Knee Replacement May Be a Lifesaver for Some -

By the time 64-year-old Laura Milson decided to undergo total knee replacement after 12 years of suffering from arthritis, even a short walk to the office printer was a struggle.
After her surgery last August at the Rothman Institute at Thomas Jefferson University in Philadelphia, Ms. Milson spent a week in rehabilitation and says she hasn't stopped walking since. "My son says to me, 'You have to slow down,' and I say, 'No, I have to catch up!,' " she said. "It's a whole different life."
For Ms. Milson, who lives in Shrewsbury, Pa., replacing the joint in her right knee came with a surprising bonus: a 20-pound weight loss in two months. "I joked with my doctor, 'I think you put a diet chip in my knee,' " she said. "The weight just sort of came off."
Now she has joined Weight Watchers to drop a few extra pounds and is training for a three-day breast cancer walk in October.
For years surgeons have boasted of the pain relief and improved quality of life that often follow knee replacement. But now new research suggests that for some patients, knee replacement surgery can actually save their lives.
In a sweeping study of Medicare records, researchers from Philadelphia and Menlo Park, Calif., examined the effects of joint replacement among nearly 135,000 patients with new diagnoses ofosteoarthritis of the knee from 1997 to 2009. About 54,000 opted for knee replacement; 81,000 did not.
Three years after diagnosis, the knee replacement patients had an 11 percent lower risk of heart failure. And after seven years, their risk of dying for any reason was 50 percent lower.
The study, presented this month at the annual meeting of the American Academy of Orthopedic Surgeons, was financed with a grant from a knee replacement manufacturer. It was not randomized, so it may be that these patients were healthier and more active to start with.
Still, the researchers did try to control for differences in age and overall health. And the findings are consistent with large studies of knee replacement and mortality in Scandinavia. Given the big numbers in the study and the size of the effect, the data strongly suggest that knee replacement may lead to improvements in health and longevity.
The theory behind knee replacement, said the study's lead author, Scott Lovald, senior associate at Exponent, a scientific consulting firm in Menlo Park, is that it improves quality of life. "At the end of the day, we're trying to figure out if quantity of life increases as well," he added, noting that the team was conducting a similar review of Medicare data on the long-term benefits of hip replacement surgery.
The founder of the Rothman Institute, Dr. Richard H. Rothman, who has performed 25,000 joint replacement surgeries in his career, urged caution in interpreting data that are not randomized and controlled. Not every patient with knee arthritis is a candidate for joint replacement surgery, he said.
"People can tolerate a lot of knee disability for reasons we don't totally understand," he went on, adding, "If the pain is acceptable, you live with it; if it's not acceptable, we'll operate on you."
Dr. Rothman said that whether patients experience better health after surgery depends on motivation — how motivated they were to stay fit before surgery and how motivated they are now to become more active.
"For the motivated patient, it allows them to walk through that portal and become better conditioned and lose weight," he said. "It's not a weight-reduction program. It's a potential avenue to improve your level of fitness, weight, cardiovascular health and mental health."
Edward Moore, a 94-year-old retired chemist in Woodbury, N.J., underwent knee replacement three years ago after pain began limiting his activity. Given his age, his own daughter had worried that the recovery would be too difficult. But Dr. Rothman agreed he was healthy enough for the procedure.
"I didn't do much mulling about it," Mr. Moore said. "It just seemed like the knee would be hampering me for the rest of my life, and that sounded like a bad idea."
Mr. Moore said he had an uneventful recovery, and in September, two days after his 94th birthday, he took his wind surfer to Lakes Bay near Atlantic City. "I got up on the board, and I sailed," he said.
William Mills, 63, of Philadelphia, had been suffering for about four years with severe pain in both knees when he opted for double knee replacement in 2006. He said his activity had dropped off, and while he could still play golf, he could no longer walk the course. Even going to a restaurant had become a burden if he couldn't find a parking space nearby.
"I think one of the things people don't understand about knees is how bad it is," said Mr. Mills, a bank executive. "It changes everything. I couldn't walk two city blocks. It was just slowly but surely changing my life where I was unable to really enjoy things."
But while the rehabilitation of both knees was "the hardest thing I've ever done in my life," he has no regrets. Six months after surgery he took part in a 250-mile bike ride in Germany. He has made a few compromises — he no longer skis, and plays doubles tennis instead of singles — but he says he now rarely thinks about his knees.
"Before surgery, I felt like I was 10 or 15 years older than I was," he said. "Now I probably feel like I'm 10 or 15 years younger than I am.
"I can understand why people might live longer, because you want to. You really feel good again."

How Doctors Die « Zócalo Public Square

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient's five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn't spend much on him.
It's not a frequent topic of discussion, but doctors die, too. And they don't die like the rest of us. What's unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
Of course, doctors don't want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They've talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that's what happens if CPR is done right).
Almost all medical professionals have seen what we call "futile care" being performed on people. That's when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, "Promise me if you find me like this that you'll kill me." They mean it. Some medical personnel wear medallions stamped "NO CODE" to tell physicians not to perform CPR on them. I have even seen it as a tattoo.
To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they'll vent. "How can anyone do that to their family members?" they'll ask. I suspect it's one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it's one reason I stopped participating in hospital care for the last 10 years of my practice.
How has it come to this—that doctors administer so much care that they wouldn't want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.
To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They're overwhelmed. When doctors ask if they want "everything" done, they answer yes. Then the nightmare begins. Sometimes, a family really means "do everything," but often they just mean "do everything that's reasonable." The problem is that they may not know what's reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do "everything" will do it, whether it is reasonable or not.
The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I've had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who'd had no heart troubles (for those who want specifics, he had a "tension pneumothorax"), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.
But of course it's not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.
Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman's terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.
Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn't restore her circulation, and the surgical wounds wouldn't heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.
It's easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they're asked, with little feedback, to avoid getting in trouble.
Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack's worst nightmare. When I arrived at the hospital and took over Jack's care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.
Even with all his wishes documented, Jack hadn't died as he'd hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack's wishes had been spelled out explicitly, and he'd left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It's no wonder many doctors err on the side of overtreatment.
But doctors still don't over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had "died peacefully at home, surrounded by his family." Such stories are, thankfully, increasingly common.
Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.
We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn't had in decades. We went to Disneyland, his first time. We'd hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn't wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.
Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don't most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.
Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

Is it in the genes? - National Post

Louise Levy attends regular Tai-chi classes, retired three years ago from her secretarial job and says she would still be driving today if her car had not "conked out before I did." None of which would be particularly unusual, except Mrs. Levy is 101 years old.

"My mind is still clear and I don't have a memory problem," says the resident of Rye, N.Y., about the latest chapter in a life that began when movies were silent and the Model-T Ford cutting edge. "It's been absolutely marvelous."

Mrs. Levy's long and generally healthy life is the focus of a fascinating scientific study, itself at the forefront of a little-noticed but radical approach to medical research. Turning upside down the traditional quest to understand and cure specific diseases, some researchers are examining instead healthy and long-lived humans and animals for their biological secrets.

By reverse engineering the source of that vigour, scientists hope to develop drugs or supplements that could give less genetically fortunate people more protection against the ravages of aging and chronic illness.

Those researchers struggle now for recognition in a medical establishment hived off into separate wars against individual diseases. A Canadian academic, however, is calling for a tectonic shift toward what he calls "positive biology." Solving the molecular mysteries of the healthy to stave off disease and aging would make the system "much more efficient," argues Professor Colin Farrelly of Queen's University in a recent paper in the journal of the European Molecular Biology Organization.

"We think it will be more important for public health than the introduction of antibiotics," echoed Jay Olshansky, a publichealth professor at the University of Illinois who has promoted a similar concept for several years. "This will be the medical breakthrough of the 21st century when it happens.- It's going to be huge."

Continuing to just combat specific diseases, on the other hand, will produce surprisingly modest advances, he contends. While curbing infant mortality and other achievements stretched life spans by 30 years in the 20th century, even a complete cure of all cancers would increase longevity by an average of just more than three years, Prof. Olshansky has estimated.

The argument seems to be slowly gaining some traction, with Canada's federal medicalresearch agency saying it is looking seriously at positive biology.

The study that has Mrs. Levy under a microscope is identifying genes linked to long life. Gabrielle Boulianne, a Toronto biologist, and others are unscrambling similar biological puzzles in exceptional specimens of fruit flies, worms and other lower life forms. Canadian infectious-disease experts have studied the lucky few people who seem naturally resistant to HIV infection; and a U.S. clinic is probing the DNA of diabetes patients who stay remarkably free of the disease's dire complications for decades.

At the core of positive biology is not an attempt to simply identify lifestyle choices - like quitting cigarettes or French fries - that can stave off disease, though those have proven value. The goal instead is to identify the mechanisms by which some people naturally live long and well, then translate that knowledge into pharmaceutical treatments.

The centenarian study at New York's Albert Einstein College of Medicine has enrolled more than 500 men and women who have lived in good health to 100 or close to it, focusing exclusively on Ashkenazi Jews, not because of any special aging quality, but to avoid ethnic variations that might complicate results. The Einstein researchers have come up with some intriguing findings.

Rather than all being paragons of lifestyle virtue, half the centenarians were overweight or obese, 60% smoked for over 30 years - and one had a tobacco habit that stretched across nine decades, noted Dr. Nir Barzilai, who heads the project.

"It's all genetics," he said. "To be 100 years old, it's strongly genetic."

More …

'Cinderella cancers' that doctors miss: Multiple visits to the GP needed for proper diagnosis | Mail Online

Many patients with less common cancers are referred to a specialist for diagnosis only after three or more trips to their family doctor, a study has found.

Those with multiple myeloma, pancreatic, stomach and ovarian cancer – which each have fewer than 10,000 victims a year – are most likely to need several GP visits before a hospital referral.

These are the so-called 'Cinderella cancers', regarded as the poor relation in cancer diagnosis and treatment.

Around half of patients diagnosed with multiple myeloma, a blood cancer, needed three or more GP consultations first. Patients with the disease are 18 times more likely to make repeat visits compared with those with breast cancer.

But even for one in three with common cancers such as lung and colon – currently the focus of a government awareness campaign – it took three GP appointments to get to hospital.

Women, young people and older patients from ethnic minorities were most likely to have to go back to the GP most often before they were given a hospital appointment.

Researchers at Cambridge University found three-quarters of cancer patients who first went to their family doctor with suspicious symptoms were referred to hospital after only one or two consultations.

But the study, published in The Lancet Oncology journal, said there were 'wide variations' depending on the type of cancer and patient.

The most pre-referral consultations occurred when the cancer was one of the less common types, or when the patient was female, aged 16 to 24 years, or an older person from an ethnic minority.

The study, which looked at 24 different cancers, comes amid concerns that some patients are not given the best chance of beating the disease because of delays in diagnosis.

The study shows patients with breast, melanoma, testicular and endometrial cancers were more likely to be referred to a specialist after just one or two consultations.

However, those with some less common cancers such as multiple myeloma, pancreatic, stomach and ovarian, as well as those with lung and colon cancers and lymphomas, were more likely to require three or more GP visits.

The findings come from data on 41,000 patients taking part in the English National Cancer Patient Experience Survey 2010.

Dr Georgios Lyratzopoulos, clinical senior research associate at the University of Cambridge, said they showed the difficulty of detecting cancer when some 'suspicious' symptoms were found in many benign conditions.

For example, it might seem obvious that a smoker with a cough could have lung cancer, but such patients would also frequently suffer respiratory infections that have similar signs.

Joy Felgate, chief executive of the Childhood Eye Cancer Trust, said: 'This is sadly something our members have experienced all too often.

'It is time GPs sat up and took notice. Just because it's rare doesn't mean it isn't there.'

A Health Department spokesman said: 'We have committed £450million to help diagnose cancer earlier.'

Managed Care Keeps the Frail Out of Nursing Homes -

Faced with soaring health care costs and shrinking Medicare and Medicaid financing, nursing home operators are closing some facilities and embracing an emerging model of care that allows many elderly patients to remain in their homes and still receive the medical and social services available in institutions.

The rapid expansion of this new type of care comes at a time when health care experts argue that for many aged patients, the nursing home model is no longer financially viable or medically justified.

In the newer model, a team of doctors, social workers, physical and occupational therapists and other specialists provides managed care for individual patients at home, at adult day-care centers and in visits to specialists. Studies suggest that it can be less expensive than traditional nursing homes while providing better medical outcomes.

The number of such programs has expanded rapidly, growing from 42 programs in 22 states in 2007 to 84 in 29 states today. In New York City, a program run by a division of CenterLight Health System, formerly known as the Beth Abraham Family of Health Services, has over 2,500 participants at 12 sites in the metropolitan area.

"It used to be that if you needed some kind of long-term care, the only way you could get that service was in a nursing home, with 24-hour nursing care," said Jason A. Helgerson, the Medicaid director for New York State. "That meant we were institutionalizing service for people, many of whom didn't need 24-hour nursing care. If a person can get a service like home health care or Meals on Wheels, they can stay in an apartment and thrive in that environment, and it's a lower cost to taxpayers."

The recent influx of adult day-care centers and other managed care plans for the frail elderly is being driven by financial constraints as President Obama and Congressional leaders seek hundreds of billions of dollars in savings in Medicare and Medicaid. Nursing homes, which tend to rely heavily on Medicare and Medicaid dollars, are facing enormous financial pressure — Mr. Obama's proposed budget includes a $56 billion Medicare cut over 10 years achieved by restricting payments to nursing homes and other long-term care providers.

Nationally, the number of nursing homes has declined by nearly 350 in the past six years, according to the American Health Care Association. In New York, the number of nursing homes declined to 634 this January from 649 in October 2007, and the number of beds to 116,514 from 119,691.

Over the next three years, New York State plans to shift 70,000 to 80,000 people who need more than 120 days of Medicaid-reimbursed long-term care services and are not in nursing homes into managed care models, Mr. Helgerson said.

The move away from nursing homes was highlighted on Thursday when Cardinal Timothy M. Dolan announced that the Archdiocese of New York, one of the state's largest providers of nursing home care, is selling two of its seven nursing homes and opening or planning to open seven new adult day-care centers over the next three years.

"Seniors and others who have chronic health needs should not have to give up their homes and independence just to get the medical care and other attention they need to live safely and comfortably," Cardinal Dolan said in a statement before he opened a 250-patient program at Saint Vincent de Paul Catholic Healthcare Center in the South Bronx.

These new adult day-care centers, known around the nation by the acronym PACE — Program of All-Inclusive Care for the Elderly — provide almost all the services a nursing home might, including periodic examinations by doctors and nurses, daytime social activities like sing-alongs and lectures, physical and occupational therapy and two or three daily meals. All the participants are considered eligible for nursing homes because they cannot perform two or more essential activities on their own like bathing, dressing and going to the toilet. But they get to sleep in their own beds at night, often with a home health care aide or relative nearby.

The nonprofit groups that operate them receive a fixed monthly fee for each participant and manage their entire care, including visits to specialists, hospitalizations, home care and even placement in a nursing home. Because Medicare and Medicaid pay set fees instead of paying for specific procedures, center operators are motivated to provide preventive care to avoid costly hospitalizations or nursing home care.

Some elderly people, however, spurn PACE programs because under managed care, they would have to switch their physicians to those at the PACE center or in its network.

Most elderly people want to live out their lives at home, a desire evident in interviews in the PACE center the archdiocese opened in 2009 in Harlem, which has a staff of three doctors and is visited regularly by a dentist, a podiatrist and a psychiatrist.

Edna Blandon, 74, a diabetic weakened on her left side by a stroke who relies on a wheelchair, is transported by specialized van to the Harlem PACE center three days a week and appreciates that it provides not only a home care attendant but sends a nurse every two weeks to change pills in her pillbox and load a 14-day supply of insulin into syringes that she will inject.

"My spirits would drop if I went to a nursing home," she said. "I love the fact that I can go home at night. There's no place like home. I can sit down, look at the TV and go to bed when I want."

James Harper, 70, a retired bank employee who spent 10 months at the archdiocese's Kateri Residence, a nursing home on the Upper West Side, after a stroke paralyzed his right side, enjoys yoga breathing classes and discussions about black history. Yet he gets to spend nights and weekends with his wife, Albertene, and daughter, Traci, both of whom work during the day and are not around to care for him.

"This way I'm around people," he said.

Dr. Fredrick T. Sherman, the Harlem PACE medical director, said that a 2009 study showed that PACE programs reduce lengths of stays in hospitals and delay assignments to nursing homes.

The archdiocese, whose new centers will serve a total of 1,500 people, receives an average of $4,000 a month from Medicaid for each participant and $3,300 from Medicare. By comparison, said Scott LaRue, the chief executive of ArchCare, the archdiocesan health care network, a month of nursing home care can cost the government $9,000.

Ultimately, the archdiocese hopes that half of its elderly clients will be served in community settings rather than in nursing homes, which currently serve about 90 percent of the archdiocese's clients. For-profit companies have not yet moved into the managed care market, in part because of uncertainties about reimbursement formulas and the risks of taking on a nursing home population.

The PACE population tends to be younger than that at nursing homes, which raises the question of whether many PACE clients would really need nursing homes without PACE. Dr. Sherman replies to such skepticism by saying that his clients "need that level of service — the question is where they're going to get it."

Without PACE, he said, "they're going to end up in nursing homes."

Facing a shortage of cadavers, professor turns to poetry to students anatomy | News | National Post

With dissection-ready cadavers in short supply and class sizes burgeoning, an Ottawa professor has come up with an unusual tool to teach the complexities of human anatomy: limericks.

Jacqueline Carnegie had students create the funny rhymes that incorporated anatomical concepts as part of her courses at the University of Ottawa, and suggests in a new study that writing body-part rhymes may have actually improved the amateur poets' class performance.

Her idea adds to a cluster of creative study aids — including a Korean professor's humorous comic strips and even folk songs — developed recently to make the age-old scientific discipline easier to grasp. Limericks are a variation on mnemonics: groups of words, numbers or letters that help people remember complicated terms.

But they also have a narrative component that can instill broader knowledge of the facts, Ms. Carnegie said.

"There's a phrase [students learn] that goes ' Never let monkeys eat bananas.' The first letter matches up with the first letter of the five different types of red blood cells," she said. "But it's not telling them anything about them. With a limerick you have to come up with a bit of a story."

Ms. Carnegie said she now wants to gather the best of her students' poems — including one about the gallbladder's green and yellow bile — and print a booklet that students could use.

Anatomy, the study of the bodily structure, has long been a staple of medical training and other healthsciences education. While the subject once took up more than 800 hours of class and lab time for medical students, though, the volume of teaching even for trainee doctors has fallen dramatically in recent decades, according to a 2009 U.S. study.

The reasons include increased enrolment, more subjects to teach in the curriculum and less emphasis on basic science, Ms. Carnegie notes in her paper in the journal Anatomic Sciences Education.

Human cadavers are also harder to obtain, and in higher demand for practising a variety of surgical and other procedures, as well as learning the body parts. While medical students still have at least some time dissecting real human corpses, students in other undergraduate programs can no longer observe anatomical facts in the flesh, Ms. Carnegie said.

With its odd-sounding vocabulary and complex systems, the topic has long been recognized as demanding. Somerset Maugham quotes a fictional anatomy teacher in his classic, 1915 novel Of Human
Bondage as saying students would learn "many tedious things … which you will forget the moment you have passed your final examination." One instructor at South Korea's Ajou University School of Medicine has created scores of comic strips that wittily — and sometimes with a little sexual innuendo — explain anatomical concepts.
"It's tough because it's got a language of its own," Ms. Carnegie said. "A lot of those names are long and complicated, a lot of them are derived from Latin."

The five-line limerick is wellsuited for retaining such facts because it places new information in a familiar context, uses rhyming to trigger recall and takes advantage of rhythm to promote long-term memory, she said. She had a total of just under 600 students over two years form into groups and come up with limericks, then assess each others' poems for their educational value, literary skill and anatomical accuracy.

Average course marks for the minority of students who did none of the limerick work were significantly lower than those who did all the limerick-related tasks. Although it's possible the students who did all the work are those who would have excelled anyway, Ms. Carnegie said she is convinced limericks helped the students better remember concepts.

That fits well with a modern educational approach that focuses less on rote, passive teaching of anatomy, and more on active learning by teams of students, said Dr. Wojciech Pawlina, anatomy-department chair at the Mayo Clinic college of medicine in Minnesota.

"You're not at a table trying to memorize those strange names; you're making something fun," he said. "I don't have anything against having fun in anatomy."

Monitoring Your Health With Mobile Devices -

Dr. Eric Topol is only half joking when he says the smartphone is the future of medicine — because most of his patients already seem "surgically connected" to one.

But he says in all seriousness that the smartphone will be a sensor that will help people take better control of their health by tracking it with increasing precision. His book, "The Creative Destruction of Medicine," lays out his vision for how people will start running common medical tests, skipping office visits and sharing their data with people other than their physicians.

Dr. Topol, a cardiologist and director of Scripps Translational Science Institute in La Jolla, Calif., is already seeing signs of this as companies find ways to hook medical devices to the computing power of smartphones. Devices to measure blood pressure, monitor blood sugar, hear heartbeats and chart heart activity are already in the hands of patients. More are coming.

He acknowledges that some doctors are skeptical of these devices. "Of course, the medical profession doesn't like D.I.Y. anything," he said. "There are some really progressive digital doctors who are recognizing the opportunities here for better care and prevention, but most are resistant to change."

Dr. Topol may be right about the caution in the industry, but he is far from the only person with this vision. Apple was promoting the iPhone as a platform for medical devices in 2009. An entire marketplace is evolving that marries the can-do attitude of hacking devices with the fervor of the wellness movement.

Smartphones make taking care of yourself more of a game, Dr. Topol said. "I recommend these devices because it makes it more fun and I get more readings than if I ask them to do it manually."

The enthusiasm for this vision of do-it-yourself medicine with a smartphone, though, must be balanced with the cold reality that all of the experimenters should consult with their physicians.

Some of the attempts to turn the iPhone into a medical device are little more than toys. The 99-cent iStethoscope Pro app warns, "This app is intended to be used for entertainment purposes." Those who have bought it have given it uniformly poor reviews.

The equally poorly reviewed iStethoscope Expert 2012, also 99 cents, offers a $24 bell to enhance the sound.

I experimented with a homemade otoscope, the device doctors use to look into the ears, connected to a smartphone so I could take pictures of a family member's eardrums. My son has had infections in his Eustachian tube and the doctor likes to take a look. I figured that if I could take a picture or a video of the eardrum, I could save the trouble of him missing school to visit the doctor.

With the help of a little duct tape, I attached the phone to a small home otoscope from a company called Dr. Mom Otoscopes. It is just a lens, a light source and a plastic sleeve and sells for $27. To improve the image, I inserted a $20 close-up lens I had bought from

The biggest problem was in the software of the smartphone. The Apple camera app balanced the light and dark over the entire image, washing out the center so the eardrum was just a sea of white. The Android camera app offered the option of using spot metering so the light balance was better.

Despite all this fiddling with the optics and the software, the result was never very good. Better results require more than duct tape.

Firefly Global in Belmont, Mass., makes a medical camera and sells it directly to doctors who want to share the images with patients and save them for the future. Its line includes cameras for dentists, dermatologists and ophthalmologists. Unfortunately, the $180 to $350 cameras connect to a computer, not a smartphone.

The most prevalent diseases and the biggest markets are getting the tools first. Devices to monitor heart disease are already available.

A French start-up, Withings, has created a blood pressure cuff for $129 that connects to an iPad or an iPhone. The cuff will automatically inflate, deflate and then record the pulse rate and the blood pressure. The app will graph the pressure over time, making trends easier to see.

Withings also includes a connection to its Web site so users can share their data with their doctors either directly through their password-protected pages or through third-party sites like

The growing incidence of diabetes is by many estimates the biggest public health challenge today, so companies are developing tools to help people with the disease manage their blood sugar.

Tom Xu, the founder of SkyHealth in El Cerrito, Calif., created the Web site to help people keep track of the sugar in their blood. The numbers must be entered manually. The site works with an app for the iPhone to gather the blood glucose level and some information about when it was taken. "Our main goal of glucosebuddy is not to just record numbers. That's the boring part," he said. "Once you know how your diet affects your blood sugar, you take your health more seriously."

Other companies are beginning to integrate the hardware and software. AgaMatrix, a company that makes a blood glucose monitor, iBGStar, that attaches to the iPhone, worked with Sanofi, the pharmaceutical giant, to develop the tool. In December, the Food and Drug Administration approved the device for sale in the United States.

"When patients are dealing with chronic conditions, you might see a doctor every six weeks or two months," said Joseph Flaherty, the senior vice president for marketing at AgaMatrix. "For people to have real command over these diseases, we need to close the feedback loop and give people the information they need to make smarter decisions in real time."

Its tool, like many other pocket meters, measures the amount of glucose in the blood, but it also transfers the data to the smartphone, which helps patients to track their glucose levels over time. It is not much different from a piece of paper and a pen, but it is faster and cleaner, and it is easy to share these values with doctors and friends.

Johnson & Johnson has also spoken publicly about developing a similar device. The ultimate goal is replicating the full-body diagnostic "tricorder" from the "Star Trek" TV show, a goal that is being encouraged by a $10 million prize put up by Qualcomm, the smartphone chip maker, through the X-Prize Foundation.

Apps that simulate the lights and sound of the TV show prop are available from app stores.

Women's Chronic Pain Misdiagnosed, Undertreated, Dismissed - ABC News Radio

Women make up the vast majority of the nation's 116 million chronic pain sufferers, yet doctors frequently dismiss their complaints as all in their heads, sending them on years-long searches for relief, a patient told

Although studies have observed women's chronic pain is more frequent, more severe and longer lasting than men's, many women still are told "their problem isn't real. Your pain doesn't exist, you must be imagining this," Christin Veasley testified.

In her case, she said, back and neck pain from an old car accident became "an unwanted companion for 21 years." Since 2008, migraine headaches, facial pain and jaw pain piled on more misery, she said.

"From the moment I open my eyes each morning, the first thing I feel is pain," said Veasley, executive director of the non-profit National Vulvodynia Association, which aims to help the one in four American women and "countless adolescents" suffering invisible but excruciating genital pain at some point during their lives.

Veasley, who has recovered from vulvodynia she had in her 20s, testified on behalf of the Chronic Pain Research Alliance. She said she hopes Congress will lead the way in enacting "long overdue change to help us regain our quality of life and ability to contribute to society."

She was among five witnesses appearing at a Capitol Hill hearing on "Pain in America: Exploring Challenges to Relief," called by Sen. Tom Harkin, D-Iowa, chairman of the Senate Committee on Health, Education, Labor and Pensions.

The hearing followed publication last year of an Institute of Medicine report that included recommendations for improving diagnosis, treatment and research into chronic pain, as well as boosting health professionals' recognition of both the problem and its toll.

The cost of chronic pain exceeds $600 billion each year -- more than cancer, heart disease and diabetes combined, the IOM report found. Chronic pain is defined as pain that lasts several months or more, according to testimony from Dr. Lawrence A. Tabak, principal deputy director of the National Institutes of Health. It may crop up as persistent pain after an injury heals, or arise as a debilitating symptom of long-term diseases like arthritis, diabetes or cancer.

Often, Tabak said, people suffer from chronic pain associated with more invisible conditions like fibromyalgia, irritable bowel syndrome, chronic headaches or jaw pain -- all more common in women than men.

"The majority of my patients are women," said Dr. Timothy A. Collins, a neurologist with the Duke Pain and Palliative Care Clinic in Durham, N.C., who was not involved in the hearing.

He said migraine headache is "three times as common in women compared to men." Fibromyalgia "appears more common in women than men," and "a number of pain conditions are directly caused by abuse (sexual and physical) and unfortunately, women are more commonly on the abused side of the equation."

Collins said U.S. culture encourages women "to voice feelings, emotions and physical complaints" while generally discouraging such complaints in men.

"This tends to affect the perception of the care provider -- if there are significant emotional issues, the other complaints may become attributed to the emotional complaints," he said.

In other words, if a woman with chronic pain also suffers from depression, a doctor may attribute all of her complaints "to being depressed, so no further evaluation or treatment is needed," Collins said.

Women with chronic pain also are subject to some of the same gender discrimination that contributes to their under-treatment for cardiac disease and or arthritis. For example, a 1999 study published in the New England Journal of Medicine found that white women (and black men) were 40 percent less likely to be referred for potentially life-saving cardiac surgery.

A 2008 study published by the Canadian Medical Association found doctors were more likely to recommend knee replacement surgery to male patients with knee arthritis than to female patients, suggesting that gender discrimination might contribute to women being three times less likely to undergo knee replacement than men.

In addition, when it comes to doctors' decisions about managing pain, a February 2003 study of doctors' pain management knowledge and attitudes, published in The Journal of Pain, found that women were less likely than men to receive "optimal treatment" for post-surgical or cancer-related pain. That study also found doctors set lesser goals for chronic pain relief than for acute pain and cancer pain.

U.S. advisers back experimental obesity pill- Reuters

Experimental obesity drug Qnexa won the backing of U.S. health advisors on Wednesday, raising hopes for approval of the first prescription weight-loss pill in 13 years.

Vivus Inc's Qnexa was one of three promising obesity drugs rejected by the U.S. Food and Drug Administration in the past two years over safety concerns.

It is the first to come back up for review after more extensive clinical trials, as public health officials urge the FDA to consider a medical treatment for a condition that affects about one-third of Americans.

A panel of outside experts to the FDA voted 20-2 to recommend approval of Qnexa, saying they were convinced that the benefits it offers in treating obesity outweighed the potential heart risks and birth defects associated with the drug.

Vivus shares nearly doubled in value to $21.01 in afterhours trade following the panel vote.

Panelists did say Vivus should conduct a study on possible heart problems and supported the company's plan to limit its use to women who are not pregnant.

During discussions, panelists seemed divided on whether the heart-focused safety study should happen before or after the drug is approved. They took no formal vote on that issue. A pre-approval study could delay the time before Qnexa is available to patients.

Shares of fellow obesity drugmakers Orexigen Therapeutics and Arena Pharmaceuticals got a 17 percent boost in extended trading.

"The vote reflects the clinical community's concern about the challenge of obesity," said JMP Securities analyst Charles Duncan.

"I continue to believe Orexigen's Contrave and Vivus' Qnexa remain approvable drugs and are going to move forward," Duncan said. "I am less positive on Arena's Lorcaserin."

The FDA usually follows panel recommendations, although it is not required to. It will make a final decision by April 17.

"Everyone around the room knows obesity and its substantial health risks," said Dr. Susan Yanovski, an advisory panel member and director of the obesity and eating disorders program at the National Institutes of Health.

"I would say not treating obesity is not risk neutral. We have few treatments for obesity for those who don't respond to lifestyle treatments."

Obesity, a leading cause of diabetes, heart disease and other serious health problems, has reached epidemic proportions in the United States, with about a third of the population obese and more than half overweight.

The FDA has set a high approval bar for weight loss drugs because such a large portion of the general population is likely to want to take them, and has not approved a new obesity drug since 1999.

The agency has experienced previous high-profile safety scares involving diet drugs. In 1997, the infamous diet drug "fen-phen" was pulled from the market after reports of fatal heart-valve problems in some users. Another diet pill, Meridia, was pulled from the U.S. market in 2010 after being linked to heart problems.

The only prescription obesity drug currently approved for long-term use is Roche Holding AG's Xenical, which got the FDA's nod in 1999. GlaxoSmithKline markets a lower-dose, over-the-counter version called Alli. But both have their side effect issues, including liver problems and uncontrolled bowel movements, and provide only modest weight loss.

Qnexa, which combines the appetite suppressant phentermine and anti-seizure drug topiramate, helped patients lose at least 10 percent of their weight after a year of treatment, the company said.

FDA staff reviewers said patients taking the drug had more safety problems, including memory loss and higher heart rates, than those on a placebo, and some of these problems could get worse over time.

However, Vivus said the drug also reduced blood pressure, and a link between heart rates and heart health was not conclusive. Panelists called for the company to study whether a higher heart rate was tied to heart health.

"They need to step up to the plate and do the cardiovascular outcomes trial, and do it fast," said panel member Dr. Sanjay Kaul, professor in the division of cardiology at Cedars Sinai Medical Center in Los Angeles. "I also encourage the FDA to hold their feet to the fire."

FDA staff also noted that exposure to one of the ingredients in Qnexa has been linked to a higher rate of birth defects. A Vivus study showed topiramate caused a higher rate of oral clefts in infants of women taking the drug during pregnancy

The FDA has said the rate of potential birth defects is about two to five times higher with topiramate than with a placebo.

Vivus officials said obesity, and its common symptom diabetes, come with their own risks to pregnancy, such as stillbirth, premature birth and other complications.

Arena and Orexigen have been pitching their own fat-fighters to the FDA after rejections.

In February, Orexigen agreed with the FDA on the design of a 10,000-patient heart-safety trial required for the approval of its Contrave drug. The FDA rejected the drug pending the outcome of the trial, despite a 13-7 positive vote from a panel of FDA advisers.

The FDA is also set to review Arena's lorcaserin by June 27, after rejecting it in October 2010 because of a potential cancer risk.

Colonoscopy Prevents Death, a Study Affirms -

A new study provides what independent researchers call the best evidence yet that colonoscopy — perhaps the most unloved cancer screening test — prevents deaths. Although many people have assumed that colonoscopy must save lives because it is so often recommended, strong evidence has been lacking until now.

In patients tracked for as long as 20 years, the death rate from colorectal cancer was cut by 53 percent in those who had the test and whose doctors removed precancerous growths, known as adenomatous polyps, researchers reported on Wednesday in The New England Journal of Medicine. The test examines the inside of the intestine with a camera-tipped tube.

"For any cancer screening test, reduction of cancer-related mortality is the holy grail," said Dr. Gina Vaccaro, a gastrointestinal oncologist at the Knight Cancer Institute at Oregon Health and Science University who was not involved in the research. "This study does show that mortality is reduced if polyps are removed, and 53 percent is a very robust reduction."

Colorectal tumors are a major cause of cancer death in the United States and one of the few cancers that that can be prevented with screening. This year, more than 143,000 new cases and 51,000 deaths are expected. Incidence and death rates have been declining for about 20 years, probably because of increased use of screening tests and better treatments. But only about 6 in 10 adults are up to date on getting screened for colorectal cancer, according to federal estimates.

Cancer screening tests have come in for greater scrutiny recently. A government panel recommended in October that men no longer get the P.S.A. blood screening test for prostate cancer after concluding it did not save lives. The new study on colonoscopy has limitations — it is not a randomized clinical trial — but some experts say it nonetheless was well done and helps answer questions about the effectiveness of the procedure.

Earlier research had proved that removing precancerous polyps could greatly reduce the incidence of colorectal cancer. But a major question remained: Did removing the polyps really save lives? In theory, it was possible that doctors were finding growths that would not have killed the patient, or missing ones that could be fatal.

"This study puts that argument to rest," said Dr. David A. Rothenberger, a professor and deputy chairman of surgery at the University of Minnesota Masonic Cancer Center. He was not part of the study.

Robert A. Smith, the senior director for cancer control at the American Cancer Society, said, "This is a very big deal."

A team of researchers led by Dr. Sidney J. Winawer, a gastroenterologist at Memorial Sloan-Kettering Cancer Center in New York City, followed 2,602 patients who had adenomatous polyps removed during colonoscopies from 1980 to 1990. Doctors compared their death rate from colorectal cancer with that of the general population, where 25.4 deaths from the disease would have been expected in a group the same size. But among the polyp group, there were only 12 deaths from colorectal cancer, which translates into a 53 percent reduction in the death rate.

The new study did not compare colonoscopy with other ways of screening for colorectal cancer and so does not fully resolve a longstanding medical debate about which method is best. Tests other than colonoscopy look for blood in the stool or use different techniques to examine the intestine. All the tests are unpleasant, and people are often reluctant to have them.

Although doctors have differed about which method is best, they agree that it is important to get over the squeamishness and have some type of test, usually starting at age 50. Screening is worthwhile because colorectal cancer is one of the few types of cancer (cervical and skin cancer are others) in which premalignant growths have been identified and the disease can be prevented if those growths are detected and cut out. Research indicates that not every polyp turns into cancer, but that nearly every colorectal tumor starts out as an adenomatous polyp.

Even if intestinal cancer has already developed, it can still be cured if it is found early and treated.

"Not all adenomas become cancers, and not all cancers cause death," said Ann Zauber, the lead author of the study and a statistician at Sloan-Kettering. But in many cases, she said, "we have gotten those that would have had the potential to go on and cause a cancer death."

Dr. Smith, at the American Cancer Society, said the new study on colonoscopy was well done, and noted that changes in death rates can be difficult to measure because they require long-term studies like this one.

But Dr. Harold C. Sox, an emeritus professor of medicine at Dartmouth Medical School and former editor of a leading medical journal, Annals of Internal Medicine, cautioned that the new study was not the last word. He said it was not clear that the same reduction in the death rate found in the study would occur in the general population.

Nonetheless, he said, "I suspect that removing polyps does reduce colorectal cancer mortality."

The type of evidence in this study, based on looking back at patient records, is not considered as reliable as that from a randomized controlled study, in which groups of patients are picked at random to have one treatment or another and then compared over time.

Dr. Sox also said that because all of the patients in the study had adenomatous polyps, it is not certain that the findings would apply exactly to the general population, in which this type of polyp is found in about 15 percent of women and 25 percent of men.

In addition, Dr. Sox said, the people with polyps were part of a study that provided high-quality colonoscopy, so they may not have been comparable to the general population.

Other studies have found that doctors vary in their ability to find polyps, that certain types of polyps are hard to detect and that colonoscopy is better at finding polyps in the lower part of the intestine than in its upper reaches.

Other screening tests look for blood in the stool, and if it is found, the patient is advised to have a colonoscopy. Another test, sigmoidoscopy, examines only the lower part of the colon. Barium enemas with X-rays can also show some abnormal growths. But sigmoidoscopy and barium enemas are not used much anymore in the United States.

Stool tests need to be done once a year; many people do not comply. In fact, a study from Spain in the same issue of the journal as Dr. Winawer's article found that when people were offered a stool test, only 34.2 percent took it. The figure for colonoscopy was even worse: 24.6 percent.

Colonoscopy does not have to be done every year: If there are no polyps, it is recommended just once every 10 years. People with polyps are usually told to have the test every three years.

But colonoscopy is expensive, costing hundreds or thousands of dollars, depending on whether polyps are removed and on the part of the country where it is done. It also carries small risks of bleeding or perforation of the intestine. And it requires sedation as well as strong, foul-tasting laxatives to clean out the intestines so that the doctor can look for polyps.

"Any screening is better than none," Dr. Winawer said. "The best test is the one that gets done, and that gets done well."

His study was paid for by the National Cancer Institute, Memorial Sloan-Kettering Cancer Center and private foundations dedicated to colon cancer.

Aging of Eyes Is Blamed in Circadian Rhythm Disturbances -


The aging eye filters out blue light, affecting circadian rhythm and health in older adults.


Dr. Martin Mainster and Dr. Patricia Turner, University of Kansas School of Medicine.

For decades, scientists have looked for explanations as to why certain conditions occur with age, among them memory loss, slower reaction time, insomnia and even depression. They have scrupulously investigated such suspects as high cholesterolobesity, heart disease and an inactive lifestyle.

Now a fascinating body of research supports a largely unrecognized culprit: the aging of the eye.

The gradual yellowing of the lens and the narrowing of the pupil that occur with age disturb the body's circadian rhythm, contributing to a range of health problems, these studies suggest. As the eyes age, less and less sunlight gets through the lens to reach key cells in the retina that regulate the body's circadian rhythm, its internal clock.

"We believe the effect is huge and that it's just beginning to be recognized as a problem," said Dr. Patricia Turner, an ophthalmologist in Leawood, Kan., who with her husband, Dr. Martin Mainster, a professor of ophthalmology at the University of Kansas Medical School, has written extensively about the effects of the aging eye on health.

Circadian rhythms are the cyclical hormonal and physiological processes that rally the body in the morning to tackle the day's demands and slow it down at night, allowing the body to rest and repair. This internal clock relies on light to function properly, and studies have found that people whose circadian rhythms are out of sync, like shift workers, are at greater risk for a number of ailments, including insomnia, heart disease and cancer.

"Evolution has built this beautiful timekeeping mechanism, but the clock is not absolutely perfect and needs to be nudged every day," said Dr. David Berson, whose lab at Brown University studies how the eye communicates with the brain.

So-called photoreceptive cells in the retina absorb sunlight and transmit messages to a part of the brain called the suprachiasmatic nucleus (S.C.N.), which governs the internal clock. The S.C.N. adjusts the body to the environment by initiating the release of the hormone melatonin in the evening and cortisol in the morning.

Melatonin is thought to have many health-promoting functions, and studies have shown that people with low melatonin secretion, a marker for a dysfunctional S.C.N., have a higher incidence of many illnesses, including cancer, diabetes and heart disease.

It was not until 2002 that the eye's role in synchronizing the circadian rhythm became clear. It was always believed that the well-known rods and cones, which provide conscious vision, were the eye's only photoreceptors. But Dr. Berson's team discovered that cells in the inner retina, called retinal ganglion cells, also had photoreceptors and that these cells communicated more directly with the brain.

These vital cells, it turns out, are especially responsive to the blue part of the light spectrum. Among other implications, that discovery has raised questions about our exposure to energy-efficient light bulbs and electronic gadgets, which largely emit blue light.

But blue light also is the part of the spectrum filtered by the eye's aging lens. In a study published in The British Journal of Ophthalmology, Dr. Mainster and Dr. Turner estimated that by age 45, the photoreceptors of the average adult receive just 50 percent of the light needed to fully stimulate the circadian system. By age 55, it dips to 37 percent, and by age 75, to a mere 17 percent.

"Anything that affects the intensity of light or the wavelength can have important consequences for the synchronization of the circadian rhythm, and that can have effects on all types of physiological processes," Dr. Berson said.

Several studies, most in European countries, have shown that the effects are not just theoretical. One study, published in the journal Experimental Gerontology, compared how quickly exposure to bright light suppresses melatonin in women in their 20s versus in women in their 50s. The amount of blue light that significantly suppressed melatonin in the younger women had absolutely no effect on melatonin in the older women. "What that shows us is that the same amount of light that makes a young person sit up in the morning, feel awake, have better memory retention and be in a better mood has no effect on older people," Dr. Turner said.

Another study, published in The Journal of Biological Rhythms, found that after exposure to blue light, younger subjects had increased alertness, decreased sleepiness and improved mood, whereas older subjects felt none of these effects.

Researchers in Sweden studied patients who had cataract surgery to remove their clouded lenses and implant clear intraocular lenses. They found that the incidence of insomnia and daytime sleepiness was significantly reduced. Another study found improved reaction time after cataract surgery.

"We believe that it will eventually be shown that cataract surgery results in higher levels of melatonin, and those people will be less likely to have health problems like cancer and heart disease," Dr. Turner said.

That is why Dr. Mainster and Dr. Turner question a practice common in cataract surgery. About one-third of the intraocular lenses implanted worldwide are blue-blocking lenses, intended to reduce the risk of macular degeneration by limiting exposure to potentially damaging light.

But there is no good evidence showing that people who have cataract surgery are at greater risk of macular degeneration. And evidence of the body's need for blue light is increasing, some experts say.

"You can always wear sunglasses if you're in a brilliant environment that's uncomfortable. You can remove those sunglasses for optimal circadian function, but you can't take out the filters if they're permanently implanted in your eyes," Dr. Mainster said.

Because of these light-filtering changes, Dr. Mainster and Dr. Turner believe that with age, people should make an effort to expose themselves to bright sunlight or bright indoor lighting when they cannot get outdoors. Older adults are at particular risk, because they spend more time indoors.

"In modern society, most of the time we live in a controlled environment under artificial lights, which are 1,000 to 10,000 times dimmer than sunlight and the wrong part of the spectrum," Dr. Turner said.

In their own offices, Dr. Mainster and Dr. Turner have installed skylights and extra fluorescent lights to help offset the aging of their own eyes.