Well: War Wounds That Time Alone Can’t Heal

Video

“Almost Sunrise”

In a clip from «Almost Sunrise,» Katinka Hooyer, a medical anthropologist and postdoctoral research fellow in Family and Community Medicine at the Medical College of Wisconsin, talks about the meaning of love and feeling moral pain.

By THOUGHTFUL ROBOT PRODUCTIONS on Publish Date June 5, 2016.

No doubt in the course of your life, you did something, or failed to do something, that left you feeling guilty or ashamed. What if that something was in such violation of your moral compass that you felt unable to forgive yourself, undeserving of happiness, perhaps even unfit to live?

That is the fate of an untold number of servicemen and women who served in Iraq, Afghanistan, Vietnam and other wars. Many participated in, witnessed or were unable to help in the face of atrocities, from failing to aid an injured person to killing a child, by accident or in self-defense.

For some veterans, this leaves emotional wounds that time refuses to heal. It radically changes them and how they deal with the world. It has a name: moral injury. Unlike a better known casualty of war, post-traumatic stress disorder, or PTSD, moral injury is not yet a recognized psychiatric diagnosis, although the harm it inflicts is as bad if not worse.

The problem is highlighted in a new documentary called “Almost Sunrise,” which will be shown next weekend at the Human Rights Watch Film Festival in New York and on June 23 and 24 at AFI Docs in Washington, D.C. The film depicts the emotional agony and self-destructive aftermath of moral injury and follows two sufferers along a path that alleviates their psychic distress and offers hope for eventual recovery.

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The new documentary “Almost Sunrise” follows Tom Voss and Anthony Anderson, two troubled Iraq war veterans, walking from Milwaukee to Los Angeles.Credit Thoughtful Robot Productions

Therapists both within and outside the Department of Veterans Affairs increasingly recognize moral injury as the reason so many returning vets are self-destructive and are not helped, or only partly helped, by established treatments for PTSD.

Moral injury has some of the symptoms of PTSD, especially anger, depression, anxiety, nightmares, insomnia and self-medication with drugs or alcohol. And it may benefit from some of the same treatments. But moral injury has an added burden of guilt, grief, shame, regret, sorrow and alienation that requires a very different approach to reach the core of a sufferer’s psyche.

Unlike the soldiers who were drafted to serve in Vietnam, the members of the armed forces today chose to enlist. Those deployed to Iraq thought at first they were fighting to bring democracy to the country, then were told later it was to win hearts and minds. But to many of those in battle, the real effect was “to terrorize people,” as one veteran says in the film. Another said, “That’s not what we signed up for.”

That war can be morally compromising is not a new idea and has been true in every war. But the therapeutic community is only now becoming aware of the dimensions of moral injury and how it can be treated.

Father Thomas Keating, a founding member of Contemplative Outreach, says in the film, “Antidepressants don’t reach the depth of what these men are feeling,” that they did something terribly wrong and don’t know if they can be forgiven.

The first challenge, though, is to get emotionally damaged veterans to acknowledge their hidden agony and seek professional help instead of trying to suppress it, often by engaging in self-destructive behaviors.

“A lot of vets won’t seek help because what’s haunting them are not heroic acts, or they were betrayed, or they can’t live with themselves because they made a mistake,” said Brett Litz, a mental health specialist with the V.A. Boston Healthcare System and a leading expert on moral injury.

The second challenge is to win their trust, to reassure them that they will not be judged and are deserving of forgiveness.

Therapists who study and treat moral injury have found that no amount of medication can relieve the pain of trying to live with an unbearable moral burden. They say those suffering from moral injury contribute significantly to the horrific toll of suicide among returning vets — estimated as high as 18 to 22 a day in the United States, more than the number lost in combat.

The film features two very troubled veterans of the war in Iraq, Tom Voss and Anthony Anderson, who decide to walk from Milwaukee to Los Angeles — 2,700 miles taking 155 days — to help them heal from the combat experiences that haunt them and threaten to destroy their most valued relationships. Six years after returning from his second deployment in Iraq, Mr. Voss said of his mental state before taking the cross-country trek, “If anything, it’s worse now.”

Along the way, the two men raise awareness of the unrelenting pain of moral injury many vets face and encourage them to seek treatment. Mr. Voss and Mr. Anderson were helped by a number of counselors and treatments, including a Native American spiritual healer and a meditative technique called power breathing. They also found communing with nature to be restorative, enabling them to again recognize beauty in the world.

Shira Maguen, a research psychologist and clinician at the San Francisco V.A. Medical Center, who studies and treats vets suffering from moral injury, said, “We have a big focus on self-forgiveness. We have them write a letter to the person they killed or to a younger version of themselves. We focus on making amends, planning for their future and moving forward,” especially important since many think they have no future.

Dr. Maguen, who studied how killing during combat affects suicidal ideation in returning vets, found that “those who had killed were at much higher risk of suicide,” even when controlling for factors like PTSD, depression and alcohol and drug abuse. She said in an interview that decades after the Vietnam War, “there was still an impact on veterans who killed enemy combatants, and an even stronger effect on those who killed women and children.”

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Tom Voss’ journey took 155 days, spanning 2,700 miles.Credit Courtesy of Thoughtful Robot Productions

To overcome veterans’ reluctance to seek help for moral injury, Dr. Maguen incorporates mental health care into routine clinical visits.

In Boston, Dr. Litz and colleagues are testing a therapeutic approach called adaptive disclosure, a technique akin to confession. With eyes closed, the vets are asked to verbally share vivid details of their trauma with an imagined compassionate person who loves them, then imagine how that person would respond. The therapist guides the conversation along a path toward healing.

“Disclosing, sharing, confessing is fundamental to repair,” Dr. Litz said. “In doing so, the vets learn that what happened to them can be tolerated, they’re not rejected.” They are also encouraged to “engage in the world in a way that is repairing — for example, by helping children or writing letters.” The goal is to find forgiveness within themselves or from others.

One fact that all agree on: The process is a lengthy one. As Mr. Voss said, “I knew after the walk I still had a long road of healing ahead of me.” Now, however, he has some useful tools and he shares them freely.

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Well: Direct-to-Consumer Lab Tests, No Doctor Visit Required

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Credit Jon Krause

Two years ago, Kristi Wood was tired and achy and could not think clearly, and she had no idea why.

“I was in a fog and feeling awful,” said Ms. Wood, 49, who lives in Seattle and is an owner of a hiking supply company.

Ms. Wood had her blood tested by a consumer service called InsideTracker, which analyzes 30 hormones and biomarkers, such as vitamin levels, cholesterol and inflammation. After the service told Ms. Wood she had excessive levels of vitamin D, she cut back on a supplement she had been using and said she almost immediately felt better.

Now she has her blood drawn and tested by InsideTracker every four months to check everything from her blood sugar to her B12 levels which, she said, “allows me to be proactive” about her health. The services typically send their customers to a nearby clinic where they can have a vial of their blood drawn and sent for analyses. But InsideTracker also offers customers the option to have nurses show up at their home and draw blood. (Such services are different from another blood testing company that has been much in the news, Theranos, which aims to provide laboratory test results from a single finger prick.)

Home testing services like InsideTracker say they are empowering consumers, allowing them to spot metabolic red flags before they progress to disease. But critics say the services often lack proper medical oversight and convince healthy people that they’re sick, leading to unnecessary testing and treatment.

Those concerns have not stopped people from seeking home testing. The market for direct-to-consumer laboratory tests was valued at $131 million last year, up from $15 million in 2010,according to Kalorama Information, a pharmaceutical-industry research firm.

In December, the New York State attorney general, Eric T. Schneiderman, accused two companies, DirectLabs and LabCorp, of violating a state law that requires laboratory tests to be carried out at the request of licensed medical practitioners.

DirectLabs had sold hundreds of health tests to consumers, ranging from checks for heavy metals and vitamins to screening for parasites and disease. But Mr. Schneiderman said the person fulfilling the medical practitioner role was actually a chiropractor who had never met, spoken to or followed up with any patients.

DirectLabs did not respond to a request for comment. DirectLabs and LabCorp agreed to pay fines, and DirectLabs ceased operating in New York. In a statement, Mr. Schneiderman said that allowing consumers to be tested for serious medical conditions without consulting a physician put “their health in jeopardy.”

Advocates of home testing, however, say such cases do not reflect industry practices. InsideTracker and another leading company, WellnessFX, said they worked with doctors who reviewed all test results.

Paul Jacobson, the chief executive of WellnessFX, based in San Francisco, said the company complied with all regulations and offered customers the option of consulting with a doctor, nutritionist or registered dietitian to discuss their results.

WellnessFX sells packages ranging from $78 to $988, offering analyses of 25 to 88 blood biomarkers, including vitamins, lipids, cardiovascular markers and thyroid and reproductive hormones. Depending on the results, the company also suggests supplements, foods and exercise.

“You need to offer solutions to people; otherwise, you’re just giving them meaningless information,” Mr. Jacobson said.

Tara Boening, the dietitian for the Houston Rockets of the National Basketball Association, said the team started using InsideTracker this season. The players look at their reports (deficiencies are highlighted in red), which include suggested corrective actions such as eating more red meat and leafy greens if they are low in iron. The players “have been really receptive” to the information, Ms. Boening said.

But some doctors say that there is no evidence that such monitoring makes a meaningful improvement in health. Dr. Pieter Cohen, an assistant professor at Harvard Medical School and an internist at Cambridge Health Alliance, cautioned that the levels of vitamin D and other biomarkers that were optimal for one person might be very different from what is optimal for another person. He said InsideTracker’s lab reports, for example, classified vitamin D levels below 30 nanograms per milliliter as “low” — even though a level above 20 is perfectly normal and adequate for most people.

Dr. Cohen said his major concern with direct-to-consumer blood tests was that they screened for so many biomarkers and created seemingly arbitrary ranges for what is considered normal. Then they give people advice that they already know they should be following.

“The best-case scenario here is you lose your money and then you’re reminded to get more sleep and to eat more fruits, vegetables and fish,” he said. “The worst-case scenario is that you end up getting alarmed by supposedly abnormal results that are actually completely normal for you.”

InsideTracker was founded by Gil Blander, a biochemist who did postgraduate research on aging at M.I.T. He said the idea behind InsideTracker was analogous to routine maintenance for cars.

“We decided, let’s try to do that for humans,” Dr. Blander said. “We can help you find a small issue today that might be a big problem in the future.”

Some, like Joseph Roberts, say the services are life-changing. Four years ago, Mr. Roberts, a former Army Ranger and a retired master sergeant, was plagued by fatigue, depression and weight gain despite frequent exercise. Mr. Roberts, then 39, said doctors told him his symptoms were a normal part of aging.

Eventually, he decided to have his blood tested with InsideTracker, and the results surprised him, he said. He was told he had low testosterone and vitamin D, as well as excessive levels of vitamin B12.

Mr. Roberts cut back on daily energy drinks, which are loaded with B12. He also saw a doctor to discuss his testosterone levels. He learned his low levels were linked to a brain injury he had sustained as a result of a roadside bomb explosion in Iraq in 2003. He began testosterone-replacement therapy and now regularly checks in with a doctor. He also has his blood tested with InsideTracker every four months.

“I’ve had a huge improvement in my quality of life,” he said. “It’s money well spent.”

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Well: A Doctor on Schedule, Rarely on Time

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Credit James Yang

Hard Cases

Dr. Abigail Zuger on the everyday ethical issues doctors face.

The minute I got on that bus, I knew I was in trouble. The driver sat at the stop just long enough to miss the green light. Then he inched along till he missed the next light and the one after that. He stopped at every stop even though not a soul was waiting.

The 20-minute trip to work stretched to a half-hour, then longer. I was late, late, late.

But this was a driver with a mission, clearly way ahead of schedule and trying to get back on track. He was very early; now I was very late. We were two people with competing, mutually exclusive agendas, and the one in the driver’s seat was bound to win.

A half-hour later, still sweating from racing the last five blocks on foot, with patients piling up in the waiting room, I became the one in the driver’s seat, with the mission and overriding agenda. Woe betide those with competing plans.

Just like that driver, I work under two mandates. One is professional: getting my passengers from point A to point B without breaking the law or killing anyone. The other one is less exalted but generally far more visible: I run according to a schedule that I ignore at my peril.

“She’s running late,” they mutter out in the waiting room. And indeed, she runs late for exactly the same reasons your bus runs late: too many slow-moving passengers lined up to board. Not enough buses or drivers. A person in a wheelchair requiring extra attention. Horrible traffic.

Not only does she often run late, but your poor driver — er, doctor — can run only so late before disaster ensues. She has obligations not only to you and your fellow passengers twitching in annoyance, but to a host of others, including the nursing and secretarial staffs and the cleaning crew at the end of the line. She can’t pull that bus in at midnight if everyone is supposed to leave by 7 p.m.

So when there is enough work to last till midnight, my agenda shifts, and not so subtly. Everyone can tell when I begin to speed. Every visit is pared down to the essentials. All optional and cosmetic issues are postponed, including most toenail problems and all paperwork. Chatting is minimized.

As a bus driver once said to me when I was foolish enough to start a conversation about his speed: “Lady, just get behind the white line and let me drive.”

Medicine is full of competing agendas. Even at the best of times, the match between the doctor’s and the patient’s is less than perfect, sometimes egregiously so. Some residents are now trained specifically in “agenda setting,” the art of successfully amalgamating all concerns.

But when it’s all about speed, an advanced skill set is required.

A patient has been waiting weeks for his appointment, anxiously rehearsing his lines. Bad luck that he showed up on a day I need him in and out in 19 minutes. He spends his first 18 unwisely, pretending everything is fine, making small talk, not quite mustering the courage to say what’s on his mind.

Then just as he is being ushered gently to the door, he pauses. “Oh, by the way …”

“Oh, by the way” is an infamous schedule buster. It means something bad: a suspicious lump, a sexually transmitted disease. Further, it is so common that an entire literature now addresses the “oh, by the way” phenomenon and how to tame it.

One favored tool is: “What else?” That question, asked by the doctor early in the visit, is intended to probe the patient’s agenda before it trumps the doctor’s.

As one set of researchers wrote: “The ‘what else?’ technique uncovers pertinent fears and anxieties up front and prevents an ‘oh, by the way, I have been having some chest pain’ from surfacing at the end of a visit.”

In other words: My agenda is to adopt your agenda, and then rework it so that I can drive on. Brutal, perhaps, but effective.

Very rarely do things work out for me the way they did for that driver who made me so late to work. Occasionally I have so much time that I can dawdle along the route.

I remember clearly the last time that happened. “How’s work?” I began. “What are you doing for exercise?” “Any hobbies?” “Your family, are they well?” I progressed rapidly through seatbelts, bike helmets, family medical history, end-of-life preferences — every single stop my bus typically has no time to make.

Every answer was “fine,” “yes,” or “I dunno.” Then the patient stood up: “Look, I have places to be. Are we done?”

We were two people with competing, mutually exclusive agendas. But that time the one in the driver’s seat lost.

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Well: Early Puberty in Girls Raises the Risk of Depression

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Credit Getty Images

When girls come in for their physical exams, one of the questions I routinely ask is “Do you get your period?” I try to ask before I expect the answer to be yes, so that if a girl doesn’t seem to know about the changes of puberty that lie ahead, I can encourage her to talk about them with her mother, and offer to help answer questions. And I often point out that even those who have not yet embarked on puberty themselves are likely to have classmates who are going through these changes, so, again, it’s important to let kids know that their questions are welcome, and will be answered accurately.

But like everybody else who deals with girls, I’m aware that this means bringing up the topic when girls are pretty young. Puberty is now coming earlier for many girls, with bodies changing in the third and fourth grade, and there is a complicated discussion about the reasons, from obesity and family stress to chemicals in the environment that may disrupt the normal effects of hormones. I’m not going to try to delineate that discussion here — though it’s an important one — because I want to concentrate on the effect, rather than the cause, of reaching puberty early.

A large study published in May in the journal Pediatrics looked at a group of 8,327 children born in Hong Kong in April and May of 1997, for whom a great deal of health data has been collected. The researchers had access to the children’s health records, showing how their doctors had documented their physical maturity, according to what are known as the Tanner stages, for the standardized pediatric index of sexual maturation.

Before children enter puberty, we call it Tanner I; for girls, Tanner II is the beginning of breast development, while for boys, it’s the enlargement of the scrotum and testes and the reddening and changing of the scrotum skin. Boys and girls then progress through the intermediate changes to stage V, full physical maturity.

In this study, the researchers looked at the relationship between the age at which children moved from Tanner I to Tanner II — that is, the age at which the physical beginnings of puberty were noticed — and the likelihood of depression in those children when they were 12 to 15 years old, as detected on a screening questionnaire.

“What we found was the girls who had earlier breast development had a higher risk of depressive symptoms, or more depressive symptoms,” said Dr. C. Mary Schooling, an epidemiologist who is a professor at the City University of New York School of Public Health, and was the senior author on the study. “We didn’t see the same thing for boys.” Earlier onset of breast development in girls was associated with a higher risk of depression in early adolescence even after controlling for many other factors, including socioeconomic status, weight or parents’ marital status.

Other studies, including in the United States, have shown this same pattern, with girls who begin developing earlier than their peers vulnerable to depression in adolescence. Some studies have found this in boys, though it’s not as clear. But there is concern that girls whose development starts earlier than their peers are at risk in a number of ways, and across different cultural backgrounds.

“Early puberty is a challenge and a stress, and it’s associated with more than depression,” said Dr. Jane Mendle, a clinical psychologist in the department of human development at Cornell University. She named anxiety, disordered eating and self-injury as some of the risks for girls. In her studies of puberty, she has found associations between early development and depression in both genders in New York children. In boys, the tempo of puberty was significant, as well as the timing; boys who moved more rapidly from one Tanner stage to the next were at higher risk and the increased depression risk seemed to be related to changes in their peer relationships.

Before puberty, Dr. Mendle said, depression occurs at roughly the same rate in both sexes, but by the midpoint of puberty, girls are two and a half times more likely to be depressed than boys.

Some of these children may already be at risk; Dr. Mendle said that early puberty is more common in children who have grown up in circumstances of adversity, in poverty, in the foster care system. But some of it is heredity and some of it is body type and some of it, probably, is chance.

Researchers have wondered about hormonal associations with depression; Dr. Schooling pointed out that their study found that depression was associated with early breast development, controlled by estrogens, but not with early pubic hair development, controlled by androgens. “There is no physical factor that we know about that would explain this; estrogen has been eliminated as a driver of depression in earlier research,” she said in an email. “We probably need to explore social factors to seek an explanation.” They also plan to follow up with their study population at age 17.

The biological transition of puberty, of course, occurs in a social and cultural context. One very important effect of developing early, Dr. Mendle said, is that it changes the way that people treat you, from your peers to the adults in your life to strangers. “When kids navigate puberty they start to look different,” she said. “It can be hard for them to maintain friendships with kids who haven’t developed, and we also know that early maturing girls are more likely to be harassed and victimized by other kids in their grade.”

Parents should be aware of the difficulties that children may experience if they start puberty earlier than their peers, but lots of children handle early development with resiliency, and even pride.

Children who start puberty early – say, 8 instead of 12 — are faced with handling those physical changes while they are more childlike in their knowledge and their cognitive development, and in their emotional understanding of what goes on around them.

Parents should keep in mind that the same protective factors that help children navigate other challenges of growing up are helpful here: All children do better when they have good relationships with their parents, and when they feel connected at school. And we should be talking about the changes to their bodies before they happen, and make it clear that all of these topics are open for discussion.

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Well: Think Like a Doctor: The Tired Gardener Solved!

On Thursday, we challenged Well readers to solve the case of a previously healthy 67-year-old gardener who abandoned his garden one summer, alarming his wife and adult children. For weeks this vibrant and energetic man had been the last one out of bed — something his family had never seen before. And his days were interrupted each afternoon with a fever that left him shaking and pale. More than 300 readers suggested diagnoses for this classic presentation of an unusual disease, and a couple dozen of you nailed it.

The correct diagnosis is…

Babesiosis

The first person to identify this unusual infection was Dr. Paige Szymanowski, a resident in her second year of training in internal medicine at the Beth Israel Deaconess Medical Center in Boston. She said she recognized the pattern of a fever with a low blood count, low platelet count and evidence of liver injury. Dr. Szymanowski hasn’t made up her mind what kind of doctor she’s going to be, but she is thinking of subspecializing in infectious diseases. I think she shows real promise in this area. Well done!

The Diagnosis

Babesiosis is caused by the parasite Babesia microti, a protozoa. It is usually transmitted by Ixodes scapularis, better known as the deer tick, the same small arthropod that transmits Lyme disease. Sometimes the two diseases occur together, passed on in the same bite. The disease can also be spread through blood transfusions from an infected donor.

Babesiosis is rare and occurs primarily in the Northeast and Upper Midwest — Minnesota and Wisconsin — regions of the United States. In healthy people it often causes no symptoms. However, those who are over 65 or who have some type of immune suppression – because of a chronic disease or medication – or those who don’t have a spleen are more likely to develop symptoms and can become quite ill or even die from this infection.

Easy to Miss

Babesiosis is difficult to diagnose, and the diagnosis is often overlooked, even in areas where infection is most common. Patients with babesiosis have few, if any, localizing signs to suggest the disease. Fever — which can be constant or, as was the case with this patient, intermittent — is common. So are shaking, chills, fatigue, loss of appetite, abdominal pain and headache. These symptoms, however, are seen in many infections. And indeed, our patient had all of these symptoms, but it took many weeks for him to get a diagnosis.

The diagnosis is confirmed when the ring form of the protozoa is seen on a blood smear, or when the Babesia DNA is detected in the blood. Doxycycline, which is used to treat other tick-borne diseases, is ineffective against this organism. An antimalarial medication (atovaquone) plus an antibiotic (azithromycin) are first-line treatments against this infection. Improvement is usually seen within 48 hours of starting the drugs.

Although the infection will often resolve without treatment, all who are diagnosed with the disease should be treated since, in rare cases, the bug will persist and become symptomatic if a patient later develops some immune system problem or has his spleen removed.

How the Diagnosis Was Made

Dr. Neil Gupta was leading the daytime on-call team at Saint Raphael’s hospital in New Haven, Conn., where the patient’s daughter had taken him. Dr. Gupta heard about this patient when the night team handed off the patients they had admitted on their shift and met him that morning. Seeing how well the patient looked, and hearing that he’d been given the usually benign diagnosis of hepatitis A, he turned his attention to patients who seemed sicker and more in need of thought and care. Until the patient spiked his usual afternoon fever.

One of the ways the doctor’s mind works is to put together pictures of what a disease looks like in a patient. We put these so-called illness scripts together based on our knowledge of the disease plus the patients we have seen who have had it.

When Dr. Gupta heard that the patient had spiked a temperature, he went back to see how he was doing. The patient was pleasant but didn’t say much. Perhaps there was a language barrier — he spoke with a thick Italian accent. Or perhaps he was one of those patients who just don’t focus on what ails them.

Hearing From the Patient’s Family

The patient’s wife and daughter, however, had been much more attuned to the changes in his health and behavior, and what they reported didn’t really sound like hepatitis. Was this the right diagnosis, Dr. Gupta wondered?

He sat down with the family in the nursing lounge and let them tell the whole story as they recalled it. The man had actually been sick for several weeks. He’d had a fever every day. And he was tired. Normally he never sat down, was never idle. These days it seemed he never left the house anymore. Never went into the garden. He just sat on the sofa. For hours.

Sometimes he had pain in his upper abdomen, but never any nausea; he had never vomited. But he did have a cough. This was not the man they knew, the women told him.

Reviewing the Symptoms

Dr. Gupta returned to the patient and examined him, this time quite carefully, looking for the signs common in hep A. The man’s skin was dark but not yellow; and his eyes, while appearing tired, showed no hint of yellow either. His liver was not enlarged or tender. He didn’t look to Dr. Gupta like a patient who had hepatitis A.

The patient did have tests that were positive for hepatitis A, however. Could these tests be wrong? Dr. Gupta suspected that was the case. O.K., if not hepatitis A, what did he have?

The young internist made a list of the key components of the case: He had recurring fevers every afternoon. He had a cough and some upper abdominal pain. Not very specific — except for the repeating fevers.

The labs were a little more helpful. His liver showed signs of very mild injury — again, not consistent with hepatitis A, which usually causes significant liver insult.

However, he did have a mild anemia that had gotten worse over the past three days. He’d had his blood count drawn two days earlier, when he went to the emergency room at Yale–New Haven Hospital. That showed a very mild anemia – slightly fewer red blood cells than normal. The evening before, the patient’s red blood cell count had dropped further. And today, even further. So his red blood cells were being destroyed somehow. To Dr. Gupta, that seemed to be a second important clue. In addition, his platelets were quite low.

Many Possiblities

So, the patient had cyclic fevers, a worsening anemia and a mild liver injury. That suggested a very different set of diseases.

The patient was a gardener and had been treated for Lyme disease. Could he have a different tick-borne illness?

Certainly a number of illnesses could present this way. The cyclic fevers were suggestive of malaria — rare in this country, but still worth thinking about.

Could this be mononucleosis? Or even H.I.V.? Those diseases can affect red blood cells and the liver. And they can last weeks or months. If those tests were negative, he would need to start looking for autoimmune diseases or cancers.

Finally, he would need to review the blood smear with the pathologist. Several of these diseases can provide clues when you look at the blood itself.

An Answer in the Blood

A call came to Dr. Gupta late the next day. The pathologist had tested the patient’s blood for the presence of the Babesia gene, and found it. The patient had babesiosis.

Dr. Gupta went down to look at the blood smear with the pathologist. There, in the middle of a sea of normal looking red blood cells, was a tiny pear-shaped object. It was one of the protozoa.

Dr. Gupta was excited. He pulled up a picture of the tick that spreads the disease and the tiny bug that causes it to show to the family. This was what was making the patient so very sick.

How the Patient Fared

The patient was started on the two medications to treat babesiosis the same day. Twenty-four hours later he spent his first day completely fever-free — the first in several weeks.

After a couple more days, the patient was up and walking around, asking to go home. He went home the following day, with instructions to take his two medications twice a day for a total of 10 days.

That was last summer. This summer, the patient is back in his garden. He is a little more careful to avoid getting tick bites. He wears his long pants tucked into his socks and his wife looks him over every night — just to be sure.

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Service Advisory: ArtsBeat Is Finished.

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In 2014, ArtsBeat wrote about David Chase and the finale of “The Sopranos,” which ended its run on June 10, 2007, just as the blog was beginning.Credit Craig Blankenhorn/HBO

This is post No. 23,231 on the ArtsBeat blog. And it is the last one.

But don’t fret, faithful readers! None of the content that appeared here is being lost. Links will persist, and past posts should be easily found through search. The Times’s online culture coverage will still be delivered on our website and to mobile devices and apps. Although posts will no longer be published on ArtsBeat, our critics, reporters and editors will continue to deliver our signature reviews, news and features for digital readers at nytimes.com/arts. And the Arts, Briefly column will continue in print.

ArtsBeat came to life on April 27, 2007, when The Times was still based on West 43rd Street, and our digital publishing systems were less nimble than they have become. It was a more innocent time: before the debut of “Mad Men,” the arrival of Lady Gaga and the first performances of “Spider-Man: Turn Off the Dark” on Broadway. Beyoncé and Jay Z had not yet married, much less taken over the cultural world.

In those nine years, the features that made the blog such an appealing alternative to our traditional publishing tools — agility, the ability to embed digital content and a chance to use a livelier voice — have largely been absorbed into the rest of our work. But before shutting off the lights, we wanted to highlight a few of the neat things that happened here.

It was on ArtsBeat that we solicited reader questions for Big Bird, Barbra Streisand and the “Game of Thrones” showrunners.

We covered literary pie-throwing, how the creators of “Avenue Q” dealt with the death of Gary Coleman, and that one time Wiz Khalifa was arrested for refusing to get off of a hoverboard.

Cumulatively, our writers and editors spent several days live-blogging any number of awards shows.

And we regularly sought response from readers, whose contributions yielded much delight, like a collection of limericks dedicated to the basketball player Jeremy Lin, who was having a breakout season in New York. Or these 92 works of art inspired by President Obama.

But the way we heard most often from readers was in the comments, where a number of regulars made the place feel familiar and welcoming. (We also heard from some of the people we cover there, like David Simon and Lin-Manuel Miranda.)

But we thought we’d give the last word here to one of the regulars, Fred Landau, who has submitted almost 4,000 comments over the years under the name Freddie. Hundreds of those contributions were in lyrical form, set to the tune of a Broadway or pop song. Mr. Miranda has also had kind words for Freddie’s work:

So with a tip of the hat, here’s Mr. Landau’s farewell number, “Ballad of the ArtsBeat Blog,” set to the tune of “The Ballad of Sweeney Todd” (original music and lyrics by Stephen Sondheim):

Attend the ending ArtsBeat blog
We’d followed here like a loyal dog
Adept at getting its interviews,
The first with the gossip, the first with the news.
Its fleetness had us all agog
The ArtsBeat blog –
The leading source on the street! Chorus: (Tweet!)

We’re reading here the blog is gone
We’d loved their tales told with great élan
The online kvetchers can go to hell
‘Cause no one did culture news nearly as well
As ArtsBeat
The ArtsBeat blog
The leading source on the beat! (Tweet!)

Say it’s not goodbye, ArtsBeat
Say it isn’t so,
We’ll despair
If you don’t share the news you know!

What grossed the most at the B.O.?
Where will the brand new Lloyd Webber go?
Domingo might do a Parsifal?
Will Banksy be taken off that Brooklyn wall?
Will “Game of Thrones” put out some grog?
That ArtsBeat blog
Was always there with each deet. (Sweet!)

So eclectic that ArtsBeat was
So electric at getting buzz
Getting the word, getting it fast
Is there dissent with a star in the cast?

ArtsBeat blogged on the Holy Pope
ArtsBeat blogged on Ms. Leanne Cope
Jeremy Lin! Lin-Miranda!
Look at the take for “Kung Fu Panda”!
(ArtsBeat! ArtsBeat! ArtsBeat! ArtsBeat! Yeahhhhhhh!)

Attend the end of the ArtsBeat blog
We’d check it out on our morning jog
We’d check in several times a day
And change is O.K. but we just want to say:
“To ArtsBeat!
The ArtsBeat blog!
The leading source on the street!” (Tweet!)

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