Legion of Angels News Archive

Doctors and psychotherapists generally don’t like it when their patients don’t get better. But the fact is that lots of patients elude our clinical skill and therapeutic cleverness. That’s often when the trouble starts.

I met one such patient not long ago, a man in his early 30s, who had suffered from depression since his teenage years. In six years of psychotherapy, he had been given nearly every antidepressant under the sun, but his mood hadn’t budged.

Weeping in my office one day, he explained that he was depressed because he was a failure and a whiner. “Even my therapist agreed with me,” he said. “She said that maybe I don’t want to get better.”

I could well imagine his therapist’s frustration. She had been working with him for nearly three years without significant progress, and she was now doing what many clinicians do when the chips are down: blame the patient for failing to improve.

“I think he has an unconscious desire to remain sick,” she told me.

About a month later, I saw this patient respond remarkably well to a novel treatment. Free of depression at last, he was joyful and relieved — an odd reaction, you must admit, from someone who secretly wished to be ill.

Not just that, but he no longer felt like a failure and was much more upbeat about his future prospects.

I decided to challenge him. “How come you’re feeling so much better despite the fact that nothing in your life has really changed in the past few weeks?”

“Well, I guess I just think like that when I’m down.”

Exactly. His sense of worthlessness was a result of his depression, not a cause of it. It’s easy to understand why the patient couldn’t see this: depression itself distorts thinking and lowers self-esteem. But why did his therapist collude with the patient’s depressive symptoms and tell him, in effect, that he didn’t want to get better?

For an all too human reason, I think. Chronically ill, treatment-resistant patients can challenge the confidence of therapists themselves, who may be reluctant to question their treatment; it’s easier — and less painful — to view the patient as intentionally or unconsciously resistant.

I recall an elderly woman who was referred by a colleague for intractable depression, in which I have a special interest. I was eager to help her.several months and many treatments later, I began to get frustrated that she was no better and noticed that my thinking about her shifted. I wondered whether there was something about the sick role that she found rewarding.

After all, she had constant visits from friends and family members, not to mention an army of medical experts who were all trying, in vain, to cure her. If she got better, she might lose all that care and attention.

Then one morning, shortly after starting a new combination of antidepressants, she called. I did not recognize the cheerful voice. “I’m feeling really good,” she told me. “Not depressed at all.”

My delight aside, I felt chagrined that I had begun to write her off as a help-rejecting crank.

Of course, it makes good medical sense for therapists to rethink the diagnosis and treatment of any patient who fails to improve. But this is a double-edged sword.

Another patient, a young woman with unstable moods, was recently hospitalized with a diagnosis of bipolar disorder. When she failed to respond to two mood stabilizers, the staff began to entertain a diagnosis of borderline personality disorder, which involves emotionally chaotic relationships and impaired ability to function in the world.

“She’s pretty aggressive and demeaning, and we think she has some serious character pathology,” one of the residents told me.

But partly treated bipolar disorder can mimic borderline personality disorder, and after she received a third mood stabilizer, her “personality disorder” melted away, along with her provocative behavior.

This patient had frustrated her clinicians with her lack of response to treatment. In turn, her doctors reacted by changing her diagnosis to a personality disorder. The change in thinking shifted the blame from the clinicians to the patient herself, who was now viewed more as bad than sick.

To be sure, some patients really do want to be sick. People with Munchausen syndrome, for example, deliberately produce physical or psychological symptoms for the express purpose of assuming the sick role. And they will go to extraordinary means to defeat doctors who try to “treat” them.

But a vast majority of patients want to feel better, and for them the burden of illness is painful enough. Let’s keep the blame on the disease, not the patient.

Source — The New York Times

For Nathan Wolfe, a 38-year-old visiting professor at Stanford, an ordinary workday can look like a clip from “Survivor” — chasing primate hunters through the dense foliage of rural Cameroon, sloshing through mud and streams, dodging branches and malaria-carrying mosquitoes.

Dr. Wolfe says he enjoys the adventure. But he has a broader purpose: staving off global pandemics before they happen.

The subsistence, or “bushmeat,” hunters he tracks face a singular occupational hazard: their blood often mingles with that of their prey. Because animals like chimpanzees and orangutans are genetically similar to humans, the likelihood of virus transmission between species is very high.

Both H.I.V. and Ebola, for example, have documented primate origins, and a paper published in Nature in February noted that 60 percent of emerging human pathogens came from animals.

“We’re starting to expand the watershed of global disease control,” Dr. Wolfe said. “Before, the best thing you could do was develop a vaccine, but now people are recognizing that’s not going to be enough.

“If you find diseases before they’ve really emerged,” he continued, “you can control them early on, before you get a major epidemic.”

That pre-emptive-strike approach to epidemic management, he said, is what makes chasing the Cameroonian hunters so crucial.

When he can persuade the hunters, whom he calls “sentinels,” to supply him with blood samples, he can form a better idea of which new animal diseases they are exposed to — and, by extension, which emerging viruses could pose the biggest threat to humans.

Since he began his hunter studies, he has come across several viruses never before seen in humans, including retroviruses from the same family as H.I.V.

“With epidemics, people have been standing on the shore, waiting for the gusher to hit the ocean,” Dr. Wolfe said, referring to the tidal-wave impact a widespread epidemic could have around the world. “But to prevent epidemics, you have to look at the various little sources that feed into the river.”

With the goal of identifying more of these “little sources” — new disease-causing pathogens — and choking them off, Dr. Wolfe started the Global Viral Forecasting Initiative this year. If new disease strains could be culled before they had a chance to take hold in humans, he reasoned, health organizations would have to spend less money and energy on developing expensive vaccines and treatment drugs.

Google’s philanthropic arm, Google.org, is announcing Tuesday that it will contribute $5.5 million to the initiative; that is being matched by $5.5 million from the Skoll Foundation, which supports the work of social entrepreneurs.

“Nathan is going to be a rock star in this field,” said Frank Rijsberman, a Google.org program director. “We have high hopes he’ll discover 5 to 10 new viruses within the next few years.”

While outsiders and colleagues alike have endorsed Dr. Wolfe’s forecasting tactics, putting them into practice is a tall order. After his team arrives in a rural Cameroonian village on a rickety bus, its first task is to convince local populations that the research poses no threat to their way of life.

“People can’t always see a connection between diseases and wild animals,” said Matthew LeBreton, a research coordinator who designs field education programs for the villagers. “And they sometimes think that we’re going to have their meat confiscated. If someone talks to them about bushmeat, that’s what they’re going to hear.”

Once rapport is established, the data collection can begin. Technicians supply the hunters with bits of filter paper, which they use to absorb blood dripping from their prey. At the same time, scientists take blood samples from the hunters themselves. All of the samples are tested for unfamiliar viruses.

“The main things we look for are: Does a particular virus cause disease, and is it transmissible?” Dr. Wolfe said. “We know there are certain types of viruses that are nasty — influenza, for instance, is an area that is not a blindside. But a lot of viruses have come out of nowhere, like H.I.V., or to a certain extent SARS. Because we know we have the potential to be blindsided, we really have to investigate the unknowns.”

To map the emergence of novel viruses, Dr. Wolfe and his colleagues in the Global Viral Forecasting Initiative — more than 100 scientists in nine countries — have begun following other sentinel populations, like people who receive frequent blood transfusions. They have recently expanded their investigations of viruses that cross the animal-human barrier, conducting research in field locations in China, Madagascar, Malaysia and Paraguay.

Thanks to new techniques for sequencing DNA in the viruses they find, epidemiologists can quickly identify the most virulent new pathogens — the ones that have high mutation rates or lend themselves to recombination, in which strands of DNA are broken and then joined to other genetic material. A new variant of influenza, for instance, could be dangerous, but it could cause epidemics only if it were genetically capable of staying one step ahead of the immune system’s defenses.

Tracking the viral mix in a given population over time is also critical, said Forest Rohwer, a microbiologist at San Diego State University who works with Dr. Wolfe.

“Imagine you’re doing routine monitoring of an area,” Dr. Rohwer said. “If you take 100 different blood samples a day to look at the viruses in those 100 samples, and at some point you see a shift away from what you normally see in that system, then you can say, ‘O.K., there’s something wrong here; let’s look at it in depth.’ ”

Once a harmful virus has been located, the next step is to determine how quickly it can spread. Dr. Wolfe’s colleagues and other scientists have developed computer simulations that can be customized to take account of population size and density, family size and transportation patterns.

“You create a population of individuals and then make the rules for how they move around based on your data,” said Dr. Donald S. Burke, dean of the University of Pittsburgh’s Graduate School of Public Health, who helped create some of these simulations. “It’s like SimEpi.”

The simulation then predicts how a virus with a given set of transmissibility properties will thrive in a particular environment. Once Dr. Wolfe and his colleagues isolate a new virus or variant that seems to be spreading in a small area, they can zero in on its primary characteristics — the likelihood that a sick person will infect someone else, for instance — and feed the data into the simulation to generate an idea of how the virus could spread.

The results offer a rough but valuable estimate of how and where a nascent epidemic could take hold. So far, simulations show that for all but the most virulent new pathogens, there is “a reasonable combination of policy options well within the range of the health authorities that, if prepared in advance and implemented quickly, could stop a global disaster,” Dr. Burke said, adding, “If that’s the case, then by God, we better get ready.”

Dr. Wolfe acknowledges that the task of preparing for the next pandemic is gargantuan — far too big for his team alone.

“What we’re doing is our best guess on the ideal way to create an early warning system, but there are going to be 20 or 30 different approaches tried,” he said. “The field of pandemic prevention will become huge over the next few years, funded on the order of billions of dollars. It’s going to be a new movement.”

Source — The New York Times

On a recent Wednesday, Karleen Perez lay unconscious on an operating table in Upper Manhattan while her surgeons and two consultants from a medical device company peered at an overhead monitor that displayed images from inside her digestive tract.

The surgeons, Dr. Marc Bessler and Dr. Daniel Davis, had just stapled her stomach to form a thumb-sized tube that would hold only a small amount of food. The operation resembled others done for weight loss, with one huge difference. In Ms. Perez’s case, there was no cutting. Instead, the surgeons had passed the stapler down her throat and stapled her stomach from the inside.

Inspecting their handiwork, Dr. Bessler said, “I don’t think you’ll get much better than that.”

The operation, meant to make people feel full after eating very little, is strictly experimental. Only a few patients have tried it in this country, as part of a study paid for by Satiety Inc., which makes the staplers and hopes the Food and Drug Administration will approve them.

Ms. Perez, a 25-year-old graduate student in social work, was the second patient at NewYork-Presbyterian Hospital/Columbia to enter the study. Satiety employees advised her surgeons throughout the operation.

The procedure is part of a trend to make surgery less painful and invasive, to minimize risks and speed recovery. Many operations that once required big incisions are now performed through small slits, with cameras inserted to let surgeons see what they are doing on video screens. Ms. Perez’s doctors took the next step: using a natural opening to avoid cutting through the abdominal wall. Dr. Bessler and other surgeons have used similar techniques to remove the appendix through the mouth, and the gallbladder through the vagina.

In Mexico and Europe over the past two to three years, 98 patients have had the new weight-loss surgery, named Toga (for transoral gastroplasty). On average, those who have passed the one-year mark have lost about 40 percent of their excess weight. Only time will tell whether they will be able to avoid gaining it back.

There are older, well-established operations that produce more weight loss, and in the United States 200,000 people have them each year. Known as bariatric surgery, it is often done through slits.

But even the slits leave scars and slice through abdominal muscles, which causes pain, Dr. Bessler said. The operations can have complications, too, like hernias and leaks in the digestive tract.

“Most people don’t want the risk,” he said, adding that only about 2 percent of those who might be helped by bariatric surgery actually have it.

About 15 million Americans are morbidly obese, meaning their body mass index — a type of weight/height ratio — is at least 40 (overweight begins at 25). Medical guidelines recommend surgery when the index reaches 40, or 35 if there are also complications like diabetes or heart disease.

Ms. Perez is 5-foot-9 and weighs 289 pounds, for a body mass index of 42 — though her height and generous frame help hide the weight. Her family, friends and boyfriend say she looks just fine.

But she has mixed feelings about her appearance. She weighed 175 or 180 pounds in high school and was comfortable with that weight. But she gained 90 pounds in college and could not take it off. She hopes the operation will help her lose 60 pounds, maybe even in time for her graduation this coming spring from Stony Brook University.

“I don’t feel like it’s a big issue, but of course it is,” she said. “If I go out with my sorority sisters or friends to buy clothes, I probably can’t buy where they do. I’m the one who comes out with accessories. That’s a bummer.”

More important, she said, is her health. She becomes winded too easily, and her blood pressure “is not great,” she said, adding, “I just want to live healthy and not be borderline anything.”

Bariatric operations typically work far better than diet, exercise or drugs, and they often cure diabetes and reduce the risk of dying from heart disease or cancer. But there is also a risk — albeit small, less than 1 percent at experienced centers — of dying from the surgery itself.

The idea behind Toga is to offer something safer and less invasive. Dr. Bessler said he thought it would appeal to many people who feared the other operations.

“It has a lot of promise,” he said. “I deal with a lot of new technologies. This, I’m really excited about.” Dr. Bessler said that he and Dr. Davis had no financial interest in Satiety but that the company did pay for their work on the study.

Other companies are also developing new devices and minimally invasive operations to cash in on America’s booming obesity epidemic, but Satiety is among the first to start testing its products in people.

A surgeon not involved in the Toga study, Dr. Philip Schauer, director of bariatric surgery at the Cleveland Clinic, called the new operation very promising and said that so far it seemed to offer “a drastic reduction in side effects and risk.”

Though she wanted surgery, Ms. Perez did not want a gastric bypass, the most common bariatric operation, which shrinks the stomach and rearranges the small intestine. Her aunt had it and lost 150 pounds, but suffered from a hernia, intestinal problems and other serious complications.

So Ms. Perez considered gastric banding, a less extreme and increasingly popular operation that inserts a loop around the top of the stomach and tightens it to form a small pouch.

But Toga, which she discovered on the Internet, seemed less invasive. Also, the price was right: the operation would be free as part of the study. She did not mind if it produced less weight loss than the other methods.

“To me, it’s not about being completely skinny,” she said. “I’m told I could lose 40 percent of my excess weight.”

If she exercises and diets after the operation, she said, “I’ll probably lose, like, 60 pounds, and that’s realistic to me.”

Temporarily, she kept her plans a secret from most of her friends and impishly told some that she was having her tonsils out. She took down her Facebook page and put a note in MySpace saying that there would be some changes made.

The operation is not as simple as it might sound. To begin, Ms. Perez was given general anesthesia and put on a respirator. Then the surgeons pushed a dilator, a formidable-looking tube about three-quarters of an inch wide, down her throat to stretch her esophagus.

Next came another wide tube, this one about two feet long, containing the stapler. The surgeons inflated her stomach with carbon dioxide to create space in which to work. Dr. Bessler struggled for 5 or 10 minutes to position the stapler properly, and then activated controls that opened it, like a miniature spaceship, inside Ms. Perez’s stomach.

A sail and curving wire emerged from the stapler to help push aside the folds of her stomach. Then Dr. Bessler turned on a vacuum pump to draw parts of the front and back walls of the stomach into the device to be stapled together.

Three rows of staples were needed, but the stapler holds only one row, so the whole apparatus had to be withdrawn, rinsed, reloaded, pushed back down Ms. Perez’s throat and painstakingly repositioned for each row. The Satiety consultants stood close by to coach, at one point warning Dr. Bessler that if he inflated Ms. Perez’s stomach too much, her first row of staples could pop. The surgery took three hours.

“Every operation has its learning curve,” Dr. Bessler said. “We saw a doctor in Brussels who took an hour and a half, but he had done 70.”

The next morning at the hospital, Ms. Perez was in good spirits despite a horrendous sore throat from the operation. She said she had awakened during the night wondering what she had done, and had thought, “This is going to be super life-changing.”

She would be on a liquid diet for several weeks. A nutritionist had given her a pamphlet that commanded, “Don’t Stretch Your Stomach!,” warned that eating too much or too fast could cause vomiting, and advised that the best time to lose weight would be in the next 6 to 12 months, because the body would try to fight the surgery by absorbing more nutrients.

She thought she could do it. She would start slowly, by taking longer and longer walks. She hoped to join a gym, start running, eventually finish a marathon. She wanted to look cool for her graduation.

“My friends are going to be shocked,” she said. “Through struggle comes success.”

Source — The New York Times

ON Wall Street, when the going gets tough, will the tough get yoga mats?

Adding classes in yoga, meditation and other so-called mind-body regimens is just one way fitness professionals in the financial district are responding to recent economic uncertainties roiling their corporate clientele. Some are also offering shorter, cheaper personal training sessions and, in at least one health club, quiet discounts for members who lose their jobs.

Amid layoffs, concerns about staying buff could seem trivial. (Imagine the headline “World Markets Near Collapse: Muscle Tone Under Threat.”) Yet, businesspeople themselves wonder how a perilous financial climate will affect their physical fitness — and if exercise could help them weather hard times.

Some struggle to squeeze in any workouts at all. But others, like Amy Sturtevant, an investment director for Oppenheimer & Company in Washington, find themselves doubling down on conditioning for relief. “Professionals are doing their best not to panic, but I know a lot of professionals who are panicking” about the markets, she said. “The only way to get away from it is to have some kind of outlet.”

Ms. Sturtevant, a mother of four, is training for her fourth marathon. With brokerage clients needing more hand-holding, she said, she stints on sleep rather than skip her 5 a.m. daily boot camp and 20-mile weekend runs.

But one of Ms. Sturtevant’s training partners, a portfolio manager, said in an e-mail message that she had not been as diligent as Ms. Sturtevant and had been “scarce” at their workouts. The portfolio manager said she had weathered some tough financial cycles, “but this one has been uniquely disabling.”

“Forget the 5 o’clock wake-up to run,” she wrote. “Who is sleeping?”

One business owner, Sheri David, is backsliding for business reasons. As chief executive of Impressions on Hold, a company based in New York that sells corporate voicemail systems, a tougher sales environment has meant Ms. David sees more of her customers and less of her personal trainer. Over the summer, she dropped from five sessions a week to three; by mid-September, she said, “it turned into one day for one hour.”

Her trainer, Chris Hall, chides Ms. David to make time and, when she does, to tune out her BlackBerry, she reported. “But I say, ‘You don’t understand — there’s 27,000 reasons I have to pay attention,’ ” referring to her accounts.

For his part, Mr. Hall — whose clients have included Catherine Zeta-Jones — is now offering 30-minute, “high-core, high-intensity” sessions and shared workouts, he said, “because people don’t necessarily have as much time as they used to, and they don’t want to spend as much money.”

According to the International Health, Racquet and Sportsclub Association, there are 41.5 million health club members in the United States. To keep them on the roster, clubs may be willing to bargain. Most customers who quit the Telos Fitness Center in Dallas, for example, must pay to rejoin. But, for suddenly strapped longtime members, “I’ll put a note in their file and we’ll let them pick up their membership without any fees,” said Clarisa Duran, the center’s sales and marketing director.

For Plus One, which operates in-house fitness centers, corporate accounts are the issue; until recently, its major accounts included the investment banks Bear Stearns, Lehman Brothers, Merrill Lynch, Goldman Sachs and Morgan Stanley. Though still operating in all of those except Bear Stearns (which closed in March), the company now must look to its recent expansion in other regions and industries for growth, said Tom Maraday, the senior vice president. (Google is one new client.)

“We’re a little experienced with stress because we went through 9/11 down here,” said Grace DeSimone, Plus One’s national director of group fitness. When disaster strikes, she noted, demand for yoga goes up, and on-site gyms exert a special pull: “People come and they want someone to talk to — it’s like Cheers.”

And, as in a bar, the televisions stay on. “In the banks, we have to keep the news on,” Mr. Maraday said. But at Cadence Cycling and Multisport Centers, TV’s show training videos rather than CNBC, because “we want this to be an escape,” said Mikael Hanson, director of performance for Cadence in New York.

During the Bear Stearns collapse, as becalmed financiers sought their escape, midday classes at the in-house gym grew crowded, according to a former Bear Stearns trader who declined to be named. When the final ax fell, they lost not just jobs but access to a club offering “everything,” she recalled, a hint of longing in her voice.

“They even gave you the shirts and shorts so you didn’t have to worry about laundry.” Now she can no longer get in her daily 5:30 a.m. workout. Her new employer has no gym and, with the markets erupting, her workday starts even earlier. “I wish there was a gym that opened at 5 in midtown,” the trader said, “but there isn’t.”

Stephanie Shemin Feingold misses a cushy fitness center, too. Since leaving a Midtown law firm in June to work at a nonprofit in Harlem, she’s been using her apartment building’s spartan fitness room. “When there are only three treadmills, it can get crowded pretty quickly,” she said.

“I’m lucky if I get in 20 minutes instead of the hour I used to do,” Ms. Shemin Feingold said. “My pants are getting tight. I’m going to have to figure out a new routine, because I can’t afford a new wardrobe.”

Fitness matters more than ever if you’re laid off, career counselors advise, not just for health, but to network and stay positive. “The last thing you want is to gain 20 pounds during a job search, ” said Dr. Jan Cannon, author of “Finding a Job in a Slow Economy.” “That just compounds that sense of, ‘What’s wrong with me?’ ”

Exercise, she added, can also spur creativity. “You know how we always have those ‘aha’ moments in the shower?” Dr. Cannon said. In the same way, “a good brisk walk can be very helpful.”

Jenny Herring, a Des Moines financial writer, usually walks or bikes for respite from the fulltime job search she began in June, after being downsized as part of the subprime mortgage fallout. But one day last month, feeling frustrated when her phone refused to ring, she varied the routine: “I said, I’m going to get outside, and I mowed the front and back yards” for exercise.

For a motivated few, extra time for conditioning actually proves a rare upside of unemployment. “A lot of people who are between jobs are using this downtime to go after a goal,” like a triathlon, said Mr. Hanson of Cadence Cycling.

Dr. Cannon recalled a client whose workouts last spring “got more frequent as time went on” — to block out the disappointment, and to give her something to get up and do every day.

“She lost 40 pounds.”

Source — The New York Times

The implanted defibrillator, a device that can automatically shock an erratically beating heart back to a normal rhythm, has been proved to save lives. Hence its nickname: an emergency room in the chest. Major medical groups have recommended that more patients receive the devices.

But in the last two years the number of patients receiving defibrillators has actually declined, as more doctors and patients decide the risks and uncertainties the devices pose may outweigh their potential benefits.

This trend — the first decline since implanted defibrillators were introduced in 1985 — has spotlighted a shortcoming that health experts have struggled with for years. Simply put, there is no adequate tool or test to predict which of the heart patients who might seem good candidates to get the expensive devices are the ones most likely to ever need their life-saving shock.

Defibrillators have undoubtedly saved the lives of tens of thousands of Americans. That is why insurers still typically pay for the devices and the surgical procedure to implant them, which can top $50,000 for each patient.

What makes many doctors and patients increasingly wary, though, is a string of highly publicized recalls in recent years, along with mounting evidence suggesting that a vast majority of people who get a defibrillator never need it.

Industry estimates and medical studies indicate that defibrillators have saved the lives of 10 percent of the more than 600,000 people in this country who have received them, at most. While survivors would no doubt take those odds, 9 of 10 people who get defibrillators receive no medical benefit. One big long-term medical study indicated the odds of a defibrillator saving a patient’s life might be even slimmer — about 1 in 14, over the five-year period studied.

The problem that defibrillators pose is in some ways singular among medical technologies. For devices like artificial knees, which improve lives but do not save them, few people would settle for only a 1 in 10 chance of success. For a potentially life-saving cancer drug, a patient might grasp at even much slimmer odds. Where defibrillators differ is that they are only a powerful standby — ready to intervene if necessary, but unlikely ever to be called into service.

If defibrillators were simply $50,000 life insurance policies, the relatively low rate of payoff might not matter much. But the long-shot statistics are significant to people who must weigh the risks of infection and malfunction after they have an electronic device anchored inside their hearts and its wires threaded through their arteries.

The slim odds also have large implications for the United States health care bill, adding billions of dollars annually to Medicare spending and to insurance payments. Dr. Larry A. Chinitz, director of the Heart Rhythm Center at New York University’s Langone Medical Center, said, “The answer isn’t just to keep implanting everybody” who fits the current guidelines.

More doctors are now thinking twice. From a peak of 160,000 new patients in 2005, the number has fallen to less than 140,000 last year, according to Lawrence H. Biegelsen, an analyst at Wachovia Capital Markets. He predicts this year’s total will end up even lower.

For the manufacturers, the numbers translate to a decline in defibrillator sales to $3.94 billion in this country last year, down from $4.29 billion in 2005, Mr. Biegelsen said.

Only overseas, where defibrillators have been slower to catch on, has the number of new implants continued to rise, hitting a new sales high of $1.93 billion last year.

Many patients, of course, are grateful for their defibrillators. “It’s saved me at least four times, including two when I passed out completely,” Matthew M. Murray, a 55-year-old former engineer in Riverbank, Calif., said of his implant.

And some experts worry that the pendulum may have swung too far away from defibrillators — putting countless lives at risk among people with the heart abnormalities and ailments most likely to cause cardiac arrest. At least several hundred thousand people in this country have such conditions, and some estimates place the figure at more than a million.

Medtronic, the leading maker of defibrillators, contends that each day 500 deaths are caused by sudden cardiac arrests among people who meet the current medical guidelines for the devices but do not have them.

(The NBC journalist Tim Russert, who died earlier this year, reportedly suffered a heart attack after an artery was blocked. While Mr. Russert had a history of heart disease, his condition was not one for which a defibrillator would have been prescribed.)

Dr. Eric N. Prystowsky, a nationally renowned heart rhythm specialist in Indianapolis, said every doctor in his field was haunted by individual cases, like that of a Purdue University graduate student who was referred to Dr. Prystowsky for a defibrillator. The student had an abnormally thick heart muscle, a known risk for sudden cardiac arrest.

“He kept putting it off,” Dr. Prystowsky said of the decision to get a defibrillator. “Six weeks later, his fiancée called to say he had been found dead in bed.”

Cases like that may be inevitable as long as doctors cannot give patients more certainty about whether a defibrillator will actually help them.

Better clues could be submerged in the medical records of the people who have gotten defibrillators over the decades. Three years ago, Medicare ordered the creation of a nationwide registry, or database, for implanted defibrillators. Overseen by two leading professional groups, the American College of Cardiology and the Heart Rhythm Society, the registry has amassed about 270,000 records from 1,500 hospitals.

But the data mining has only recently begun, and results are not expected before 2010 at the earliest.

There is no guarantee that the information will lead to more effective use of defibrillators. Unlike drugs, many medical devices evolve so quickly that long-term data on their performance can be obsolete by the time it is available.

There are also efforts to find genetic markers and to develop new diagnostic tests that might more precisely identify patients who are predisposed to the type of sudden cardiac arrest a defibrillator could prevent. So far, though, the only federally approved screening test identifies some patients who are unlikely to need a defibrillator in the next year — not those most likely to require one.

The defibrillator decline began after highly publicized reports of a small number of deadly malfunctions. The biggest blow came in June 2005, when the Guidant Corporation — later acquired by Boston Scientific — recalled 29,000 implanted defibrillators because of flaws that might have caused them to short-circuit instead of delivering critical shocks. At the time, at least two deaths had been linked to the failure.

Medtronic, the market leader, and St. Jude Medical, the third major player, subsequently announced product recalls, although neither was prompted by known deaths.

Heading into 2007, as those headlines faded, many analysts predicted a rebound in defibrillator sales. But last fall Medtronic recalled its newest version of the main wire that connects a defibrillator to the heart. A small percentage of the more than 200,000 Fidelis-brand leads that had been implanted were developing fractures suspected of either preventing some defibrillators from delivering shocks when needed or causing them to deliver unnecessary shocks.

Even with properly functioning devices, patients risk unnecessary shocks — jolts recipients often describe as a painful and frightening kick in the chest. “Almost as many get shocked unnecessarily as benefit,” Dr. Paul J. Hauptman, a professor of medicine at St. Louis University, said.

And even problem-free patients need surgery to replace their unit’s batteries when they run low. Most of today’s batteries are expected to last five to seven years. Manufacturers say patients generally get better software and longer battery life with each replacement. But the repeat procedures also raise costs and risks.

Meanwhile, there are signs that improved treatment of cardiac disease with drugs, diet and behavioral changes could be reducing the need for defibrillators. At a meeting of heart rhythm specialists in May in San Francisco, Dr. Douglas P. Zipes, an Indiana University medical professor, cited data suggesting a decline in the percentage of heart patients who suffered the kinds of heart stoppages that defibrillators were intended to address.

Hoping to stay relevant, the makers of defibrillators have been developing higher-priced devices with new features, including software to limit unnecessary shocks. Most are built to communicate wirelessly, allowing doctors to remotely monitor their performance. Many can perform other rhythm-regulating functions, like synchronizing contractions in different chambers of the heart.

“Adding additional therapy will get at more of the market,” said Daniel J. Starks, chief executive of St. Jude Medical, citing plans to add sensors that could warn of impending heart failure. But adding complexity could also make it even more difficult to calculate the costs and benefits of implanting the devices in the first place.

That bothers patients like one 50-year-old business consultant in the San Francisco Bay Area. The man, who declined to be identified for fear of alarming his clients, ignored recommendations from three doctors to get a defibrillator. Online research suggested his risk of sudden cardiac arrest would be 3 percent a year without a defibrillator — and about 1 percent with one.

Doctors thinking about thousands of patients might see that as a significant difference, he said. But for him, he said, it did not seem a fair tradeoff for becoming “part of the medical-industrial complex for the rest of your life.”

Source — The New York Times