In Cybertherapy, Avatars Assist With Healing

“When I saw that, I slowed down and then stopped what I was saying,” said the speaker, a 47-year-old public servant named Gary, who last year took part in an unusual study of social anxiety treatment at the University of Quebec.

The anxiety rose in his throat—What if I’m not making sense? What if I’m asked questions I can’t answer?— but subsided as his therapist, observing in the background, reminded him that the audience’s reaction might have nothing to do with him. And if a question stumped him, he could just say so: no one knows everything.

He relaxed and finished the talk, and the audience seemed to settle down. Then he removed a headset that had helped create an illusion that the audience was actually there, not just figures on a screen.“I just think it’s a fantastic idea to be able to experience situations where you know that the worst cannot happen,” he said.“You know that it’s controlled and gradual and yet feels somehow real.”

For more than a decade, a handful of therapists have been using virtual environments to help people to work throughphobias, like a fear of heights or of public spaces. But now advances in artificial intelligence and computer modeling are allowing them to take on a wider array of complex social challenges and to gain insight into how people are affected by interactions with virtual humans— or by inhabiting avatars of themselves.

Researchers are populating digital worlds with autonomous, virtual humans that can evoke the same tensions as in real-life encounters. People with social anxiety are struck dumb when asked questions by a virtual stranger. Heavy drinkers feel strong urges to order something from a virtual bartender, while gamblers are drawn to sit down and join a group playing on virtual slot machines. And therapists can advise patients at the very moment those sensations are felt.

In a series of experiments, researchers have shown that people internalize these virtual experiences and their responses to them— with effects that carry over into real life.

The emerging field, called cybertherapy, now hasannual conferencesand a growing international following of therapists, researchers and others interested improving behavior through the use of simulations. The Canadian military has invested heavily in virtual-reality research; so has theUnited States Army, which has been spending about $4 million annually on programs with computer-generated agents, for training officers and treating post-traumatic stress reactions.

The trend has already generated a few critics, who see a possible downside along with benefits.

“Even if this approach works, there will be side effects that we can’t anticipate,” said Jaron Lanier, a computer scientist and author of“You Are Not a Gadget: A Manifesto” (Knopf, 2010).“And in some scenarios I would worry about defining humans down: defining what’s normal based on what we can model in virtual environments.”

But most researchers say that virtual therapy is, and will remain, no more than a therapist’s tool, to be used only when it appears effective.“There’s a real and understandable distrust of technology as a shortcut for good clinical skills,” said Albert Rizzo, a psychologist at theUniversity of Southern California,“but I think, deep down, most therapists will want any tool that can help them do their work, and they’ll be open to using virtual approaches.”

Virtual Humans, Real Therapy

“My abilities are somewhat limited,” says a female voice.“For example, I can speak and listen to what you say, but I can’t do anyphysical activity.”

In an office at theInstitute for Creative Technologiesat the University of Southern California, a virtual woman named Angelina is addressing a college student from a computer screen.

Angelina looks to be about 30 or so, a pretty, athletic figure with an open, intelligent face framed by short black hair. Her eyes and expression, guided by video cameras and microphones, stay in sync with the student’s, as an empathetic therapist’s would.“What are some of the things you hate about yourself?” asks the voice.

The student stalls for a moment.“Well,” she says, ina video of the exchange,“I don’t like that I can be really quiet in social situations. Sometimes people take that as me being rude, but it’s just me being quiet.”

Angelina nods sympathetically and then asks another question, about what the student fears most.

Interacting with a virtual human programmed to be socially sensitive in this way is oddly liberating. The figures are clearly not human; some are balky with language, others mute. Many have a two-dimensional graphic-arts quality.

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Exercise in Small Increments - Personal Health

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AIDS Risk Greatly Lowered by Daily Pill, Study Finds

Inthe study, published Tuesday by theNew England Journal of Medicine, researchers found that the men taking Truvada, a common combination of two antiretroviral drugs, were 44 percent less likely to get infected with the virus that causes AIDS than an equal number taking a placebo.

But when only the men whose blood tests showed that they had taken their pill faithfully every day were considered, the pill was more than 90 percent effective, said Dr.Anthony S. Fauci, head of theinfectious diseasesdivision of theNational Institutes of Health, which paid for the study along with theBill and Melinda Gates Foundation.

“That’s huge,” Dr. Fauci said.“That says it all for me.”

The large study, nicknamed iPrEx, included nearly 2,500 men and was coordinated by theGladstone Institutesof theUniversity of California, San Francisco.

The results are the best news in the AIDS field in years, even better than this summer’s revelation that a vaginal microbicide protected 39 percent of all the women testing it and 54 percent of those who used it faithfully.

Also,Truvada, a combination of tenofovir and emtricitabine that prevents the virus from replicating, is available by prescription in many countries right now, while the microbicide gel is made in only small amounts for clinical trials.

The protection, known as pre-exposure prophylaxis, is also the first new form available to men, especially men who cannot usecondomsbecause they sell sex, are in danger of prisonrape, are under pressure from partners or lose their inhibitions when drunk or high.

It“does not involve getting permission from the other partner, and that’s important,” said Phill Wilson, president of the Black AIDS Institute, which focuses on the epidemic among blacks.

Michel Sidibé, the head of theUnited Nationsagency that fights AIDS, called it“a breakthrough that will accelerate the prevention revolution.”

AIDS experts and the researchers issued several caveats about the study’s limitations, emphasizing that it looked only at gay men and Truvada. More studies, now under way, are needed to see whether the results can be duplicated, whether other antiretroviral drugs will work and whether they will protect heterosexual men and women, prostitutes and drug users who share needles.

There is no medical reason to think the pill would not work in other groups, since it attacks the virus in the blood, not in the vaginal wall as a microbicide does. Pre-exposure prophylaxis became possible only in recent years as newer, less-toxic antiretroviral drugs were developed.

Some scientists fear that putting more people on the drugs will speed the evolution of drug-resistant strains, though that did not occur in the study.

Because Truvada is available now, some clinicians already prescribe it for prophylaxis, Dr. Fauci said, but whether doing so becomes official policy will depend on discussions by theCenters for Disease Control and Prevention, theFood and Drug Administration, medical societies and others, which could take months.

Although the C.D.C. would prefer that doctors wait for further studies, more will probably prescribe the drugs now that this study is out, said Dr. Kevin Fenton, chief of the agency’s AIDS division, so the C.D.C. will soon release suggested guidelines.

The agency will suggest that the drug be prescribed only with close medical supervision and used only with other safe-sex practices.

“The results are encouraging, but it’s not time for gay men to throw away their condoms,” Dr. Fenton said.

AIDS advocacy groups were very excited by the results.

“If you comply with it, this works really well,” said Chris Collins, policy director of amfAR, the Foundation for AIDS Research.“This is too big to walk away from.”

Mitchell Warren, executive director of AVAC, an organization that lobbies for AIDS prevention, called the study“a great day for the fight against AIDS” and said gay men and others at risk needed to be consulted on the next steps.

In the study, 2,499 men in six countries— Brazil, Ecuador, Peru, South Africa, Thailand and the United States— were randomly assigned to take either Truvada or a placebo and were followed for up to three years. For ethical reasons, they were also given condoms, treatment forvenereal diseasesand advice on safe sex. There were 64 infections in the placebo group and 36 in the group that took Truvada, a 44 percent risk reduction.

Two in the Truvada group turned out to have been infected before the study began. When the remaining 34 were tested, only 3 had any drug in their blood— suggesting that the other 31 had not taken their pills.

Different regimens, like taking the pills not daily but only when sex is anticipated, also need testing.

Also, many men in the study failed to take all of their pills, and some clearly lied about it. For example, some who claimed to take them 50 percent or 90 percent of the time had little or no drug in their bloodstreams.

The pills caused no major side effects, though men who began to show signs of liver problems were taken off them quickly. Some men stopped taking the pills because they disliked relatively minor side effects like nausea and headaches. Also, some stopped bothering once they suspected that they might be taking a placebo.

“People have their own reasons,” Mr. Collins said.“People don’t take theirLipitorevery day either.”

A major question now is who will pay for the drug.

In the United States, Truvada, made by Gilead Sciences, costs $12,000 to $14,000 a year. In very poor countries, generic versions cost as little as 40 cents a pill.

Globally, only about 5 million of the 33 million people infected with the AIDS virus are on antiretroviral drugs, and in an era of tight foreign-aid budgets, that number is not expected to rise quickly.

Hundreds of millions of Africans, Eastern Europeans and Asians are at risk and could benefit from prophylaxis, but that would cost tens of billions of dollars.

In this country, insurers andMedicarenormally pay for the drugs, and the Ryan White Act covers the cost for the poor, but none of these payers yet have policies on supplying the drugs to healthy people.

No participant in the study developed resistance to tenofovir. Three were found to have strains resistant to emtricitabine, but investigators believe that all three were infected before the study began at levels low enough to have been missed by their first H.I.V. tests.

Another concern was that the participants would become so fearless that they would stop using condoms, but the opposite effect was seen— they used condoms more often and had fewer sex partners. But that can also be a result of simply being enrolled in a study and getting a steady diet of advice on safe sex and free condoms, the investigators said.

Other trials of pre-exposure prophylaxis have about 20,000 volunteers enrolled around the world. Their results are expected over the next two years.

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A Safety Kink in Hair Relaxing? - Skin Deep

Mark Garrison, the owner of a salon on the Upper East Side of Manhattan that bears his name, set aside a floor for the treatment, equipped it with special ventilators and began providing industrial-strength respirators to his clients and stylists. And a West Hollywood salon, John Frieda, relegated its straightening treatments to an open-air courtyard.

Just like the permanents that were once the height of fashion, the lucrative process of converting frizzy or kinky hair into smooth locks produces unpleasant odors. But is it dangerous, especially to the operators who apply the product repeatedly?

Last month, the beauty world was rattled when the occupational health agency in Oregon found significant levels of formaldehyde in the hair-smoothing solution sold under the name Brazilian Blowout. (A common ingredient found in many products, formaldehyde is a recognized carcinogen if it is present at high levels.) The agency said it had conducted lab tests after receiving numerous complaints from stylists citing nosebleeds, breathing problems and eye irritation after applying the product. Last Friday, Oregon authorities broadened their warning to include other hair-smoothing products, particularly those described as“keratin-based,” and said employers should take steps to protect their workers.

The report came soon after a warning from Canadian health authorities about the potential dangers of Brazilian Blowout. Subsequently, the United StatesFood and Drug Administrationannounced that it was working with state and local authorities to determine if Brazilian Blowout and similar products, known generically as Brazilian or Keratin treatments, are safe. The F.D.A. does not approve cosmetics other than color additives in advance, but will respond to consumer complaints, said a spokeswoman, Siobhan Delancey.

Brazilian Blowout, also the name of the company based in Los Angeles that distributes the solutions by that name— which it says are manufactured in Brazil by Cadiveu— initially repudiated the Oregon findings. But in response to the most recent report, it said that the Oregon tests showed that formaldehyde exposure from Brazilian Blowout was“safely below” permissible levels.

The warnings have prompted various responses from salon owners. Some, like the Sally Hershberger salons in Los Angeles and New York and the John Barrett Salon at Bergdorf Goodman in New York, decided to ban the brand Brazilian Blowout, but continue to use products from other companies. Some manufacturers acknowledge that their products contain formalin, a substance made up in part of formaldehyde, but say the amounts are insignificant.

Michael Angelo’s Wonderland Beauty Parlor in the meatpacking district of Manhattan stopped doing Brazilian treatments years ago because of the presence of formalin. Michael Angelo, the owner, said he began offering the Brazilian Blowout solution again when the company assured him the product was formaldehyde-free, but has now ceased altogether.“A lot of money went out the door,” he said.

Other salon owners believe the health agencies are overreacting.“I say, you putBotoxin your face, lead in your lipstick, and you smoke,” said Mr. Weisberg of the Neil George salon.“Pick your poison.” He said his salon does up to 20 treatments a week, mostly using Brazilian Blowout, and has no intention of stopping.

At Studio Noi, a small Los Angeles salon, Mar Fujimoto, the owner, said she had personally performed the Brazilian Blowout 300 times in six weeks after discounting the price to $125 from $300. She said the company had assured her that the product was not harmful.“I trust their claims that it is formaldehyde-free,” she said.

Questions about the safety of Brazilian treatments have been raised for years, most notably in a widely read 2007 article in Allure magazine. Yet for many salon owners and stylists, who are usually independent contractors, it is hard to contemplate eliminating such a profitable procedure.“It’s one of the most popular services we’ve had in years,” said the salon owner John Barrett.“People think it’s an absolute godsend.”

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Antibiotics Research Subsidies Weighed by U.S.

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Observatory - Hope for Human Fertility in Study of C. Elegans Worm

Now,a study in the journal Cellsuggests that one of the favorite animals for experiments in modern science, the tiny worm C. elegans, may provide new insight into female fertility. For the worm, as for women, it is diminished egg quality, not quantity, that marks the first sign of reproductive aging.

Coleen Murphy, a molecular biologist atPrinceton University, and colleagues found that as C. elegans ages, its oocytes, or unfertilized eggs, start to degrade because of increased secretion of a protein called transforming growth factor beta, or TGF-beta. The same protein is found in humans and other mammals.

The researchers also experimented with mutant worms that had low TGF-beta activity levels. In these worms, reproductive ability was lengthened and egg quality did not degrade.

In women, too, aging brings about a decline in the quality of oocytes, leading to a greater chance ofbirth defectslikeDown syndrome. Scientists have tested the protein in mice and found a similar effect, but in humans it may not play exactly the same role.

Still, this kind of research may eventually provide the knowledge to extend female fertility, Dr. Murphy said.

“The dream would be that you could give a woman in her early 30s a supplement or a drug to keep her oocytes healthy as long as possible,” she said.“We have treatments now that extend life span, but nothing extends our reproductive span.”

There are limits, as witnessed in some of the mutant worms. Although their reproductive ability increased, their life span did not, and reproducing in old age— 13 days for the worms— was fatal.

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Doctor and Patient - Sick Doctors, Sick Patients

Within days of the onset of my symptoms, other clinicians on my team were felled with the same. For weeks, we passed the cold back and forth in what became a viral game of hot potato. Even if I felt well enough one day to breathe through my nose, taste the nursing station holiday cookies and laugh without spiraling into a coughing fit, I knew that it would be only a matter of days, if not hours, before I would become sick again, invariably with a virus that had mutated just enough in the interim to dodge anyimmunitybuilt up during the last go-around.

The doctors and nurses on my team started referring to me as“the vector.”

Nonetheless, I continued to drag myself in to work each day. I didn’t want to desert the other doctors and nurses or my patients. And any time I was overtaken with a yearning to go home and crawl back in bed, one memory from medical school would quickly push that thought from my mind.

I had been a third-year medical student and had asked my senior doctor-in-training if I could go home because of anupset stomach.

“Sure, go on home,” he replied, an impassive look on his broad face.“Just remember that I’venevermissed a day at the hospital in my life. They’ll have to put me in the hospital to keep me from taking care of my patients.”

Hacking, febrile or racked with the sequelae of chronic illnesses, doctors who are sick have continued for generations to see their patients. Although published reports for over a decade have linked patient illnesses likethe flu,whooping coughand resistant bacterial infections to sick health care workers, as many as80 percent of physicians continue to work through their own ailments, even though they would have excused patients in the same condition.

For many doctors and other health care professionals, such self-sacrifice is proof of their dedication and professionalism. Moreover, in what are often precariously balancedhospitalsand practices, one individual’s absence can inflict tremendous stress upon others. Overstretched colleagues are forced to shoulder additional clinical responsibilities, supervisors must solve impossible staffing challenges and, worst of all, patients are left with inadequate care.

Being present— it seems, anyway— causes fewer problems than being absent.

But over the last few years, researchers in the business world have begun to question this assumption. Instead of focusing on problems incurred by absenteeism, these researchers have analyzed the impact of what’s been called presenteeism, or working despite being ill. And it turns out, at least in early studies, that those employees who choose to go to work sick are expensive. Presenteeism costs companiesmore than $150 billion a year in lost worker productivity.

Now, areport in the current issue of The Journal of General Internal Medicineexamines the impact of sick workers in health care. Anchoring their analysis with a description of a nursing home outbreak of norovirus gastroenteritis, an infection that causes nausea, vomiting anddiarrhea, researchers from theUniversity of California, San Francisco, address an issue that goes beyond the business school matter of worker productivity. They argue that in the health care setting what is important is that the decision to continue working while sick contradicts a core ethical principle of medicine: primum non nocere, or“First, do no harm.”

“The culture of medicine is so completely focused on self-sacrifice that when doctors come into work so sick they need intravenous fluids, it’s considered a badge of courage,” said Dr. Eric Widera, the study’s lead author and an assistant professor of geriatrics at the University of California, San Francisco.“No one is standing up for the patient and saying,‘This is wrong.’ ”

Initially the nursing home infection described by Dr. Widera and his co-authors affected only one staff member and three patients. But over the course of less than two weeks it spread to an additional 22 staff members and 30 patients despite restrictive— but voluntary— measures like stricter hand hygiene and disinfecting procedures, limiting visitors, closing down the dining hall and suspending group activities and outings. Only after the local health department required sick employees to be medically cleared before returning to work was the outbreak finally controlled.

“People probably felt they were showing up at work out of empathy for their patients and out of the kindness of their hearts,” Dr. Widera observed.“But they weren’t thinking about the risks.”

Resisting the pressure to go to work when ill can be particularly difficult for some health care professionals. Students, doctors-in-training and nurses may be afraid that their supervisors will frown upon any absence, regardless of the reason.“It’s a sign of being soft,” Dr. Widera said,“and they may get a tongue-lashing the next day from those in charge.”

Fully trained physicians or nurses who work in a small practice or who may be the only clinician available may feel a heightened sense of personal responsibility toward their colleagues and patients, and their decisions necessarily end up more complicated. For these individuals,“going into work sick becomes a risk-benefit analysis that must be weighed carefully,” Dr. Widera said. They may have to reschedule routine visits and limit patient contact to absolute emergencies, instead of what many clinicians have felt pressure to do in the past,“coming in then doing everything you would in a normal day because you are at work anyway.”

Dr. Widera and his co-authors suggest that policy changes that include unrestricted paid leave and mandatory time off for sick health care workers, as well as increased redundancy in clinician staffing may help decrease presenteeism in health care.“We need to create a culture where patient safety is more important than making the ultimate sacrifice or maximizing efficiency,” he said.

“Patients are happy just to have gotten in to see a physician,” Dr. Widera added,“but they are basically cornered when that doctor is sick. The onus and responsibility for changing how we deal with presenteeism has to come from us. It has to come from within the health care system.”

After I had struggled for a couple of months with that cold, the chief of my division at the hospital ordered me to go home, turn off my beeper and stay away from the hospital for 48 hours. I protested at first, as did a fellow doctor who was quick to grouse about being left with all the work to do.

But I finally got better. And within days, everyone else did, too.

Join the discussion on the Well blog,“Why Doctors Should Take Sick Days.”

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