"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
The More Things Change, The More They Stay The Same II:
Thus we find that each new form which arises, in following the ascending scale of creation, retains a strong affinity to that which had preceded it, and also tends to impress its own features on those which immediately succeed. -Peter Mark Roget, 1834, in Animal and Vegetable Physiology, Considered with Reference to Natural Theology
Requiescat in pace: Another recipent of the artificial heart dies. That’s number five out of seven recipients. Judging by it's success, the artificial heart should be put to rest, too. posted by Sydney on
4/13/2002 08:07:00 AM
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Coming Soon to Pharmacies Near You: A new contraceptive device. It's a hormone saturated ring that's inserted each month into the vagina. The hormones are the same as those found in oral contraceptives and according to this most recent study (involving only 247 women) it’s effects on periods are about the same as a birth control pill. It’s name is NuvaRing, and it was approved by the FDA last October, but it isn’t yet for sale. posted by Sydney on
4/13/2002 08:04:00 AM
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The FDA is making Vioxx add a warning for heart patients on it's label. Vioxx is an anti-inflammatory drug used for arthritis. You can debate whether it is an improvement over the older anti-inflammatory drugs, but to say that it's linked to heart disease is pushing it. The study in question found more heart attacks among Vioxx users than among users of Naprosyn. The trouble is, Naprosyn inhibits blood clotting, and Vioxx doesn't. It may be that Naprosyn has a more protective effect against heart disease than Vioxx, but it doesn't necessarily mean that Vioxx causes more heart attacks. A better study would be to compare Vioxx to placebo in rates of heart attacks. For some reason the FDA is being overly cautious here. Maybe the makers of Vioxx didn't pony up as much money as they were supposed to, or maybe they’re intimidated by the number of class action lawsuits in the works. posted by Sydney on
4/13/2002 07:59:00 AM
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Friday, April 12, 2002
The More Things Change, The More They Stay The Same: “But know also, man has an inborn craving for medicine. Generations of heroic dosing have given his tissues such a thirst…for drugs. As I once before remarked, the desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures. It is really one of the most serious difficulties with which we have to contend. Even in minor ailments, which would yield to dieting or to simple home remedies, the doctor's visit is not thought to be complete without the prescription.” - William Osler, 1895 posted by Sydney on
4/12/2002 06:03:00 AM
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Dubious Drug Marketing II: A pharmaceutical executive admits that drug companies exaggerate disease prevalence to sell drugs. The drugs mentioned in this article are from England and Australia, but the same thing was done in the United States for Paxil. posted by Sydney on
4/12/2002 06:02:00 AM
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Dubious Drug Marketing: Physicians and drug company collude to profit from an expensive rheumatoid arthritis drug. Shame on them. And we wonder why society is losing confidence in doctors. posted by Sydney on
4/12/2002 05:58:00 AM
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The British Medical Journal has devoted this week’s issue to the medicalisation of life. It addresses not only our tendency to view all of life’s vicissitudes as medical illnesses, but also the drive to expand the defintion of disease by the pharmaceutical industry and patient advocacy groups:
“Although some forces -the internet and patients' empowerment- might offer opportunities for "de-medicalisation," many others encourage greater medicalisation. Patients and their professional advocacy groups can gain moral and financial benefit from having their condition defined as a disease. Doctors, particularly some specialists, may welcome the boost to status, influence, and income that comes when new territory is defined as medical. Advances in genetics open up the possibility of defining almost all of us as sick, by diagnosing the "deficient" genes that predispose us to disease.Global pharmaceutical companies have a clear interest in medicalising life's problems, and there is now an ill for every pill. Likewise companies manufacturing mammography equipment or tests for prostate specific antigen can grow rich on the medicalisation of risk. Many journalists and editors still delight in mindless medical formulas, where fear mongering about the latest killer disease is accompanied by news of the latest wonder drug. Governments may even welcome some of society's problems - within, for example, criminal justice - being redefined as medical, with the possibility of new solutions.”
There is certainly pressure to use more and more drugs for more and more conditions, not only from patients requesting specific drugs that they’ve seen advertised, but from within the medical profession itself. We are expected to meet certain measureable standards in disease control and prevention of conditions that could be modified by diligent lifestyle changes on the part of the patient - for example in diabetes or in cholesterol management. Human nature being what it is, however, the diligence is wanting, and to achieve the desired goal physicians must turn to medication. I find it unsettling to have to use three or four drugs to get acceptable blood sugar or cholesterol values when I know the person taking those drugs isn’t making any effort to reign in his appetite, but it happens all the time. posted by Sydney on
4/12/2002 05:49:00 AM
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This is a nice bit of basic research, but it’s really over reaching to think that it will result in a pill that replaces exercise. It will probably result in drug research that may help sick muscles work better, but I doubt that we’ll ever see a population of muscle-bound couch potatoes. posted by Sydney on
4/12/2002 05:46:00 AM
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"I’m Nobody, Who are you?" : This article from the Washington Monthly on memoirs by nobodies reminded me of one of my favorite medical memoirs, Diary of a Medical Nobody , by Kenneth Lane. Dr. Lane recounts practicing in rural England in the 1930’s, when antibiotics were the cutting edge of medicine and the telephone was a helpful but intrusive technological innovation. It’s out of print, but available at used book web sites like abebooks.com and alibris.com. posted by Sydney on
4/12/2002 05:34:00 AM
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Thursday, April 11, 2002
Foil Polyp Man, have your colon screened for cancer. (But please note, that the “virtual colonoscopy” described in the article is an as yet unproven method of screening. We don’t know how good it is compared to colonscopy or flexible sigmoidoscopy combined with occult blood testing) posted by Sydney on
4/11/2002 07:56:00 AM
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"What profit is there of circumcision? Much every way..."-Epistle of Paul to the Romans
A study in the New England Journal of Medicine would seem to back this up in a small way, but it’s advantage is more toward the man than his partner as the BBC story suggests. Human papilloma virus infections were defintely more frequent in uncircumcised men (19.6%) than in circumcised men (5.5%). Human papilloma virus causes venereal warts. It plays an important role in the genesis of cervical cancer, and it probably plays some role in squamous cell cancer of the penis, too. The study, however, did not find much of a difference in cervical cancer rates among those men’s partners. It compared 977 women with cervical cancer to 936 women who didn’t have cancer. 783 of the women with cervical cancer had partners who weren’t circumcised, compared to 760 of the women without cervical cancer. Furthermore, 194 women with cervical cancer had circumcised partners, as did 176 of the women without cancer. These numbers are about the same, and not even statistically significant.
It would appear from the study that the women with cervical cancer have only themselves to blame. The biggest risk factor was the number of sexual partners they had. 315 of the women with cervical cancer slept with two or more men, compared with only 177 of the women without cervical cancer. Now that is a statistical difference. It’s true that within this group of women with cancer, their partners were more likely to be uncircumcised, but they were probably also likely to have more sexually transmitted diseases and other confounding variables that could contribute to a greater incidence of cancer.
Circumcision probably provides a health advantage in that it reduces papilloma virus infection in men, but it’s not at all clear that it does anything to promote women’s health. This hasn’t stopped the media from portraying it as women’s health issue, though. They get more attention that way. posted by Sydney on
4/11/2002 07:47:00 AM
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George Spencer drew my attention to a piece by Jerome Groopman in the April 8 edition of the New Yorker, “A Knife in the Back.” It delivers a knife in the back to spinal fusion surgery for chronic low back pain. Unfortunately, the article isn’t available on-line.
Spinal fusion surgery involves fusing the vertebrae together to stabilize the spine on the theory that degenerative changes (wear and tear) make the vertebrae and discs more likely to “slip” and cause pain. However, it isn’t all that effective for most cases of chronic low back pain. Groopman finds that in his community it is overdone. That’s not surprising. He lives in Boston, our nation’s medical Mecca. Patients travel long distances in hopes of a cure at the hands of prestigious specialists. The problem is, when the treatment fails, they don’t travel those long distances to complain about it, they return to their primary care doctors at home. It isn’t done in my community with anything like the frequency it’s done in his. We only have a handful of surgeons who do back surgery, and their patients live here, not miles away, so they have to take responsibility for their treatment failures. The result is that they are much more conservative in selecting people for the procedure. This is one case where you're probably better off staying with the local specialists for treatment.
My experience backs up what Dr. Groopman so eloquently expresses in the article; patients with chronic back pain who undergo spinal fusion rarely get relief. They seem to do best when they are treated with physical therapy or a chronic pain program that combines physical therapy with counseling.
Even acute low back pain from a herniated disc resolves on its own 97% of the time. If you can live with the pain, it’s better to do so for the six to eight weeks it takes to get better than to undergo the risks of surgery. Of course, if the pain is intolerable, then surgery is worth it. It’s also a good idea to keep moving around as much as you can. We used to tell people with back injuries to rest their backs, but staying in bed all day makes the muscles stiffen and prolongs the pain. A good rule of thumb is, “If it hurts, don’t do it,” but otherwise don’t restrict your activities. You won’t injure your back anymore than it already is, and you won’t let those muscles get tight and achey, either.
Blessed are the fish-eaters: Two studies came out this week ( from the same research institution) that suggest fish-oils may provide cardiac protection. Both involved large populations, one of men, the other of women, and both were well-designed. Neither of them were funded by the fishing industry. Fish oil is also known to help reduce cholesterol levels, and some think that it helps arthritis. Certainly, it can’t hurt to eat more fish, as long as they don’t come from polluted waters. posted by Sydney on
4/11/2002 05:57:00 AM
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The National Medical Association, a professional organization of African-American physicians, wants more drug advertising aimed at minorities. That’s a little like complaining that telemarketers are ignoring you. They seem to feel that drug advertising is an advantage that minorities are somehow missing out on. This assumption is based on two fallacies. It assumes that information in drug advertisements is honest and useful (it isn’t) and that minorities somehow don’t see the ads on network television and in magazines and newspapers. A survey, sponsored by Pfizer, found that 53% of black physicians thought that drug advertising promoted patient education, and 48% thought they improve doctor-patient communication. This is not the same as thinking that drug advertisements are overall desirable. The National Medical Association, though, wants more advertising dollars spent on minority media outlets, including their own journal. They should just admit that, like the Canadian media, they want a share of the lucre the drug companies have been spreading around and not try to disguise it as a health issue or a race issue. posted by Sydney on
4/11/2002 05:42:00 AM
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There has been a spate of articles on alcohol in the news lately. There was this one a few days ago about drinking in pregnancy and then this one about college drinking. The good news is that pregnant women are drinking less. The bad news is that large numbers of college students are dying and sexually assaulting each other while under the influence of alcohol. But wait, when you read the article, it’s not actually college students, it’s people of college age and the numbers of casualties at the hands of alcohol are “estimates” taken from traffic accidents, coroner reports, and CDC figures. I thought the 1400 deaths and 70,000 sexual assaults sounded awfully high. If that many deaths and assaults were occurring each year on college campuses, there would be a huge outcry about it. The numbers are probably overestimates given the diversity of sources from which they were culled, and they aren't just college students, but inner city youths, young employed adults, and the rural poor as well. (How many traffic accident reports say if a person is a college student? None, I'd wager) The fact is, you’re probably still safer from drunks on a college campus than you are at the average professional sporting event. Of course, presenting the problem as if it is peculiar to college students makes it sound more threatening and grabs the attention of the middle class better.
St. John’s Wort failed to make a difference in depression, but Zoloft wasn't effective either, and placebo was! Maybe the patients weren’t really depressed, only unhappy. Maybe it just proves that drugs need to be tested on more than a few hundred people to be able to draw any valid conclusions about them. I favor the latter. posted by Sydney on
4/10/2002 08:52:00 AM
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I stumbled on this blog yesterday, by a fellow physician. He vents his spleen on the medical malpractice crisis, and the Institute of Medicine report on racism, and he has the lowdown on the Texas doctor strikes. My favorite post: "Opinions are like sphincters - everybody has them." posted by Sydney on
4/10/2002 08:47:00 AM
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Tuesday, April 09, 2002
The New York Times has two good articles on cancer screening (links require registration). Gina Kolata interviews the experts on the pros and cons of breast cancer screening and of prostate cancer screening. The breast cancer article revisits the mammogram controversy. The prostate cancer article centers on the blood test for prostate specific antigen, a protein whose levels increase with prostate cancer and with benign enlargement of the prostate gland. Both screening procedures are controversial, both find tumors that may not be clinically significant, and both involve treatments that can have life-altering consequences. The articles are well-balanced and she does a good job of detailing the nuances involved in these two very uncertain screening programs. Some excerpts:
Breast Cancer Screening
Con: “The problem, Dr. Kramer said, is the numbers of cancers found early and found later, corrected for size and age of the population. If screening worked perfectly, every cancer found early would correspond to one fewer cancer found later. That, he said, did not happen. Mammography, instead has resulted in a huge new population of women with early stage cancer but without a corresponding decline in the numbers of women with advanced cancer.”
Pro: "In some situations, it may be that early diagnosis is important and in others it is not," Dr. Norton said. But until there is a way of sorting out which tiny tumor is dangerous or until treatment gets so good that it does not matter when a tumor is found, early diagnosis makes sense, he said.”
Prostate Cancer:
Con: “Dr. Brawley said the data indicated that the test was finding tumors that would not be noticed and would cause no medical problems. But these tumors look exactly like dangerous ones.
"There are cancers that fulfill all the histological criteria for malignancy," Dr. Brawley said. "When a pathologist looks under the microscope, he says, `Yes, this is cancer.' " But these tumors are not dangerous, and many that are dangerous may not be cured by early diagnosis and treatment.
"The concept that every cancer that can be found early can be cured is a faulty concept," he said.”
Pro: "Yes, there are probably some people who are treated unnecessarily," he said. "But all of medicine is that way. Is there a chance that when you have your appendix removed it will turn out to be normal? Yes."
The standard position on prostate cancer screening has been to provide the patient with the pros and cons of testing and let him decide if it’s worth the risk. In breast cancer screening, there is no such discussion. Women are just told they should have it done and handed an order. Brochures on the topic from my own professional academy illustrate this. Compare the one on prostate cancer to the one on breast cancer. Furthermore, women who decline to have mammograms done are often nagged by their insurance companies and their doctors to have them done. Insurance companies even make decisions on the quality of care a doctor provides based on the percentage of his patients who have mammograms each year.
The reason for this difference is that prostate cancer doesn’t have a powerful interest group to sway opinion as breast cancer does. It’s time to rethink our position on the absolute value of breast cancer screening and give women a chance to decide for themselves if the risk of screening is worth the effort. posted by Sydney on
4/09/2002 06:19:00 PM
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Alternative Medicine Watch Update: The comments of the two dissenting members of the presidential panel on alternative medicine become known. Interestingly, one of them is an herbal advocate, but she's honest enough to admit her bias:
"Part of the problem is that it was a commission of advocates, myself included,'' said Dr. Tieraona Low Dog of Corrales, N.M., who along with Fins sent the dissenting letter. As a result, the commission wouldn't take a stand about which alternative therapies have a growing body of science behind them and those that were unproven, possibly unsafe or downright fraudulent, said Low Dog, an expert in herbs.
"To not take a stand on some of these things that are quackery is just nonsense," she said. Fins agreed. "We should try to identify those things that are promising, and the key element is objectivity and science, not partisanship and advocacy," he said. posted by Sydney on
4/09/2002 08:16:00 AM
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Derek Lowe over at Lagniappe wonders what I think about homeopathy, the process of diluting substances in water until all that's left is water. The answer: not much. I don't see them as a threat to health since they are just water,afterall. They only become dangerous if someone uses them in place of real medication to treat a real disease. If a patient wants to waste their money on them, that's their business. Herbal dietary supplements, on the other hand, are real drugs with real side effects masquerading as risk-free cures and preventatives. They can do far more damage, and often do. That really makes my blood boil. posted by Sydney on
4/08/2002 11:05:00 PM
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Cloning Update: The mad Italian scientist who claims he's cloned a human has popped up again in the pages of New Scientist. A reporter in Rome has been in touch with him:
"Antinori's office continues to refuse to confirm or deny the reports of a pregnancy. But Giancarlo Calzolari, a science reporter on Il Tempo in Rome, claims Antinori told him on Friday it is real and that it was carried out in a Muslim country. "He told me it was a clone of an important, wealthy personality," Calzolari said. "The doctor added: 'I have at my disposal whatever amount of money is needed to reach the result. Imagine, it has been possible to carry out in a Muslim country a kind of research that was impossible to do in the West."
Yes, imagine that. Someone in a Muslim country with fabulous wealth is using that wealth for dubious, some would say evil, purposes. Life is becoming too weird, and too much like a bad movie. First we have Bin Laden, a villain straight out of James Bond, and now we have a scientist doing secret genetic experiments for Middle Eastern potentates like in the movie Godzilla vs Biollante (For those of you who haven't seen the movie Saradia is a fictional Middle Eastern nation and terrorists play heavily in the opening scenes). posted by Sydney on
4/08/2002 07:40:00 PM
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Baby aspirin comes through again, this time in preventing colon polyps. The study was presented at a conference yesterday, so it's impossible to examine it closely, but it certainly sounds promising. It would have been more promising if there had been a greater difference in polyps between the aspirin and the placebo groups, but aspirin is cheap and pretty safe at the small doses used, so it would probably be worth recommending. I suspect that there is a genetic difference at work that predicts who responds to aspirin and who doesn't when it comes to the polyps. Maybe someday we will be able to identify that gene and aim the aspirin therapy at those who would benefit from it. Earlier this month,
sulindac , another anti-inflammatory drug failed to show much of an influence on polyp formation (but it was in a much smaller sampling of patients) and research continues on two of the newer, and much more expensive anti-inflammatories,
Vioxx, and Celebrex. posted by Sydney on
4/08/2002 07:34:00 AM
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Sleep that knits up the ravelled sleeve of care,
The death of each day’s life, sore labor’s bath,
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast.
I used to discourage people from going to such extremes for weight loss, but surgery techniques have improved significantly over the past ten years, so there are fewer complications from it now. The few patients I have who have had it done all say it was worth while and they’d do it again without a second thought, even those who had complications. That says a lot about the strength of eating compulsions, and the difficulty many people have in overcoming them. What the surgery does is make you sick if you eat too much. The complications, when they occur, can be nasty, though. Crohnic diarrhea and nutritional deficiencies are the big ones. Also, the article implies that it's a hopeless task for the morbidly obese to lose weight through diet and exercise. Not so. I have seen people lose up to 150 pounds with diet and exercise alone, and keep it off. They are committed to a change in their lifestyle and they succeed by eating sensibly and exercising religiously. posted by Sydney on
4/08/2002 07:13:00 AM
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Cancer patients try to bully drug companies into giving them drugs before they are approved or available.
This particular drug is for colon cancer, and hasn't been shown to be very promising in providing anything like a remission or a cure, yet cancer patients and their relatives are pressing the company to provide them with it before it's FDA approved. They seem to be painting the drug company as a villain, but really, what is a drug company to do? They aren't offering a miracle drug, here. There's no reason for them to succumb to the unrealistic expectations of the terminally ill. posted by Sydney on
4/08/2002 07:08:00 AM
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" How tainted by commercial conflicts has medicine become? Heavily, and damagingly so, is the answer. A more important question arises: do those doctors who support this culture for the best of intentions--eg, to undertake important research that would otherwise remain unfunded--have the courage to oppose practices that bring the whole of medicine into disrepute?"
They list some pretty damning examples: the American Heart Association's acceptance of $11 million dollars in donations from the maker of a drug whose use they have advocated in a clinical guideline, research that shows authors of guidelines fail to disclose financial ties to companies whose products they recommend, the Seattle cancer center that failed to disclose the financial interests of its researchers in a clinical trial (that one is still being debated), and an editor of a psychiatric journal in Britain who accepted an annual stipend from a drug company then accepted a paper for publication that favored a drug made by that company. A lot of this is circumstantial, to be sure. There is no proof of strict quid pro quo, but do we really want our medical institutions to be financed along the same lines as our politicians? posted by Sydney on
4/08/2002 07:04:00 AM
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More News from the Genetic Revolution: On Friday, an Italian infertility researcher suggested in a conference in the Middle East that he had created a human clone and that it was residing in a woman's womb somewhere in the world at about eight weeks gestation. Since giving that tantalizing tidbit, he's been mysteriously quiet. Meanwhile, our own Senate is set this week to consider making human cloning illegal.
No one knows if the Italian has succeeded in creating a human clone or if he was just indulging in some braggadacio, but his acknowledged attempts to do so should give us pause. We already know that human manipulation of the genesis of life can have unintended consequences. There are more complications among babies born of in vitro fertilization, than occur in those conceived naturally, and cloning involves far more manipulation of eggs and genetic material than in vitro fertilization does. Furthermore, we don't yet know what the long-term effects of this manipulation may have over the course of a lifetime. When Dolly the sheep was cloned, her genetic material was the same age as her donor's , meaning she was chromosomally older than her chronological age. This could have extensive ramifications for a human clone. It could mean a higher incidence of early cancer, Alzheimer's, Parkinson's, and other diseases of old age in a cloned person. If you are born with thirty-year old chromosomes, are you going to have the health risks of a fifty year old when you are twenty? No one knows.
It seems cruel to bring a life into this world knowing those possibilities exist, especially when there are other alternatives to treat infertility, including adoption. We are only now beginning to learn the effects of assisted reproduction on the offspring, both medically and psychologically. One can't help but suspect that the motive behind the Italian researcher's efforts is rooted in gaining glory and renown rather than altruism. He clearly could not have the best interests of his patients at heart to proceed with such an attempt. Scientific American published a review of cloning a few years ago that predicted just such an act by just such a man:
“One would hope that such research will be done openly in the U.S., Canada, Europe or Japan, where established government agencies exist to provide careful oversight of the implications of the studies for human subjects. Less desirably, but more probably, it might happen in clandestine fashion in some offshore laboratory where a couple desperate for a child has put their hopes in the hands of a researcher seeking instant renown.”
Well, the future is now. It's too early to tell if the Italian will be successful. Miscarriages are common in the first twelve weeks of pregnancy, and the clone may not be perfect enough to survive nature's process of elimination. There is no doubt, however, that he and others like him will try and try again until they achieve their goal, unless they are stopped. We know too little to fool around with life at this level. To think otherwise is sheer arrogance. posted by Sydney on
4/07/2002 01:03:00 PM
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Keep using the baby shampoo until they reach dating age.
I'm always skeptical about the supposed earlier puberty that girls are going through. Some people have tried to blame it on milk and the dairy industry, now the shampoo industry is getting hit with the blame. The thing is, we really don't have any good data on the rates of development in the past, so there is no good comparisons to back up the claim that girls are maturing faster. Also, development and growth depend on so many factors (nutrition, genetics, etc.) that it's almost impossible to finger one lone culprit among a diverse population. posted by Sydney on
4/07/2002 09:04:00 AM
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They're being forced to send their prescriptions in to a mail-order firm, AdvancePCS , instead of filling them at the pharmacy of their choice. The mail order firms can offer cheaper prices because they grab large volumes of customers by signing deals like this with insurance companies, employers, and unions. The trend is driving small, independent pharmacists out of business, and it's having it's effect on the chain stores, too. The disadvantage to the mail-order system, and it's a big one, is that there are no pharmacists for the patient to consult when there is a problem. I've had patients tell me the pill they got in the mail is a different color and shape than the one they received last time and they aren't sure if there was an error in the dispensing. I can't tell, either, since the color and shapes of pills vary by manufacturer. Only the pharmacy can tell if there was an error or just a change in supplier. When that happens at a local pharmacy the patient can take the pill back and check with the pharmacist. No such luck with the mail-order firms. Half the time you can't even get a person to answer the phone, only a prerecorded message that has no directions for "speaking to a pharmacist".
Mail order pharmacies like Advance PCS also use their captive audiences to practice big brother medicine in the guise of their “disease management” program. They send mailings out once a month suggesting changes in patient medications. When they were owned by Eli Lily it was always a request to change to a medication made by Eli Lily. Sometimes it wasn't even a request to change medicine, but one to initiate a medication. For instance, to start Evista for osteoporosis prevention because the patient was a woman over fifty. When that happened, I began disregarding them completely, and I still throw them away without reading them. I didn't realize until now that they are no longer owned by Eli Lily. I'll probably read the next one they send, but I doubt it will change my therapy. How could it? They haven't examined and talked over the treatment options with my patients, only I have. How can they presume to suggest that they know what's better for them? posted by Sydney on
4/07/2002 08:59:00 AM
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