The general public’s image of the lives that medical professionals face is colored by 50 minute sitcoms where problems related to the characters, both personal and professional, are often neatly resolved by the time the final credits roll. The trauma patient who was crashing at the beginning of the episode is seen smiling and leaving the hospital by its conclusion. Furthermore there is a misconception by many that most doctors have amassed vast riches and lavish lifestyles at the expense of the illness of others. Does this translate to the real lives of medical doctors?

A recent study appeared in the American Journal of Bone and Joint Surgery which examined the quality of life among orthopedic surgery residents and attendings. While this article focused on a specific group of individuals, the issues identified as both protective and risk factors are of relevance to everyone. Some of the items which showed a high correlation to dissatisfaction were concern over regular use of alcohol, difficulty disconnecting from work life while at home and high levels of sleep deprivation. Protective factors included making time for exercise and hobbies, spending quality time alone with partner, sense of support or mentor and taking non-work related vacations. Curiously, although high levels of stress were reported, 80% of residents and 88% of the faculty members who responded felt that the sacrifice was worthwhile, and many reported that they would still make the same career choice.

Combined with the 80 hour work week guidelines, this new information leaves us to wonder if patient care is affected. Earlier this year a multi-center study performed in three United States hospitals and one in Canada evaluated whether the outcome of orthopedic surgery performed after-hours was different to that conducted during the day. After-hours surgery refers to procedures conducted outside of the confines of a usual work day, usually at night or in the early hours of the morning. The results of this investigation by Ricci and colleagues showed that most factors were similar, including infection rate, but the after-hours group required more re-operations to remove painful hardware. However, the article was unable to identify what caused this one difference: whether it was related to surgeon fatigue or the varying levels of experience between surgeons who operated during the day or night. Other than that one factor, we can feel reassured that our surgical outcome will be similar regardless of the time of day it is done. To gather more information, more studies into the role of physician quality of life on level of medical care will have to be carried out.

Perhaps these findings will improve the doctor-patient relationship, by ensuring that patients receive a high standard of care regardless of when they see their doctor. Physicians are subject to the same stresses their patients are and, hopefully, will feel more e comfortable addressing risk factors affecting their quality of life.

References

Sargent MC, Sotile W, Sotile MO, Rubash H, & Barrack RL (2009). Quality of life during orthopaedic training and academic practice. Part 1: orthopaedic surgery residents and faculty. The Journal of bone and joint surgery. American volume, 91 (10), 2395-405 PMID: 19797575

Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, & Leighton R (2009). Is after-hours orthopaedic surgery associated with adverse outcomes? A prospective comparative study. The Journal of bone and joint surgery. American volume, 91 (9), 2067-72 PMID: 19723981

New research published in the medical journal The Lancet posits that most babies born since the year 2000 will live to be at least 100 years old. The authors studied the life expectancies of children born in several countries of Europe and North America, wealthy countries that already have long life expectancies. However, the trend of increasing life expectancy is similar throughout the world. We have known for decades that people are living longer, thanks to advances in medical treatment, better understanding of healthy lifestyle habits, and improvements in living and working conditions. The real question is: what is the quality of the extra years of life?

Will the someday-centenarians simply be alive longer, but be afflicted with the same maladies and disabilities seen in aging populations today? Or, will they maintain their strength and fitness longer into life? Thankfully, the authors of the current article believe that aging is a modifiable process, and that the aging populations of the future will be healthier than those today, making the extra years a blessing rather than a curse.

Much research has been conducted on the process of aging and a great deal of it focuses on calorie and nutrient intake. Reducing caloric intake in rats, mice, and primates extends their lifespan up to 40 percent, and is accompanied by health benefits. Caloric restriction protects against the damaging effects of aging by blocking certain proteins and activating signaling molecules, which lead to leaner body mass, stronger bones, protection against type 2 diabetes, improved immunity, and increased cognition and motor skills.

Drugs that might mimic caloric restriction and the function of proteins and signaling molecules are being investigated, including the well-known diabetes drug metformin and the immunosuppressant rapamycin. Clinical trials are already underway investigating the effects of highly concentrated antioxidants, such as those found in red wine, that have similar effects to reducing caloric intake.

Just adding more years to life may not be desirable, unless we can add life to the years. With an ever-aging population that will live longer than ever before, it is important to ensure that people live healthier lives. Healthy aging, no matter what the life expectancy, includes proper nutrition and physical activity, disease and disability prevention, and optimal social structure. By manipulating the process of aging, people no longer have to assume that poor health and disability are unavoidable, but can live long, healthy lives.

References

Um, S., D’Alessio, D., & Thomas, G. (2006). Nutrient overload, insulin resistance, and ribosomal protein S6 kinase 1, S6K1 Cell Metabolism, 3 (6), 393-402 DOI: 10.1016/j.cmet.2006.05.003

Christensen, K., Doblhammer, G., Rau, R., & Vaupel, J. (2009). Ageing populations: the challenges ahead The Lancet, 374 (9696), 1196-1208 DOI: 10.1016/S0140-6736(09)61460-4

Selman, C., Tullet, J., Wieser, D., Irvine, E., Lingard, S., Choudhury, A., Claret, M., Al-Qassab, H., Carmignac, D., Ramadani, F., Woods, A., Robinson, I., Schuster, E., Batterham, R., Kozma, S., Thomas, G., Carling, D., Okkenhaug, K., Thornton, J., Partridge, L., Gems, D., & Withers, D. (2009). Ribosomal Protein S6 Kinase 1 Signaling Regulates Mammalian Life Span Science, 326 (5949), 140-144 DOI: 10.1126/science.1177221

Sadovsky, R. (2009). Facilitating healthy aging among men: making some impact Journal of Men’s Health, 6 (2), 98-100 DOI: 10.1016/j.jomh.2009.02.002

Both physical and psychological factors are believed to be involved in the development of chronic pain, and individual differences exist in pain sensitivity and tolerance, making treatment difficult. Current treatment options for chronic pain include analgesic drugs, physical activity and rehabilitation, antidepressant medications, and behavior modification, but patients rarely experience a decrease in symptoms over time. Since the condition is believed to have biological and psychological causes, new treatment options are focusing on treatment options that enhance mind-body awareness and control. A study published in BMC Musculoskeletal Disorders in September reports positive effects of hypnosis for the treatment of chronic widespread pain.

Hypnosis is not routinely used in general treatment programs in the United States, but is garnering more attention is recent years, as scientists search for effective, holistic treatment options for chronic pain. Many small studies have shown that hypnosis can provide at least temporary pain relief, and may also lead to a reduction in pain over time. Such approaches to pain management can enhance quality of life and reduce disability related to chronic pain.

The current study involved 16 men and women, aged 23 to 54 years, who were randomized to a treatment group or a non-treatment control group. The treatment group participated in 30-minute hypnosis treatment sessions once weekly for 10 weeks. Both groups continued to receive standard treatments, including analgesic and antidepressant drugs, physiotherapy, and chiropractic therapy. After the initial 10-week treatment period, the patients in the control group were offered hypnosis therapy. Patients completed a 25-item questionnaire evaluating pain, fatigue, concentration problems, activities of daily living, pain interference in work and social life, anxiety and pessimism, and overall quality of life. These subjective scores were rated on a scale from 1 to 100, with higher numbers representing more suffering.

In total, 7 patients from the initial treatment group, plus 5 from the original control group, completed hypnosis therapy. These 12 patients experienced a significant reduction in pain and suffering scores, with a mean improvement of 9.9 points, from 51.5 to 41.6. The 7 patients from the initial treatment group experienced a significant score reduction from 62.5 to 55.4. The 5 patients who completed hypnosis treatment after participating in the control group experienced a near 13-point improvement in functioning, with scores decreasing from 35.97 to 23.54. The 8 patients in the initial control group showed an increase in suffering, with a near 8-point score increase from 37.2 to 45.1.

All 12 patients that completed hypnosis therapy completed follow-up after 1 year, and reported a score of 41.3, indicating maintenance of quality of life improvement. All of the patients reported using self-hypnosis methods at least once weekly during the year and would have taken advantage of additional hypnosis therapy if it had been available.

The small sample size and subjective nature of the questionnaire limits widespread application of these results. Also, the large difference in the baseline scores of the treatment and control groups may indicate unreliability in comparing the 2 groups.

However, many small studies have shown similar results, and a plausible approach to treating chronic pain is to combine pharmacological, physical, and psychological modalities based on each patient’s needs.

References

Carli G, Suman AL, Biasi G, Marcolongo R, Santarcangelo EL (2008). Paradoxical experience of hypnotic analgesia in low hypnotizable fibromyalgic patients. Arch Ital Biol, 146 (2), 75-82 PMID: 18822796

Jan Grøndahl, Elin Rosvold (2008). Hypnosis as a treatment of chronic widespread pain in general practice: A randomized controlled pilot trial BMC Musculoskeletal Disorders, 9 (1) DOI: 10.1186/1471-2474-9-124

M JENSEN, S HAKIMIAN, L SHERLIN, F FREGNI (2008). New Insights Into Neuromodulatory Approaches for the Treatment of Pain. The Journal of Pain, 9 (3), 193-199 DOI: 10.1016/j.jpain.2007.11.003

Molton IR, Graham C, Stoelb BL, Jensen MP (2007). Current psychological approaches to the management of chronic pain. Curr Opin Anaesthesiol, 20 (5), 485-489 PMID: 16911061

T OSBORNE (2006). Psychologic Interventions for Chronic Pain. Physical Medicine and Rehabilitation Clinics of North America, 17 (2), 415-433 DOI: 10.1016/j.pmr.2005.12.002

Hope is on the horizon, however, with the FDA’s approval of the first drug to treat HD in August of 2008. The drug, Xenazine (tetrabenazine) was developed in the 1950’s to treat psychosis, but had limited success. Now, it is available in the United States, as well as Europe, Canada, and Australia, to treat one of the hallmark symptoms of HD — chorea.

HD is inherited — each child of a parent with HD has a 50% chance of developing the disease – and is caused by an abnormal repeat of CAG basepairs on the short arm of chromosome 4. Symptoms of HD usually appear in people aged 30 to 50 years, and include chorea, or involuntary, jerky movements, dystonia, and dementia. The disease is characterized by a build up of malformed proteins in brain cells, primarily in the basal ganglia and the cerebral cortex. Usually, cells destroy waste products, such as malformed proteins, through a process called autophagy, or “self-eating”, but this process is incomplete in HD. This gradual build-up of protein, and the lack of autophagy, leads to the death of millions of neurons, which leads to cognitive difficulties, personality changes, and psychiatric symptoms.

Since there is no cure for HD, treatments are focused on symptom management and supportive care. Many adults with HD take neuroleptics or antipsychotic medications, such as haloperidol, or muscle relaxants to reduce chorea, but these drugs can severely impair alertness and learning ability. Newer antipsychotic drugs are associated with fewer side effects, but none — other than tetrabenazine — are approved for use in HD. Antidepressants are sometimes useful in adults with HD, and reduce sleep disturbances, but may aggravate seizures and trembling. Several high blood pressure and migraine medications are under investigation to stimulate autophagy, but have not yet been tested in humans.

Xenazine works in the brain to reduce the amount of dopamine available in the brain. Dopamine normally functions to communicate between brain cells, but in HD, dopamine is overactive and leads to the abnormal, involuntary movements called chorea. In clinical trials, patients with HD experienced at least a 25% improvement in chorea, leading to a dramatic improvement in quality of life. Patients with HD are often not able to complete daily activities, including eating at restaurants or attending church, and patients taking Xenazine were able to reclaim part of their daily life lost to HD.

Xanazine does present significant side effects, but many patients, and their physicians, feel that the benefits of improved symptoms outweigh the risks. The most common side effects seen in clinical trials were insomnia, depression, drowsiness, restlessness, and nausea. Most importantly, depression and thoughts of suicide were associated with Xenazine. Many HD patients are already at increased risk for suicidal behavior and close monitoring by family members and caregivers is critical.

Xenazine does not stop the disease process involved in HD, or delay its progression. But, its approval as an orphan drug is symbolic, as HD is increasingly becoming the focus of drug research and development.

Most HD patients die within 15 to 20 years after symptom onset, usually not from the disease itself, but from medical complications resulting from immobility. While this new drug cannot stop, or even delay, HD progression, it may offer patients and families suffering from HD improved quality of life.

References

Huntington Study Group (2006). Tetrabenazine as antichorea therapy in Huntington disease: A randomized controlled trial Neurology, 66 (3), 366-372 DOI: 10.1212/01.wnl.0000198586.85250.13

Aubeeluck A, Brewer H (2008). Huntington’s disease. Part 2: treatment and management issues in juvenile HD. Br J Nurs, 17 (4), 260-263 PMID: 18414272

Andrea Williams, Sovan Sarkar, Paul Cuddon, Evangelia K Ttofi, Shinji Saiki, Farah H Siddiqi, Luca Jahreiss, Angeleen Fleming, Dean Pask, Paul Goldsmith, Cahir J O’Kane, Rodrigo Andres Floto, David C Rubinsztein (2008). Novel targets for Huntington’s disease in an mTOR-independent autophagy pathway Nature Chemical Biology, 4 (5), 295-305 DOI: 10.1038/nchembio.79

Heitz F, La Rosa S, Gonzalez-Couto E, Gaviraghi G, Terstappen GC (2008). Drug discovery and development for Huntington’s disease – an orphan indication with high medical need. IDrugs, 11 (9), 653-660 PMID: 18763216