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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Tuesday, January 01, 2008

    Year's End, Blog's End: I've been making my annual year end inventory - deciding what to keep and what to toss. It's become obvious in the past several months that this blog is one of the things that it's time to toss. This will be the last post for Medpundit. Truly.

    Wishing you all the best in 2008 and the years beyond.

    Click to enlarge

    posted by Sydney on 1/01/2008 08:22:00 PM 4 comments

    Thursday, November 22, 2007

    Thanksgiving Remembrance: Mayflower Medicine.

    posted by Sydney on 11/22/2007 08:31:00 PM 0 comments

    Sunday, November 11, 2007

    Any Excuse Will Do: Any excuse to justifying prejudice, or to stir up fear mongering of what may come:

    At the same time, genetic information is slipping out of the laboratory and into everyday life, carrying with it the inescapable message that people of different races have different DNA. Ancestry tests tell customers what percentage of their genes are from Asia, Europe, Africa and the Americas. The heart-disease drug BiDil is marketed exclusively to African-Americans, who seem genetically predisposed to respond to it. Jews are offered prenatal tests for genetic disorders rarely found in other ethnic groups.

    Such developments are providing some of the first tangible benefits of the genetic revolution. Yet some social critics fear they may also be giving long-discredited racial prejudices a new potency. The notion that race is more than skin deep, they fear, could undermine principles of equal treatment and opportunity that have relied on the presumption that we are all fundamentally equal.

    "We are living through an era of the ascendance of biology, and we have to be very careful," said Henry Louis Gates Jr., director of the W. E. B. Du Bois Institute for African and African American Research at Harvard University. "We will all be walking a fine line between using biology and allowing it to be abused."

    We have been living in an era of ascendant biology since Darwin. Remember eugenics? Jews have been offered prenatal testing long before the mapping of the human genome, as have African-Americans. But prenatal screening is not quite the same as the eugenics movement heyday.

    So why the hyperventilating? It turns out that the Times is taking its cue from blogs commenting on studies studies like this. Well, if the blogs say that genetics justifies prejudice, it must be true! I never thought I would see the day that the New York Times took that attitude on its front pages. It must be part of their plan to join the internet age. Here's the part that's gotten the Times convinced that genetics is going to bring back the days of institutionalized prejudice:

    There exists a publicly available gene database, The HapMap Project, that contains random samples of genetic sequences from people in China, Japan, Nigeria, and people in the United States with European ancestry. It’s now possible to search the HapMap database for genes that have been linked with intelligence in published scientific studies. In this manner, we can determine if high intelligence genes occur with greater or lesser frequency in the various races.

    Now, here’s an interesting point. If even a single gene correlated with intelligence occurs with different frequencies in the different races, this alone proves that there are racial differences in intelligence. How is that? Well, the egalitarian theory holds that every race has identical intelligence. Therefore, whatever genes there are that affect intelligence, they must be distributed exactly equally in all human races. Once even a small race difference is proven, the egalitarian theory is proven false. At that point, it’s only a matter of determining which race has the higher average intelligence based on the genetic evidence.

    Oh, please. Here's a take home lesson for everyone on the science of genetics, and one that should never be forgotten - these studies are about associations of genes with traits, not the concrete coding of a trait by a given gene. Just because a locus on a chromosome can be found more often in people with schizophrenia than in the general population doesn't mean that everyone with that genetic code in that spot will have schizophrenia, anymore than it means that every sibling of a schizophrenic will have the disease. Ditto with intelligence. Ditto, too, with cancer risks and most other traits and diseases human genome mapping is linking to genes. The essence of a man is not written into his DNA.

    Here's another important point to remember - our science is still young and uncertain:

    These genomewide association studies have been able to examine interpatient differences in inherited genetic variability at an unprecedented level of resolution, thanks to the development of microarrays, or chips, capable of assessing more than 500,000 single-nucleotide polymorphisms (SNPs) in a single sample. This "SNP-chip" technology capitalizes on a catalogue of common human genetic variations that is provided by the HapMap Project, which was made possible by the completion of the consensus human-genome sequence...

    ....The main problem with this strategy is that, because of the high cost of SNP chips, most studies are somewhat constrained in terms of the number of samples and thus have limited power to generate P values as small as 10–7. In addition, most variants identified recently have been associated with modest relative risks (e.g., 1.3 for heterozygotes and 1.6 for homozygotes), and many true associations are not likely to exceed P values as extreme as 10–7 in an initial study. On the other hand, a "statistically significant" finding in an underpowered study is more likely to be a false positive result due to chance than is such a finding in an adequately powered study, and "statistically significant" associations could be attributable to systematic bias (e.g., from confounding due to ethnic ancestry, also known as population stratification). Thus, the sine qua non for belief in any specific result from a genomewide association study is not the strength of the P value in the initial study, but the consistency and strength of the association across one or more large-scale replication studies. Robust replication should permit the identification of true positive results and the weeding out of false positive results.

    In other words, take these genome studies that link intelligence and race just as about as seriously as you would take studies linking intelligence to sex, or that predict elections with brain scans.

    UPDATE: Best of the Web draws an important distinction:

    Note that "the presumption that we are all fundamentally equal" is quite different from the notion "that all races are equal." The former is a moral principle, a premise about the basic dignity of every individual; the latter is an empirical presumption about group averages in measurable traits. Someone with an IQ of 80 is as human as someone with an IQ of 120; and this is so regardless of whether the average IQ of one race is different from that of another.

    What worries people like those in the Times story is that racial differences in IQ or other traits seem to lend empirical support to racist theories. But those theories are qualitatively wrong, so that no empirical evidence could make them right. If all individuals are of equal dignity and worth regardless of IQ, then a group is not fundamentally superior or inferior to another group by virtue of differences in average IQ.

    It seems that some very smart people mistakenly think that intelligence is a measure of fundamental worth. Maybe they're a little too impressed with their own brilliance.

    posted by Sydney on 11/11/2007 10:02:00 PM 2 comments

    In Remembrance:
    Winged Victory

    Veteran's Day movie recommendation - Wooden Crosses.

    Veteran's Day medical reading - the influence of World War I on heart surgery.
    posted by Sydney on 11/11/2007 12:25:00 PM 0 comments

    Saturday, November 03, 2007

    A Word About MRSA: I've been fielding a lot of doorknob questions about MRSA lately. (Doorknob questions= questions thrown out just as my hand reaches the doorknob to leave the room.) Little wonder. It's been in the news again and again, and has even prompted the closing of schools and cancelling of football games. Despite what some editorialists say, it is being framed as a threat to our children. Here's an example of the typical coverage:

    A 16-year-old Springfield High School junior remained in serious condition Friday in the intensive-care unit of Akron Children's Hospital with a drug-resistant staph infection. Michael Forester of Lakemore was hospitalized Oct. 24 and was to undergo surgery Friday, said his mother, Mary Baxter. "The more prayers I can get, the better," Baxter said Friday at the hospital.

    On Wednesday, Springfield School Superintendent William Stauffer, in a letter sent to parents, acknowledged that a student had become ill and was admitted to the hospital. The superintendent said rumors that the student has a contagious disease that puts other students at risk and that the high school has an ongoing problem with staph infections are not true. Stauffer could not be reached for comment Friday.

    What is this MRSA? A better question might be "What is SA"? The "SA" in MRSA is Staphylococcus aureus, a bacteria that resides in our nasal passages and skin. That is its habitat. Normally, it causes us no problem, but if conditions are right, it can make us quite ill. It's often the culprit behind boils and styes and cellulitis and urinary tract infections. It can also cause more serious infections such as pneumonia (as in the case of the young man in the linked to article above), meningitis, sepsis, endocartditis, and osteomyelitis. It is one of the most common causes of sepsis. Penicillin conquered Staph infections for a little while, but the bacteria acquired resistance within a few years of the antibiotic's introduction. When penicillin became widely used in the community, the population of Staph aureus living in noses and on skin shifted toward those containing an enzyme that could cut the betalactam ring on penicillin, rendering it ineffective. New antibiotics were developed to get around this. One of those antibiotics was methicillin, which brings us to the "MR" part of "MRSA".

    We don't use methicillin any longer. We use drugs like Augmentin instead. But, when we say that a Staph aureus infection is "methicillin resistant" we mean that it's resistant to all penicillins, even those that were developed to get around the betalactam-eating defenses of the Staph aureus population. This doesn't mean that it's resistant to all antibiotics, however, just the ones that we typically use for a Staph infections. In the hospital, we often use vancomycin for MRSA infections. In the outpatient setting, we use drugs like Bactrim and clindamycin. In most cases, the infections respond nicely to these drugs. There is, however, concern that the bacteria may one day develop resistance to these, too, as we use them more to treat the growing resistant population of Staph.

    So here are the take home points about MRSA:

    1) It isn't running amok in our schools like the blob or killer tomatoes. It's living on our skin and nasal passages just as it always has before it developed resistance to penicillin and its cousins.

    2) One of the reasons bacteria acquire resistance is because we expose them to antibiotics when we don't need to. Don't insist on an antibiotic for every runny nose, even if the snot is yellow. And don't insist on one of the special antibiotics for MRSA for every pimple or pustule or red scratch. If we overuse our remaining effective antibiotics, we'll only end up with a population of Staph aureus that is resistant to those, too.

    3) Don't freak out if you or your child develops a skin infection. Most staph infections are easily treatable. Even most MRSA infections are easily treatable.

    4) When you read the newspaper, always remember that they lean to the dramatic in all things. It makes for more entertaining reading.

    posted by Sydney on 11/03/2007 07:14:00 PM 2 comments

    Trusty Dentist: Not so trusty with music and a drill.
    posted by Sydney on 11/03/2007 06:01:00 PM 0 comments

    Thursday, November 01, 2007

    All Saints' Day: A list of medical saints - albeit an incomplete one.

    posted by Sydney on 11/01/2007 09:57:00 PM 0 comments

    Forever Young, Forever Firm: Lipo-etching- maybe not all it's cracked up to be.
    posted by Sydney on 11/01/2007 09:51:00 PM 0 comments

    Lies, Damned Lies, and, Well, You Know: The New York Times is parsing Rudy Guiliani's prostate cancer statitistics:

    "I had prostate cancer five, six years ago," Mr. Giuliani, a Republican presidential candidate, said in a speech that has been turned into the radio commercial. "My chance of surviving prostate cancer — and, thank God, I was cured of it — in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine."

    .... The Office for National Statistics in Britain says the five-year survival rate from prostate cancer there is 74.4 percent. And doctors also say it is unfair to compare prostate cancer statistics in Britain with those in the United States because in the United States the cancer is more likely to be diagnosed in its early stages.

    "Certainly, if you intensively screen for prostate cancer, you will find early disease,” said Dr. Ian M. Thompson, chairman of the department of urology at the University of Texas at San Antonio. "And simply because you find it earlier, you will always have longer survival after the disease is diagnosed."

    One reason that prostate cancer is diagnosed earlier in the United States than in Britain is that they don't screen for it at all in Britain - at least not at the expense of the NHS. (Which is one of the reasons they spend less on healthcare than the United States. They don't indulge in as much screening as we do.) At any rate, his statistics don't appear to be all that far off the mark, at least for men in their 80's. But even the NHS admits that prostate cancer survival is increasing because more people are starting to have their PSA checked - meaning that slow growing early cancers are being added to the mix, just as happens here in the US. As it happens, even back in 2002, the five year survival rate for prostate cancer in the US was 99% - still a much better figure than the UK's 71%.

    But, as the astute bloggers point out, prostate cancer isn't the best example of the benefits of screening. Prostate cancer is, in most cases, slow growing - and although our screening policies detect many early cancers that would never do harm if left undetected, we also end up spending a lot more money treating these same cancers. When given the choice between watchful waiting and removal, many choose removal. (Another reason why we end up spending more and being less healthy in surveys like this.)

    But the Astutes take a closer look at cancer in England and cancer in the US:

    See this report, entitled "Cancer Survival Rates Improving Across Europe, But Still Lagging Behind United States" (and remember that England's rates, not broken out, are among the worst in Europe).

    Taking recent figures, female five-year cancer survival rates are 62.9 per cent on average in the US and 52.7 per cent in England. To compare America's privately insured with England's NHS patients, you'd need to bump up that American survival rate a bit (the uninsured most likely have lower survival rates--otherwise why worry about universal coverage) and bump down the English one (because some Brits have private insurance, and so buy better care).

    Nationally, American cancer survival rates are significantly better. Certainly not by the 40-point margin Giuliani implied, but still.

    Looks like the truth is somewhere between Rudy and the Times.
    posted by Sydney on 11/01/2007 09:43:00 PM 5 comments

    Monday, October 29, 2007

    Take Some Tylenol and Call Me in the Morning: What will we do without cough and cold medicine? I can hear it now, that familiar refrain - "Tylenol doesn't do anything." And it doesn't, at least not for runny noses, sneezes, and coughs, despite what the expert says:

    Children’s Tylenol and Children’s Motrin, when sold by themselves, were excluded from the discussions because the medicines in those products, acetaminophen and ibuprofen, respectively, are safe and effective in treating fevers and aches even in young infants.

    Tylenol and Motrin are sold in syrupy concoctions that help coughs because the syrup coats the back of the throat and calms cough receptors, said Dr. Ian Paul, a pediatrician at Penn State Children’s Hospital in Hershey, Pa., who consults for industry.

    The committee skipped any lengthy discussion of antihistamines like Benadryl, because there is little debate that such medicines are effective for allergies. Benadryl, also known as diphenhydramine, also puts some children to sleep. But nearly all the experts said deliberate sedation should be discouraged.

    The medicines that earned the most scorn were those commonly sold to treat coughs, runny noses and congestion, including dextromethorphan and phenylephrine.

    None of them have any proven effect on children’s cold symptoms. All have risks.

    The advisory panel is right, however, about the effectiveness of the medications. They are effective mostly in that they give a parent something to do so they don't feel as if they're standing by while their child suffers. The number of children injured by the drugs, however, has been exceedingly small:

    A study by the Centers for Disease Control and Prevention found that at least 1,519 children younger than 2 had serious health problems from 2004 to 2005 after having been treated with common cold medicines. Three children died, the disease control agency found.

    But the argument is, that if they don't do any good in the first place, then why tolerate any risk? But, according to this story, the pharmaceutical companies say the issue is accidental overdosage, not inherent risk in properly dosed drugs:

    The Consumer Healthcare Products Association (CHPA), which represents manufacturers and distributors of over-the-counter medicines, said in a statement: "The data clearly show that these medicines are very safe when used as directed and that harm to this age group, while very rare, is attributable in most cases to accidental ingestion an issue of safekeeping that is best addressed through education."

    So what to do? My recommendation would be not to use them. Runny noses and coughs aren't in the category of intolerable suffering, and these products aren't likely to be much benefit anyway.

    posted by Sydney on 10/29/2007 08:10:00 AM 3 comments

    I Screen, You Screen: The American Academy of Pediatrics is recommending that all children be screened for autism. They've only press-released their recommendations, however, so it's difficult to assess them. Wouldn't it be nice if professional organizations actually released their recommendations to their members before they did so to the public? It would make it so much easier for doctors to discuss the news stories with their patients. They're releasing them today at their annual conference, and later in the November issue of their journal, which is not yet available online. (Though it may be in AAP member's mailboxes.)

    Part of any well child visit is screening for developmental delays, so one has to wonder what's different about these recommendations. Are they setting lower limits for what's abnormal so that those mild cases of autism (which some argue aren't really autism or even disease) can be treated? If that's the case, then don't be surprised when a couple of years from now there's a upward spike in the number of cases of autism. And don't blame it on vaccines.
    posted by Sydney on 10/29/2007 07:56:00 AM 5 comments

    Sunday, October 28, 2007

    Magnet-Free Europe: For some reason, the EU was proposing severe restrictions on the use of MRI scans, a proposal which has been halted- for now. Here's the reasoning behind the original restrictions:

    The Directive was drafted by DG Employment, with the aim of minimising workers’ exposure to electromagnetic fields (EMF). Currently eight million MRI patient examinations per year are carried out in Europe, said Professor Dag Rune Olsen, who works in experimental radiation therapy at the Norwegian Radiation Hospital, Oslo, Norway, and is chairman of the physics committee of the European Society for Therapeutic Radiology and Oncology (ESTRO). “But these are likely to have to stop, since the Directive sets limits to occupational radiation exposure which will mean that anyone working or moving near MRI equipment will breach them, thus making it possible for them to sue their employers. Even those maintaining or servicing the equipment may be affected,” he said.

    Radiation exposure? MRI's don't emit radiation, they detect the magnetic spin of atoms. The EU is worried that workers will be mesmerized by the MRI's. Sally Szwarc has more.

    posted by Sydney on 10/28/2007 10:19:00 PM 4 comments

    Spooky Skulls:Spooky brain pictures. Background here.
    posted by Sydney on 10/28/2007 09:58:00 PM 0 comments

    Of Mice and Mazes: Do high blood pressure medications prevent Alzheimer's? They do in mouse brains - in test tubes and in mazes:

    The researchers then tested Diovan in mice that were genetically at risk for Alzheimer's disease.

    Some of the mice drank water laced with Diovan. Their Diovan dose was lower than that used for people with high blood pressure.

    For comparison, other mice got ordinary water without Diovan.

    After drinking their assigned water for 11 months, the mice took a memory test in which they had to learn and remember the path through a watery maze.

    The mice that drank the Diovan water fared best in the maze test.

    But when the researchers tested mice without the dementia gene glitch, Diovan treatment didn't help or hurt the mice navigate the watery maze.

    We'll have to wait a while to see how this pans out. What works on mice in mazes doesn't necessarily work on men in mazes.
    posted by Sydney on 10/28/2007 09:48:00 PM 0 comments

    Errors, Errors: The sad story of a medical error and learning to deal with errors.
    posted by Sydney on 10/28/2007 09:35:00 PM 2 comments

    Inspiring Lives: Speaking of the supreme champion of eugenics, here's an inspiring story from the days of his reign.
    posted by Sydney on 10/28/2007 06:07:00 PM 0 comments

    Medical Science Fiction: Late to the party, but here are the winners of Medgadget's Medical Sci-Fi Contest. Enjoy.
    posted by Sydney on 10/28/2007 06:06:00 PM 0 comments

    Eugenics Past and Present: I've been reading an essay from 1907 by David Starr Jordan, a great mind of his time - scientist, peace activist, president of Standford, and eugenicist. The essay is the The Human Harvest, an anti-war argument grounded in eugenics. From a eugenics perspective, wars are bad because they kill the best men, leaving behind the weakest to perpetuate the race- and weaken the human harvest. Even in the service of a profound good the the callousness and cruelty of eugenics:

    Startling results may follow from the selective breeding and preservation of paupers. In the valley of Aosta in northern Italy, and in other Alpine regions, is found the form of idiocy known as cretinism. What is the primitive cause of the cretin, and what is the causal connection of cretinism with goiter, a disease of the thyroid glands which always accompanies it, I do not know.

    It suffices for our purpose to notice that the severe military selection which ruled in Switzerland, Savoy, and Lombardy for many generations took the strongest and healthiest peasants to the wars, and left the idiot and goitrous to carry on the affairs of life at home. To bear a goiter was to be exempt from military service. Thusin some regions the disease has been a local badge of honor. It is said that when iodine lozenges were given to the children of Savoy in the hope of preventing the enlargement and degeneration of the thyroid gland, mother would take this remedy away from the boys, preferring the goiter to military service.

    In the city of Aosta the goitrous cretin has been for centuries an object of charity. There is a special hospice or asylum devoted to his care and propagation. The idiot has received generous support, while the poor farmer or laborer with brains and no goiter has had the severest of struggles. In the competition of life a premium has thus been placed on imbecility and disease. The cretin has mated with the cretin, the goiter with the goiter, and charity and religion have presided over the union. The result is that idiocy is multiplied and intensified. The cretin of Aosta has been developed as a new type of man. In fair weather the roads about the city a re lined with these awful paupers - human beings with less intelligence than the goose, with less decency than the pig.

    No acknowledgment that those cretins might have even a glimmer of a soul. The disabled are genetically impure. Eugenics caught up with the goitrous of Aosta. They were forbidden to marry and ceased to be a pollute the public streets. They also became a celebrated example of the power of eugenics to improve the human harvest public health. Many an American eugenicist cited the success of Aosta in ridding itself of goitrous cretins when advocating state eugenic boards.

    David Jordan Starr must have been horrified by World War I and it's toll on the best and brightest. he died in 1931, before the supreme triumph of eugenics in Europe. No doubt, he would have argued that eugenics was misused in Europe precisely because the best men had all perished on the battlefields of World War I. But the problem with eugenics is its denial of the humanity of those it deems unworthy - whether they be cretins or those with seizure disorders (they were sterlized, too, under the compulsory sterilization laws) or Jews.

    Science (and society) has pretty much given up on the old fashioned eugenics that relied on controlling reproduction the same way one would in plants or livestock. But we still flirt with eugenics using modern methods of RichardDawkins.net>genetic selection. It might not seem like eugenics because it isn't imposed by the state, but it is. It may be framed as a personal choice, but the end result is the same - to cull those deemed inferior or undesirable. Today prospective parents can prevent a Down's syndrome child from being born, or a child with cystic fibrosis. Tomorrow they may be able to de-select the hyperactive child or the child prone to depression. It seems like such a positive thing when framed as a personal choice that improves the life of a family, but is it good to kill off certain traits? Don't we diminish biological diversity when we do that?
    posted by Sydney on 10/28/2007 08:32:00 AM 1 comments

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