When a devastating tornado touched down in Moore, Okla., on Monday afternoon, Shayla Taylor was on the upper floor of the local hospital, in active labor with her second child.

As the floor shook “like an earthquake” beneath her and ceiling tiles and insulation fell overhead, the 25-year-old huddled with four nurses, braving both the peak contractions of childbirth and the wrath of the worst twister the veteran Oklahoman had ever endured.

“We were all just sitting there holding each other’s hands and praying,” Taylor told NBC News.

Norman Regional Health System

Jerome Taylor, left, Shayla Taylor, center, and Shaiden Taylor, right, welcomed baby Braeden Immanuel at the height of Monday's killer tornado in Moore, Okla.

Moore Medical Center, a 46-bed acute care hospital at 700 S. Telephone Road, took a direct hit from the F-5 tornado, with wind speeds that topped 200 miles per hour.

The blow devastated the hospital, as news photos plainly show, ripping away the roof and walls.

After the chaos, Taylor said she heard not the freight train sound described by so many witnesses, but the absolute silence of the storm’s center. Then she opened her eyes.

“All of a sudden I could see daylight and the wall was gone,” she said. “I look out and I see I-35 and part of the Warren theater,” which later became the triage center for victims of the tornado that killed 24 and injured more than 230 people.

Rick Wilking / Reuters

An aerial view of damage at the Moore Medical Center is shown in Moore, Okla., on May 21, after a tornado ravaged the suburb of Oklahoma City.

She had been dilated to 9 centimeters, nearly ready to deliver the baby, when nurses gave her a quick shot to slow labor during the height of the storm. 

Taylor was quickly reunited with her husband, Jerome Taylor, 29, who had taken their 4-year-old son, Shaiden, to wait out the tornado with others in the hospital cafeteria. With the help of hospital workers, she was carefully carried through the destroyed building and out to a waiting ambulance, which whisked her 5 miles to another hospital in the Norman Regional Health System.

Three hours later, after doctors determined that the petite Taylor would need a cesarean section due to the baby's size, she delivered Braeden Immanuel, a healthy 8-pound, 3-ounce boy.

“His middle name means ‘God is with us,’” said Taylor. “The name had been picked out for months. Now I know why.”

Taylor is among 30 patients and staffers at Moore Medical Center who survived the tornado, which destroyed the hospital, said Kelly Wells, a health system spokeswoman. No decision has been made yet about whether to rebuild or simply raze the site.

Two days after the storm, Taylor and her family are recovering from the trauma of the chaotic birth. The family can’t locate their car, a Toyota Camry, which had been parked in the hospital lot and is now nowhere to be found.

Sossy Dombourian / NBC News

Newborn Braeden Immanuel Taylor is fine after his harrowing birth, his mother says.

“I don’t know if it ended up inside the hospital or down the street,” she said.

Their home is safe, however, and Jerome Taylor, who works for The Hartford insurance company, has been overwhelmed trying to help his neighbors cope.

Oklahomans are used to tornado warnings and Taylor said she wasn’t particularly alarmed before Monday’s storm.

“I’m used to sirens,” she said. “If you panicked, you’d be in a constant panic.”

Now, however, she’s thinking twice about living in Tornado Alley.

“The tornadoes always track through here,” she said. “It’s not to say everybody’s going to pack and leave tomorrow, but they start to reconsider things.”

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• Post-tornado peril: Victims could face deadly fungal infections
• Tornado victims identified

CDC

The Mucor fungus was responsible for infections that sickened 13 patients, including five who died, after a 2011 tornado in Joplin, Mo. Health officials are urging Oklahoma doctors to be on the alert for similar infections after Monday's twister.

Doctors treating victims hurt badly in Monday’s devastating Moore, Okla., tornado should be alert for a rare but deadly complication of wind-whipped debris: fungal infections like those that killed five people after the Joplin, Mo., twister in 2011.

That’s the word from government experts in fungal infections, who documented 13 serious cases of necrotizing cutaneous mucormycosis -- terrible soft tissue infections -- after the Joplin tornado, including instances when visible mold started growing from the patients’ wounds.

“We want to encourage clinicians to be aware that these infections can happen,” said Dr. Benjamin Park, chief epidemiologist with the mycotic diseases branch at the Centers for Disease Control and Prevention.

It's not yet clear whether any fungal infections are suspected in the victims of this week's disaster. In Joplin, it took five days for the first infections to show up; within 10 days, 10 patients had been identified. 

"In the chaos of everything, it's very hard," said Dr. Gary Wells, medical director for the Norman Regional Health System emergency department, who was at the initial triage site during Monday's storm. "It is something you keep in the back of your mind."

Early detection and diagnosis are key to treating the infections, which occur when molds usually found in dirt, decaying wood and other matter become airborne during a heavy storm.  

“When they are picked up out of their natural environment and injected into the skin, we’re always concerned about infection,” Park said.

The molds can contaminate the wounds that occur after the blunt trauma, fractures and penetrating injuries common in tornadoes. The resulting infections can lead to serious illness and death. “The case fatality rate can be very high -- 50 percent,” Park noted.

The Joplin tornado struck at 5:34 p.m. on May 22, 2011, a monster of a storm rated EF-5, with winds exceeding 200 miles per hour on the Enhanced Fujita Scale used to measure tornadoes. More than 1,000 people were hurt and 162 died.

The Moore tornado was upgraded to an EF-5 late Tuesday. At least 24 deaths and 237 injuries have been reported. The injuries are typical of tornadoes: crush injuries, impalements and major cuts, according to NBC’s Dr. Nancy Snyderman, who spoke to trauma officials in Oklahoma.

Doctors and other health workers have been swamped caring for the victims, so it’s not clear what steps they’re taking to detect or treat potential fungal infections.

“I’m not sure that they’ve gotten that far yet,” said Pamela Williams, spokeswoman for the Oklahoma Department of Health.

The need for vigilance is clear, according to a 2012 review of the Joplin infections published in the New England Journal of Medicine. Skin-related Mucormycosis infections have been reported after other natural disasters, including a 1985 volcanic eruption in Colombia and after the 2004 Indian Ocean tsunami.

“The risk of complex wounds with foreign-body contamination during natural disasters is high, and wound management can pose considerable clinical challenge in post-disaster settings, especially when the local health care infrastructure has been damaged,” wrote authors from the CDC.

Related: 

• Joplin victims had rare fungus from dirt
• Okla. tornado injuries: Even the doctors are 'crying'
• Latest NBC coverage of the Oklahoma tornado

A dog may not only fill a home with joy, it fills a home with a whole lot of bacteria, new research suggests.  But that doesn't mean you have to kick your pooch out of the bed.

featurepics.com

This adorable puppy is loaded with bacteria, but those germs may actually be beneficial.

Research from North Carolina State University published Wednesday in the journal PLoS ONE found homes with dogs have both a greater number of bacteria and more types of bacteria than homes without dogs. 

The findings were part of a larger study that analyzed the types of microbes living in 40 homes in the Raleigh-Durham area of N.C.  Participants swabbed nine areas of their homes and informed researchers about aspects that could influence bacterial life, such as whether there were dogs or cats and how many people lived in the home. 

“The project was a first step toward making an atlas of microbes found in the entire home and how they may affect our health and well-being” said Holly Menninger, a co-author and director of public science at NC State’s Your Wild Life program.

Of the places where household bacteria were found, pillowcases and television screens had the most detectable dog-related microbes.

“Some of the microbes we know come from dogs themselves,” said Menninger. “Some of these bacteria come from the outdoor environment, such as dogs bringing bacteria from the soil and into homes.” 

The researchers were able to identify a few classes of bacteria linked to dogs, and certain microbial classes that may cause disease in humans, such as gingivitis and pneumonia.  However, genetic testing of the bacteria was not specific enough to determine whether any harmful strains were there.

All those germs tracked in on dirty paws don’t mean dog-free homes are necessarily healthier, though. While the researchers did not identify the specific species of bacteria living in each household, they were able to say that most of the organisms they found are not disease-causing – and may actually provide some benefits.

“We co-exist with bacteria and healthy, small exposures to bacteria do not pose any risk and might, on the other hand, be beneficial, as long as we keep a good hygienic environment,” said Dr. Rani Gereige, director of medical education at Miami Children's Hospital.  Gereige was not involved in the research.

A recent study found that exposure to a microorganisms from a pet during a child’s first year of life of life may help ramp up the immune system, lowering the risk of developing allergies later. 

“Research has actually shown that mothers who live with dogs while pregnant are less likely to have children with conditions like atopic dermatitis or to develop allergies,” said veterinarian Dr. Andy Roark of Greenville, S.C. 

Certain bacteria from dogs – such as salmonella and listeria -- can cause infections in humans, however, so it is important to be vigilant, he cautions.

“It is always a good idea for both adults and children to wash hands after playing with pets, especially before eating,” said Roark.

The study did not control for certain factors that could affect bacterial growth, such as household climate and cleanliness, and there were not enough homes with cats to accurately analyze the feline contribution to residential bacteria.  The researchers did not analyze whether certain dog breeds harbor more bacteria than others.

The microbes found throughout the different homes fell into three general groups: those that come from skin and live on surfaces we touch, such as door knobs and toilet seats; bacteria linked to food found in kitchens; and organisms found in places where dust gathers, such as television screens and moldings.

Menninger added that the research team is in the process of analyzing samples and other data from a total of 1,300 homes across the United States. 

“We know we have all these bacteria in our home,” said Menninger.  “Let’s learn to live with them.” 

 Related: 

Your skin microbes prove you're a 'dog person'

Family photo via University of Michican

Kaiba Gionfriddo of Youngstown, Ohio, has a bioprinted splint holding his airways open. Without it, he wouldn't be able to breathe.

The Youngstown, Ohio, baby turned blue again and again as his little airways collapsed and kept air from reaching his lungs. But doctors used a 3-D bioprinter to custom-make a splint that is holding his airway open and helping him breathe.

Now 19-month-old Kaiba Gionfriddo is “into everything”,  says his mother, April Gionfriddo.

"Quite a few doctors said he had a good chance of not leaving the hospital alive," she adds.

Kaiba’s life was saved by a brand-new field of regenerative medicine based on plastics and inkjet printers. Doctors at the University of Michigan used CT scans of Kaiba’s little airways to custom-design a scaffolding to pull open the passages and hold them open until they could grow strong and healthy on their own.

Kaiba was born with a rare condition called tracheobronchomalacia. This deformity affects about one in 2,200 babies and causes the airways to be weak and prone to collapse. In tiny babies, it can look like asthma and it can take a while to diagnose.

University of Michigan.

Doctors at the University of Michigan bioprinted this splint, custom designed for Kaiba Giofriddo's trachea. It fits around the outside and supports the windpipe.

Kaiba showed early symptoms. “At 6 weeks of age, he had chest-wall retractions and difficulty feeding,” the researchers wrote in this week’s issue of the New England Journal of Medicine. April Gionfriddo says it wasn’t immediately clear what was wrong, until one morning the family was eating out when Kaiba was 2 months old.

“We went to the Waffle House,” she said in a telephone interview. “He ended up turning blue and stopped breathing on us.” They rushed to the emergency room, where doctors said the baby had just aspirated something, and sent him home.

“Two days later, he ended up turning blue on us again,” says Gionfriddo, a 32-year-old mail room worker in Youngstown, Ohio. “He ended up spending four months in the hospital.”

Kaiba needed a ventilator to breathe, and wasn’t going to be able to survive without it. Worse, he struggled and had to be sedated to tolerate the breathing tube.

“Some of the arteries, especially those coming off the aorta, are malformed,” said Scott Hollister, a professor of biomedical engineering at Michigan. “They almost form a ring around the trachea. If it’s too tight, they actually compress the airway, which happened in Kaiba’s case.”

Again and again, Kaiba’s floppy airways collapsed.

"Even with the best treatments available, he continued to have these episodes. He was imminently going to die,” said Dr. Glenn Green, a pediatric ear, nose and throat specialist at the University of Michigan “The physician treating him in Ohio knew there was no other option, other than our device in development here.”

Green had been working with Hollister to develop exactly what Kaiba needed – support for his growing bronchial tubes.

“Our laboratory has been working on this area for a long time,” Hollister said in a telephone interview. “It was a little bit intimidating as well. We had been developing the prototype and gearing it toward this application.”

Family photo/ Via University of Michigan

Kaiba Gionfriddo can't walk yet, but he can scoot around, his mom says.

Replacing the entire trachea is complex. “We felt the simplest solution was to build a device that would go around the trachea,” says Hollister.

They developed a program that would design the horseshoe-shaped device, complete with small holes to allow a surgeon to suture it into place. “Then we made a model of his trachea,” says Hollister. “Just to be sure, we made it in a range of sizes.”

Hollister’s team used a bioplastic powder called polycaprolactone.  “It’s a polymer that is approved by the Food and Drug Administration to fill small holes in the skull,” Hollister says. The bioprinting machine melts the powder, and builds the desired shape layer by layer.

The University of Michigan team got special permission from the school’s advisory board and the FDA to go ahead. “I was a little scared at first because the doctor said he wasn’t sure it was going to work at first,” Gionfriddo says.

“But we decided to go ahead and try it. It gave him a chance. We were pretty happy they had at least something. It kind of seemed kind of cool and the other part was science fiction.”

In February of 2012, a surgical team re-arranged Kaiba’s twisted heart arteries and trachea, and then carefully placed the splint.

"It was amazing. As soon as the splint was put in, the lungs started going up and down for the first time and we knew he was going to be OK," says Green. In three years, they expect the material will be completely reabsorbed and excreted by the body. By then, his own airways will be able to function on their own, doctors say. 

"Severe tracheobronchomalacia has been a condition that has bothered me for years," he added. "I've seen children die from it. To see this device work, it's a major accomplishment and offers hope for these children."

Three weeks after surgery, the ventilator was taken out and Kaiba was sent home. "He’s not walking yet, but he’s starting to learn how to scoot backwards on his little butt,” Gionfriddo says.

Now, Kaiba’s 6-year-old brother and 11-year-old sister spoil him, Gionfriddo says. “They sit there and laugh at him. They end up getting in trouble with them.”

Related:

Girl gets artificial trachea

Toddler is youngest to get new windpipe

Regenerative medicine - a 'growing' field

Editors note: A graphic image of the patient post surgery is at the bottom of the page.

A 33-year-old Polish man received a life-saving total face transplant just three weeks after being disfigured in a workplace accident, in what his doctors said Wednesday is the fastest timeframe to date for such an operation.

Face transplants are extraordinarily complicated and relatively rare procedures that in the past have required extensive preparation, typically months or years. But medical officials said the Polish patient's condition was deteriorating so rapidly that a transplant was seen as the only option, though now he still faces a high risk of infection.

The patient worked at stonemason's workshop, where in April a machine used to cut stone severely damaged his face and crushed his upper jaw. The man, identified only as Grzegorz, received intensive treatment at a hospital in Wroclaw, but an attempt to replant his own face failed, doctors said.

/ AP

The skull of a 33-year-old Polish man after it was damaged in a work accident, right, alongside the healthy skull of another person.

So he was taken to the Cancer Center and Institute of Oncology in Gliwice, which is the only place in Poland licensed to do face transplants and has experience in facial reconstruction for patients disfigured by cancer. Doctors at the center said the 27-hour face and bone transplant was performed May 15 soon after a matching donor was found.

The surgery reconstructed the face, jaws, palate and the bottom of the man's eye sockets. Pictures show surgery stitches running from above the patient's right eye, under the left eye and around the face to the neck. The donor was also a young man.

The head of the team of surgeons and other specialists, Adam Maciejewski, said it was the world's first life-saving face transplant carried out so soon after the damage.

He and other doctors said the surgery was the patient's only shot at survival — prior to the operation the man faced danger from infections because of the tremendous damage to his mouth area and the skull bone. The man also could not breathe on his own nor eat.

"We assume the surgery will allow the patient to return to normal life," Maciejewski said. "He will be able to breathe, to eat, to see."

/ AP

A 33-year-old Polish man whose face was torn off by stone-cutting machinery is shown after undergoing a total face transplant. Picture provided by the Cancer Center and Institute of Oncology in Gliwice, Poland,

However, surgeon Michal Grajek told The Associated Press that the patient still runs a risk of infection because the team did not have time to cure any potential infections in the donor tissue. For now, the patient is in sterile isolation to protect him from infection, but he has already started the rehabilitation process.

He will stay on immunosuppression drugs for the rest of his life to keep his body from rejecting the donated face.

A picture of the patient taken Tuesday, six days after the surgery, showed him giving a thumbs-up sign from his hospital bed.

More than two dozen transplants of the face or parts of the face have been performed around the world. The first one was a partial face transplant in a woman maimed by her dog in France in 2005.

Related:

'A wonderful gift': Lye attack victim reveals new face after transplant

Maj. Geoff Legler/Oklahoma National Guard/Handout via Reuters

A rescue worker and his search dog sit outside the remains of the Plaza Towers Elementary School in Moore, Okla. Emergency workers have pulled more than 100 survivors from the rubble.

Search teams, including some with trained dogs, are scouring the rubble left behind by the monster tornado that flattened miles of homes, schools and businesses in Moore, Okla., and the nearby area Monday. More than 100 people had been found alive by rescuers as of Tuesday afternoon.

While it's uncertain exactly how many people are still missing, rescuers are up against the clock to find survivors, experts say.

The window of opportunity for someone to still be alive but out of sight under the wreckage is usually about 48 hours, says Bill Dotson, president of the Search Dog Organization of North America. 

“We have got probably until tomorrow night to be optimistic,” Dotson, who has been training search dogs since 1977, said in a telephone interview.  “There is an urgency to this. There is a time factor, but it is always possible that we are going to find somebody," added Dotson, who is not involved in the Oklahoma search and rescue effort.

Authorities said they were still searching Plaza Towers Elementary School in Moore, Oklahoma, where seven children died, but said search dogs had not found anyone else amid the shattered pieces of wood, metal and concrete. Among the searchers are dog units from Texas, Missouri and Nebraska.

Search and recovery experts know it’s possible to survive a building collapse. People have been pulled alive from impossibly small spaces after quakes, explosions and accidents. Most recently, a young mother was pulled alive from the pancaked remains of a Bangladesh clothing factory, 16 days after the disaster.

Slideshow: Tornadoes ravage Plains

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Destroyed vehicles lie in the rubble outside the Plaza Towers Elementary school in Moore, Okla., on Tuesday.

Launch slideshow

The keys to survival are that something must have protected the person from being crushed, they’ll need to be somewhat mobile, they’ll need air and, after a few days, water.

“Voids – we look for voids,”“We look at the wreckage to determine survivability,“ said Dotson, who's helped train dogs for mine rescue, rescues after disaster and to help look for people who are lost or missing.

Survivors will have to have escaped the worst of the flying debris and gotten stuck under a piece of the building’s frame, or something similarly strong and stable.

“Maybe they are buried pretty deep in a basement, a house collapsed on top of it, and nobody could get to them,” Dotson says. “We know from earthquakes that 48 hours is the optimal time to locate living persons and find them alive and get them to hospital.”

Even a minor injury can kill someone after a few days, Dotson notes. “Imagine someone has a cut to the leg. They’re fine, and it stops bleeding on their own,” he says. “Then a day goes by and they start having an infection. Then a second day goes by and the infection’s worse. The mere infection can kill a person who was alive when the tornado left.”

Being completely pinned can also cause what's known as crush syndrome, which severely damages the nerves and muscles. Releasing the victim can even precipitate a heart attack or a stroke, so rescuers must take care.

Specialized equipment can check for the carbon dioxide exhaled by survivors, but it’s usually quicker to use a trained dog.

“They are very successful and very efficient at locating people that you can’t see or hear,” Dotson says. “If someone’s five or six feet down in the rubble, it can be pretty hard to hear them.”

Rescue dogs are specially trained to detect people who are still alive. They can smell exhaled breath, for a start, says Dotson. “Imagine a picture of Pigpen from the Charlie Brown cartoons,” he said. “We all put off molecules that a dog can pick up. Their sense of smell is extremely acute.”

It takes years of training, however – people’s pets are very unlikely to help rescue anyone, even their own families. “They are absolutely, positively of no help whatsoever,” Dotson says.

If someone was trapped for longer than a few days, water would be the next immediate need, experts say. “People can last without water intake, if conditions are pretty good, for around five days or a week,” says Randall Packer, a professor of biology at George Washington University.

Some survivors have said hearing the sounds of the search have given them hope, and the will to hang on.

People can last for weeks without food, but looking at images of the devastation in Oklahoma, Dotson says he doubts any buildings have intact enough spaces for anyone to survive that long.

Fire and rescue officials said they would check every structure in Oklahoma from top to bottom.

“We are always optimistic that the next foot the dog puts down, he is going to say yes, we have got somebody here alive,” Dotson said.

Related:

• Crews comb devastation in Oklahoma
• School came apart; students had nowhere to hide
• Water secret to long-term survival

SAN FRANCISCO -- Thousands of healthcare workers walked off the job at the University of California's five medical centers on Tuesday, delaying surgeries, diagnostic procedures, treatments and emergency care throughout the state. 

The union representing nearly 13,000 vocational nurses, respiratory therapists and radiology technologists said they staged the strike -- scheduled to last two days -- to draw attention to staffing shortages that they say undermine patient care at the hospitals in San Francisco, Davis, Los Angeles, San Diego and Irvine.

Some of the public hospital system's estimated 3,400 pharmacists, social workers, psychologists, occupational therapists and lab scientists also walked out on Tuesday in a one-day sympathy strike at the five medical centers.

"The allegation is they're doing this for patient safety," UC spokeswoman Dianne Klein said. "If we had unsafe staffing levels, we wouldn't be in operation. I really don't understand how walking off the job and leaving patients stranded is helping them."

Todd Stenhouse, spokesman for the American Federation of State, County and Municipal Employees, which represents the striking workers, said the union's primary consideration was ensuring adequate staff for patient care.

"Our top concern is about safe staffing, and we need to put a stop to the diversion of resources away from patient care," he said. He said the workers have been working without a contract since September.

Klein said the sticking point in negotiations has been the union's unwillingness to agree to changes to a pension system that most of the university's other workers have already accepted. "What AFSCME wants is a special deal for them, and we don't think it's fair," she said.

Proposed changes include raising employee pension contributions, revising eligibility rules for retiree health benefits, and creating a second tier of retirement benefits for new workers.

Tim Thrush picketed outside UC San Francisco, where he works as a diagnostic sonographer, holding a sign saying, "Striking for our patients, our family and our future."

"I'm very excited and energized to be in the middle of hundreds of my co-workers who are standing up to UC and letting them know that their messed-up priorities that are shortchanging patient care on a daily basis need to stop," said Thrush, 46.

University of California Vice President for Human Resources Dwaine Duckett said his organization had offered the workers a four-year contract with up to 3.5 percent annual wage increases. The average employee in the union earns $55,000 a year, he said.

Fuse / Getty Images

The decision to withdraw life-sustaining care varies widely in intensive care units, ICUs, across the U.S., a new study finds.

If you land in an intensive care unit sick enough for doctors to consider withdrawing life support, be warned. Whether and when to pull the plug may depend in large part on the practices and culture of the ICU itself -- perhaps more than your needs or wishes, a new study finds.

That may be especially true if you’re so ill or incapacitated that you can’t make decisions about your own care, according to research being presented Tuesday at the American Thoracic Society International Conference.

After accounting for patient factors such as age, function, gender and race, the probability of having life support withdrawn ranged from 3.5 percent in some ICUs across the nation to 20.6 percent in others -- a six-fold variance.

“The really important message for patients and their families is, before you end up in an ICU, talk to your loved ones about what you would want,” said Dr. Caroline M. Quill, lead author of the study by researchers at the Perelman School of Medicine at the University of Pennsylvania.

Quill and her team analyzed records of more than 269,000 patients treated in 153 ICUs in the United States between 2001 and 2009. Overall, nearly 12 percent of patients had a decision made to go from a “full code” -- an all-out effort to save lives -- to some kind of limit on care.

That could have included: a DNR or do-not-resuscitate order; an order to withhold CPR or cardio-pulmonary resuscitation plus removing mechanical ventilation; dialysis or other life-saving treatments; or simply an order to provide only comfort measures or hospice care. About 59 percent of the patients died in the ICU and another 41 percent survived to discharge, the study found.

Particular patient characteristics accounted for most of the variability in decisions to withdraw life support, Quill acknowledged. But even after age, illness, functional status and other factors were analyzed, the variation among ICUs to authorize a DFLST -- decision to forgo life-sustaining therapy -- was striking.

“The finding of a six-fold variability among ICUs strongly suggests that the ICU to which a given patient is admitted strongly influences his or her odds of having a DFLST, regardless of personal or clinical characteristics,” the authors write.

The study didn't find particular variance by geography and the decision to withdraw care wasn't related to regional differences in cutting costs, Quill said.

End-of-life experts have known for years that individual doctor and ICU practices can affect the decision to withhold care, said Dr. J. Randall Curtis, director of the Palliative Care Center of Excellence at the University of Washington in Seattle.

In some ICUs, there’s a kind of heroic standard, an atmosphere in which doctors don’t talk about dying and every effort is made to sustain life, he said. In others, there’s an early effort to acknowledge the likelihood of death and to talk about the risks and benefits of care and how it fits into what a patient would want.

“I think there are still parts of our medical culture that say it’s our job to keep people alive no matter what,” he said. “As opposed to talking with patients and families about their values.

In the absence of instructions from the patient or their family members, the ICU’s culture is more likely to sway the decision about whether to prolong care -- or not.

Quill emphasizes that the study didn’t draw any conclusions about the rates of ICU decisions to withdraw support. “We don’t necessarily think that the 3.5 percent rate is too low or the 20.6 percent rate is too high,” she said.

Surprisingly, perhaps, there actually are no hard-and-fast guidelines in the critical care field about when to withdraw life support. That’s mostly because it would be too hard to envision every potential scenario, said Dr. Douglas White, an associate professor of critical care medicine and director of the program on ethics and decision making in critical illness at the University of Pittsburgh.

“These decisions about whether and when to withdraw life support are not scientific decisions,” he said.

In an ideal scenario, a patient would have made his or her wishes about end-of-life care known well in advance. In practice, however, although the number of people who spell out their wishes is growing, only about 10 percent of the general public has completed an advance directive or obtained a durable power of attorney for health care, Curtis noted.

That means that the final decision often is left to family members or other “surrogate” decision makers, and to doctors and clinicians.

“If the patient hasn’t articulated a clear preference, it’s very, very hard for doctors and families to work together to make the decision, “ White said. “(They’re) left to do the best that they can that generally reflects who the patient is as a person.”

It would be far better, experts agree, if more people anticipated the possibility of end-of-life decisions and left clear instructions. Ten years ago, that might have been preferences for -- or rejection of -- specific treatments such as CPR or mechanical ventilation, experts say.

Today, the discussion centers much more on the overall goals of care and the values of the patient. Take the end-of-life instructions drafted by Dr. John Luce, an emeritus professor of anesthesiology and medicine at the University of California, San Francisco.

Luce, who has researched and written about end-of-life care, said he values a “sentient existence” in which he retains the ability to  “think, read, speak, write and communicate with people.”

“Anything that could not restore me to this, I would not want it,” he said.

So that’s how Luce’s advance directive reads, if heaven forbid, he should need it. The new research that underscores the variability of ICU practices should also emphasize the need for ordinary people to make their wishes known, Luce said.

“The really important thing is to get people talking with those who could become their surrogates,” he said. “The written document is less important than the conversation that leads up to the directive.”

Related: 

• Good news about aging: Get older, feel better, study finds
• Doctor-assisted death: A dad's choice sheds light on a national issue
• Americans in denial about long-term care

Newscom

A new study shows adding olive oil or nuts to that healthy diet can protect your brain.

It might seem against all logic, but adding a little olive oil or a handful of nuts to your diet each day may help keep your mind clear, researchers reported on Monday. It’s the same diet that’s also been shown to reduce deaths from heart attacks and strokes.

The researchers found that people who ate these healthy fats were less likely to show the early signs of  dementia than those who stuck to a more traditional diet.  And this was done in Spain -- where people are already eating a so-called Mediterranean diet.

“Our findings support increasing evidence on the protective effects of the Mediterranean Diet on cognitive function,” Miguel Martinez-Gonzalez of the University of Navarra in Spain and colleagues reported in the Journal of Neurology, Neurosurgery and Psychiatry.

The findings come from a large and well-publicized trial that showed the Mediterranean diet rich in fruits, vegetables, olive oil and a little wine can cut the risk of heart attacks and strokes by 30 percent. Martinez and colleagues took a part data on 500 volunteers from their own study center, who were followed for more than six and a half years after starting the diet.

A Mediterranean diet includes lots of salad, fruit, vegetables, nuts, a little fish, a little lean meat, a small amount of cheese and olive oil.  Wine is also served at meals. In the main study, 7,400 volunteers got extra counseling, and either a weekly supply of extra-virgin olive oil or mixed nuts -- walnuts, almonds and hazelnuts.

The volunteers, aged 55 to 80, were all at high risk of heart disease because of diabetes, a family history of the disease, high blood pressure, unhealthy cholesterol levels -- or they were overweight or smokers. They were randomly assigned to either add more extra-virgin olive oil to their daily diets, a daily handful of the mixed nuts, or just a standard diet with advice to cut fat.

Such “randomized” studies are considered more powerful, because people don’t choose which diet to adopt -- and so other outside factors don’t interfere with the results. For instance, people who choose to eat nuts might also dislike meat, or they might like sweets, or they might exercise more or less than people who don’t think much about eating nuts.

Six years after starting on the diet, the 500 Navarra volunteers took two standardized tests for dementia and the confused thinking, called cognitive impairment, that often leads to dementia.

The researchers found that 60 volunteers had developed mild cognitive impairment. Eighteen had been told to eat more olive oil, 19 had been on the diet with added mixed nuts and 23 of them had been advised to eat a low-fat diet. And 35 people developed dementia: 12 on the added olive oil diet; six who got nuts and 17 on the low-fat diet.

There are several ways that adding olive oil or nuts to the diet might protect the brain, the researchers said. Olive oil and nuts contain monounsaturated fats, which are better for artery health than the saturated fats found in butter, meat and lard. These foods are also high in fiber and vitamin E, as well as minerals. Walnuts are rich in omega-3 fatty acids.

The diet could reduce damaging inflammation, Martinez says. And some studies have suggested that virgin olive oil -- which is cold-pressed and unrefined -- might fight the beta amyloid "plaques" found clogging the brains of Alzheimer's patients. "A third mechanism may be that an improvement in vascular health leads to better brain blood flow," Martinez said by e-mail.

These nutrients protect against the oxidative damage that can cause heart disease, cancer and Alzheimer’s. Various studies have shown little benefit from taking vitamins alone, but this study shows the combination of the factors in a healthful diet does seem to have an effect.

Groups like the Alzheimer’s Association have been warning that the U.S. will have to cope with a tsunami of Alzheimer’s disease as the population ages, with projections that the number of patients with this untreatable form of dementia will triple in the next 40 years, to 13.8 million in 2050.

“Currently, there is no effective therapy to delay the onset or halt the progression of dementia,” the researchers noted.

Related:

• Tasty diet cuts heart disease
• Alzheimer’s rates accelerating
• Alzheimer's fastest-growing health threat
• Healthy diet may delay Alzheimer's

The dangers of texting while driving gets more headlines and drunk driving remains one of the main causes of automobile accidents, but a large, new study published Monday helps explain why so many teens and young adults are involved in motor accidents.

Indiana State Police/AP

Motor Carrier Inspector Master Trooper Mike Probasco, left, looks over the remains of a box truck with its driver Dagoberto Perez, of Cicero, Ill. in November 2010. Perez, who said he fell asleep and veered off the road, was cited for being a fatigued driver. Both drivers received non-life threatening injuries.

They're sleepy.

Report after report shows it -- sleepy drivers cause car crashes. In the new study, researchers at The George Institute for Global Health in Sydney, Australia suggest that a long-term lack of sleep may not only cause immediate drowsiness at the wheel, but may affect a young driver’s judgment over time.

“Less sleep per night significantly increased the risk for crash for young drivers,” the researchers wrote in the American Medical Association journal JAMA Pediatrics.

Alexandra Martiniuk and colleagues studied the driving records of more than 19,000 young men and women, aged 17 to 24, who had just received their driver’s licenses. These new drivers had filled out questionnaires that included specific details about how many hours sleep they got each night in the previous month.

Then the researchers went through police records on road crashes for the next two years after the drivers were licensed.

 “Those who reported sleeping six or fewer hours per night had an increased risk for crash compared with those who reported sleeping more than six hours,” they wrote. The people who slept the least were 21 percent more likely to have been involved in a crash than those who got more sleep, Martiniuk’s team found.

On the weekends, the risk rose even more. Those who got six hours or less sleep on the weekend were 55 percent more likely to be in a crash than those who slept more.

It’s a global problem affecting not only young drivers, they noted. “For drivers of all ages, estimates in the United States, United Kingdom, and Australia report that between 5 percent and 30 percent of crashes are attributed to fatigue,” the researchers noted. “Not only are they more likely to have sleep-related crashes; these crashes are more likely to be fatal compared with other crash causes.”

 The AAA Foundation published a survey last year that found one in seven licensed drivers ages 16-24 admits they had fallen sleep at least once while driving in the past year and that 10 percent of all drivers say they’ve dozed off at the wheel. The Centers for Disease Control and Prevention found that 5 percent of adults aged 18 to 44 admitted to nodding off at the wheel.

One in six crashes with a fatality was caused by a drowsy driver, according to the National Highway Traffic Safety Administration (NHTSA).

The NHTSA says sleepy driving is involved in 100,000 crashes serious enough to generate a police report each year. Such crashes have killed more than 1,500 Americans and injured 71,000.

Sabrina Birch was one of those victims. According to the Daily Oklahoman and other media reports, Birch, 17, was thrown out of the pickup truck when her boyfriend, Colby Ruthardt, also 17, fell asleep at the wheel and crashed last November.  The Gracemont, Okla. teen died from her injuries.

Martiniuk’s team found some suggestion that a lack of sleep may affect other behaviors, too.

“Risky driving, sensation seeking, self harm ... and greater drug and alcohol intake were reported more often by individuals who obtained less sleep,” they reported. It’s not clear whether a lack of sleep was a cause or a symptom, but they said the finding  points the way to doctors, parents and others trying to help.

They also noted direct measures that can help prevent crashes caused by sleepy drivers. “Changes to road design (eg, tactile road edges and divided highways), as well as education campaigns, may help reduce crash risk,” they wrote.

“Using a rest stop, drinking coffee, and playing the radio while driving have been shown to be significantly protective against crashes, at least in the short term,” they added.

Related:

• Automakers look to curb drowsy driving
• One in 24 admits to nodding off at the wheel
• The dangers of drowsy teen drivers

Federal health regulators say an experimental insomnia drug from Merck can help patients fall asleep, but it also carries worrisome side effects, including daytime drowsiness and suicidal thinking.

The Food and Drug Administration on Monday released its review of the company's sleep aid, suvorexant, ahead of a public meeting on Wednesday. The pill works by temporarily blocking chemical messengers that keep people awake.

The FDA said company trials show suvorexant is better than placebo at helping people fall asleep and stay asleep. And regulators said the drug's effectiveness was consistent across several doses tested by Merck & Co. Inc.

But patients taking the higher doses of the drug showed an eight-fold increase in daytime drowsiness, which sometimes interfered with driving the next morning. Patients taking 20 milligrams and 40 milligrams of suvorexant had trouble staying in their driving lanes when tested by company researchers. FDA notes that four women actually had to stop the driving test due to excessive sleepiness.

The FDA review also notes that suvorexant was associated with increased risk of suicidal thinking. Over 12 months, there were eight cases of suicidal thinking or behavior reported among patients taking the drug, compared with no cases among patients given placebo.

Merck has proposed a starting dose of 15 milligrams for seniors and 20 milligrams for non-seniors. Doctors would gradually raise these doses to 30 milligrams and 40 milligrams, respectively, or until the patient's insomnia has been successfully treated.

On Wednesday the FDA will ask a panel of outside experts to vote on questions of the drug's safety and effectiveness. The agency appears to favor eliminating most of the higher doses of the drug tested by Merck.

The FDA says Merck data suggest that a 10 milligram dose may be safer, while still being effective.

"Indeed, if a dosage strength lower than 15 milligrams is unavailable, we would need to consider if the drug could be marketed safely at all, if we believe that a substantial proportion of the indicated population needs a lower dose," the agency states in its review.

The agency plans to ask its advisers whether there is enough data to support a 10 milligram dose, according to draft questions posted online.

ISI Group analyst Mark Schoenebaum called the FDA's review "tough."

"The high dose is deemed unsafe, and the FDA wonders if there is enough data at the safer low dose to draw firm safety conclusions," Schoenebaum said in a note to investors. He says it could take Merck 18 months to resubmit its drug, if FDA requires another study of low-dose suvorexant. The potential impact on Merck's revenue is relatively small, since the drug is only expected to generate peak sales of $650 million by 2018.

In January, the FDA required drugmakers of Ambien and similar sleeping pills to lower the dosage of their drugs, based on studies suggesting a link to drowsiness-related injuries. The agency cited research showing that the drugs remain in the bloodstream at levels high enough to interfere with driving.

A typical boy with ADHD can appear to be in perpetual motion, but that activity doesn’t guarantee a healthy weight when he grows up. A long-term study released Monday finds that men diagnosed with attention deficit hyperactivity disorder as children are twice as likely to be overweight or obese in adulthood as those who never had the disorder.

These findings, published in Pediatrics, may be surprising to parents because drugs such as Ritalin or Adderall used to treat ADHD can suppress appetite, said Dr. F. Xavier Castellanos, the study co-author and a professor of child and adolescent psychiatry at New York University.

Robert Bukaty / AP

Ritalin can suppress the appetite in children who take it for ADHD.

“It’s not uncommon for kids treated with ADHD medications to be fairly thin,” Castellanos said. Because parents often worry that thinner boys won't grow as tall, “sometimes [they] will encourage their boys to eat more.”

Instead, to help avert weight problems down the road, parents should be alert to poor eating habits. “If anything, you have to pay attention to how many times they’re having fast food, how many times they’re having fried food, whether they’re getting meals supersized," Castellanos said.

The study comes at a time when ADHD rates are rising. A new report from the Centers for Disease Control and Prevention found that ADHD is the most common mental health issue in children ages 3-17, with nearly 7 percent of kids receiving a diagnosis.

The NYU researchers followed 222 boys -- 111 with ADHD and 111 without, for an average of 33 years -- hoping to better understand the disorder's effects on the brain. The boys with ADHD, all from middle-class, white families, were diagnosed between the ages of 6 and 12.

Decades later, when some of the men returned for brain scans, many of the now 40-something adults who had ADHD as children had gained so much weight they barely fit into the fMRI machine, Castellanos said.

The researchers then asked about the body-mass index of all 222 participants, discovering that men diagnosed with ADHD as children were significantly heavier than those without the disorder. The average BMI for the ADHD participants was 30.1, compared to 27.6 among those who never had the disorder. The obesity rate among the men who’d had an ADHD diagnosis was 41.4 percent, compared to 21.6 percent among those who never had the disorder.

An adult with a BMI of 25 or higher is considered overweight, according to the Centers for Disease Control and Prevention. 

Castellanos suggested the connection between obesity and an ADHD diagnosis may be explained by some of the disorder's common symptoms: lack of impulse control; difficulty paying attention to details; and poor planning skills. These symptoms could lead to problems such as unhealthy food choices and an irregular eating patterns that continue into adulthood, he said.

While the study was only of men, Castellanos suspects that the results would hold true for women as well. 

The new study “shows exactly what I would have expected,” said child psychiatrist Dr. James McGough, director of the UCLA ADHD clinic. “People with ADHD have a terrible time delaying gratification. They’re very impulsive and they don’t think about consequences. Their problems with organization may make it more difficult to stay on a regular eating schedule which leaves them more likely to binge eat.”

Obesity expert Dana Rofey says “sneak eating and aberrant eating patterns” are common among many of her young, male patients with the disorder.

“Once they start eating, they don’t stop,” said Rofey, an assistant professor of pediatric psychiatry and psychology at the University of Pittsburgh Medical Center and weight management director at the Children’s Hospital of Pittsburgh.

Rofey hopes the study will prompt parents to help their sons develop healthful eating habits -- before they become a problem.

“That may mean tracking food intake or using a pedometer to keep track of activity, she said. “You want to encourage your child to do more outside with their friends, instead of spending hours texting or looking up their friends on Facebook.”

Related:

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