, to assess brain responses among 35 women with fibromyalgia and 25 similar women without the disorder.

    The fibromyalgia patients were more sensitive to non-painful stimulation compared to people without the disorder, they report in Arthritis and Rheumatism.

    Researchers showed the subjects some colors, played some tones and asked subjects to perform very simple motor tasks at the same time, like touching the tip of the right thumb with another finger.

    Areas of the brain's cortex primarily responsible for processing visual, auditory and motor signals were significantly activated in the healthy comparison group, but not in the fibromyalgia group.

    However, other brain regions that are not relevant for primary processing were activated in fibromyalgia sufferers but not in healthy controls.

    What seems to be happening is that the brains of fibromyalgia patients are under-processing certain forms of sensory information at the first stages of processing, but are also amplifying the signal at a later level of sensory integration of multiple sensory inputs, Lopez-Sola said.

    "When you are in pain, it is probable that you are more concentrated on your own pain than on the tasks you have to pay attention to," said Dr. Pedro Montoya of the Research Institute on Health Sciences at the Universitat Illes Balears in Palma de Mallorca, Spain, who was not part of the new study.

    "For me, these findings provide further support for the idea that psychological strategies aimed at changing the focus of attention from the body to external cues could be useful for these patients," Montoya said.

    There were only a small number of people involved in the study, and the researchers did not account for other mental health conditions the participants may have had, both factors that limit the results, said Dr. Winfried Hauser, associate professor of Psychosomatic Medicine at Technische Universitat Munchen in Germany.

    People with fibromyalgia often also have conditions like depression, so some people believe the disorder has a mental basis, said Michael E. Geisser, professor in the department of physical medicine and rehabilitation at the University of Michigan in Ann Arbor.

    But evidence for a neuro-anatomical basis for fibromyalgia is growing, said Geisser, who was not part of the new study.

    "There is increasing evidence that fibromyalgia is not just a pain condition," he told Reuters Health by email. "More recent research done on persons with fibromyalgia, such as the research by Lopez-Sola and colleagues, suggests that persons with fibromyalgia suffer from a central processing deficit of multiple types of sensory stimuli, not just pain."

    "It's as if the volume control for sensation in persons with fibromyalgia is turned up, or louder, for many types of sensation compared to persons without the disorder," he said.

    That might help explain why many people with fibromyalgia also often suffer from fatigue, cognitive problems or mood disturbance, Geisser said.

    Currently, people with the disorder can take anticonvulsant medications, such as pregabalin (Lyrica), and antidepressants such as duloxetine (Cymbalta) and milnacipran (Savella), which have been FDA approved for treating fibromyalgia.

    Further research to improve understanding of where there are problems in the brain for people with the disorder could lead to the development of new treatments, Geisser said.

    For example, it would be interesting to see if a treatment targeted at dampening response in an area of the brain that "overreacted" in this study helped to treat fibromyalgia symptoms, he said.

    SOURCE: http://bit.ly/1mbOikg Arthritis and Rheumatism, online September 15, 2014.

  • Angelina Jolie surgery sparks surge in female cancer tests-study

    By Laura Onita

    LONDON (Thomson Reuters Foundation) - Hollywood star Angelina Jolie's decision to make public her double mastectomy more than doubled the number of women in Britain seeking to have genetic breast cancer tests, according to a study released on Friday.

    Jolie, 39, who has become a high-profile human rights campaign, announced her surgery in May last year, saying she acted after testing positive for a mutation of the BRCA1 gene that significantly increases the risk of breast cancer.

    She said she was going public with news of her surgery as she hoped her story would inspire other women to fight the life-threatening disease.

    Researchers studied 21 clinics and regional genetic centers and found there were 4,847 referrals for testing in June and July last year compared to 1,981 in the same period of 2012.

    The study of the so-called "Angelina effect", published online in the journal Breast Cancer Research, credited Jolie's glamorous appearance and relationship with Hollywood actor Brad Pitt for helping to lessen women's fears about surgery.

    "Angelina Jolie ... is likely to have had a bigger impact than other celebrity announcements, possibly due to her image as glamorous and strong woman," researcher Gareth Evans of the charity Genesis Breast Cancer Prevention said in a statement.

    "This may have lessened patients' fears about a loss of sexual identity post-preventative surgery and encouraged those who had not previously engaged with health services to consider genetic testing."

    "These high-profile cases often mean that more women are inclined to contact centers such as Genesis - and other family history clinics - so that they can be tested for the mutation early and take the necessary steps to prevent themselves from developing the disease," he continued.

    "Of course, in some cases this may mean a risk-reducing mastectomy, however cancer preventing drugs, such as tamoxifen, and certain lifestyle changes like a healthy diet and more exercise, are also options which many women may consider."

    Breast cancer is the most common cancer in women worldwide. The World Health Organization estimated that more than 521,000 women died of breast cancer in 2012.

    Oscar-winning Jolie has in recent years drawn nearly as much attention for her globe-trotting work on behalf of refugees and victims of sexual violence in conflicts as for her acting.

    Jolie was named a Goodwill Ambassador for the UNHCR in 2001 and promoted to be Special Envoy to High Commissioner Antonio Guterres in 2012. Since 2012 she has also led a campaign against sexual violence in conflict zones.

    SOURCE: http://bit.ly/1u5z5nc Breast Cancer Research, September 18, 2014.

  • U.S. nutrition program for mothers, infants sees falling demand

    By Annika McGinnis

    WASHINGTON (Reuters) - A government nutrition program for pregnant mothers and small children has not kept pace with technology and U.S. poverty experts say its paper voucher system is driving low-income women away from the program when they need it most.

    The Special Supplemental Nutrition Program for Women, Infants and Children, known as WIC, has seen a sharp drop in participation since 2010, unlike food stamps and other anti-poverty programs that ballooned during the 2007-9 recession and the economic recovery that followed, government figures show.

    "WIC providers are tearing their hair, beating their chests, 'what are they doing wrong?'" said Laurie True, California WIC Association director.

    Poverty experts say the shrinking demand does not reflect less need. They are pushing for faster changes to an outdated, cumbersome distribution process they say stigmatizes recipients.

    Participants complain of customers "shaming" them in grocery lines, said Sarah Monje, California's Native American Health Center WIC director.

    "I can feel the aura: 'Oh my god, this girl is taking forever,'" said WIC recipient Marquel Davis of Austin, Texas.

    With a generation of Americans "used to getting everything on their smartphones," True said, WIC is still "stuck in the hands-on experience."

    "That doesn't make the program as attractive to people who may be on the borderlines, the working poor and very busy - most of our participants work at least one job," she said.

    Congress mandated in 2010 that WIC switch to electronic benefit cards by 2020. All but nine U.S. states still rely on paper vouchers that program directors say hold up grocery-store lines and embarrass mothers.

    Davis, 26, said it was a hassle trying to redeem her WIC checks before Texas switched to an electronic system several years ago. The program pays only for specified foods sold in certain quantities.

    "You've got to separate (your groceries) and make sure it's the right one, right size, and on top of that, you got to sign and they got to initial," Davis said. "It's just hectic, especially if you have a kid shopping with you and you're trying to get home."

    WIC gives low-income pregnant, post-partum or breastfeeding women and kids up to age five vouchers worth about $43 each month for formula and healthy foods that adhere to federal nutrition requirements, such as limiting added sugar in yogurt and mandating that bread include whole wheat flour.

    The program requires recipients to attend classes on eating well and breastfeeding.

    Though WIC grew fairly steadily since its inception in 1972, U.S. Department of Agriculture data shows it shrank 10.6 percent between fiscal year 2010 and May 2014.

    Staff members "don't have a sense of declining need in their communities," said analyst Zoe Neuberger of the Center on Budget and Policy Priorities, a poverty-focused think tank.

    Participants dropped from 9.2 million to 8.2 million from 2010 to May, decreasing in every state and the District of Columbia, according to USDA. In Georgia, caseload plummeted 46 percent since 2009.

    Conversely, food stamp enrollment skyrocketed from 28.2 million in 2008 to 47.6 million in 2013 under expansions in President Barack Obama's 2009 stimulus package, though it fell to 46.2 million in May after benefits expired last November.

    But the smaller, more targeted WIC started shrinking years earlier and to a greater extent relative to enrollment, USDA data shows.

    SOCIAL STIGMA

    The social stigma, always a factor for some people, was accentuated by a distribution system largely unchanged in four decades, directors said.

    Many women have switched to food stamps, which use a debit-like card but lack such WIC benefits as affording expensive baby formula, feeding children healthier food and learning workplace breastfeeding rights, directors said.

    Being required to attend WIC advising sessions every one to three months can be a problem for low-income workers.

    Those include illegal immigrants, who may be deterred over fear of an immigration crackdown, New York-based nonprofit Community Food Advocates co-founder Agnes Molnar said. The WIC program does not require proof of citizenship, though state or tribal residency is required.

    Michael Osur, who runs 18 WIC clinics in southern California's Riverside County, saw an almost 40 percent drop in the percentage of people requesting materials in Spanish from 2007 to 2013.

    Lingering effects from last October's government shutdown, when clinics shuttered or scraped by on reserve funds, also hurt WIC, National WIC Association CEO Douglas Greenaway said.

    If caseload continues to drop, Congress will cut funding and clinics will close, consolidate and limit overtime and weekend services, True said.

    In California, Osur was opening mobile neighborhood clinics, insisting many women were neglecting critical help.

    "I think the need is there," he said. "We've just got to find a way to reach them."