Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Ties That Bind Help Stroke Patients

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Fred Kemp, 38, a former restaurant manager in Atlanta, Ga., has one simple goal: To open a refrigerator door with his left hand.

Five years ago, Kemp suffered a stroke as he dozed in front of his TV. When he woke up, he recalled, “I couldn’t get up. I tried again and again. I couldn’t move my left side,” forcing the former military hospital corpsman to dial 911 for an ambulance with his good right hand.

Ever since – until very recently – doctors gave him little hope that he would regain use of his left arm.

Every year, 600,000 Americans like Kemp have a stroke, a kind of heart attack in the brain caused by a blood clot or hemorrhage. Many stroke victims die, and many others don’t get effective treatment because they don’t get to the hospital soon enough. Indeed, stroke is still the third leading cause of death in America, after heart disease and cancer.

But, increasingly, people are surviving strokes. While that’s good news, it also means that there are more than 4.4 million stroke survivors living with varying degrees of disability.

Now, preliminary research shows that rehabilitation of long-paralyzed arms and legs may be far more possible than doctors once believed, at least for some types of stroke survivors. At the mecca for stroke rehabilitation, the University of Alabama at Birmingham, victims such as Kemp are achieving recovery levels once thought impossible.

There, psychologist Edward Taub has pioneered a simple but dramatic approach. It’s called CIM – constraint-induced movement therapy, or, as some put it, tough love.

The therapy involves putting the unaffected arm in a splint for most of a patient’s waking hours for two weeks and getting the patient to spend six hours every day using the bad arm in a series of increasingly precise exercises. For the therapy to work, the stroke survivor must have some control over the bad arm, such as the ability to open and close the hand.

To the astonishment of many in the stroke rehabilitation field, this approach seems to work, perhaps by rewiring parts of the brain or spinal cord.

“The idea that people can still experience improvement in the use of the affected side even years after their stroke, this is a revolutionary concept,” said Dr. Leonardo Cohen, chief of the human cortical physiology section at the National Institute of Neurological Disorders and Stroke. “The new approach, now being studied across the country, provides for the first time a treatment alternative for stroke patients, at a time when it was thought there was no treatment.”

One scientist who is not surprised at the way the new therapy is catching on is Taub. Back in the 1970s, Taub began working with monkeys who had had the sensory nerves surgically cut in one arm, but not the motor nerves. The monkeys could feel nothing in the bad arm, but the nerves that control movement were still intact.

Typically, Taub said, the monkeys learned that the bad arm was useless because they couldn’t feel anything. They’d try to move that arm, fail, and soon stop trying, a lesson that Taub calls “learned non-use.”

But, when he put a straightjacket on the monkey’s good arms, the results were remarkable. The animals started using their bad arms within two hours, Taub said, and, after just a week of training, used them fairly normally for the rest of their lives, even when their nerves had been injured as long as four years before treatment.

Recently, Taub and others have achieved similar results in people up to 21 years after they have survived strokes. So far, the method has been tried in about 200 patients.

In research published in June in the journal, Stroke, Taub, working with a German team led by Dr. Joachim Liepert, studied 13 people who had had strokes at least six months earlier and found that they were able to regain75 percent of their arm movement with constraint-induced movement therapy.

Moreover, a brain-mapping technique called Transcranial Magnetic Stimulation, or TMS, showed that, after constraint therapy, the part of the brain that controls the stroke-affected arm doubled in size, getting back nearly to normal.

That suggests that the damaged part of the brain might actually be coaxed to work again. In addition, the constraint therapy seems to boost activity in the side of the brain that does not control the paralyzed limbs. (Normally, the right side of the brain controls the left side of the body, so a stroke in the right brain may paralyze the left arm and leg.) That suggests that, for a person who had a stroke in the right brain, the left brain might be coaxed to take over the right’s work.

TMS does more than just show scientists what’s going on in the brain. It can also be used to change the pattern of electrical activity in parts of the brain, a technique that has already been used to treat severe depression.

In TMS, a coil of wire is placed on the head and an electrical current is passed through the wire in a rapid on-off pattern. That triggers a brief magnetic pulse that excites nerves in a specific region of the brain. Depending on how rapidly the current is turned on and off, the magnetic pulse can either increase or block nerve activity in the targeted brain area, explained Dr. Alvaro Pascual-Leone, director of the laboratory for magnetic brain stimulation at Beth Israel Deaconess Medical Center in Boston.

This suggests that, perhaps even without constraint therapy, TMS could be used to rewire the brain and restore movement to paralyzed limbs, though this has not yet been shown. And there’s one big caveat: Scientists must learn to control TMS sufficiently so that they don’t inadvertently block nerve activity where they’re trying to increase it. “That could actually make the outcome worse,” Pascual-Leone said.

For the immediate future, though, constraint therapy is grabbing the attention of patients and researchers, even though most insurers do not yet cover the technique.

At the National Institute of Neurological Disorders and Stroke, Cohen is analyzing the results of a controlled trial to see whether the constraint therapy is superior to conventional therapy, in which the patient is relatively passive and the therapist moves the patient’s paralyzed arm or leg.

At Emory University in Atlanta, neuroscientist and physical therapist Steven Wolf has begun enrolling 240 patients at seven medical centers around the country in a constraint therapy study called the EXCITE trial.

Like Taub’s monkeys, people learn not to use their weak arm or leg after a stroke, Wolf said, a problem made worse by the trend toward shorter hospital stays. Instead of being hospitalized for months as patients once were, most stroke victims are out in 14 days, which means “about the only thing a rehabilitation specialist can do is train people to get from the bed to the wheelchair,” he said. “That reinforces the notion of how not to use the impaired arm.”

In Boston, Judith Schaechter, who is both a neuroscientist and a physical therapist, has tried constraint therapy on four patients at Northeastern University. All four made clear gains, said Schaechter, who has moved her research to Massachusetts General Hospital.

One of her patients, Richard Mahoney, a 54-year-old Boston man who had a stroke last summer, barely used his right arm before constraint therapy. The treatment “helped me immensely,” he said. Now he uses his right hand all the time.

And Fred Kemp? After only three days of constraint therapy, he was able to open a refrigerator door with his bad left hand without having to think much about it. “I know I can open it. I couldn’t before.” The therapy is rigorous, he added. But it’s “going to be worth the effort to me to get something back.”

For more information on constraint-induced movement therapy, call:

  • The University of Alabama at Birmingham, Taub Training Clinic, at205-975-9799.
  • The EXCITE trial, headquartered at Emory University, at 404-712-2222 begin_of_the_skype_highlighting              404-712-2222      end_of_the_skype_highlighting.
  • Behavioral Neurorehabilitation Unit, Beth Israel Deaconess Medical Center, at 617-667-4074 begin_of_the_skype_highlighting              617-667-4074      end_of_the_skype_highlighting.

NUTS

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Let’s face it: We were brainwashed. For years, nutritional gurus strummed a one-note samba: All fats are bad. And many of us played along, giving up some of our favorite foods. Like nuts.

“Eighty to 90 percent of calories [in nuts] are from fat. So they were labeled as a high-fat food,” said Frank Hu, an assistant professor of nutrition at the Harvard School of Public Health. And, for the last two or three decades, he said, “health-conscious people tended to avoid them to lose weight and avoid heart disease.”

“We’ve been so biased about fat,” said Jeffrey Blumberg, a nutrition professor at Tufts University. “The thinking was that any high-fat food is bad.”

At long last, nutritionists are changing their tune. Now, they concede, there are both good fats and bad fats, and nuts are good again because they contain “the good kind of fat,” said Dr. George Blackburn, director of the center for nutrition and medicine at Beth Israel Deaconess Medical Center. They’re also good, he said, because “they satisfy in small portions.”

The emerging consensus is that saturated fats (the kind found in meat and dairy products) are the bad ones because they raise LDL or bad cholesterol in the blood. Monounsaturated and polyunsaturated fats (the kind found in nuts and olive, canola, corn, safflower and sunflower oils) are good because, though high in fat and calories, they do not raise LDL. In fact, polyunsaturated fats can actually lower LDL.

The same principle holds for peanuts and peanut butter, too, even though peanuts, despite their name, are technically classified as legumes, not nuts. Peanuts are good for you because they’re high in monounsaturated fats.

For the record, It’s only fair to note that this good-fat, bad-fat message is heavily promoted by some food industry groups, including the International Tree Nut Council, which sponsored a conference on the health benefits of nuts this fall at Georgetown University. The nut folks are also sponsoring a number of ongoing studies of the nutritional pros and cons of nuts.

But, with that caveat in mind, consider the growing evidence that nuts are good for you:.

The Iowa Women’s Health Study of 34,000 women, conducted between 1986 and 1992, found that women who ate nuts had a 35 percent reduction in heart attacks, compared to those who didn’t.

In 1992, a California study of 34,000 Seventh Day Adventists (who don’t drink or smoke) found that those who ate a small handful of nuts five days a week had 50 percent fewer heart attacks than those who didn’t. And no matter how the researchers sliced up the data looking at men alone, women alone, young people, old people, vegetarians or meat-eaters, the protective effect of nuts on the heart held up, said Dr. Gary Fraser, leader of the study and a cardiologist at Loma Linda University. The gist of 20 other studies, he said, is that regular consumption of nuts lowers blood cholesterol 8 to 10 percent.

In 1998, the Nurses Health Study of 86,000 female nurses confirmed the heart benefits of nuts, showing that women who ate at least 5 ounces of nuts a week had 40 percent fewer heart attacks than those who didnt. Many of the women who ate nuts substituted nuts for greasy steaks and fries, but the protective effect of nuts held true even for those who made less-drastic diet changes, said Hu, of Harvard, the lead author.

Preliminary results from a similar study, the Physicians Health Study, suggest that there are fewer sudden deaths among men who eat nuts, suggesting a similar heart-protecting effect in men, although, so far, the research has not been published.

It’s much less clear whether eating nuts helps prevent cancer. So far, limited data in human studies suggests no dramatic benefit. In rats, a study paid for by the Almond Board of California and conducted by Paul Davis, a research nutritionist at the University of California at Davis, found that rats that were fed almonds were less likely to develop precancerous changes in the colon after being injected with a cancer-causing chemical, compared to rats that didn’t get almonds.

Naturally, there’s a downside to this good PR for nuts: Because of their high-fat content, nuts are loaded with calories. But that doesn’t automatically mean they’re diet-busters. In fact, a nibble or two of nuts a day may actually help with weight loss, provided you don’t go overboard on overall calories.

In research presented last year at a scientific meeting, Kathy McManus, a registered dietitian at Brigham and Women’s Hospital in Boston, studied 101 overweight people who were put on either low- or moderate-fat diets that didn’t exceed 1,200 calories a day for women or 1,500 for men.

At the end of the 18-month study, the people on the low-fat diet had typically dropped out and regained some of their lost weight, while the moderate fat group was maintaining weight loss. Those on the moderate fat diet ate an ounce of nuts a day (170 calories worth), plus a tablespoon of oil and a teaspoon or two of peanut butter.

“The point is that, with a moderate-fat diet, people seem to be able to stay with a diet longer,” said McManus, whose research was paid for by three industry groups – the Institute and the International Tree Nut Council.

International Olive Oil Council, the Peanut

Among other things, she said, having an ounce or so of nuts in late afternoon can ward off the hungry horrors. You’re not so ravenous when you walk in the door, which means you’re less likely to eat a lot while you’re cooking dinner.

And there’s yet another reason to eat nuts: They are full of arginine, an amino acid that helps the body make nitric oxide, which helps blood vessels dilate, thus lowering blood pressure. They’re also loaded with vitamin E and other antioxidants, which prevent damage to DNA and cells from chemicals called free radicals.

The bottom line is that nuts are no longer taboo. If you want to add them to your diet, you probably should try eating them instead of something like cream or red meat. And keep portions modest, like the small packets of nuts that airlines hand out. In other words, don’t go totally nuts.

SIDEBAR: Going Nuts Over Nuts

For years, nuts were regarded as unhealthy because they are high in fat. But researchers believe nuts got a bad rap: they contain no cholesterol and are high in both polyunsaturated and monounsaturated fats, which are considered good because they promote a healthy heart. And nutrients in nuts compare favorably to common foods such as chicken and hamburger.

Calories (kcals)

Protein (grams)

Cholesterol (mg)

Saturated fat (grams)

Mono- un saturated fat (grams)

Poly unsaturated fat (grams)

Total fat (grams)

Almonds

578

21

0

4

32

12

51

Cashews

574

15

0

9

27

8

46

Hazelnuts

628

15

0

4

46

8

61

Macadamian

716

8

0

12

59

1

76

Pecans

691

9

0

6

41

22

72

Pistachios

567

21

0

4

25

14

46

Walnuts

654

15

0

6

9

47

65

Lean hamburger

268

24

78

7.2

8

1

18.3

Chicken

173

31

85

1.3

1.5

1

4.5

Butter

108

0.1

33

7.6

3.5

0.5

12.2

Note: Nutrient information is based on 3.5-ounce servings, except butter, which is based on one tablespoon. SOURCES: USDA Nutrient Database for Standard Reference, Bowe and Church’s Food Values of Portions Commonly Used

Stressed Out

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BURNED BY LAWSUITS AND LOW PAY, RADIOLOGISTS ARE QUITTING, MAKING WOMEN WAIT LONGER TO FIND OUT IF THEY HAVE BREAST CANCER.

For years, breast cancer specialists have quite rightly touted mammograms as the best way to detect tumors while they’re small and highly treatable 

Indeed, if a tumor is caught early – while it’s 1 centimeter or less in diameter – the odds of living 16 to 20 years are better than 90 percent, according to the American Cancer Society.

But, just as women are getting the message – doubling the number of mammograms performed annually since 1985 – doctors who read the X-rays seem to be fleeing the field at an alarming rate. Caught between rising litigation over allegedly missed tumors and low reimbursement for their services, a growing number of radiologists say their field just isn’t worth the stress any more.

“I personally would not recommend that a resident or fellow work full time in breast imaging because of the likelihood of burnout,” said Dr. Ferris Hall, a radiologist at Beth Israel Deaconess Medical Center in Boston.

And Hall appears to speak for many in his profession. The retirement rate of radiologists doubled from 1995 to 1997, from 400 to 800 a year, while the number of new radiologists specializing in mammograms dropped by 80 percent, according to a study by the American College of Radiology. Lamented Hall in the September issue of the journal of the American College of Radiology: “There is a disproportionate shortage of qualified mammographers.”

For women, radiologist burnout translates into a months-long wait for routine screening at many centers – when the mammograms are available at all. A prominent clinic, run by New York University, shut down altogether recently because it was losing too much money.

“It’s ridiculous what patients have to put up with,” said a disgruntled 61-year-old Needham woman who asked that her name not be used. She was told that she would not be able to get an annual mammogram until next February – even though she has had “suspicious things that needed to be checked” on past mammograms. “I’m extremely uncomfortable about that extra five-months wait,” she said.

While no one claims the radiologist shortage is costing lives – at least, not yet – delays in getting a routine mammogram can be dangerous. The five-year survival rate for breast is confined to the breast when it is discovered, but plummets to 21.3 cancer is 96.3 percent if the tumor percent if the tumor has spread to other organs.   Ironically, the mammogram crunch comes at a time when there are a number of technological advances that could make breast cancer screening more accurate, albeit more expensive.

“We are on the verge of possible significant breakthroughs in cancer detection, especially with digital mammography and MRI, or magnetic resonance imaging,” said Dr. Daniel Kopans, director of breast imaging at Massachusetts General Hospital.

Yet, far from a golden age of breast cancer screening, the signs of an impending crisis in mammography are growing:

Young doctors are avoiding the field.

Fellowships in breast imaging, an important part of the training for radiologists who want to specialize in mammograms, now go begging. “Two years ago, there were not enough fellowships for would-be mammographers,” said epidemiologist Robert Smith, director of cancer screening for the American Cancer Society. “Now, they can’t fill the ones they have.”

At the same time, overburdened radiology offices are cutting back on discount mammograms for uninsured and low-income patients. Last year, more than 2,200 facilities offered discount mammograms during a national screening day organized by the American College of Radiology; this year, half that number signed up.

“How can I offer free mammograms when I have a four- to five-month wait for my own patients?” one doctor said.

Adding to the disenchantment, technologists, the people who actually take the mammograms, are dropping out of the field as well. “Techs take a lot of abuse from patients who are scared or upset thinking they might have cancer, and they don’t get paid well,” said Linda Santos, a technologist who manages the breast imaging service at Mass. General.

Perhaps most distressing, some centers, such as the NYU clinic in New York, are simply shutting their doors.  “For every patient we see, we lose money. And the more patients we see, the more money we lose. It’s very simple, really,” explained Dr. Gillian M. Newstead, NYU’s director of breast imaging.

And epidemiologist Smith of the American Cancer Society said he believes that a lot of other facilities “would love to give it up, but are compelled to keep it because of contracts with managed care groups and employers.”

Indeed, the math is not even faintly fuzzy.

Medicare, the federal insurer, pays $67.81 for a screening mammogram, of which the doctor gets less than $22 (And unlike other reimbursements, the Medicare fee for mammograms is set by federal statute; that means that raising it takes congressional action.)

Some private insurers pay a bit more, up to $90, but the costs of maintaining X-ray machinery up to stringent federal and state standards, paying technologists and keeping offices running can run $100 per mammogram, not even counting the doctor’s fee, Newstead said.

“It’s ridiculous, what they expect us to do,” said Dr. Norman Sadowsky, director of the Faulkner-Sagoff Breast Imaging and Diagnostic Centre at Faulkner Hospital.

“The result is that some radiologists are being forced out of the breast-imaging business,” said Dr. W. Max Cloud, president of the American College of Radiology and a mammographer at the Baystate Medical Center in Springfield. “We are going to see more and more facilities dropping out of breast imaging.”

Making matters worse is the growing fear of malpractice suits. A decade ago, gynecologists were the most likely to be sued for failure to diagnose breast cancer. Now it’s radiologists, according to a 1995 study by the Physician Insurers Association of America, a Maryland-based trade group of physician-owned medical malpractice companies.

“Failure to diagnose breast cancer is the number-one allegation against all doctors, in Massachusetts and nationally,” said Martha Byington, a loss-prevention specialist at the Risk Management Foundation, which insures Harvard doctors and hospitals.

Part of the trend toward naming radiologists in breast cancer lawsuits is undoubtedly due to rising public expectations for mammography, despite the fact that mammograms can be extremely difficult to read. Indeed, with hindsight – that is, after a diagnosis of breast cancer – radiologists say they can often look back at old mammograms and pick up tell-tale signs of cancer that, on first reading, did not raise a red flag.

Still, there is no question the rise in litigiousness  and high monetary awards in malpractice cases is scaring radiologists. Last year, for instance, a Topsfield woman was awarded $5.5 million after a jury decided her doctors at Beverly Radiology Associates failed to detect her breast cancer on mammograms taken in 1989 and 1992. Since then, the parties in the case have reached a settlement for an undisclosed sum.

In June, a woman from the Bronx in New York sued her doctors for not catching her breast cancer on a mammogram, after the state health commissioner in May suspended the doctors’ licenses for poor breast cancer screening practices, including the use of mammograms done with the wrong film and the wrong machine. Other high-profile cases in Hawaii and Florida have also resulted in significant monetary awards.

One result of such cases, Byington noted, is that “physicians are practicing more cautiously now and they do order more tests, for which they may not get paid.” And that, of course, compounds the problems for mammographers.

“The legal climate in which radiologists work is potentially severe,” said Dr. R. James Brenner, director of breast imaging at the John Wayne Cancer Institute in Santa Monica, Calif., and head of a new task force convened by the radiology college to document the growing problems in mammography.

The bottom line, said one Massachusetts radiologist who has been sued for failing to find breast cancer on a mammogram, is:   “If given the option, many radiologists would not do mammograms anymore. It’s just too stressful.”

Judy Foreman is a Lecturer on Medicine at Harvard Medical School. Her column appears every other week. Past columns are available on www.myhealthsense.com.

SIDEBAR: Imaging Systems Improve Accuracy

Were it not for the economic and legal problems now facing mammographers, these would be exciting times in breast imaging. A number of advances in imaging technology could make breast cancer detection considerably more accurate than mammograms, which miss about 15 percent of cancers.

“We hope that these techniques will help us detect cancers that are not visible on mammograms and can’t be felt,” said Dr. Daniel Kopans, director of breast imaging at Massachusetts General Hospital.

Traditional mammograms, which take an X-ray photo of the breast, remain the overwhelming majority of the 30 million breast images made in the United States annually. But that may soon change, especially as digital film and magnetic resonance images become more available – and affordable.

Digital mammography, in which an X-ray image of breast tissue is captured electronically instead of on film, gives the radiologist far more flexibility in how he or she views the image. A film mammogram that is too dark or too light cannot be significantly altered.

But, with digital mammography, the image can be manipulated on a computer to heighten contrast and tease out details of suspicious areas.

“The excitement about digital is not just that you can manipulate the image but that we will be able to do things with X-ray imaging that we have never been able to do before,” Kopans said. Most importantly, he said, radiologists will be able to look at sequential levels of breast tissue, in essence becoming able to spot tumors that would otherwise be hidden.

The big drawback is that a digital mammography machine can cost roughly $750,000. “It’s very, very expensive,” said Dr. Kevin Hughes, director of the breast centers at the Lahey Clinic in Peabody and Burlington. Even so, he predicted, the number of centers that will have it will go up year by year.

A number of centers are also beginning to use a variant of digital mammography called CAD, or computer-aided detection. With this technique, a film image of the breast is converted to a digital image so that a computer can read it. In essence, this system enables a mammographer to improve accuracy by doing a double read: The radiologist reads the standard X-ray, then the computer checks the digital image and highlights suspicious areas.

“MRI [magnetic resonance imaging] scans are also pretty exciting,” said Dr. Norman Sadowsky, director of the Faulkner-Sagoff Breast Imaging and Diagnostic Centre at Faulkner Hospital, who is using the technique for certain patients.

Because MRI scans involve an injection of a substance that heightens the contrast between normal and abnormal tissue, and because the machines cost $500,000 to $2 million, they aren’t likely to be used soon for standard screening of healthy women.

But researchers are already using MRI to test women at high risk of breast cancer whose breasts are dense or whose breasts are difficult to image on regular mammograms for other reasons. MRIs are also beginning to be used to define the extent of cancer in a woman whose mammogram clearly shows a tumor. MRI already appears to be the best way doctors have of determining how large a tumor is.

Ultrasound, too, is increasingly being used as an adjunct to standard screening in women who have suspicious mammograms. In ultrasound, sound waves are bounced off breast tissue to detect abnormalities. The images generated are less effective than standard mammograms at picking up areas of calcification that might need further testing, which means they probably wont be used for initially screening healthy women. But they are very good at differentiating between a harmless, fluid-filled cyst and a cancer, Hughes said.

Other techniques also are in the works. At Lahey, researchers are studying several heat-based tests for breast cancer detection, including a technique called computerized thermal imaging, which uses low levels of electrical current to detect the heat signature of the breast. The idea is that cancerous lumps have more blood flow and therefore become hotter than normal tissue. Whether that translates into an accurate detection test is not yet clear.

Overlooked Benefits of RU-486

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Doris Laird, a humanities professor at Florida A&M, believes RU-486, the controversial abortion pill that won government approval late last month, will be a lifesaver.

She should know. The 69-year-old Laird has been taking the drug for seven years, not to induce abortion but to control a slow-growing, benign brain tumor called meningioma that once threatened her vision and her life.

Though the medical community is divided on the effectiveness of RU-486 on meningioma, you can’t tell that to Laird. Since she’s been on it, “my brain tumor has not grown at all,” she said.

Lost in all the heated rhetoric and debate over RU-486, which the Food and Drug Administration OK’d after years of political wrangling, is the likelihood that the drug could be much more than just an abortion inducer.

Researchers around the country are already gearing up to study other potential uses of the drug in projects that had been impossible while RU-486 was not legally available in this country and research supplies were limited.

Research was stalled for years because there has been virtually no supply of the drug, said Eleanor Smeal, president of the Feminist Majority Foundation, a Virginia-based national women’s-rights group that helped provide Laird and the roughly 40 other Americans who have been using the drug for nonabortion purposes on a compassionate-use basis.

But now that the drug is approved, “researchers are beating on my door to test it for other uses,” said Dr. Richard Hausknecht, medical director at Danco Laboratories in New York City, the drug’s distributor. “We’re anxious to see this research go forward,” he added, noting Danco has plenty of the drug on hand to share with researchers.

Researchers are excited about RU-486 as a multipurpose drug because of its effectiveness at blocking the hormone progesterone. Because a woman’s uterus cannot maintain pregnancy without progesterone, blocking its production effectively ends gestation.

But progesterone also can drive a number of tumors – both benign tumors like meningioma and malignant ones such as breast, uterine and ovarian cancer. Thus, blocking progesterone in patients with these conditions should, in theory, slow tumor growth.

Progesterone also drives a number of non-cancerous conditions such as uterine fibroids, which affect more than 20 percent of women over 30 and contribute substantially to America’s 600,000 hysterectomies every year, and endometriosis, an abnormal growth of uterine tissue outside the uterus, which affects 5 to 15 percent of reproductive-age women.

Moreover, by lowering levels of the stress hormone, cortisol, RU-486 may also help people with Cushing’s disease, a disorder of the pituitary.

Even outside of research trials, some patients may soon be able to get access to RU-486, also known as mifepristone and Mifeprex, for nonabortion uses. Once the drug is on the market, which is expected within a month, any qualified doctor who sets up an account with Danco can legally provide

Mifeprex to patients both for abortion and “off-label,” or nonapproved, uses as well. The first off-label uses are likely to be other pregnancy-related conditions. In France, Hausknecht noted, the drug is already approved to soften the cervix before a surgical second trimester abortion and to induce labor in women whose fetuses have died in utero.

Mifeprex also may help women who have early ectopic pregnancy, in which the fertilized egg implants in a Fallopian tube rather than the uterus. Hausknecht, who is also an associate professor of obstetrics and gynecology at Mount Sinai School of Medicine in New York, hopes to start a multicenter trial of Mifeprex for this use soon. In Europe, he said, researchers have already shown that when RU486 is combined with another

drug, methotrexate, it boosts the success rate for early ectopic abortion from 75 to 90 percent.

Uterine fibroids, which, like the uterus itself, are sensitive to progesterone, also respond to Mifeprex, though they may start growing again when the drug is stopped. A small study by California researchers published in 1993 in the Journal of Clinical Endocrinology and Metabolism showed that RU-486, taken daily for three months at far smaller doses than those used for abortion, shrank fibroids significantly.

Another small California study, published in 1998 in the American Journal of Obstetrics and Gynecology, showed that RU-486, in tiny doses, reduced the pain of endometriosis, although it did not seem to slow the abnormal growth per se. More data are needed, said Dr. Johanna Perlmutter, an obstetrician-gynecologist at Beth Israel Deaconess Medical Center in Boston, but Mifeprex should be useful for endometriosis.

For cancer treatment, perhaps the most tantalizing findings were those published earlier this year in the Journal Gynecologic Oncology by researchers from the Robert Wood Johnson Medical School in New Jersey.

They studied 34 women whose ovarian tumors had not responded to standard chemotherapy drugs and found that Mifeprex seemed to slow the cancer in about a quarter of the women, resulting either in at least a temporary shrinkage of the tumor or a decrease in a tumor marker called CA-125 as shown by blood tests.

In uterine cancer, preliminary data suggest that RU-486 can stop tumor growth in the test tube. In breast cancer, early studies suggest that the drug may hold the disease in check in some women, according to a 1994 review of the data by Dutch researchers.

And what of those, like Doris Laird, who struggle with meningioma? Laird’s tumor seems not to have grown, though whether that’s due to RU-486 or the naturally-slow growth of this kind of tumor is unclear. Other people with meningioma, among them, Sheila, a 53-year old writer and editor who lives in a Boston suburb and did not want her last name used, have not been so lucky. Sheila took RU-486 as part of a study and believes “it bought me at least18 months or better of time.” She stopped taking the drug when brain scans showed her tumor was growing slowly. Unfortunately, the biggest study to date on RU-486 and meningioma seems to be yielding disappointing results.

Several years ago, a pilot study led by Dr. Steven Grunberg, a medical oncologist at the Vermont Cancer Center in Burlington, showed that the drug seemed to benefit about a half-dozen of the 28 people tested.

“You do not get dramatic shrinkage of the tumors but vision improved in two people who had been losing their sight,” he said. “It only takes a slight change in the right direction to see that they were delighted.”

At Beth Israel in Boston, Dr. Daniel Karp, director of cancer clinical research, also saw two of his meningioma patients stay stable for many months after stopping the drug.

But a number of researchers around the country, including Karp and Grunberg, have now pooled their data on 192 meningioma patients and the emerging picture is less rosy. In fact, patients taking RU-486 did not fare any better than those on placebo, Karp said.

“For the average patient, it did not look promising,” said Dr. Peter Ravdin, a medical oncologist at the Southwest Oncology Group in San Antonio, Texas, who is analyzing the study. “But we’re still looking to see if there is a subset of people who would benefit.”

Such hopes and disappointments, of course, are the essence of medical research. But even if RU-486 does not fulfill all of researchers’ hopes, that it can now be studied for many conditions other than abortion is welcome news.

Smeal, of the Feminist Majority, vows to continue fighting for the drug, this time for nonabortion uses: “Our next major campaign is to press the NIH [National Institutes of Health]for funding for these trials.”

When Drugs Are The Only Choice For A Mother-To-Be

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Jennifer Peterson was 35 and barely one week pregnant when she noticed a lump the size of half a banana in her breast. A few weeks later, tests  showed she had invasive breast cancer.

The irony was mind-numbing: A potential new life beginning inside her,   her own life threatened. For months, Jennifer, a resident of Manchester, N.H., who runs a small Boston law firm with her husband, had been trying to get pregnant. Now, the choices were stark: If they waited to treat the cancer until Jennifer gave birth, her survival could be greatly diminished. If they terminated the pregnancy, they might never conceive again, because chemotherapy can put a woman into premature menopause.

And then there was the third terrifying option, the one they chose: To go ahead with both treatment and the pregnancy.

“There were bad times – three surgeries and three months of chemo. I was bald, fat and one-breasted,” she said. But, through it all, Jennifer said, husband Karl Sucheki “loved me and was just as excited as I was.” Their “chemo kid,” Michael, was born full term and healthy two years ago.

Not long ago, many prospective parents – and doctors, too – would have shuddered at the very idea of subjecting a pregnant woman and her fetus to powerful drugs or surgery. But growing evidence suggests that, in many cases, such interventions may not only be safe but essential to protect both mother and fetus.

Mercifully, the collision of pregnancy and serious illness is not an everyday occurrence. But some cancers, notably leukemia and some types lymphoma, often strike in the mid to late 20s, said Dr. Lawrence Shulman, an oncologist at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital. Breast cancer is an even bigger threat, now occurring in one in 3,000 pregnancies, according to the National Cancer Institute. That figure is likely to rise as more women have babies later in life.

Other serious problems, including depression, asthma, epilepsy and infections also can occur during pregnancy and may need to be treated just as aggressively as if the woman were not pregnant, said Dr. Michael Greene, director of maternal-fetal medicine at MGH.

The biggest problem is drugs that cross the placenta, which nourishes the fetus. Once inside, some drugs can cause congenital malformations, especially during the first trimester of pregnancy, when the major organs are forming.

But, surprisingly, few prescription drugs are “absolute no-nos,” Greene said. Those are Accutane, an acne medication; thalidomide, now used to treat leprosy; ACE inhibitors to control blood pressure; Cytotec, which both causes birth defects and induces abortion; methotrexate, an anticancer drug that also induces abortion; and Coumadin, a blood thinner that can induce fetal hemorrhage.

Not quite as dangerous but still risky are some antiseizure medications and drugs used to control an overactive thyroid gland. Curiously, some over-the-counter drugs may also carry risks, especially aspirin and the NSAIDS (nonsteroidal anti-inflammatory drugs like ibuprofen).

With those caveats firmly in place, however, it’s often better for both mother and fetus to treat a serious disease than leave it untreated.

Take depression. For many years, doctors thought the sheer bliss of expecting a baby – not to mention the hormone surges of pregnancy – meant “that patients would do fine psychiatrically without medications even if they had been on them for many years,” said Dr. Lee Cohen, director of the perinatal and reproductive psychiatry research program at Mass. General.

It is now clear, Cohen said, that women who stop antidepressant medications during pregnancy fare poorly, generally relapsing in three to six months. That prospect terrified a Boston lawyer, now in her mid-30s, who had been taking Prozac for years and didn’t want to stop when she got pregnant. She “had to keep on working and stay highly functional,” she said, and knew her own “mental health would be important for the baby.”

Indeed, leaving depression untreated can be life-threatening for women who are suicidal and may be bad for the fetus as well because of the stress hormones that accompany depression. Pregnant women who are depressed are more likely to have obstetrical complications, including premature labor, low-birth-weight babies and to have babies who are cognitively impaired, Cohen noted.

Once the baby comes home, women who were depressed during pregnancy are five times more likely to suffer postpartum depression, which can interfere with parent-child bonding.

Moreover, some antidepressant medications appear to be quite safe for the fetus, particularly Prozac, a so-called SSRI (selective serotonin reuptake inhibitor) whose effects have now been tracked in 2,000 pregnant women.

In a major study published in 1997 in the New England Journal of

Medicine, Canadian researchers studied the children of 80 mothers who took Prozac or an older type of antidepressant drug such as Tofranil and Pamelor during pregnancy. As other studies had hinted, no matter when in the pregnancy a woman took the medications, there were no congenital malformations in the fetus, said psychiatrist Donna Stewart, who heads the women’s health department at the University of Toronto and was a co-author of the study.

In fact, the researchers followed the children for up to seven years and still could find no evidence that those exposed in utero to antidepressants were any different from unexposed children in global IQ, language or behavioral development A separate study in California in 1996 did show a slightly increased risk that babies with in-utero exposure to antidepressants would be placed temporarily in intensive care nurseries for observation, but more recent research by Cohen’s team at MGH refutes this.

For pregnant women with manic depression, severe anxiety or schizophrenia, it may also make sense to continue on medication. Lithium, a major treatment for manic depression, has caused concern because it can raise the risk of congenital heart disease. But the risk with lithium is smaller than once thought, Cohen said. He calls lithium “100 times safer than

Depakote,” an antiseizure drug that’s often used in manic-depression, but that can significantly raise the risk of spina bifida (incomplete closure of the spinal cord) in the fetus.

For pregnant women who are schizophrenic, older antipsychotic drugs such as Haldol and Stellazine do not increase the risk of birth defects, though there’s less data on newer antipsychotic drugs such as Zyprexa and Risperdal. Anxiety and especially panic attacks may also need treatment during pregnancy, either with antidepressants (that combat anxiety, too) or low dose benzodiazepines such as Klonopin if psychotherapy fails to help.

For pregnant women with cancer, the decision to treat the cancer is a delicate balancing act that is slightly easier at the extreme ends of pregnancy.

If a woman develops acute leukemia in the first few weeks of pregnancy, said Shulman of Dana-Farber, “you have little option to” wait because the woman could die quickly, which means terminating the pregnancy often makes sense. And if a woman is close to the end of pregnancy – say, 30 weeks (a normal pregnancy is 40 weeks) – doctors can often deliver the baby safely and then treat the mother’s cancer.

But for women who learn of their cancer mid-pregnancy, the choices get tougher. Fortunately, some chemotherapy drugs such as Cytoxan appear to

be safe for the fetus, at least in the last trimester, even though such drugs often act on rapidly dividing cells (and a fetus could be viewed as a collection of such cells).

Radiation is usually avoided during pregnancy because of possible damage to the fetus, but if the mother has a tumor that’s pressing on major blood vessels in the chest, it may be necessary. Jennifer Peterson, for example, delayed radiation treatment for her breast cancer until six days after her son, Michael, was born.

On the other hand, surgery – except on the uterus itself – is often safe for pregnant women. Even general anesthesia is not a big deal, said Greene of MGH. “The fetus gets sleepy, but it wakes up” when the operation is over.

No pregnant woman, of course, wants to have any of these interventions if she can help it.

Chemotherapy, in particular, is terrifying, Jennifer Peterson said. “You are putting a highly toxic substance into your body at this sacred time in life when your body is supposed to be a temple and all of a sudden you’re turning it into a toxic waste dump.”

But right after Michael, her “chemo kid,” was born, she and her husband began thinking of having another child. Their second gorgeous baby, Matthew, was born two months ago, and Jennifer has no signs of cancer.

“I think the human body is truly amazing,” she said. “And it’s never more awe-inspiring than during pregnancy and birth. My beautiful son, Michael, is testament to the fact that you and your in-utero baby can endure surgery and chemotherapy while pregnant and both end up healthy. And my wonderful newborn, Matthew, is proof that the circle of life does, indeed, continue to miraculously turn.”

Ambiguous Losses Leave Survivors In Limbo

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This is a love story – but one with the kind of anguished twist that millions of Americans must grapple with.

“Betsy, Betsy, Betsy, I love you,” Frederick “Pete” Peterson, now 84 and living in an assisted-living facility in Peabody, used to say, before Alzheimer’s disease slowly stole his brain.

Betsy and Pete Peterson met decades ago when Pete, then an English teacher at Phillips Academy in Andover, hired Betsy to help him run the school’s summer enrichment program.

He was tall, handsome and charming – a recreational sailor with a warm smile and a firm handshake. She was pretty, bright and vivacious. They worked together for a few years until Betsy left to become the first woman dean at Yale College. Then, after Pete’s first wife died, Betsy and Pete saw each other again – and married 22 years ago.

Now, it’s been ages since Pete called Betsy by name. “I miss that,” said Betsy, 62, who lives alone in the couple’s Boston condominium. “After a while, you realize you haven’t heard it. It’s the sort of non-event that marks the transition” from a marriage of soulmates to a strange limbo in which one spouse is alive but has lost much of his personality, while the other is essentially widowed – but without the closure, the rituals that foster healing, or the freedom to rebuild a life.

For years, psychologists had no name for the anguish of situations like that of Betsy. Now they do, thanks in part to Pauline Boss, a psychologist in the department of family social science at the University of Minnesota.

In her book, “Ambiguous Loss,” published by Harvard University Press, Boss explores the corrosive uncertainty and deep confusion faced by people who have lost, yet not quite lost, someone or something dear to them.

Sometimes, the loss occurs when a spouse has Alzheimer’s disease, or a stroke or other brain injury that leaves them alive but “not there.”

Sometimes, it’s the reverse – a loved one is physically absent but psychologically present, as happens, for instance, when children are abducted or vanish.

In fact, that’s exactly what happened 49 years ago to Betty and Kenneth Klein, now 75 and 83, whose three young sons – ages 4, 6 and 7 – simply disappeared one Saturday morning from a playground near their home in Minneapolis.

At the time, the Kleins also had one other son, age 9, and a baby on the way. After their sons’ disappearance, they went on to have three more children. But even a half-century later, their loss is as vivid – and perplexing – as ever.

When a reporter calls, for instance, Kenneth quickly summons Betty to the phone, hope and fear in his voice: “It’s about the boys.” She picks up the phone – and the story. To this day, she said, every time someone walks by or a strange car pulls into the driveway, “I always think, `Is it one of my boys?’ “

She and Kenneth have dealt with their baffling loss by praying, not blaming each other, and sticking together “very tightly,” she said.

The issue of ambiguous loss first intrigued psychologist Boss when she studied the families of pilots who had been shot down over Vietnam and were declared missing in action.

She said she found that, in contrast to more clear-cut losses, such as the death of a spouse, ambiguous losses can be even “harder to deal with because there is no closure, there’s no death certificate, there’s no public validation that this has ended.”

Carol Wogrin, a nurse, clinical psychologist and executive director of the National Center for Death Education at Mount Ida College in Newton, said that “one of the tasks of grief is really knowing that that loss has occurred. Even with a loss as clear cut as a death, she said, people often acknowledge the loss intellectually long before they really know it emotionally.

With a more ambiguous loss, emotional understanding can be harder because, Wogrin said, “a person doesn’t have all those factors that help reinforce” the reality.

It’s dangerous to get into the game of “competitive grief,” downplaying someone else’s pain because you think it’s not as bad as your own, warned Deborah Rivlin, a consultant at the Good Grief Program at Boston Medical Center, a nonprofit program that teaches grief education to children.

Still, she said, ambiguous losses can be particularly difficult, especially because, at least initially, other people may not recognize them clearly as legitimate losses. Many situations, including gradual changes like physical decline or being pushed aside at work, fall into this category.

For instance, parents who have had a stillbirth or lost a hoped-for baby to miscarriage may suffer grief that is all the more painful because the rest of the world fails to acknowledge it. This grief may even be compounded if, as used to happen routinely in hospitals, the “remains” of that pregnancy are whisked away, leaving no tiny body to cry over or bury.

But other situations may also provoke the same kind of long-term, wrenching ambiguity.

It can happen in families in which one member is an alcoholic or addicted to drugs. It can happen to children of divorce who may grieve for the death of the family, even though both parents are present in their lives. And it can happen to spouses of workaholics, who may be home in body, but whose minds are chronically at work, Boss said.

The toughest issue, she said, is the question of how not to become “frozen” in grief and how – and when – to move on.

The Kleins of Minnesota managed to move forward by realizing they had to be strong for their other children, Betty Klein said.

But does moving on, in cases where one spouse has Alzheimer’s, mean that it’s OK for the healthy spouse to form a new romantic relationship?

That issue comes up often, said Paul Raia, a psychologist at the Massachusetts chapter of the Alzheimer’s Association. “The men in my support group will date while the wife is still alive, though it’s very controversial in the group,” he said. “I have never seen a woman do that.

But other mental health specialists, including Dr. Bessel van der Kolk, professor of psychiatry at Boston University, don’t see such a clear gender breakdown on this issue.

“People need to go on with their lives,” he said, though forming a new relationship “raises enormous moral questions.” If the relationship includes sex, he said, it often generates considerable guilt. But short of that, he said, “it’s amazing how many different arrangements people make: Many people find people who meet their emotional needs.”

Betsy Peterson has tried to do just that, learning, as she puts it, “to be a widow” even though Pete is still alive.

She said she feels “very married” to Pete, still works part time as a lawyer and has “reached out a lot in the last few years,” especially to members of her church and book groups.

Even so, it’s tough. But one thought never fails to boost her spirits: “Knowing Pete has been such a gift. His friendship was such a gift. Our marriage is the best thing that’s happened in my life, so I am still ahead, even at this stage. That sense of the gift is one of the ways I get through it.”

Treatments For Manic Depression Are Improving

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Michael Penney, 53, of Holliston used to have, as he puts it, “a charmed life.” Marriage. A son. A master’s degree in marine economics and law, and good jobs, including an eight-year stint at the state office of Coastal Zone Management.

But his charmed life came to an end five years ago when he worked for an employer who humiliated him in meetings. One day, Penney erupted in a rage that stunned him as much as his colleagues. He was hustled away when he couldn’t stop sobbing.

Though the explosion seemed to come out of the blue, there had been clues. His mother and father were both mentally ill, and Penney had been very depressed in college. Even so, it took years for his psychiatrist to put the pieces together: Penney’s problem, it turns out, was manic depression, a hard-to-diagnose brain disorder that afflicts 5 to 10 million Americans.

People with manic depression have profound mood swings from paralyzing despair to agitated “highs” that can include paranoia and delusions. “Rapid cyclers” swing between these two extremes more than four times a year, and some, like Penney, swing even faster: “I can go from real bereavement to laughing like a nut in seconds,” he said.

For most of the last 50 years, there has been only one treatment for manic depression – lithium, a mood stabilizer. But lithium causes troublesome side effects, such as tremors and intestinal problems. It also may be only partially effective, and raising the dose can make side effects worse without improving symptoms.

Today, however, the outlook for people with manic depression, also known as bipolar disorder, is brightening considerably and should improve even more as a new study of manic depression – the largest psychiatric clinical research program ever undertaken – gets underway at Massachusetts General Hospital in Boston and elsewhere.

Central to the improving prospects for those with manic depression is psychiatrists’ discovery that drugs designed to treat schizophrenia – in which sufferers often endure hallucinations as well as emotional numbness – also work againstmanic depression.

That may be because of a common biochemical pathway between manic depression and schizophrenia, according to Dr. Andrew Stoll, director of the psychopharmacology research lab at McLean Hospital in Belmont. Because delusions, which are false beliefs that cannot be rationally refuted, and hallucinations, hearing or seeing things that aren’t there, often occur in both schizophrenia and mania, drugs that treat these symptoms in one disorder may help in the other as well.

In addition, these antipsychotic drugs help some people with manic depression even if they are not out of touch with reality, suggesting that the drugs directly affect mood as well as psychoses, said Dr. Nassir Ghaemi, an MGH psychiatrist.

The antipsychotic drugs that help most with manic depression include Risperdal, Seroquel and Clozaril, a medication that can also cause a potentially fatal drop in infection-fighting white blood cells. Because of this, patients taking Clozaril must get frequent blood tests.

In March, the US Food and Drug Administration increased the options for people with manic depression by approving a drug for mania called Zyprexa, already on the market for schizophrenia.

Zyprexa causes fewer side effects than the somewhat similar Clozaril and does not necessitate frequent blood tests, said Dr. Franca Centorrino, a Zyprexa researcher and director of bipolar and psychotic disorders at McLean Hospital. Its expanded approval is exciting, she said, because it’s “the first antipsychotic approved for acute mania.”

And it’s not just antipsychotic drugs that help with manic depression, but drugs that prevent convulsions, such as Depakote, Tegretol and Lamictal, as well. Two other anti-convulsants, Neurontin and Topamax, also may help stabilize mood, though the data is less clear. Designed for epilepsy, these anticonvulsant drugs may reduce the intensity of both mania and depression.

But perhaps even more important than the growing array of drug treatments – including two dozen new drugs in the pipeline – is an emerging understanding of how to combine these medications with specific talk therapies.

At MGH, the University of Pittsburgh, the University of Colorado and 17 other sites nationwide, a five-year, $20 million research project is gearing up to find the best drug and talk therapy combinations for manic depression.

Sponsored by the National Institute of Mental Health and led by Dr. Gary Sachs, director of the bipolar treatment center at Massachusetts General Hospital, the Systematic Treatment Enhancement Program for Bipolar Disorder project is now enrolling 5,000 people with bipolar disorder.

All participants in the project, known by its acronym, STEP-BD, will get one or more state-of-the-art medications for bipolar disorder; no one will be put on placebo alone.

Here’s how it will work. If a patient cruises along feeling well for months and then lapses into depression, he or she may choose whether to keep on receiving standard treatment such as lithium plus Depakote and an antidepressant such as Paxil or Wellbutrin, or to be randomized to get some combination of these and other medications, but not know which ones.

This design is aimed at getting answers to crucial questions, such as the pros and cons of using antidepressants in people with bipolar disorder. Many patients, including those misdiagnosed as depressive when they actually have manicdepression, are given antidepressants. But in some people, antidepressants can trigger mania or cause rapid cycling and a long-term worsening of disease.

In addition to choosing to be randomized for medicine, patients who relapse also will be offered a chance to be randomized to one of the talk therapies.

Talk therapies include cognitive behavioral therapy in which patients learn how to cope with their symptoms. There is also family therapy, and “interpersonal social rhythms” therapy, in which patients learn to keep normal sleep-wake cycles, a problem for people with manic depression.

It will be several years – probably 2005 – before answers from the study are in. But the mere fact that resources are being committed to the disease sends a long overdue signal that manic depression is not a matter of minor mood swings but a brain disorder that can lead to suicide.

Michael Penney knows all too well how serious his condition is. So far, his illness has kept him out of work for nearly five years, although he’s recently begun to work works 12 hours a week at Blockbuster Video in Milford. On a good day, he said, he’s grateful for the work and is reasonably content.

But on a bad day – and he still has many, despite medications and psychotherapy – he fears he will never rebuild his life. “I enjoyed all the work I used to do,” he said. “I’ll never get back to all of that.”

Treatments Offer Some Relief For Incontinence

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Maria Dube is a 37-year-old Burlington woman with two young sons who has a problem that’s often hushed up, though it’s shared by 20 million Americans, two-thirds of them women.

The wear and tear of childbirth left Dube, a telephone service representative for a Boston bank, with stress incontinence, which meant that every time she sneezed, laughed, jumped or chased her kids, she leaked urine. Asthma made things even worse. “I coughed so frequently, I had to use a pad all the time,” she said.

But several months ago, Dube underwent a 30-minute, minimally invasive surgical procedure that, some doctors say, is the most dramatic improvement in incontinence treatment in years.

While Dube was awake but under local anesthesia, her physician, Dr. George Flesh, head of urogynecology and pelvic reconstructive surgery at Harvard Vanguard Medical Associates, implanted a ribbon called a Tension-free Vaginal Tape between her urethra, through which urine flows, and her vagina. The tape is designed to act like a sling to support the urethra. The procedure is so new that only 20,000 patients worldwide have had it. Many doctors, even in a medical mecca like Boston, haven’t yet had the special training to perform it. But a three-year study in Sweden, where the procedure was developed, shows it works 90 percent of the time, and it clearly did for Dube.

Urinary incontinence comes in two basic forms: urge problems, in which bladder muscles go into spasm, making it impossible to stop urine flow once it starts; and stress problems like Dube’s, in which weak sphincter or pelvic muscles fail to keep the bladder neck closed during sudden physical stresses like coughing or exercising.

Incontinence can also occur in men when an obstruction – such as an enlarged prostate – blocks urine flow, leading to overflow or urge problems.

While the vaginal tape procedure is creating the biggest buzz, other new approaches – including an acupuncture-like system called SANS and a muscle-stimulating device called NeoControl – also may dramatically improve the quality of life for millions of incontinence patients.

For those with mild incontinence, the best way to start is with the simplest, least-invasive options.

For stress incontinence, this means doing Kegel exercises to strengthen pelvic floor muscles (the muscles that support pelvic organs). To identify these muscles, try stopping urine flow in midstream. If you can, you’ve found the right muscles. Once you’ve located them, practice this maneuver 100 times a day, but not during voiding, lest you retain urine.

If you can’t pinpoint the right muscles on your own – and many people can’t – go to a continence center (many hospitals have them) and ask for biofeedback training. Biofeedback is a system in which electrical sensors are placed on patches of skin or in the vagina or rectum; they send a painless signal to let you know you’re contracting the right muscles.

A new alternative, NeoControl, may be more appealing for some people with stress or urge incontinence. You sit on a special chair, fully clothed, with an empty bladder. Magnets under the chair produce a pulsed magnetic field that acts on nerves to cause pelvic muscles to contract.

“When you stand up, you feel like you just got out of the gym, but only in the pelvis. It feels sore but not unpleasant, like a workout,” said Dr. Peter Rosenblatt, a urogynecologist and codirector, with Dr. Neeraj Kohli, of the Cambridge Continence Center at Mt. Auburn Hospital in Cambridge.

About 60 percent of patients who use NeoControl improve after two months of twice-weekly sessions, Rosenblatt said.

Vaginal cones, which are available by prescription, are another simple solution for stress and urge problems. These are tampon-like devices held in the vagina for 15 minutes twice a day to strengthen muscles.

Other devices, also available by prescription, include Capsure and FemAssist, which are reusable suction cups that cover the opening of the urethra and are pulled off before urination. There is also a disposable patch called Impress that sticks to the urethral opening like a BandAid; it, too, must be changed before urination, but it may be available over-the-counter soon.

If urge incontinence is your problem, bladder retraining may help. The idea is to stick to a pre-set schedule, urinating regularly before the bladder gets too full, and learning to suppress the urge to urinate at other times. A variant on this is the AcuTrainer, a prescription beeper that your doctor programs to tell you when to urinate. The program gradually increases the interval between voids.

Recently, the US Food and Drug Administration approved another option for urge incontinence, the SANS (for Stoller Afferent Nerve Stimulation) system, after research showed that 55 percent of women who tried it had at least a 25 percent reduction in urgency or frequency.

In SANS, the tip of an acupuncture-type needle is placed just under the skin above the ankle, a site known to acupuncturists as “spleen 6.” A mild electrical current is passed through the needle to stimulate a nerve that controls the sacral nerve in the lower back, which in turn controls the bladder. The treatment calms the nerves to the bladder, which are hypersensitive in many people with urge incontinence.

The SANS treatment is similar to a more invasive, and expensive, surgical procedure in which a device called InterStim is implanted in the lower back to control nerves to the bladder.

And there are other options, too. For stress incontinence, especially a severe form called intrinsic sphincter deficiency, collagen injections – via a needle passed through the urethra – fill the space around the urethra, squeezing off urine flow.

A similar approach involves injections with Durasphere – carbon pellets in a gel-like suspension. Unlike collagen injections, whose effect tends to wear off after two years, Durasphere injections should last longer because the material is not absorbed by the body.

For sheer convenience, however, many people opt for medications rather than devices.

Estrogen can make the urethra more pliable and help it close more easily. It can be taken as pills, patches, vaginal cream or a vaginal ring called Estring that releases the hormone slowly over three months.

Nasal decongestants like Sudafed and a prescription decongestant called Entex can also help with stress incontinence because, as a side effect, these drugs act on proteins called alpha-receptors, which help the urethra contract.

For urge incontinence, other drugs help – notably the old standbys Ditropan and Levbid, and newer ones such as Detrol and Ditropan XL (extended release). These drugs block acetylcholine, a chemical secreted by nerves that tells muscles to contract. The newer drugs cause fewer side effects like dry mouth and constipation.

Tofranil, an antidepressant that, like the decongestants, has the useful side effect of relaxing bladder spasms and tightening the urethra, can also help. For men with incontinence caused by an enlarged prostate, drugs like Hytrin or Flomax that relax the urethra also work. So does shrinking the prostate itself – with drugs or surgery.

Surgery is an option for some women, too. For those with stress incontinence, the traditional approach is the Burch procedure, a “suspension” technique in which surgeons tighten up the pelvic fascia (fibrous tissue that lies on top of muscles) by stitching it to ligaments near the pubic bone.

Traditionally, this is done through an open abdominal incision, which means the patient spends several days in the hospital, but can count on an 80 to 90 percent chance of being markedly improved for at least five years.

Recently, some surgeons – perhaps half a dozen in Boston – have been using a laparoscopic approach. Instead of making a 4- to 5inch abdominal incision, they operate through two tiny incisions using miniature TV cameras to guide their way. The surgery is technically difficult, but appears to have the same success rate as the standard Burch procedure.

But it’s the new vaginal tape procedure that may prove most appealing for women whose main problem is a sagging urethra, not a sagging bladder as well.

“It’s fantastic,” said Rosenblatt of Mt. Auburn Hospital, who has done 150 such procedures. So far, it seems to enable women to have less pain, a shorter recovery and to solve the problem in 85 to 90 percent of cases.

Dube, the energetic mother who had the tape procedure, agreed. “I used to have to cross my legs every time I sneezed,” she said. “Now I swim, run, everything. I don’t have to use pads.” Her advice? “Just do it. It will take a week of your time” to fully heal. “But it’s worth it.”

Should We Worry About Altered Foods?

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In the early 1990s, while almost nobody was looking, the biotech industry pulled off quite a coup.

Led by industry giants like Monsanto, DuPont, Novartis and Aventis, genetic engineers began commercializing an idea they’d worked on for years – tinkering with genes to make crops more resistant to insects and herbicides.

The basic idea was clever. If, say, a gene could be inserted into soybean seeds so the plants would be resistant to an herbicide, farmers could spray their fields with that herbicide, killing the weeds without fear that it would harm the cash crop. If a gene could be introduced into corn that would produce a protein toxic to corn-eating caterpillars, farmers could grow that kind of corn without using high quantities of pesticides.

The idea has not only worked – it’s worked too well in the eyes of the anti-biotech crowd, which has been staging counter-demonstrations this week in Boston during BIO2000, the biotech industry’s annual gig. Yesterday, four protesters were arrested on disorderly conduct charges for dumping 30 gallons of “genetically altered” soybeans outside the Hynes Convention Center, marring otherwise orderly demonstrations.

Worldwide, the area planted with transgenic crops has soared from 2 million hectares in 1996 to nearly 40 million in 1999, according to the Worldwatch Institute, a research organization based in Washington. In the United States, the world leader in growing genetically modified foods, half of the soybean crop carried the herbicide-resistant gene last year while a third of the corn crop carried the anti-caterpillar gene.

The problem, opponents say, is that in the rush to get “GM,” or genetically modified, food out of the lab and into the mouths of consumers – who had not been clamoring for it – the biotech industry did not completely answer the one question that consumers care most about: Are GM foods safe to eat?

In theory, they should be. After all, we eat DNA all the time (we just call it steak or fish), so what’s an extra gene or two? We eat corn that over the centuries has been cross-bred so many times – the old, Mendelian way – that it bears little resemblance to its wild ancestors.

And, even if a transplanted gene, or a special kind of DNA called a promoter, did have a destructive effect, the damage would likely show up in the plant into which it was inserted, not the humans who ate the plant. Besides, our digestive enzymes should chew up GM food the same way they process everything else we eat.

Among other things, that means that it’s unlikely that, say, a gene from a flounder that’s inserted into a tomato (as scientists are doing to make tomatoes more resistant to freezing) would somehow lodge itself forever in the human genome. In fact, if it were that easy to transfer genes, scientists wouldn’t have to resort to sophisticated tricks to create transgenic animals in the lab: They could just feed them GM food.

Indeed, there’s no evidence that any human has ever been harmed by eating GM food. (This is in contrast, by the way, to evidence that some herbal products, which people assume are safe because they’re “natural,” can be harmful.)

Given that 60 percent of the processed food now on the American market contain ingredients that have been genetically engineered (a fact many people don’t realize), chances are that if the stuff were dangerous, somebody would have noticed.

But none of this is what really irks consumers – including this one – on both sides of the Atlantic. What is irksome is that, even though GM foods may be safe, there’s too little testing to say for sure – and there are no labels to guide us.

We don’t know, for instance, whether the proteins made by genes inserted into plants could cause serious, even fatal, allergic reactions. In one notorious case, scientists inserted a Brazil nut gene into soybeans to increase protein. When the hybrid was lab tested in 1996, human antibodies reacted to the nut gene, a sign that the product could have caused allergies in people.

“Bioengineering could produce novel protein combinations that the human body has never seen before, potentially resulting in serious allergies that would be difficult to diagnose,” said Martin Teitel, executive director of the Council for Responsible Genetics, a Cambridge-based watchdog group.

Another concern is that gene-altered foods may have different nutrient value than standard foods. Though the biotech industry disputes it, GM soybeans may have fewer phytoestrogens than normal, a potentially important change, since some consumers eat soybeans precisely to get the hormone-like effects of these plant estrogens.

Opponents of GM foods also worry that gene-altered crops might contain pesticide residues or, worse in the eyes of some opponents, genes that make pesticides in every cell in the plant. (On the other hand, with some gene-altered crops, farmers can use fewer pesticides than normal.)

And then there’s the concern that these crops could increase antibiotic resistance.

Bioengineers use antiobiotic-resistance genes as markers to see whether the genes they put into plants get into the DNA. The worry is that eating the altered food could allow the marker genes to pass into bacteria in the human digestive system, making people resistant to potentially life-saving antibiotics.

“That argument is totally bogus for two reasons,” fumed Val Giddings, a geneticist and vice president for food and agriculture at the Biotechnology Industry Organization in Washington. “Number one, the antibiotic resistance genes used as markers in biotech do not [cause] resistance to antibiotics used to treat human disease. Number two, those resistance genes are already present in the human digestive tract.”

Furthermore, he said, “crops improved by biotechology have been subjected to more scrutiny in advance, depth, detail and rigor than any other foods introduced into the food supply in human history.”

But have they?

In 1992, faced with the imminent onslaught of GM foods, the FDA decided to regulate those products the same way as new foods created by old-fashioned plant breeding, said Laura Tarantino , deputy director of the office of premarket approval at the FDA’s Center for Food Safety and Applied Nutrition.

The agency also decided not to consider genes inserted into foods as “additives,” which would have required FDA approval before marketing. That means, she acknowledged, that, as of now, “there is no requirement that someone come in for premarket approval” of GM food just because it is “made by recombinant DNA.”

This stance so outraged lawyer Steven Druker, executive director of the Alliance for Bio-Integrity, a nonprofit watchdog group based in Iowa, that he and others filed a lawsuit against the FDA in 1998 seeking mandatory safety testing and labeling of GM foods. That suit is still pending.

In Europe, consumer pressure against “Frankenfoods” has grown so intense that some grocery chains are tossing transgenic products off their shelves. That, in turn, is making farmers around the world uneasy about growing gene-altered crops.

Indeed, after four years of rapid growth, farmers are expected to reduce planting of genetically engineered seeds by as much as 25 percent this year, the Worldwatch Institute predicts.

Giddings of the biotech organization counters that, at least in the United States, farmers are increasing their plantings of biotech soybeans. They are planting less GM corn, he conceded, but that’s not because of consumer resistance but because that crop, engineered to resist a European corn-borer, is no longer endangered by that pest.

The bottom line is that, even if GM foods are safe, and they seem to be so far, consumers have a right to demand labels so they know what they’re eating.

Margaret Mellon , a lawyer, molecular biologist and director of the agriculture and biotechnology program at the Union of Concerned Scientists in Washington, put it this way:

Consumers “deserve the opportunity to know which foods have been altered and to make a choice about whether they want to take any risk at all, even if that is a very tiny risk.”

 

SIDEBAR

QUESTIONS REMAIN ON `ORGANIC’ LABEL

If you want to avoid genetically modified foods, the only way to do that with certainty is to buy foods labeled “organic.”

The US Department of Agriculture recently developed new labeling standards to clarify what “organic” means. Among other things, the new standards prohibit organic labeling on any foods produced with genetic engineering.

Organic foods, however, may have their own problems. Since they’re often grown without pesticides, you may get some pests with your food. Organic food is often more expensive as well.

If you want to find out more about the controversy over genetically modified foods, visit these Web sites:

  • www.ucsusa.org (Union of Concerned Scientists)
  • www.gene-watch.org (Council for Responsible Genetics)
  • www.biointegrity.org (Alliance for Bio-Integrity)
  • www.fda.gov
  • www.monsanto.com
  • www.bio.org (Biotechnology Industry Organization)
  • www.ificinfo.org (International Food Information Council)
  • www.gmabrands.com (Grocery Manufacturers of America)

Domestic Abuse: Out Of The Shadow

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Alerting The Neighbors, Doctors, Courts To Domestic Abuse Helps Women Bring problem To The Fore – And It May Save Their Lives

The rice was the tip-off.

When the young woman’s mother came to visit her in New York, she was astounded at all the rice her daughter kept in the cupboard. When the mother asked why, the daughter shrugged. Her husband, she explained, always complained that she “didn’t make rice as fluffy as his mother did.” So she’d keep trying over and over.

“There’s nothing wrong with the way you make rice,” gasped the mother. What was wrong, both women realized, was that the daughter was caught in an abusive relationship. Her husband’s constant criticism about her cooking was part of a larger pattern of psychological humiliation and beatings.Since that incident 22 years ago, the story has become legendary in the domestic violence field, not least because the daughter was Sarah Buel, who left her husband and went on to Harvard Law School, and now runs the domesticviolence clinic at the University of Texas Law School in Austin.Domestic violence – overwhelmingly a male-against-female problem but a major issue in same-sex relationships as well – is a public health dilemma of staggering proportions that crosses boundaries of wealth, race and class.

As researchers probe the enormity – and complexity – of domestic abuse, they are becoming more sophisticated at helping victims fight back with “safety plans” and other long-term strategies for physical, and psychological, survival.

A decade ago, the standard question for a woman in an abusive relationship was: “Why don’t you just leave?”

But evidence is mounting that “just leaving” can be dangerous; some men become vengeful when a woman stands her ground. This is complicated by the fact that women often feel ambivalent toward their abusers, and want legal intervention one day and not the next.

Leaving an abusive relationship is no small task – anywhere.

Between 10 and 50 percent of women worldwide are hit or otherwise physically attacked by an intimate male partner at some point in their lives, according to researchers from the Johns Hopkins School of Public Health and the Center for Health and Gender Equity in Takoma Park, Md., in a recent report based on 500 studies.

Often this leads to physical injury. Sometimes it leads to murder. Worldwide, 40 to 70 percent of homicides of women are committed by intimate partners, the Hopkins team found. By contrast, only a small percentage of men who are murdered are killed by their female partners and, in those cases, the women are often acting in self-defense or retaliation.

“Around the world, at least one woman in every three has been beaten, coerced into sex, or otherwise abused in her lifetime,” said the researchers in their report.

Abuse can run the gamut from hitting, slapping and kicking to sexual coercion to psychological control by intimidation and humiliation.

Sometimes the physical symptoms last long beyond the wounds have healed; some women live with irritable bowel syndrome and chronic pain syndrome. Others suffer with psychological problems such as depression, anxiety or abusealcohol and drugs. And because abuse and intimidation mean that a woman often can’t negotiate the terms of sex, she’s also at risk of sexually transmitted diseases such as AIDS and unwanted pregnancy.

While heterosexual women are the main victims, researchers now know that violence is just as common in relationships between gay men and lesbian women.

Studies suggest battering occurs in 25 to 46 percent of same-sex relationships, said Beth Leventhal, executive director of the Boston-based Network for Battered Lesbians and Bisexual Women, a nonprofit group.

Emily Pitt, a domestic violence worker at the Fenway Community Health Center in Boston, said the “cycle of violence” can be similar in heterosexual and homosexual relationships.

It often begins with psychological abuse – threats of violence like walking around the bed with a knife, humiliating comments such as “you’re getting fat” or surrogate violence such as attacking pets, said Lois Haggerty, an associate professor at Boston College School of Nursing who, with colleagues, is studying abuse in women who visit prenatal clinics.

Emotional abuse often escalates into physical abuse, which in turn is often followed by a “honeymoon” period in which the abuser apologizes and the victim takes responsibility for helping him change. Then the cycle begins again.

That abuse is similar in heterosexual and homosexual relationships suggests that, while the basic pattern fits into cultural definitions of masculinity and feminity, abuse is really about power and control, said Sally Engle Merry, a legal anthropologist at Wellesley College. It’s “the opportunity, and the entitlement, for the powerful to use force to control the less powerful.”

How can such a complex dynamic ever be changed?

“What seems most effective,” Merry said, “is a three-layered approach.” First, there must be “some kind of punishment for the batterer. In the absence of punishment, other approaches don’t have much impact. . . . Second, there has to be some effort at reform – treatment programs.” Over time, educating batterers that their behavior is not acceptable can change cultural norms. Data suggest that, although many batterers drop out of treatment programs, 80 percent of those who stay stop battering, at least for a year.

“Third, there must be mechanisms that focus on the woman’s safety.” Shelters help, but so do the much-maligned temporary restraining orders – civil court orders aimed at keeping the batterer away from his victim.

Over time, Merry said, “the law acts not just by imposing sanctions but also by creating normative standards for how people ought to treat each other.” In recent years, the number of restraining orders has soared in many states, including Massachusetts.

Restraining orders may not deter someone who is homicidal but they can work with a “relatively new batterer who has not had a lot of experience with the courts.”

Daria Niewenhous, a health care lawyer at the Lahey Clinic who for years headed the pro bono domestic violence project at the law firm, Mintz Levin, agreed. “Restraining orders can and do work when the batterer has something to lose if the order is violated,” she said. But they “should always be part of a safety plan.”

Such safety plans – specific steps developed over the years from hard-won experience – don’t give blanket advice to women to leave an abuser immediately. For one thing, it’s when a woman leaves that an abuser is most likely to feel he’s losing control, and to attack. For another, it usually takes four to five attempts – and a good long-term plan – before a woman manages to leave for good.

Rather, today’s safety plans read like survival manuals for living in a war zone. They advise, for instance, that a battered woman tell one or more neighbors about the violence so they can call 911 if they hear or see a disturbance in the woman’s home.

During an argument, a woman should walk into a room that she can leave easily. Staying away from rooms, such as the kitchen, where there are items that could be used as weapons, is also a good idea. Having a bag packed with spare keys, money, documents and clothes and keeping it at the home of a friend or relative also makes sense.

If your abuser is stalking you, you can “tell your employer if you need to be walked to your car,” said Kristie Wang, spokeswoman for the San Francisco-based Family Violence Prevention Fund, a national policy and advocacy group. Your employer may also be able to help if your abuser makes harassing calls at work or if you need to have a desk away from a window.

It also helps to tell health professionals about the violence. They can suggest resources to turn to, offer emotional support and keep records of the injuries.

In fact, asking about domestic abuse is now the standard of care for health care providers. “All health care providers should ask every patient, every visit,” said Buel of Texas.

The key is not to keep the abuse secret. Ask friends and family members, especially men, to confront the abuser if they see or hear him being threatening or humiliating. If a man knows others are watching, he may think twice about his behavior or become embarrassed by it.

No one deserves to be hit or threatened. Even if she overcooks the rice.