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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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    Saturday, July 27, 2002

    No Free Lunch: I don't know who’s behind this website, but I found it in Jane Galt’s comment section. For those of you who aren't in medicine, "CAGE" is an acronym for a basic set of questions you ask people to screen for alcoholism:

    -Have you ever felt you should Cut down on your drinking?
    -Have people Annoyed you by criticizing your drinking?
    -Have you ever felt bad or Guilty about your drinking?
    -Have you ever had an Eyeopener? (A drink to get over a hangover or to get you started in the morning)

    I haven’t signed the pledge yet. I can’t bring myself to give up those pens!

    posted by Sydney on 7/27/2002 10:48:00 PM 0 comments

    My Kind of Psychiatrist: Thanks to Ian Murray, I found this interview with Theodore Dalrymple, a columnist for The Spectator and a British psychiatrist who works in an inner city hospital and a prison. Here’s what he says about his approach to drug abuse:

    Peter Saunders: You’ve been writing this column in The Spectator for 12 years, and now the book has come out. Your essays are very rich descriptively, but what is the basic message that we should take away from reading them?

    Theodore Dalrymple: I think it’s the idea that people are not billiard balls. They’re not impacted on by forces like cold fronts in the weather and react accordingly. They actually think about what they’re doing. For example, criminals are conscious of what they’re doing and they respond to incentives. And they have a culture—they have beliefs about what they’re doing.

    PS: But what comes through in your essays is that they themselves talk as though they are billiard balls.

    TD: Well, I think they’ve been taught to speak like that. And you can actually break it down by saying to them, ‘Now come on! You didn’t burgle that house because of your bad childhood, you burgled that house because you wanted to take something in it and you didn’t know how else to go about getting it because you’re unskilled, you have no intention of getting any skills’—and they start laughing! And oddly enough, when I speak with them quite plainly, my relations with them improve.

    PS: Has anybody ever hit you!?

    TD: No, never! I mean there are the true psychopaths who make one’s blood run cold because they are untouchable by normal human relationships. But they are relatively few. So my relations with the prisoners are extremely good. To give you another example, drug addicts come in and they spin me a line, and I just won’t have it. There’s initially friction because I refuse to prescribe for them and one of the things that’s very difficult to get across is that withdrawal effects from heroin, for example, are very minor. They’re trivial.

    PS: Really? That’s not the way it’s portrayed, is it?

    TD: It’s not the way it’s portrayed but it is actually the truth. I can’t tell you how many people I’ve withdrawn from heroin. You never get any problems with it. It’s not like withdrawal from serious drinking which can be, and often is, a medical emergency. From a medical point of view, I’m much more worried in the prison when someone tells me he’s an alcoholic. I’m much more worried about the physical consequences of his withdrawal because they are really serious, and he can die from them. But nobody ever dies from heroin withdrawal. With the vast majority of them, you just take them aside and say: ‘I’m not prescribing anything for you, I will prescribe symptomatic relief if I see you have symptoms, but what you tell me has nothing to do with it, I’m not going to be moved by any of your screaming.’ One chap came in and said ‘What are you prescribing me?’ and I said ‘Nothing’, and he screamed at me, ‘You’re a butcher! You’re a f***ing butcher’, and he screamed and shouted and eventually I said ‘Take him away’. Everyone outside heard this, and they were like lambs!

    There’s a lot to be said for this approach, whether you're dealing with manipulative patients or manipulative countries. “Root causes” are hard to change, but the behavior that occurs in response to them can be changed. That’s why welfare reform has worked, and that’s why the war on terrorism has to be willing to use military force as well as the full force of the law. And that’s why no civilized nation should be appeasing terrorist states.
    posted by Sydney on 7/27/2002 11:12:00 AM 0 comments

    Well At Least They're Doing Something: The CDC is looking for medical labs in the nation that test for chickenpox. The theory is that an initial smallpox case would resemble chickenpox. A physician might order a test to confirm chickenpox, and the CDC wants to send instructions to the labs to be on the alert for smallpox, too. The reality is, not too many people test for chickenpox. In the absence of smallpox, it's hard to confuse it with anything else.
    posted by Sydney on 7/27/2002 10:51:00 AM 0 comments

    Tribune Titillation: Fairhaven also sent me this link about the Connecticut hospital detailed in the Chicago Tribune’s series on hospital infections. The hospital is suing the two people who talked to the newspaper, as well as their lawyer. The patients reached a settlement with the hospital over their nosocomial infections, a settlement which included an agreement that they wouldn’t discuss the matter. Since the suit, the hospital has lowered its infection rate from 22% to 1% or less, so it’s hard to fathom why they would break their agreement and talk to the Tribune. Guess those fifteen minutes of fame are just too hard to resist.
    posted by Sydney on 7/27/2002 08:54:00 AM 0 comments

    Bioterror Preparedness: Fairhaven, the River saw a letter to the editor in his newspaper wondering why no one was demanding anthrax vaccination and answers it. He also addresses Ebola virus as a bioterror weapon.

    He’s right about the reasons for not immunizing for anthrax. We don’t have enough anthrax vaccine to immunize everyone, the vaccine is unpleasant, and the disease isn’t passed from person to person. The damage would be limited to the scene of the attack. Those who advocate widespread immunization do so in the hopes of protecting cities from a weaponized anthrax attack. Anthrax, however, can be treated with antibiotics if recognized early. It can also be prevented by giving antibiotics to those exposed. It does make sense to immunize selected populations, however, such as military personnel, who can’t afford to be sick in the battlefield. Anthrax just isn’t the public health disaster that smallpox has the potential to be.

    Ebola virus, on the other hand, is infectious, and it has been weaponized by the Soviet Union and the United States. Aum Shinrikyo, the Japanese terrorist cult, also tried to obtain weaponized versions of it, but fortunately didn’t succeed. The mechanism of transmission of Ebola isn’t completely understood. Most cases, as Fairhaven points out, occur from direct contact with body fluids, but there is some evidence that it has the potential to be spread by airborne droplets, and the outbreaks that have occurred have ultimately been stopped by exercising airborne precautions. Ebola doesn’t appear to be infectious until the person has symptoms of the disease, unlike smallpox which has a two day window of infectivity before manifesting symptoms. That means it exhausts its supply of hosts quickly and dies out before it can be transmitted far and wide. An outbreak of Ebola, therefore, would be easier to contain, and not carry the same threat as smallpox.
    CORRECTION: The Ebola outbreaks in Africa were stopped without using airborne precautions. My mistake. I misread my source. There were, however, a few cases in recent outbreaks where the method of transmission wasn't clear, raising the possibility that it could be spread by air-borne droplets.
    posted by Sydney on 7/27/2002 08:45:00 AM 0 comments

    Friday, July 26, 2002

    Medical Device Regulation Update: Why companies can’t be trusted to police themselves.

    posted by Sydney on 7/26/2002 08:25:00 AM 0 comments

    Dubious Public Health Problems: According to "America's finest news source", today is National Scoliosis Screening Day. (What can I say, The Onion is on a roll.)

    Dubious Public Health Problem II: Unfortunately, this isn't a satire. A national summit on childhood obesity kicks off today. I acknowledge that more of us are obese today than fifty or thirty years ago, but obesity isn't a public health problem the same way infectious disease or clean water is. You can't catch obesity from those around you. It's an individual problem, and largely a matter of personal choice. You can't force people to eat right and exercise regularly. Well, maybe you can, but to do so would require the worst sort of tyranny.
    posted by Sydney on 7/26/2002 07:49:00 AM 0 comments

    Antibiotic Resistance, Threat or Hype? A reader in the pharmaceutical field had this to say about emerging antibiotic resistance:

    I work for a biopharmaceutical company that's developing (among other things) anti-bacterials for MRSA and VRE. My sense, from the market research we've done, is that antibacterial resistance, while really scary, is not a really big (patient numbers) problem. Nor indeed, does it look posed to become significantly bigger soon. Obviously, we aren't writing the area off as an area w/o medical need -- we're trying to develop drugs for it. But it does seem to me that the coverage of the danger in the lay press has been overblown. I see a lot more writen about vanc resistance than (say) Hep C or Hep B, and this seems odd to the point of crazy. The Tribune account you site doesn't do a lot to convince me otherwise.

    He’s right that we don’t see huge numbers of these resistant bacteria, but they are a growing problem and one that would best be confronted now before it does become one of greater magnitude. Right now, the problem is largely one of a few infections here and there that don’t respond to the usual antibiotics, at least in the average community practice. The numbers of, say, drug resistant meningitis cases, aren’t nearly of the magnitude of hepatitis cases, but they do seem to be emerging. Drug resistant tuberculosis, on the other hand, is a significant problem. The Tribune articles were overblown almost to the point of hysteria, but the problem of antibiotic resistance isn’t going to go away, and it would be best for us all if we addressed it now before they become the rule rather than the exception.
    posted by Sydney on 7/26/2002 07:35:00 AM 0 comments

    Thursday, July 25, 2002

    Insider Medical Trading: The Bloviator has a post about possible insider trading by people who are privy to medical research results before they get published.

    posted by Sydney on 7/25/2002 01:04:00 PM 0 comments

    Dog Days of Summer: What the phrase does and doesn't mean.
    posted by Sydney on 7/25/2002 07:29:00 AM 0 comments

    Antibiotic Resistance II: The New England Journal of Medicine has two studies this week that highlight the problem of antibiotic resistance and the overuse of antibiotics. For several years now, it has been the standard of care to treat women with a type of bacteria called Group B streptococci in their vaginas with antibiotics during labor. The bacteria can cause deadly infections in newborns. There were two ways to go about this: you could test everyone for the bacteria and give them anitbiotics during labor if they were positive, or you could not screen and give antibiotics only to those women who would be at higher risk of passing the bacteria to their babies: those with preterm labor, those whose water broke early, or those who had a fever. In our litiginous society, guess which approach is used most? You got it. Screen and treat everyone. The two studies show that while screening everyone reduces the rate of Group B strep infections in babies, it also increases the rate of infections by another type of bacteria, E. coli.

    Both E. coli and Group B strep are natural residents in the vagina. Not every newborn is threatened by them. Yet, it can be difficult to predict which baby will pick up the infection. A direct comparison of screening everyone with taking a risk-based approach found fewer babies got Group B strep if everyone was screened and treated. But, at the same time, another study that looked at infections in low birth weight babies found that the same number of babies get sick, but more of them have infections caused by antibiotic resistant E. coli. This was especially true if their mothers received antibiotics for Group B strep during their delivery. The study in low birth weight infants is particularly relevant because these infants are very vulnerable to infection. Any trends in types of infection and in their resistance to antibiotics would likely show up in them before it shows up in the normal newborn population. This is a warning to us all. We need to be more careful with antibiotics, even though it may mean we will miss the chance to prevent a few group B step infections.

    The neonatal nursery at the hospital where I practice has made the prevention of Group B strep a priority. Not only do all women get screened and treated with antibiotics, all babies get antibiotics for at least fourty-eight hours if their mothers weren’t screened or if their mothers didn’t recieve the requisite two doses of antibiotics during labor. It’s a mandatory protocol that all doctors caring for newborns there must follow. I don’t know what effect this has had on Group B strep infections, but I know that this past weekend I treated my first case since residency of E. coli sepsis in a normal newborn. Makes me wonder.....
    posted by Sydney on 7/25/2002 07:19:00 AM 0 comments

    Best Doctor of All Time: The British Medical Journal is looking for nominees for the best doctor, real or fictional, dead or alive.

    My vote would be for Dr. McCoy. Despite living in a high-tech world where diagnoses could be made with the pass of a scanner, he never lost sight of the essential requirement for a good doctor: keeping the humanity of his patients at the forefront. He treated enemies and crew members with the same dignity and respect and competence. He was a hands-on doctor, and compassionate. Unlike later Star Trek doctors who spent more time beside their computers than at the sides of their patients, he was always at the bedside, keeping an eye on his critically ill patients. In many an episode he pulled all-nighters to come up with a cure for the latest alien malady to strike the crew. He never hestitated to stand up to his captain if his orders were contrary to his medical ethics. And, I suspect, he was the inspiration of many a child from my generation to go into medicine. (Although you won't find it admitted on any medical school application essays.)
    posted by Sydney on 7/25/2002 06:25:00 AM 0 comments

    Sidewalk Ambulances: Britain has launched a bicycle ambulance service. Not only can they go places a traditional ambulance can't go, they can get there quicker and call off the ambulance if it isn't really needed.
    posted by Sydney on 7/25/2002 06:12:00 AM 0 comments

    Celebrity Medical Watch: GlaxoSmithKline has hired Ricky Williams to tell the world how he conquered shyness with Paxil. Do you suppose they found out he was taking it through Walgreen's?
    posted by Sydney on 7/25/2002 06:03:00 AM 0 comments

    Pharma Marketing: Never underestimate the influence of small gifts.
    posted by Sydney on 7/25/2002 05:40:00 AM 0 comments

    The Price of Medicine: A reader had this to say about comparing medical care to other basic needs:

    I think you're drawing an imaginary non-parallel [healthcare v. food, shelter, clothing]. You got it right in the next graf, though: it's the third-party paying, not the second-party providing.

    As a practical matter, I really can't provide my own food, for example. I need the asssistance of a supermarket for it. Always have, always will.

    The big difference, though, is that I don't have "food insurance." I pay it right there, right then, out of pocket. Nor does my employer think of providing me food as a "benefit."

    I'm just so puzzled that people think medical care should be free; why?

    As a practical matter, we may rely on someone else for food, shelter, and clothing, but if needed we could grow and make our own food, build our own home (no matter how humble) and make our own clothing. But no one, not even a surgeon, could remove his own gallbladder. It’s hard to even perform an adequate medical exam on yourself. I know, I’ve tried. The lung sounds aren’t the same when you hear them from the outside and the inside at the same time, and the abdominal exam isn’t the same when you can anticipate your every move.

    As to why so many expect medical care to be free, I have occasion to ask myself that several times a day, and I still haven’t come up with a good answer.
    posted by Sydney on 7/25/2002 05:38:00 AM 0 comments

    It's The Same the Whole World Over: The whole English-speaking world, anyways. This Australian study of general practioners in Australia, Canada, the Netherlands (OK, they aren't English-speaking), New Zealand, the United Kingdom and the United States, showed we all had the same medical error rates.
    posted by Sydney on 7/25/2002 05:28:00 AM 0 comments

    Wednesday, July 24, 2002

    Department of Corrections: Charles Murtaugh (permalinks not working, scroll down to the plasmid post) correctly takes me to task on the biology behind antibiotic resistance in bacteria. It’s a matter of survival of the fittest in the presence of antibiotics more than it is spontaneous mutation.

    posted by Sydney on 7/24/2002 10:52:00 PM 0 comments

    Malpractice Crisis Update: Chris Rangel has an excellent review of the state of malpractice in Nevada and the nation.
    posted by Sydney on 7/24/2002 07:38:00 AM 0 comments

    JAMA's weekly art history lesson.

    NOTE: For those of you who enjoy JAMA’s art history lessons, Dr. Southgate has collected her essays and art collections in two books: The Art of JAMA and The Art of JAMA II. They’re kind of expensive, but you might be able to find them at your local library if the price puts you off.
    posted by Sydney on 7/24/2002 06:35:00 AM 0 comments

    Drug Prices: Jane Galt has an excellent post about the economics of drug prices. The comment section is excellent, too. She has another one, here. I'm still convinced the pharmaceutical companies spend disproportionately on marketing. Attend any large medical conference and see the extravagance of the drug displays and you'll be convinced, too. They don't seem to worry about maintaining a budget at all when it comes to promotion. The response to the hormone replacement therapy study from two weeks ago is a case in point. Wyeth sent me the same letter defending Premarin three times: by special UPS courier, at home, at night, the day the study hit the newspapers; by fax the next morning, and yesterday by regular mail. They spend on promotion as if there's no tomorrow. They must have so much money in the promotion budgets that they don't know what to do with it.
    posted by Sydney on 7/24/2002 06:31:00 AM 0 comments

    Hospitals Will Kill Ya, Part III: The last of the Chicago Tribune’s series of articles on deadly hospital infections, Drug-Resistant Germs Adapt, Thrive Beyond Hospital Walls, ran yesterday. The theme of this last is that the dangerous germs from the hospitals are escaping into the community and threatening us all. Again, the Tribune reminds us that they have done an epidemiological study of the issue:

    In Illinois, the Tribune identified 4,712 cases during 2000 in which individuals contracted hospital-born germs without setting foot in a hospital or other medical center--a 1,000 percent increase in the last decade, an analysis of state patient records and public health reports show.

    Last year, at least 200 people in Illinois died after contracting drug-resistant germs in their homes, at work or during leisure activities. Victims developed strains of pneumonia, blood poisoning and dozens of other infections rarely identified outside hospitals as recently as five years ago.

    And again, the newspaper doesn’t share the details of their methods or of their results. They only share their conclusions, and their dramatic anecdotes:

    -Gershenson, owner of a medical supply company, believed he had a lingering cold-weather flu, his wife said. For five weeks, mild fever and nausea flared every few days, then disappeared. By November 2000, symptoms became so constant and severe that he went to the emergency room at Illinois Masonic Medical Center. He died less than 30 hours later.

    -In July 1997, a 7-year-old girl from Minnesota who complained of fever and a pain in her right groin died from MRSA.

    -In January 1998, a 16-month-old girl from North Dakota arrived at a local hospital in shock, with a temperature of 105 degrees. She died within two hours of admission. MRSA was found in her lungs.

    -In January 1999, a 13-year-old girl from Minnesota was taken to an emergency room after complaining of fever and spitting up blood. MRSA was found in her blood. She died seven days later.

    -In February 1999, a feverish 12-month-old boy from North Dakota was taken to the emergency room after repeatedly vomiting. MRSA, which was found in the lungs, resulted in pneumonia. The boy died a day later.

    The culprit in each of these vignettes, MRSA, is a bacteria known as methicillin resistant staphylococcus aureus. Staphylococcus aureus is a common bacteria that inhabits the human body. It’s especially plentiful in the nose and the skin. The methicillin resistant part is relatively new, and it’s the consequence of using antibiotics indiscriminately for the past fifty years. Having been in contact repeatedly with antibiotic molecules, the bacteria have genetically altered themselves to be resistant to them. These resistant strains first showed up in hospitals, not surprisingly, because people with chronic illnesses are most likely to end up in the hospital and also more likely to have been treated repeatedly with antibiotics for infections. Now, however, community bacteria have been so overexposed to antibiotics that they, too, have altered their genes. It isn’t so much that the bacteria are escaping from the hospital to the community, it’s that we have overused antibiotics in both the hospital and the community, and now we are paying the price. The article acknowledges that this is the true crux of the problem, but only after suggesting several times that hospitals are the chief culprit.

    The Real Story: The New York Times has a better account of this same phenomenon. They put the blame squarely where it belongs: with all of us -doctors and patients. It truly is a challenge sometimes to prescribe antibiotics appropriately. There is a large segment of the population who have been taught over the past fifty years that antibiotics are necessary for every cold, every sinus headache, every cough, every fever. It’s no easy task to undo such extensive and long-standing indoctrination. Then, too, there are pressures from daycare centers and babysitters who do not want sick children attending, understandably. Parents, however, see antibiotics as a quick cure that will get the child back to the daycare center or the babysitter within twenty-four hours. The antibiotic may not be doing any good, and in fact, may be doing more harm, but the daycare centers and babysitters think the children aren't contagious if they’re on antibiotics. In fact, when placed needlessly on antibiotics, they are more likely to be spreading antibiotic-resistant strains of bacteria to all the other little kids. The demand for antibiotics isn’t just limited to children, however. Adults demand them for themselves for the very same reason. Their co-workers feel safer from their contagion if they can tell them they are on antibiotics.

    Doctors are to blame as well, of course, for all the reasons the Times lists. Most of the time, though, the fight to avoid unneccessary antibiotics is such an endless Sisyphian task, that we sometimes succumb to fatigue. Despite all of our best efforts to educate; despite posters, patient handouts, and ready explanations; sometimes, many times, we are just too tired to fight. It’s so much easier to whip out that prescription pad and write a prescription for the antibiotic du jour. No long explanations, no arguments, no unpleasantness when the illness lingers or when the throat culture comes back positive after all. We all succumb at some time or another, and so do our bit to further the spread of antibiotic resistance.

    The sister article to the Times piece has good suggestions for approaching common infections. Although the article is geared toward pediatrics, the same rules of thumb apply for adults as well:

    -Eighty percent of ear infections will go away without antibiotics within a week.

    -For a bad sore throat, the agency advises doctors always to test for strep with a throat culture and to wait for the results before prescribing an antibiotic. The test is easy, but pediatricians do not always perform it.
    (Nor do family physicians and internists)

    -For bronchitis, which is almost always viral, the C.D.C. recommends withholding antibiotics unless pneumonia is suspected or the cough lasts longer than 10 to 14 days without improvement.

    And remember this pearl of wisdom:

    Medical experts say using antibiotics judiciously can be the best thing a parent can do for a child. Children who have recently taken antibiotics and then contract other infections are three to nine times as likely to have a drug-resistant infection as they would have been if they had not taken the antibiotic.

    Ditto for adults.

    CORRECTION: Charles Murtaugh (permalinks not working, scroll down to the plasmid post) correctly takes me to task on the biology behind antibiotic resistance in bacteria. It’s a matter of survival of the fittest in the presence of antibiotics more than it is spontaneous mutation.
    posted by Sydney on 7/24/2002 06:08:00 AM 0 comments

    Placeboes and Pain: Ian Murray has an article in The Christian Science Monitor about the power of placebo:

    Perhaps the most convincing evidence for its existence was revealed in February, when Science magazine announced that Swedish and Finnish researchers had shown that placebos activate the same brain circuits as painkilling drugs. It may be that the placebo response is actually part of all painkilling treatments. These studies show that we dismiss the power of the placebo at our peril.

    I’ve always felt that responses to pain are very much influenced by the mind. I suspect that the placebo effect applies when real pain drugs are used, too; that it enhances the action of pain medication, and that the failure to muster such a response accounts for the failure of pain medications in some people. Fear and anxiety, for example, seem to enhance pain. Sometimes, the best thing I can do for a patient is to reassure them that the pain isn’t caused by a fatal illness or that it won’t last forever. Anger also seems to enhance the pain response. Auto accident victims seem to suffer more recalcitrant pain when they weren’t the ones at fault and even moreso when the responsible driver was uninsured or drunk. It would be interesting to do an experiment to see if anger, anxiety, or fear inhibited the activation of those brain circuits.
    posted by Sydney on 7/24/2002 06:05:00 AM 0 comments

    Study Finds: Blacks are People, Too! A recent study finds that smoking cessation drugs help people of African descent quit smoking. (Although the methods section doesn't say how genetically pure the subject's were.) The study found that 36% of blacks who took Zyban quit smoking by seven weeks compared to 19% who took placebo. The same type of study, without regard to race, was already done in 1997, with essentially the same results. Why repeat it? Because some subjects are favored more both for funding and for publishing: minority health, women’s health, and HIV research. They are the trifecta of medical science affirmative action.
    posted by Sydney on 7/24/2002 05:57:00 AM 0 comments

    Tuesday, July 23, 2002

    Surgeon General Update: We have one now. (Couldn't tell we didn't have one, could you?)

    posted by Sydney on 7/23/2002 06:45:00 PM 0 comments

    The Original Red Book: For 106 years, pharmacists have relied on a reference called the Red Book to quickly look up details about prescription drugs. Turns out the Welsh had the same book 600 years ago:

    Myddfai is a village in South Wales. Here, in the early thirteenth century, a physician named Rhiwallon founded a line of doctors that spread across Wales and persisted for hundreds of years - some Welshmen still claim descent from the physicians.

    Legend has it that Rhiwallon's mother was a lake fairy who told him which plants had medicinal uses and where they could be gathered.

    The Myddfai's most important text, the Red Book of Hergest, dates from around 1400. It describes nearly 500 remedies for ailments such as deafness, lumps and fever, derived from more than 200 plants.

    One of the plants the Myddfai used was foxglove, which gives us a drug we still use today for heart conditions, digitalis. (Although now we use the more reliable synthetic version, digoxin.)
    posted by Sydney on 7/23/2002 08:12:00 AM 0 comments

    Hospitals Will Kill Ya Part II: The Chicago Tribune continued its investigative series on deadly hospital infections yesterday with Lax Procedures Put Infants at High Risk. The story tells some heart wrenching tales of babies dying at the unclean hands of doctors and nurses. The babies, however, are all premature infants who are already particularly vunerable to infections. Once again, the paper tells us that they have done an indepth analysis and data gathering, but they don’t bother to detail their methods:

    The Tribune linked the deaths of 2,610 infants in 2000 to preventable hospital-acquired infections. Examining patients of all ages, the Tribune identified 75,000 preventable deaths where hospital-acquired infections played a major role. This analysis, based on the most recent national data, is the most comprehensive of its kind and draws on thousands of hospital and government inspection reports.

    Pediatric intensive care units experience up to three times the number of infections as other hospital areas, including operating rooms, according to the Tribune analysis and records at the federal Centers for Disease Control and Prevention.

    And though overall infant mortality rates continue to decline inside U.S. hospitals, the rate of lethal pediatric infections acquired in hospitals is rising, state and federal health-care records show.

    They then proceed to detail several cases of infection, all of which happen in neonatal intensive care units. Every case involves premature infants, no cases involve older children or healthy newborns. Premature infants are particulary vulnerable to infection, which the article does point out. Their immune systems are underdeveloped, their skin is thin and easily penetrated by bacteria, and they are born with problems that require invasive procedures such as catheters and respirators to keep them alive. With such poor immune systems, it is harder for antibiotics to do their job. They require the assistance of the body to be most effective. In addition, once such a vulnerable and small patient aquires an infection, things go bad fast. A baby who seems to be doing fine one minute, can be dead from sepsis within a few hours. All of this makes the fight against hospital aquired infections particularly difficult.

    It is also true that they are kept in the same room as other premature babies rather than in separate rooms as in adult intensive care units, but unlike adult intensive care, the preemie nurses are at the bedsides of their patients at every moment, watching for clues that something may be going wrong. As a group, they are the most diligent of nurses. It is not at all clear that putting each preemie in their own room would improve their mortalitiy.

    Many of the cases highlighted by the article are infections caused by Pseudomonas aeruginosa, a bacteria so ubiquitous that it has even been found in distilled water. Certainly, basic hand washing is a must when dealing with such vulnerable patients, but pseudomonas is very difficult to eliminate entirely. No matter how careful a hospital staff is, there will always be some risk of patients aquiring it, especially premature infants.

    Maybe the Tribune series will do some good by getting hospitals to re-examine their infectious control techniques and by reminding doctors and nurses of the importance of basic hand washing, but it unfortunately leaves the overwhelming impression that hospitals are a more dangerous environment than they actually are.
    posted by Sydney on 7/23/2002 07:41:00 AM 0 comments

    Nurses Needed: The Senate has done its part to help end the nursing shortage. They passed a bill:

    The legislation calls for scholarships for people who enter nursing school and a repayment program for nurses' education loans. To qualify, nurses would have to work at least two years in a new "nurse service corps" that will serve health facilities with a critical shortage of nurses.

    UPDATE:Ian Murray has a post about the consequences of nurse shortages, and the attempt to deal with them, in England.
    posted by Sydney on 7/23/2002 07:40:00 AM 0 comments

    Blood and Disaster: The New Republic covers what went wrong with the blood banks after September 11. They collected far more blood than we ever could use. They knew they were doing so, but collected it anyway. The problem was exacerbated by publicity stunts by our leaders who, like Yasser Arafat, knew a good photop when they saw it:

    The naiveté reached the highest levels of government. Around 11 p.m. on September 11, as an exhausted staff of the Washington-area Red Cross slumped around a meeting table, a call came in from the office of the president of the United States: Would they be so kind as to conduct a high-visibility Executive Office blood drive the next morning? Dutifully they did, on little sleep and for no practical purpose. Two days later, well after it became clear the donor spigot simply had to be turned off, they got a call from the U.S. Congress to run a blood drive among senators and representatives--and to present each member with a videotape of him or her giving blood to show constituents. Not a single unit from these collections went to the victims of 9/11.

    Couldn’t the Red Cross have just told them they didn’t need the blood? Evidently not. They, too, wanted to take advantage of the situation:

    The people who knew the most about blood tried vainly to control the flow. In order to avoid bottlenecks in the system, the Food and Drug Administration (FDA) issued emergency waivers to allow new technicians to shorten their training time and to accept blood that had not been fully tested. Such blood was labeled "For Emergency Use Only." On September 14 the Health and Human Services Department held a meeting at which the nation's leading blood-banking organizations agreed to put out a statement telling Americans to stay home and come back in a few months. They were about to issue it when the Red Cross, led by the headstrong Dr. Bernadine Healy, reneged. "What [the Red Cross] did was irresponsible and dangerous," says Dr. Ronald Gilcher, president and CEO of the Oklahoma Blood Institute. "They actually told people to keep donating."

    Healy adhered to the obsolete dogma that the Red Cross should never turn away a qualified donor. She also had another plan in mind. The Red Cross had been thinking about creating a frozen blood reserve to make the nation's blood supply more secure. With all the excess blood sloshing around, this might be the right time to launch it. The agency announced a crash program to freeze 100,000 units of blood. Never mind that there was no scenario under which such quantities could imaginably be used, even as a backup supply. (The military, the only population that might require such quantities, has its own independent blood system and frozen reserve.) The Red Cross quickly bought up most of the available blood freezers in the country and gutted a warehouse in Philadelphia to use as a frozen blood bank. But it was unprepared for other realities: For example, in order to freeze blood you need a glycerol solution, which protects the red cells from breaking. There wasn't enough glycerol to treat the quantities of blood Healy envisioned. The Red Cross also lacked aluminum canisters, freezing bags, and even FDA approval to utilize the process they had chosen. In the end they froze fewer than 10,000 units, while tens of thousands of others continued to accumulate and contribute to the overall waste. The subsequent revelation that the agency intended to commit $50 million of the Liberty Fund for the victims of 9/11 to the frozen blood reserve project was said to be a factor in Healy's resignation. "It was a disaster," says Dr. Harvey Klein, chief of the Department of Transfusion Medicine at the National Institutes of Health (NIH), "a total, total disaster."

    The author goes on to suggest some changes in the current method of gathering blood so that we have a more reliable and stable supply than we have now. The current system relies on volunteers who travel around a community setting up blood drives in schools and churches and such. The hours are always inconvenient for those who work. The author's suggestion:

    Maybe the Red Cross and regional collectors could lease space in hospitals to make their services more widely available, something they have never really considered. That would help compensate for the demise of the big factories and union halls that used to be the staple of community blood-giving.

    That probably would help year-round donations, but his next suggestion is a little iffy:

    Finally, we need to look for new categories of blood donors. Gay men face a lifetime ban because as a group they have a statistically higher risk of HIV. The ban is too blunt an instrument: Most gay men are perfectly healthy, and the new lab tests at blood centers can quickly detect the virus. We need to loosen that ban as aids becomes an increasingly heterosexual disease.

    Given that two people in Florida recently contracted HIV from blood donated by a man who had aquired the infection too recently to make it detectable by testing, we definitely should not relax that rule.

    We also need to accept blood from the nearly one million Americans with hemachromatosis, a genetic condition in which the body absorbs too much iron. Doctors treat this condition with phlebotomy, the only modern use for the ancient practice of bloodletting; all that precious blood goes down the drain. There's nothing inherently wrong with using that blood, which according to even conservative estimates could provide hundreds of thousands of pints per year. But because accepting it requires special FDA permission and extra expense, only 29 of the nation's more than 4,000 blood centers do so.

    Hemochromatosis isn’t the only condition that is treated today by phlebotomy. There is also a condition called polycythemia vera, in which the body makes too many red blood cells. They have a tendency to get all clumped up in the small blood vessels, potentially depriving essential organs of blood. The problem is, the blood taken from hemochromatosis patients and polycythemia patients may not be appropriate to give someone else. The blood of hemochromatosis patients has a higher than normal iron load, that of polycythemia patients has a higher than normal concentration of red blood cells. I don’t know enough about transfusion medicine to know if this absolutely negates their value as donor blood, but intuitively it seems that using them may impose risks on the recipients that would be better to avoid.
    posted by Sydney on 7/23/2002 07:35:00 AM 1 comments

    Monday, July 22, 2002

    Narcissus's Child: An American couple explains their desire for a cloned baby:

    My father was a very brilliant man as were my uncles on my mother's side of the family. I have strong genes in my background as does my husband. The intelligence is just part of it. I come from a very warm, loving family and I hope that we can bring a child into this world who has that warmth and intelligence. If the baby is healthy and normal I'll be happy. I understand that she might not look like me.

    'If we adopted a child we could not be sure that the child would have that love or intelligence. I'm not saying I am the best or the worst but I would not want to adopt a child whose parent was a murderer for example.'

    Hasn’t she noticed that brilliance doesn’t run in families?

    posted by Sydney on 7/22/2002 06:01:00 AM 0 comments

    Life Will Kill Ya, Especially If You’re Hospitalized: The Chicago Tribune is running an investigative series on infections in hospitals. They opened it yesterday morning with a story entitled Infection Epidemic Carves Deadly Path. According to the newspaper people are dropping dead like flies because of hospital-aquired infections. They know this because they have done their own epidemiological study:

    To document the rising rate of infection-related deaths, the Tribune analyzed records fragmented among 75 federal and state agencies, as well as internal hospital files, patient databases and court cases around the nation. The result is the first comprehensive analysis of preventable patient deaths linked to infections within 5,810 hospitals nationally.

    The Tribune's analysis, which adopted methods commonly used by epidemiologists, found an estimated 103,000 deaths linked to hospital infections in 2000. The CDC, which bases its numbers on extrapolations from 315 hospitals, estimated there were 90,000 that year.

    They’re a newspaper, however, not a peer-reviewed journal, so they don’t have to disclose how they gathered the data or what the data actually were or how they extrapolated their results. We are just supposed to trust them. They do, however, bring out a specialist in infectious diseases to confirm their worst fears:

    "The number of people needlessly killed by hospital infections is unbelievable, but the public doesn't know anything about it," said Dr. Barry Farr, a leading infection-control expert and president of the Society for Healthcare Epidemiology of America.

    "For years, we've just been quietly bundling the bodies of patients off to the morgue while infection rates get higher and higher."

    Dr. Farr certainly has worthy credentials, but he also has a penchant for the dramatic. There may be an increase in hospital infection rates, but we aren’t yet at the point where we’re hauling dead bodies to the morgue in carts.

    The Tribune also accuses hospitals and doctors of colluding in a secret pact to prevent the general public from finding out about the rampant infection rates in American hospitals:

    The health-care industry's penchant for secrecy and a lack of meaningful government oversight cloak the problem. Hospitals are not legally required to disclose infection rates, and most don't. Likewise, doctors are not required to tell patients about risk or exposure to hospital germs. Even a term adopted by the CDC--nosocomial infection--obscures the true source of the germs. Nosocomial, derived from Latin, means hospital-acquired. CDC records show that the term was used to shield hospitals from the "embarrassment" of germ-related deaths and injuries.

    The implication is that the CDC came up with the term "noscomial" to hide the fact that infections happen in hospitals. According to Webster’s dictionary, the term dates to around 1843, just about the time doctors were realizing that germs cause disease and that they could be spread from unwashed hands. It was also a time when medicine relied on Greek and Latin to name new diseases and trends. Thus, it isn’t surprising that the Latin term for hospital, nosocomium would be changed to the adjective nosocomial to describe hospital aquired diseases. I’d like to see those CDC records that demonstrate the term was chosen to “shield hospitals”. As to the Tribune’s claim that doctors and hospitals rarely advise patients of the risk of infection, that, too is nonsense. The standard consent form for surgeries and procedures clearly states that one of the risks of having it done is infection. It may be true that we don’t sit down before hospitalizing a patient and tell them that they could pick up an infection by being in the hospital, but is it really appropriate to tell a man having a heart attack, “You need to be admitted to save your life, but I must warn you, you may develop an infection or other complication if we do so?"

    It’s too bad the story starts off with such hyperbole, for surely there is a worthy story here. If the rates of hospital aquired infection are going up, and if those rising rates are due to hospital understaffing, then those are problems that must be addressed. The Tribune claims that:

    - Serious violations of infection-control standards have been found in the vast majority of hospitals nationally. Since 1995, more than 75 percent of all hospitals have been cited for significant cleanliness and sanitation violations.

    In thousands of cases observed by federal or state inspectors, surgeons performed operations without washing hands or wearing masks. Investigators discovered fly-infested operating rooms where dust floated in the air during open-heart surgeries in Connecticut. A surgical assistant used his teeth to tear adhesive surgical tape that was placed across an open chest wound during a non-emergency procedure in Florida.

    - Hospital cleaning and janitorial staffs are overwhelmed and inadequately trained, resulting in unsanitary rooms or wards where germs have grown and multiplied for weeks, sometimes years, on bed rails, telephones, bathroom fixtures--most anywhere.

    Because of cost-cutting measures, U.S. hospitals have collectively pared cleaning staffs by 25 percent since 1995. During the same period, half of the nation's hospitals have been cited for failing to properly sanitize portions of their facilities, a shortcoming that can colonize new patients with lingering germs.

    - Hospitals are required to have professional staffs devoted to tracking and reducing infections, but rampant payroll cutbacks have gutted those efforts. These staffs have been reduced an average of 20 percent nationally in just the last three years. Many hospitals disregard the CDC's recommendation of at least one infection-control employee for every 250 beds.

    ....Nurses, in particular, say staffing cutbacks have made the most basic requirements of their jobs difficult to fulfill, and a major study by the Harvard School of Public Health recently linked nurse staffing levels to hospital-acquired infections.

    How much of this can we believe, and how much of it is hyperbole? There’s no doubt that staffing cuts have resulted in fewer custodial workers and fewer qualified nurses, but only the nursing shortage has been conclusively linked to increased infections. The other examples cited are isolated anecdotes, not global trends . The assistant who tore the tape with his teeth (really stupid), and the surgeons who perform surgery without washing their hands (good God!) are isolated incidents and hardly the standard of care. The days of performing surgery like this, are long gone. Still, the description of the Connecticut operating room is a distubing one:

    A hidden camera was installed outside Operating Room2, and the tapes revealed that up to half of doctors, primarily surgical residents from Yale University, did not wash their hands before entering the operating room, according to hospital records.

    Operating rooms should be secured and sterile during surgeries, but nurses and doctors routinely stepped inside Room2, even while open-heart surgery was under way, to make personal calls on a phone mounted on the wall.

    Doctors also are supposed to change from street clothes into clean scrub outfits in a changing room at the hospital, but many doctors wore the scrubs home and back into the hospital the next day--and then directly into the operating room.

    It doesn’t say much for Yale Medical School that their surgical residents don’t understand the necessity of basic hygiene, but it’s still hard to believe that this is the norm nationwide.

    We’ve long been aware that hospitals are fraught with dangers for the sick. Anytime you put sick people together in one building there will be an increase in the exposure to bacteria. Anytime foreign material is placed in the body, or the skin’s defenses are breached, the risk of complications and infections rise. To some degree, we can’t help the patient without taking those risks. We should, however, do our best to maintain personal hygiene and hospital cleanliness to minimize them. If the Tribune's series helps us to remember that, then it's all for the good. I just wish they had done a more measured and less hysterical job of it.
    posted by Sydney on 7/22/2002 05:39:00 AM 0 comments

    What's Wrong With This Picture? The US healthcare system is not serious enough about tackling the rapidly growing "obesity epidemic," experts say. They call for better doctor training and, perhaps, government regulation of the food industry. ...the US government, physicians, insurance companies and the food industry all bear responsibility for ignoring the seriousness of the national obesity problem.

    Watch out, the Health Totalitarians are gearing up to bring the same weapons they routinely use against tobacco and alcohol to food. Only it will be worse. They can just look at you and tell if you are guilty of misusing food. Obesity is fundamentally a personal problem, not a public health problem. I can not follow my patients home and cook their meals for them or do their grocery shopping for them. I can not stand next to them with a whip and make them exercise. I can only give them advice and counsel, what they do with that advice and counsel is their own business and their own choice, not the business of the US government or insurance companies. And who in their right mind wants the government to regulate what kind of food we can eat? Yuck. Puritanism at its worst.
    posted by Sydney on 7/22/2002 05:36:00 AM 0 comments

    The Poor Need Not Apply: The Cleveland Clinic, one of those outstanding hospitals listed in US News and World Report, refused to treat a woman in need of a liver transplant because she was an illegal immigrant, or maybe it was because she was poor. The hospital says that it was because she was an illegal, but this is the same hospital that gives special shirts to high-paying patients so they won’t have to wait in line with the rest of the world to have tests done. They finally agreed to treat the woman when local politicians and an immigration lawyer stepped in. It may be a fine hospital, but only if you can show them the money.
    posted by Sydney on 7/22/2002 05:34:00 AM 0 comments

    School of Hard Knocks: The learning experiences of Israeli and Palestinian physicians.
    posted by Sydney on 7/22/2002 05:34:00 AM 0 comments

    Pharma Sales Mischief Update: The Prozac promotional gimmick of mailing free unsolicited samples to patients included a teenager, who has never been on Prozac, and isn’t a patient of the doctor who signed the letter. The carelessness with which their campaign was carried out only underscores that it was a promotion and not a patient service. They deserve the lawsuit.
    posted by Sydney on 7/22/2002 05:33:00 AM 0 comments

    Sunday, July 21, 2002

    Supply and Demand: Thanks to a reader for alerting me to this New York Times piece on healthcare market laws. (via the Brothers Judd.):

    Supply seems to drive demand. More hospitals in an area mean many more days spent in hospitals with no discernible improvements in health. More medical specialists mean many more specialist visits and procedures.

    My experience backs this up. My first practice was in a small rural town with limited access to specialists. Patients expected me to take care of the majority of their problems, and I did. They only went to the specialists, who were an hour away, when they really needed them. But now I practice in an area, where there are three hospitals within a thirty minute drive that made US News and World Report’s top 100 hospitals list. To get on that list, they have to have a lot of specialists, and they do. Here, my patients expect to see a rheumatologist for their arthritis, a dermatologist for their acne, and a cardiologist for their chest pain, even if it clearly is not coming from their heart. Just last week I had a thirty year old ask me for a referral to a cardiologist for no other reason than he had a family history of coronary artery disease. No symptoms, no other risk factors. He just “wanted the best.”

    Part of this is the fault of the medical profession. Dermatologists promote themselves with offerings of “free skin cancer screenings”, then tell the patient to come back yearly for photographs to monitor the changes in their skin. Is this cost effective? Does it decrease the number of deaths from malignant melanoma? Probably not. Hospitals also promote themselves by touting the specialty care they provide: neurosurgeons for back pain, arthritis centers, pain clinics, sleep labs and geriatric centers are all used to lure patients into the hospital system, and all are actively promoted by the hospitals. One hospital in our area has a cancer center that promotes itself by sending out questionnaires to people asking them about their cancer risks. It covers such things as family history and symptoms. After sending in the questionairre, the patients usually get a letter back encouraging them to come to the center for cancer screening and evaluation. The visit is much more expensive than what the same visit would be in their primary care doctor’s office, who is just as capable of screening for cancer as a specialist is. The patient doesn’t really get better care at the cancer center, just the illusion of better care.

    The medical profession, however, isn’t entirely to blame for the overdemand for medical services. These sort of tactics wouldn’t work if health care were a normal commodity, which it isn’t. Providing and buying health care isn’t the same as producing and buying widgets, and the same market laws that govern widgets don’t apply to healthcare. For one thing, healthcare isn’t really a commodity at all. It’s a need. You might argue that food and clothing and shelter are basic needs, too, and they all operate by the same laws of supply and demand. But, what separates healthcare from these basic needs is that healthcare is a need that people can not provide for themselves. They need the assistance of a physician for it. Always have, always will. Add to that, the natural tendency for people to worry about their health, and you get a market skewed toward demand. If the supply of physicians is there to assuage that worry, then people will take advantage of it. If not, they’ll deal with it with the best means available.

    This is why carte blanche third party medical coverage is such a bad idea. Give free health care to all, and no one will have an incentive to deal with even the most minor illnesses on their own. Experience also bears this out. I once participated in an HMO plan that did not have any co-pay at all for office visits. Patients with that plan were the most demanding I have ever encountered. They wanted to be seen the day a symptom appeared, even if the symptom was just a sneeze or two. (No kidding.) They also had their drugs covered completely. They invariably demanded the most expensive, latest drug when an older, less expensive one would have done just as well. When I attempted to convince them to use the cheaper medicine, they accused me of trying to save the insurance company money. That plan, not surprisingly, folded. Now those same patients have other types of insurance that require them to pay at least something for their visits and their drugs. They aren’t so demanding anymore. They don’t come in as often, and they don’t want expensive drugs. If we really want to diminish demand, then we have to make access a little harder. To make access harder, we have to make individuals more financially responsible for their health care spending. That’s the only way to control the demand, regardless of the supply.

    posted by Sydney on 7/21/2002 12:42:00 PM 0 comments

    Of Mice and Men: Researchers have identified a gene connected to anxiety. Other researchers have recently observed a similary gene in mice. In both cases, the gene acts as a suppressor to anxiety. If the gene is flawed, or missing, the people or the mice are more anxious.

    The gene involved codes for a protein in nerve cells. The protein is responsible for bringing serotonin into the cells. Serotonin is one of the chemicals that nerve cells rely on to communicate with one another. It is also the chemical that is influenced by the newer antidepressants such as Prozac, Zoloft, and Paxil. In the human study, people who had a shortened version of the gene reacted with more anxiety to frightening stimuli than people with longer versions of the gene. Mice can be manipulated in ways that people can’t, so in the mouse study, the gene was turned off or turned on at various stages of the mouse’s life. When the gene was turned off, the mice acted anxious and inhibited in unfamiliar situations. When it was turned on, they acted like normal mice. If the gene was turned on in mouse childhood, but switched off in mouse adulthood, the mice behaved normally as adults. They had no anxiety. If it was turned off in mouse childhood and turned on in adulthood, they remained anxious mice throughout their life. If what holds true in mice also holds true in men, then behaviors learned in childhood are difficult to change, even if we can manipulate their molecular and genetic sources. The Jesuits were apparently on to something when they said, “Give me a child until the age of seven and I will show you the man.”
    posted by Sydney on 7/21/2002 07:46:00 AM 0 comments

    Pesky Mosquitoes: All you ever wanted to know, and then some, about mosquitoes and mosquito repellants. (To review the most recent study on mosquito repellants, click here.)
    posted by Sydney on 7/21/2002 07:38:00 AM 0 comments

    West Nile Madness: In Illinois, health officials are being inundated with dead bird calls. They are begging people to stop:

    "Stop calling us," said Cook County Health Department spokeswoman Kitty Loewy.
    "We are no longer collecting birds -- you can underline that," said Fred Carlson, Kane County's director of environmental health.

    Illinois is one of the states where West Nile virus is already known to be established. Others are: Alabama, Arkansas, Connecticut, Delaware, the District of Columbia, Florida, Georgia, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Virginia and Wisconsin. So don’t worry about those dead birds if you live in any of those states. Health officials already know the virus is there. Just wear your mosquito repellant.
    posted by Sydney on 7/21/2002 07:37:00 AM 0 comments

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