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    "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.''
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    Saturday, August 03, 2002

    Museum Watch: Antiqua Medicina

    posted by Sydney on 8/03/2002 08:51:00 AM 0 comments

    Ice Cream Headaches: What causes them:

    The best explanation for ice cream headaches is the location of sinuses all over your face, including the cheekbones and at the top of the mouth, Sohn said.

    So when the ice cream - typically served at 3 degrees Farenheit - or anything else served very cold hits the bones at the roof of the mouth, there's a rapid cooling all over the face and in the teeth.

    It's the swift change in temperature that causes the pain. It causes the nerves at the back of the throat to signal the blood vessels to dilate - and fast. This causes the ache in the teeth and the stabbing head pain.

    And how to avoid them (without giving up ice cream):

    "Don't let the ice cream come in contact with your palate or teeth if you can help it. Let it melt on your tongue."

    ...Other home remedies used by some people to thaw "brain freeze" quickly include running your tongue along or placing your thumb on the roof of your mouth, swallowing salt and putting your head lower than your heart.

    (For a more detailed discussion of the subject, click here.)
    posted by Sydney on 8/03/2002 08:42:00 AM 0 comments

    Medical Visas: The New York Sun has an article on the abuse of medical visas. I didn't know there was such a thing, but I guess it makes sense, considering all the foreign potentates who come here for medical care. The most ominous quote:

    But as the nation’s immigration net tightens, Mr. O’Kelly fears that his program is being exploited and said he had seen a worrying increase in treatment seekers from countries such as Pakistan. He added that if terrorists should strike again, “The last thing I want to do is wind up on Nightline explaining how it happened.
    posted by Sydney on 8/03/2002 08:39:00 AM 0 comments

    Disintegration: The Bloviator had this link to the story of a small town Indiana doctor who was hired by a nearby hospital to set up a practice. They wanted him to have a bustling practice of 30 patients a day by the end of two years. Instead, he had twenty patients a day. They think he’s lazy. Their estimates were off base. It takes about five years to firmly establish a practice, and to have thirty patients a day, you have to be firmly established.

    Unfortunately, it’s not an uncommon story. A decade ago, the rage in the medical business world was “integration.” Hospitals and medical management companies thought they would make vast amounts of money by buying up physician practices. Hospitals thought by doing so they could capture patients for the hospital referral services like x-ray, labs, and specialized testing as well as hospitalizations. They thought that possessing a network of physician practices would give them money-saving “economies of scale” with which to bargain with insurance companies and medical supply companies. It didn’t quite work out that way. Patients are people and not cogs in a machine. They sometimes have very definite preferences of where they want to go for testing and hospitalization. A doctor can’t force them (nor would most of us want to force them) to go to the hospital of his choice if they prefer another. “Economies of scale” may work in other fields of business, but not in medicine. Vaccines are only made by one or two companies who thus have the market advantage in pricing. Insurance companies set their rates by the current Medicare fee schedule, not by what physicians demand.

    But the biggest reason the integration venture has failed is that physician offices do not have a large profit margin. They are small businesses, very small businesses. They usually consist of a doctor or two and a couple of employees. Most privately run doctor’s offices don’t offer benefits to their employees. They can’t afford them. When they become “integrated” by larger management entities, the cost of doing business goes up. The hospitals and management companies, being larger corporations, have to offer benefits. They also add a layer of administrative overhead that isn’t present in a normal doctor’s office. Someone has to pay the salaries of the hospital vice president who runs the integrated network of practices and all of his underlings, and that someone is the doctor, the only person in the entire scheme who generates revenue. (Hospitals generate revenue, but when they own a network of practices they usually consider the network a separate entity and don't use hospital funds to run them.) It has proven to be a burden that doctor’s offices can’t shoulder. Doctors offices aren’t assembly lines. There’s a limit to how many patients a day a doctor can safely see, and in our system of corporate socialist medicine, there’s a limit to how much he can charge.

    So now, the buzz word is “disintegration.” The medical management companies were the first to fall, and now hospitals all over the country are beginning to divest themselves of physician practices. The administrators of the Indiana hospital in the article haven’t realized the no-win situation they are in yet. They hired another doctor to take Dr. Wagner’s place, thinking that she will be a more productive unit. She won’t be; and even if she is, she’ll never generate enough revenue to cover the overhead. My advice to Dr. Wagner: start your own practice in town. Five years from now you’ll still be standing. The hospital-owned practice won’t.
    posted by Sydney on 8/03/2002 08:24:00 AM 0 comments

    Some People Will Do Anything: Breast enhancement via vacuum device:

    The device is "relatively cumbersome, is heavy, and induces a fair amount of skin irritation along the silicone border/skin interface," Greco writes. "Yet the motivation to have larger breasts seems to overcome this in the correctly chosen individual."
    posted by Sydney on 8/03/2002 07:50:00 AM 0 comments

    Just Found My Second Career: Britain's most exclusive grocery store is looking for a chocolate taster to travel the world and find the finest chocolate.
    posted by Sydney on 8/03/2002 07:49:00 AM 0 comments

    Friday, August 02, 2002

    Don't Inhale the Butter: Lung disease in popcorn workers.

    posted by Sydney on 8/02/2002 07:06:00 AM 0 comments

    Anthrax Update: The FBI continues to investigate an American scientist in the anthrax case. It's hard to tell if their suspicions are just:

    The agents told her they were under intense pressure to solve the case before the anniversary date of the attacks, she said. The first anthrax letters were postmarked in mid-September last year.

    "One of them said, 'Every time my boss passes my desk he points to the calendar,'" Rosenberg said.

    Doesn't sound just, does it?
    posted by Sydney on 8/02/2002 07:02:00 AM 0 comments

    More West Nile: Specialists are perplexed that West Nile virus has spread to Texas and Louisiana. Do they think that birds and mosquitoes don't travel? I'm sure as it spreads among the bird and mosquito populations, it will slowly spread across the nation. But, keep in mind, the risk to people is still very small:

    Less than 1 percent of those infected develop severe illness; of these, less than 1 percent die. Most cases cause slight flulike symptoms, but the risk increases for the elderly. Two-thirds of the 161 cases and 18 fatalities since 1999 involved seniors.
    posted by Sydney on 8/02/2002 06:54:00 AM 0 comments

    Mystery Street Blobs: New Jersey residents think there's something mysterious about the waxy black blobs on their sidewalks. I've seen these blobs on sidewalks before. It's stuff used in mixing some surfacing materials. It melts in the heat and bubbles to the surface.
    posted by Sydney on 8/02/2002 06:44:00 AM 0 comments

    Sweep On You Greasy Statistics: DB's Medical Rants thinks I’ve been too hard on the NEJM paper about obesity and the risk of heart disease. I don’t think I have. The paper is a classic case of “stasticulating”, to use a term coined by Darrel Huff in his book How to Lie With Statistics. Instead of presenting their results in straightforward numbers, the authors chose to use complicated sets of statistics which are easily manipulated and prone to exaggeration, and which are poorly understood by those of us who aren’t statisticians. (I count myself among the innumerate, and suspect that the majority of my colleagues, including editors of medical journals also belong) Take, for instance, the much repeated phrase:

    ”After adjustment for known risk factors, there was an increase in the risk of heart failure of 5 percent for men and 7 percent for women for each increment of 1 in body mass index.”

    This statement is based on a ratio of rates of incidence of heart failure over the years of the study, not on a comparison of the actual incidences. It is one more convolution of the numbers that wasn’t really necessary to get the message across, but which makes the results sound so much more impressive. I’m not even sure how valid it is. What kind of risk goes up? Actual risk? Relative risk?

    As for the attributable risk, DB thinks that is the meat of the paper:

    The population attributable risk of heart failure due to overweight was 14.0 percent in women and 8.8 percent in men. The corresponding population attributable risks due to obesity were 13.9 percent in women and 10.9 percent in men.

    The attributable risk is nothing more than a stastician’s device to make his conjectures seem more dramatic. It is a conjecture with numbers, but numbers don’t lie, so we accept it as truth. But, coming up with that number relies on assumptions about possible contributing factors that the authors had to make. We aren’t privy to those assumptions because they are cloaked behind the calculations. Therefore, I’m not at all sure, as DB is, that 50,000 heart failure cases a year are caused by obesity.

    My main point about the paper, is not that it didn’t show an increase in heart failure among the obese. It did. My point is that the increase wasn’t as dramatic as we are being led to believe. The data are being maniuplated to give the greatest possible effect, so that the authors can make concluding statements like this:

    Our findings suggest that obesity is an important risk factor for heart failure in both women and men. Approximately 11 percent of cases of heart failure among men and 14 percent among women in the community are attributable to obesity alone. The contribution of obesity to the risk of heart failure has not been adequately recognized, and our observational data suggest that efforts to promote optimal body weight may reduce the risk of heart failure. Our results are particularly relevant given the alarming trend toward increasing obesity in the United States.

    The authors have very neatly made it clear that their paper is a significant one on a timely and fashionable subject. It now becomes more likely to be published in a prestigious journal. They are more likely to get another government grant to do yet more obesity research. And, most importantly, they can make the pharmaceutical company that gave them a grant, Roche Laboratories, happy. Roche is the maker of the weight loss drug Xenical. (Once upon a time Servier Amerique, another source of grant money for the study, would have been happy with the results, too. But their drug, Redux, is no more.)

    Statistics Have Consequences: Statistics are the use of numbers to make a point. They are used not only to validate the money spent by companies and governments on research studies, but to sway public opinion. As such, we should be just as critical of them as we are of ideas. They have consequences. Sometimes big consequences. Take, for example, Newsweek’s story on the whole obesity issue:

    Now lawyers are filing class-action lawsuits against fast-food makers, charging that deceptive marketing practices encourage obesity. “For years I ate fast food because it was efficient and cheap,” says Caesar Barber, 56, a maintenance worker with heart disease and the lead plaintiff in an anti-fast-food lawsuit filed in New York last week. “I had no idea I could be damaging my health.” This fall, Northeastern University law professor Richard Daynard is holding a closed-door strategy session for nearly 100 lawyers interested in pressing similar claims against Big Fat, or what—in reference to “Big Tobacco”—they’re calling “Big Food.” “Five years ago, when we said we’d take junk-food makers to court,” says Daynard, “people laughed.

    Forget about personal responsiblity and free choice. Armed with numbers, these lawyers will make sure none of us enjoy a burger again. Don’t think they’ll be satisfied with the hamburger at the fast food restaurant. Hamburger at the butcher counter has to be just as bad, so why not go after the beef industry, too?

    UPDATE: The Washington Post offers up an example of the consequences of the obesity study statistics. This, from the director of the NHLBI, which provided a grant for the study:

    Obesity "is almost a primordial risk factor," said Claude Lenfant, director of the National Heart, Lung and Blood Institute. "If you have it . . . you are going to be pulled to all these problems, and eventually . . . to heart failure."

    Is that right? The study showed a ten year incidence of heart failure in the obese of 6.8%(women) to 10%(men). That means the overwhelming majority of the obese didn't have heart failure in the ten year time frame, not a 100% incidence as the good director implies.

    UPDATE II: Another consequence of the statistics, this time from the Boston Globe:
    "Overweight people who gain as little as 4 to 8 pounds can significantly increase their risk of heart failure."

    They can statistically increase their risk, but not clinically increase it at 4 to 8 pounds.
    posted by Sydney on 8/02/2002 06:23:00 AM 0 comments

    Thursday, August 01, 2002

    Nevada Malpractice Crisis Update: A reader e-mailed this update about the malpractice crisis in Nevada. Lawmakers passed a tort reform bill that would cap damages at $350,000 unless the jury finds gross negligence or a judge feels a higher award is warranted. The trial lawyers are upset:

    Bill Bradley of the Nevada Trial Lawyers Association decried the legislation, saying special interests got "the upper hand at the expense of society in general."

    Mr. Bradley got it precisely wrong. In this case the special interests lost.

    posted by Sydney on 8/01/2002 06:13:00 PM 0 comments

    Self-Medicating: Andrew Sullivan offers this report on marijuana and anxiety as proof that pot should be legal. Just because a substance helps anxiety doesn't mean that its free and liberal use is a good thing. Many an alcoholic drinks to allay his anxieties. Ditto the tranquilizer addicts and narcotic addicts. (Remember The Ramones' "I Just Want to be Sedated"?) There may be many good arguments for legalizing marijuana, but this isn't one of them.
    posted by Sydney on 8/01/2002 07:23:00 AM 0 comments

    Art History: There is no JAMA this week, so for the weekly art history lesson, here is an old selection, in memory of all the massacred innocents of terrorist attacks.
    posted by Sydney on 8/01/2002 07:07:00 AM 0 comments

    Death of Norplant: Wyeth is no longer offering Norplant, the “miracle contraceptive” of a decade ago that was hailed by the media as the next best thing since sliced bread:

    Due to limitations in product component supplies, Wyeth does not plan to reintroduce the six-capsule Norplant System (levonorgestrel implants). Therefore, your patients will need to consider other contraceptive options as they approach the five-year expiration dates of their Norplant Systems. If your patients would prefer to have the Norplant capsules removed, Wyeth will pay for removal procedures until December 31, 2002.

    When Norplant first came out, it was all the rage. Newsweek had a cover story on it. All the network news programs ran stories about it. It was hailed as the most wonderful contraceptive to ever be developed. It was just slipped under the skin and forgotten about for five years. Patients flocked to the doctors to have them put in. When they were told about the side effects they got all glassy eyed and signed consents anyways. (The media conveniently forgot to mention that they caused irregular bleeding and were difficult to remove.) It didn’t take long for reality to set in. After an initial upsurge in interest, the demand for them quickly declined. I can’t remember the last time I saw someone who used it, or even wanted one. Evidently Wyeth can’t either.
    posted by Sydney on 8/01/2002 07:04:00 AM 0 comments

    Sweep on, you fat and greasy citizens: -Shakespeare, As You Like It.

    So say our senators and congressmen, who have heard the call of the CDC and the Department of Health and Human Services that we are a nation of gluttons and are determined to do something about it. Along with such truly weighty matters as a Department of Homeland Security, whether or not to go to war with Iraq, patent laws, and aid to low-income seniors for prescription drugs, they are also asked to consider this:

    “...the three senators are proposing spending as much as $217 million next year and additional money in future years on a variety of programs to encourage better nutrition and more physical activity.

    The money would go to the Institutes of Medicine, the Centers for Disease Control and Prevention and the Department of Health and Human Services to identify risk factors, analyze government food assistance programs and work with state governments on nutrition and exercise programs.

    At first glance, this seems innocuous. Nothing wrong with encouraging nutrition and exercise, or with making sure government sponsored food assistance programs offer healthy foods (shouldn’t they be doing that anyway?). But, do we really need the government this involved in our lives? That money would be better spent on, say, beefing up local health departments to deal with the threat of bioterrorism, or helping to finance immunizations for the poor.

    Besides, How Do You Define Fat? How many of those senators are themselves fat? And how many of those consider themselves fat? Often, fat is in the eye of the beholder. (I once had a partner whose chart notes described all women as “obese” if they weighed over 140 pounds. He never referred to a man as obese unless he had an obvious beer belly.) When researchers define obesity, they use the body mass index, a calculation using height and weight. It’s supposed to be more accurate than the life insurance charts that we used to use. A body mass index greater than 25 is considered overweight. However, even using that calculation, you’d be surprised to see who’s considered fat. (As usual, the Boston Globe makes it impossible to link directly to their story. Cut and paste this URL into your browser: http://www.boston.com/dailyglobe2/211/science/Who_you_calling_fat_+.shtml) Although it’s a more useful measure than the actuarial tables were, it still has it’s drawbacks. I’ve often had patients give up their diets and exercise programs in despair because they can’t achieve the final ten pounds that will take them to a BMI of less than 25, even though they have done splendidly with weight loss to that point. Just a ten or twenty pound weight loss can improve health, so it’s important not to get too fixated on an abstract number. If you feel good and exercise regularly, you’ll be doing all right even if your BMI tells you otherwise.

    And Ignore the NEJM: As if on cue, the lead paper in the New England Journal of Medicine is about obesity and the role it plays in heart failure:

    The researchers calculated that there was an increase in the risk of heart failure of 5 percent for men and 7 percent for women for each increment of 1 in the body-mass index...

    Or so says the result section of the not-so-helpful abstract of the paper, a statement which was duly copied in CNN’s report of the study. That sounds pretty impressive, but the abstract doesn’t tell us how many overweight subjects had heart failure compared to the non-obese. It only talks of rates of risk which can be misleading. In fact, the paper itself isn’t much clearer. It, too, never gives out the absolute numbers, preferring instead to deal with “person-year of follow-up” compared to numbers of heart failure cases. Even using these gymnastics, the final results aren’t all that impressive. For women of normal weight there was a 10-year cumulative age-adjusted incidence of heart failure of 3.4%. For overweight women (BMI 25.0- 29.9) it was 3.7%. For the obese (BMI > 30), it was 6.8%. Yes, it doubled, but the percentages are still pretty small. The figures for men are similar. Normal weight men had an incidence of 4.9% over ten years, overweight men had an incidence of 6.1% and the obese had an incidence of 10%.

    There is no doubt that being morbidly obese is detrimental to your health. It puts a strain on your joints, it probably strains your heart, and it batters your self esteem. But you don’t have to be a doctor to know that, and you certainly don’t have to have research projects to tell you that, either. Judging by this one, even when they try their hardest to prove it, they come up short.
    posted by Sydney on 8/01/2002 06:46:00 AM 0 comments

    Politics Trumps Charity: No help for the needy when it comes to prescription coverage. But, given the recent events in Massachusetts, you have to wonder if any government-operated prescription plan would work, no matter how modest. The pharmacies there are refusing to participate in Medicaid:

    With CVS, Brooks, and Walgreens, over half of the state's pharmacies are now on record saying they plan to withdraw from the Medicaid program. Many independent operators are expected to withdraw as well.

    ''I think you'll see the majority of independents withdraw,'' said Steven Grossman, the owner of J.E. Pierce Apothecary in Brookline. ''I don't see how anyone can stay in business losing money on every transaction.”

    You can’t. That’s why so few physicians in private practice accept Medicaid, and why many are leaving Medicare. And that’s why more and more of them are getting fed up with insurance companies.
    posted by Sydney on 8/01/2002 06:25:00 AM 0 comments

    A Simple Solution: One Vermont doctor has cut the middle man and managed to offer lower cost medicine as a result. I remember reading about her two years ago and thinking that’s the way to go. It seems much more just than “retainer medicine.” More and more doctors are talking about dropping out of insurance plans completely, though few do it out of fear they’ll lose their patients. Someday, though, I think it will happen. There will come a time when payments are squeezed down so low that overhead can’t be met and we’ll have no choice. As it stands now, most insurance companies have abyssmal reimbursement rates. You can only see so many patients in one day. It’s impossible to keep increasing productivity to compensate for the lower payments. Patient care suffers and the physician’s mental health suffers. Simple fee-for-service where the patient actually pays the doctor just like he pays everyone else from the grocer to the plumber to the lawyer, just may be the answer to our health care woes.
    posted by Sydney on 8/01/2002 06:16:00 AM 0 comments

    Medical Reserve Corps: The Department of Health and Human Services is offering grants to communities to help start up a Volunteer Medical Reserve Corps:

    In addition to assisting during a local emergency, Medical Reserve Corps volunteers can assist their communities with ongoing public health needs, such as immunizations, blood drives, health and nutrition education, anti-smoking campaigns and increased physical activity campaigns.

    I’d volunteer if I thought they would train me to help out in an emergency, be it a tornado, a flood, or a terrorist attack. I'd help out with blood drives and immunization programs. But I certainly wouldn’t want to be using my time to nag people about smoking and exercising. Are they ever going to get a clue as to what real public health problems are?
    posted by Sydney on 8/01/2002 06:12:00 AM 0 comments

    Wednesday, July 31, 2002

    Testing for Cancer Risk Derek Lowe has a very good explanation of the Ames test. (The essay begins on July 30, so scroll down then go back to today.)

    posted by Sydney on 7/31/2002 09:52:00 AM 0 comments

    So It's True: School cafeteria food really does make you sick. (And my mom always thought I was just exaggerating.)
    posted by Sydney on 7/31/2002 09:49:00 AM 0 comments

    Genetic Screening: Insurance companies are starting to cover genetic screening for “certain conditions”. The article hails Aetna as a leader in the movement, but their website makes it clear that they are rather restrictive in the cases they’ll cover. Their policiy is basically the same as that described by the other insurance companies in the article. For example, genetic testing for colon cancer is only covered for hereditary nonpolyposis cancer of the colon. This is a rare cause of colon cancer, and not like the more common colon cancers that arise from polyps. (Which can also be hereditary). Aetna says it will cover genetic testing for nonpolypsosis cancer of the colon if certain criteria are met. It is not offering to pay for genetic testing in everyone who has a family member with colon cancer. Even in cases of hereditary nonpolyposis cancer of the colon, the utility of genetic screening to guide colonoscopy is questionable:

    Expert panels convened by the AHCPR7 and the Cancer Genetics Studies Consortium (CGSC)29 recommended that persons who are members of a family that fits the clinical criteria for hereditary nonpolyposis colorectal cancer undergo colonoscopy at 20 to 25 years of age and every one to three years thereafter. In addition, these patients and their family members should be referred for genetic counseling. Germline testing for mismatch repair gene mutations can be considered, but the predictive value of such testing is only 50 to 80 percent. Therefore, regardless of the outcome of such testing, colonoscopy should be performed.

    The surgeon described in the article, who I am sure has very good intentions, is a little too gung-ho in his treatment methods:

    Dr. Frederick Slezak, an Akron area surgeon who specializes in colon and rectal problems, has spent hours writing letters or calling insurers to persuade them to cover a genetic test for patients already diagnosed with colon cancer.

    Female patients whose colon cancer is caused by a specific inherited genetic mutation are at higher risk for endometrial cancer, so their uteri should be removed as a preventive measure he said.

    His suggestion that a woman with the mutation for colon cancer have a hysterectomy to prevent uterine cancer harkens back to the days of old when surgeons did hysterectomies for the slightest of reasons. Their rationale was that none of those organs were needed past the childbearing years and that they would some day develop cancer (uterine, ovarian, cervical), so best be rid of them.The genetic mutation in question doesn’t condemn a woman to uterine cancer, it only increases her risk. A better approach would be to counsel her about the signs and symptoms of uterine cancer (bleeding after menopause) and encourage her to get yearly pelvic exams to monitor her uterus size. These days ultrasounds are sensitive enough to measure the lining of the uterus and can be used to monitor the potential for uterine cancer development. Proophylactic hysterectomy isn’t a necessity.

    The same is true for breast and ovarian cancer screening using genetic tests:

    A woman with certain known mutations in BRCA1 has a lifetime risk of 56 to 85 percent for breast cancer and an increased risk of ovarian cancer.

    The gene increases the risk of developing breast or ovarian cancer. It does not pre-ordain a woman to develop them. The question becomes “what do you do with this information once you have it?” Does a woman with the gene for breast cancer have a prophylactic mastectomy? (Sometimes even then, breast cancer shows up later). Does she take tamoxifen to prevent future cancer? (We don’t know the consequences of taking tamoxifen for many years) Does she get early and frequent mammograms? (She may have more biopsies for benign breast lumps and the early diagnosis may not make a difference in long term survival anyways). Does she have her ovaries removed? (She may still develop ovarian cancer) Does she get yearly ultrasounds and blood tests to screen for ovarian cancer? (Again, she may undergo procedures for benign cysts and early detection may not make a difference in survival.) Does she spend a lifetime worrying about the significance of her genetic test results? Probably. Consider the experience of Sweden in testing for a genetic predisposition to lung disease:

    However, the results of a failed newborn screening program for alpha1-antitrypsin deficiency in Sweden point to more complex reasons for resistance to genetic screening and testing. This deficiency is an autosomal recessive genetic condition that predisposes to adult, early-onset emphysema particularly in the presence of environmental factors such as cigarette smoking. Avoidance of cigarette smoke and smoky or dusty environments would presumably be a beneficial action if persons with this genetic predisposition could be identified.

    Using this hypothesis, an experimental newborn screening program was established in Sweden and involved approximately 200,000 newborns. The program was prematurely cancelled after severe, negative psychologic consequences (that were still evident at a five- to seven-year follow-up evaluation) were identified in more than one half of the families. Families reported viewing affected children as "different" and their anxiety about the disease led many of the parents to increase their cigarette smoking rather than decrease it as recommended.

    And that was a program that only required smoking cessation to make a difference.

    There is also the very real concern of what use third parties will make of genetic test results:

    Most people who work for large companies that automatically extend health-insurance coverage are most likely safe from discrimination, Mehlman said.

    But unless new laws are enacted, he said, people who are covered by an individual health insurance plan, as well as those who work for small companies, might want to consider paying for genetic tests out-of-pocket when possible.

    ``The law is full of gaps and loopholes,'' he said.

    To address these concerns, Aetna is publicly supporting the creation of a federal law that would prohibit insurers from requiring genetic testing for coverage, as well as ban insurers from disclosing tests results without a patient's approval.

    Even paying for the test out of pocket won’t keep the test results out of your medical chart. Life insurance companies routinely request medical records, with the patient’s consent, to assess risk and eligibility. But even though they consent to the release of information, I’m always amazed at the number of people who are upset because a policy was denied or a rate was increased because of the information in the medical record. Imagine what life insurance companies would do with genetic results. Would they insure anyone with a positive test? Would they force people to have the tests like they do now for HIV? As for health insurance companies, if you test positive for a cancer gene at thirty and then develop cancer at sixty, what are the chances that they’ll deny coverage of the medical care for the cancer because it’s a pre-existing condition? Believe me, the chances are pretty good. The original insurance company may not discriminate against you, but people rarely keep the same health insurance company for thirty years. A new insurance company could very definitely use the information to discriminate in coverage.
    posted by Sydney on 7/31/2002 09:38:00 AM 0 comments

    What Works for the Father Doesn't Necessarily Work for the Son: A 7-year-old boy suffering from a rare medical condition was hospitalized after his family ran out of his sedative. His stepfather used vodka as a substitute.
    posted by Sydney on 7/31/2002 09:27:00 AM 0 comments

    The Chicken or the Egg: Polycystic Ovary Syndrome is a condition in which the ovaries malfunction, leaving a woman with irregular menstrual cycles, increased male hormone production, and resistance to insulin. The result is a syndrome of irregular periods, male-pattern hair growth, and often obesity. It’s really very poorly understood, but it gets a lot of press in women’s magazines. I’ve had patients bring in articles that suggest physicians ignore the syndrome to the detriment of their patients, and that suggest that women who have it should be on metformin. The women highlighted in these articles were also all told to lose weight with diet and exercise, a fact which isn’t given nearly as much attention as the drug therapy by the writers. The truth is, metformin, while it may be of some help, is still being experimented with in this syndrome. And truthfully, we don’t know all that much about the condition itself yet. A lot of our therapy is just conjecture and theory. We’re not even sure which comes first: the polycystic ovaries or the obesity. In fact, many women improve just with weight loss, as the London Times article notes. It doesn’t even take a special diet. It’s just a matter of watching the calories:

    High-protein, low-carbohydrate diets are widely recommended, but two studies presented at the American Endocrine Society meeting in San Francisco in June suggest that it is cutting calories that matters, not the type of diet. The good news is that you don’t have to be sylph-like before you improve. “Losing 11/2 to 2st can make a big difference just to the way you ovulate.[There are fourteen pounds in one stone.]
    posted by Sydney on 7/31/2002 06:49:00 AM 0 comments

    Tuesday, July 30, 2002

    I think my family would say it's an underestimate, but:

    18.75 %

    My weblog owns 18.75 % of me.
    Does your weblog own you?

    (Via Ian Murray)

    posted by Sydney on 7/30/2002 07:51:00 PM 0 comments

    Every Man His Own Doctor: An online exhibit of colonial popular medicine. Don’t miss the book on The Heinous Sin of Self Pollution.
    posted by Sydney on 7/30/2002 05:58:00 AM 0 comments

    Too Much Fertilizer: Lettuce has been implicated in an E. Coli outbreak at a cheerleading camp. The outbreak happened about ten days ago, and lettuce only has a shelf life of two weeks at best, so there hasn't really been a recall. The article mentions that the contamination could have come from contaminated irrigation water, but it could also have come from organic fertilizer. Moral of the story: The solution to pollution is dilution. Wash your lettuce and other produce thoroughly before eating, especially if it comes from South Africa.
    posted by Sydney on 7/30/2002 05:55:00 AM 0 comments

    And in Other Developments: The House approved the Department of Homeland Security. The department will take over bioterror preparedness from the Department of Health and Human Services:

    The House-approved language transfers authority over the national strategic pharmaceutical stockpile from the Department of Health and Human Services ( news - web sites) to the Department of Homeland Security. The stockpile contains reserves of dozens of drugs and vaccines, including antibiotics designed to protect against anthrax and other biological weapons.

    It gives the Secretary of Homeland Security control over all of the government's efforts to research, develop, and store stocks of smallpox vaccine.

    And it makes provisions for the trial lawyers:

    In a move that could be key to pharmaceutical manufacturers, the bill also limits liability faced by companies that develop products to counter terrorism. US government officials have expressed interest in finding ways to encourage drug makers to develop bioterrorism-specific drugs and vaccines.

    We’ll see what’s left of that when the Senate gets through with it.
    posted by Sydney on 7/30/2002 05:54:00 AM 0 comments

    Pox Britainnica: Britain may have ordered a less effective strain of smallpox vaccine for their bioterror preparations, or at least says one American expert on the subject. The reason isn't too flattering to the government:

    Ministers already face an investigation by the National Audit Office over their controversial decision not to put the vaccine contract out to tender before awarding it to PowderJect, a company run by the Labour donor Paul Drayson, in January. Dr Drayson has given £100,000 to the party, including £50,000 a few weeks before winning the £28 million contract.

    Isn't it the Tories who are supposed to be pro-business to a fault over there?

    UPDATE: Other experts say Britain's vaccine is just as effective as any other vaccine. That means no one knows how effective either vaccine is, but they would still be more effective than no vaccine.
    posted by Sydney on 7/30/2002 05:53:00 AM 0 comments

    For The Birds: CNN is all breathless about the discovery of a dead crow with West Nile virus on the White House Lawn. Is it a terrorist plot? Naw. West Nile virus is already known to be established in Washington, D.C. You can probably find a lot of dead birds there who test positive for it. I’m surprised they’re still testing them for it. Usually once a region’s health department knows it’s established in the bird population, they stop testing all the dead birds, and just adopt a mosquito-spraying policy to minimize the risk that people will get it. But then again, Washington D.C. isn’t like most other places.
    posted by Sydney on 7/30/2002 05:49:00 AM 0 comments

    Afraid of Their Own Shadows: There’s a shortage of blood these days, especially in New York, because the FDA has introduced stringent new donation requirements to protect us against mad cow disease:

    In May, the federal government began to ban blood donations from people who spent three months or more in Britain — where mad cow disease first appeared — between 1980 and 1996, or more than six months on European military bases, or at least five years in France. This fall, the government plans to extend the ban to people who have spent at least five years in Europe.

    And, in a move that could have a tremendous impact on blood supplies in the New York region, the government plans to institute a ban on importing blood from Europe. The ban on imported blood will have its greatest impact in New York, which imports at least a fifth of its blood supply from Europe, and sometimes more.

    There’s only one problem. As far as anyone can tell, there’s never been a case of mad cow disease being transmitted by blood. The World Health Organization puts it this way:

    Experimental results investigating the infectivity of blood have been conflicting, however even when infectivity has been detectable, it is present in very low amounts and there are no known transfusion transmissions of CJD.

    Cruetzfeldt-Jakob disease (of which mad cow disease is a variant) is one of those diseases that sticks in the mind. (Pardon the pun.) Out of the endless litany of diseases that is a pathology textbook, the description of Cruetzfeldt-Jakob springs from the pages, at least in my student days it did, because it was invariably accompanied by a description of the disease Kuru:

    ”Kuru is confined to the Fore tribe of the eastern highlands of Papua-New Guinea, among whom the disease was transmitted by cannibalism. At one time it was the cause of death in 90% of women of the tribe since they mainly came into contact with or ate the brains of the deceased. With the termination of cannibalism in the tribe, the disease has all but disappeared.”
    -from my med school copy of Robbins Pathological Basis of Disease, published more years ago than I care to admit.

    The crux of the matter is that Cruetzfeldt-Jakob disease and its mad cow variant, appear to be most transmissible from neurological tissue, although it has also been found less often in lung, liver, kidney, spleen, lymph nodes, and placenta. Blood is at best only a risk in theory. The FDA is being prudent to a fault.
    posted by Sydney on 7/30/2002 05:46:00 AM 0 comments

    Monday, July 29, 2002

    Pox Americana Update: Deroy Murdock's rant about Statism includes a call for mass smallpox vaccination. He gives out Tommy Thompson's phone number. (It's near the end of the page)

    posted by Sydney on 7/29/2002 08:15:00 AM 0 comments

    No Kidding: Narcissists are lousy lovers. Guess that explains why so many Hollywood marriages fail.
    posted by Sydney on 7/29/2002 06:14:00 AM 0 comments

    Breastfeeding Contest: Women in Berkeley hope to break a world record in simultaneous breastfeeding.
    posted by Sydney on 7/29/2002 06:12:00 AM 0 comments

    On the foolish fretting of our care, lay thy soft touch of healing: Researchers find separate nerve endings for soft and gentle caresses.
    posted by Sydney on 7/29/2002 06:11:00 AM 0 comments

    Tetanus Africanus: Tetanus (aka lockjaw) is still a problem in much of Africa. The vaccine needed to prevent it has to be refrigerated and giving it requires someone who knows how to give shots, both of which are lacking in many areas. But, now, for the first time, they are trying a single-dose pre-loaded autoinoculator. The drug company is "donating" the device and vaccine (i.e. conducting human trials), but still, it has to be better than the alternative of no shots at all. (How can they be expected to combat AIDS when they haven't yet been able to conquer something as easily combatted as tetanus?)
    posted by Sydney on 7/29/2002 06:06:00 AM 0 comments

    Pox Israel: Israel debates the smallpox vaccine issue:

    "Now is the time to decide how to proceed with vaccination," writes Prof. Dan Michaeli, an infectious-disease expert and chairman of Clalit Health Services, in the July 2002 issue of IMAJ, the Israel Medical Association Journal. "Revaccination of people who were vaccinated once or more will enable us to acquire vaccinia-immune globulin in substantial amounts. This should be used for people who are prone to immune deficiencies. Other measures may also be applied to reduce the risks from vaccination, although these risks may be acceptable in view of the risks of smallpox re-introduction [by bioterrorists].

    "The time has come," Michaeli concludes in his editorial article, "for governments and health ministries to sit down, prepare plans and implement them without delay, especially in countries already exposed to terrorism and/or heavy international traffic."

    "The methods of smallpox outbreak control are known and can be implemented - in fact they were successfully carried out in Israel [to deal with a natural outbreak] in 1949," write Health Ministry chief epidemiologist Dr. Paul Slater and colleagues in the same IMAJ issue.

    "The economic cost of preparation is relatively small.... A smallpox outbreak in Israel must not be regarded as a doomsday event. If it occurs, it can and will be overcome.

    "If we make the necessary commitment now to vaccine production and stockpiling, laboratory preparation, planning, professional training and public education, the losses - although substantial - can be minimized. Moreover, the reinstitution of routine smallpox vaccination in Israel must be given serious consideration, now and in the future, as improved vaccine [with a lower mortality rate] becomes available."

    The Israeli government, though, won't publicly talk about their plans.
    posted by Sydney on 7/29/2002 06:04:00 AM 0 comments

    Stem Cell Promise: Researchers used stem cells from bone marrow to generate new blood vessels in the eyes of mice. It's only in mice, but it does offer hope for stem cell therapy that uses bone marrow rather than fetal or cloned cells.
    posted by Sydney on 7/29/2002 06:03:00 AM 0 comments

    One Day At a Time: The British Medical Journal published a paper last week on the end-of-life decisions made by the elderly. By and large, they don't make them, preferring instead to live one day at a time:

    An 84 year old woman living alone in retirement apartments said: "I just take it from day to day .... don't know what is going to happen tomorrow cause tomorrow is not promised to you.....You live from day to day, you don't worry about tomorrow ....tomorrow never comes sometimes ....Today is the day, not tomorrow."

    An 80 year old recently widowed woman who was confined to a wheelchair said she didn't have any concerns regarding future illness: "I don't have any, I mean, why worry about it? What's going to happen is going to happen and I believe in crossing that bridge when you get to it, you know."

    There's a lot to be said for that approach when every day may be your last.
    posted by Sydney on 7/29/2002 06:01:00 AM 0 comments

    Dysfunctional Dynamics: Isn't America wonderful? You really can make a living doing just about anything here.
    posted by Sydney on 7/29/2002 06:00:00 AM 0 comments

    Sunday, July 28, 2002

    Alternative Medicine Alert: Even traditional Chinese herbalists are skeptical about the modern herbal "medicine" industry:

    There is no formula in traditional Chinese medicine for slimming," Bill Guan, a traditional Chinese medicine specialist and scientist at the Institute of Chinese Medicine, told a news conference. He added there was neither scientific basis nor historical record for the claim.

    Leung Ping-chung, chairman of the institute at the Chinese University of Hong Kong, which does research on the use of traditional Chinese medicine, urged the Hong Kong government to tighten regulations on slimming products.

    "We need to have some standards, like what is safe? Content such as metals, fertilizers must be banned and the government must rule out absurd advertising," Leung said.

    That's right. You can't trust the companies to regulate themselves.

    posted by Sydney on 7/28/2002 07:42:00 AM 0 comments

    Smallpox Vaccine Update: The Administration is expecting to announce their decision on smallpox vaccine in a few days. If they decide against large scale vaccination to protect the public, it looks like we can thank the trial lawyers:

    Complications include a skin infection called eczema vaccinatum. People with eczema who touch a recently vaccinated person can develop this potentially fatal complication.

    HIV infections, cancer treatments that can suppress the immune system, and people with transplanted organs all are more susceptible to complications from smallpox vaccines.

    That raises the question of lawsuits, and Henderson said his team is thinking seriously about that.

    "To me it looks like this is going to be a great place for a trial lawyer to go to make a lot of money," Tennessee Republican Senator Bill Frist, a doctor, told the briefing.

    When they tell the story of the fall of democracy, the central players will be the trial lawyers.

    UPDATE: Fairhaven, the River has a link today to the Yearbook of the American Association for the Advancement of Science, which includes this essay by D.A. Henderson on bioterror preparedness.
    posted by Sydney on 7/28/2002 07:30:00 AM 0 comments

    My Kind of Journal: A group of medical organizations is banding together to publish a new family medicine journal. They're going to try to do it without drug company money:

    There will be no pharmaceutical advertisements, but there will be classified ads and ads on education. The sponsoring organizations will contribute money to run the journal.

    The organizations involved are: the American Academy of Family Physicians, the American Board of Family Practice, the Society of Teachers of Family Medicine, the Assn. of Depts. of Family Medicine, the Assn. of Family Practice Residency Directors and North American Primary Care Research Group.

    Good luck to them. If it works, maybe they can start a trend of divestment from drug companies in the journal world.
    posted by Sydney on 7/28/2002 07:22:00 AM 0 comments

    Anachronistic Public Health: They still require premarital syphilis tests in Washington, D.C.?
    posted by Sydney on 7/28/2002 07:03:00 AM 0 comments

    Fishy Advice: The FDA has told pregnant women to limit their tuna fish intake out of fear that they might accumulate too much mercury and damage their unborn children. Tuna isn’t one of the high-end mercury containing fish. In fact, by FDA standards it’s safe:

    Pregnant women would have to eat more than two cans of tuna a day for weeks to really be at risk, FDA scientist Michael Bolger argued Thursday.

    ..The FDA deems safe fish that contain less than 1 part per million of methylmercury. The average commercial fish contains 0.12 ppm. Canned tuna on average contains only slightly more than that, but amounts can vary to as much as 0.75 parts per million.

    Consumer advocates, however, feel that the danger is still there. Pregnant women might overdose on tuna, you know:

    But the FDA's advisory panel, ending a three-day inquiry into the controversy, countered that no one knows what proportion of the mercury in a woman's diet tuna actually contributes to.

    In fact, women could absorb far more mercury if they also eat freshwater fish that friends or family catch in local lakes or rivers. Some state waters are heavily polluted with mercury, and the FDA doesn't regulate recreationally caught fish.

    What are pregnant women to do? The beef has E. Coli, the chicken has Salmonella, the bread and potatoes have acrylamide, and now all the fish have mercury. They could just stop eating. But then, that would put their babies at risk, too, wouldn’t it?
    posted by Sydney on 7/28/2002 06:56:00 AM 0 comments

    The Sky’s the Limit: Now that I have a respite from on-call duties, I can rant a little more about drug prices. Of course, drug companies are in it for the profit and their business decisions are based on purely monetary concerns. But do they have to be so voracious? They are, after all, in the business of providing drugs to help the sick, and although they don’t pretend to have any sort of covenant with the patient , like doctors do, they do have some responsibility to make their product available at a fair and reasonable price. If food were as over-priced as some medication, there would be rioting in the streets. But then again, by and large we don’t pay for our own medications directly the same way we do for bread. We let someone else do it, and therein lies the problem. There is no incentive to shop around. Not for physicians. Not for patients.

    Jane Galt says that drug companies have a limited market, and are therefore hit harder by price decreases. But they use this limited market to their advantage, too. A person with high blood pressure, for example, doesn’t have much of a choice in what drugs are going to work to keep his blood pressure down. Ditto a diabetic and his blood sugar. And a person in the throws of a heart attack isn’t in a position to shop around for the most cost-effective thrombolytic therapy. The hypertensive, the diabetic, the heart attack patient all rely on their physician to give them the right drug. The physician, in his turn, doesn’t always choose the most cost-effective drug, either. Given the choice between reducing mortality by 1% or saving money, the doctor is going to choose lowering mortality, even if it comes at a higher price. Part of this is due to the litiginous nature of our society. No one wants to be accused of skimping on medical care. Some of it is due to third party payers. As long as someone else foots the bill, the sky’s the limit.

    The drug companies realize this. That’s why they raise their prices whenever the market for their drug increases. Take a look at the report of Families USA on the increase in drug prices from 2000 to 2001. For many of the drugs, their market increased because of the increase in the elderly population who uses them. In some cases, however, the market increases coincide with the publication of research or treatment guidelines that suggest an advantage in mortality or morbidity by using them. The price of metoprolol, a drug used for blood pressure and heart disease, rose 20% (almost eight times the rate of inflation) in that one year period. Why? Because the demand increased. In 1999, a study showed that metoprolol improved survival rates after heart attacks. I can attest that the number of patients taking metoprolol compared to other beta-blockers rose steeply in my community after the publication of that paper. I’m sure the same thing happened elsewhere.

    Let’s look at some of the other drugs whose prices increased dramatically in the same time period. Demadex, a water pill that is especially useful in people with chronic renal failure, increased by 17.8 percent (nearly seven times the rate of inflation). The latest numbers I could find for the incidence of chronic renal disease were from 1997, but the incidence, even then, had increased from 150 new cases per 1,000,000 population in 1988 to 287 new cases per 1 million population in 1997. My guess is that it has continued to increase since then and will continue to do so as the population ages. Expect the price of Demadex to keep going up, too.

    The cost of Premarin, the now much maligned estrogen, rose 17.5% (seven times the rate of inflation). This was before the recent hormone replacement study called its usefulness into question, and corresponds to a time when doctors believed estrogen protected against heart disease. As a result they recommended it unequivocally for postmenopausal women. It also happens to correspond to a time when baby boomers were beginning to enter menopause, pushing the market for estrogen up. Market went up, so did the price.

    The price of Plavix, a drug that inhibits blood clotting, rose 16.8 percent (more than six times the rate of inflation). The drug is favored by cardiologists to keep cornary artery stents open after placement. In addition, the American College of Cardiology together with the American Heart Association recommended it in 1999 as the drug of choice for heart attack patients who couldn’t take aspirin. Not coincidentally, Plavix sales rose 128 percent in the first quarter of 2000. Sales and price jumped up together. How many car companies could do the same and get away with it? None. People would stop buying the car if they kept increasing the price. But there is no alternative to Plavix in the guidelines, so drug companies do get away with it.

    Zestril prices rose 14.6 percent (more than five times the rate of inflation). Zestril belongs to a class of drugs called ACE inhibitors (angiotensin converting enzyme inhibitors.) ACE inhibitors are exceedingly popular and urged on physicians as a drug of choice in many situations: diabetics with high blood pressure, diabetics without high blood pressure, people who have heart disease, nondiabetics with high blood pressure, and people with congestive heart failure. In 1999, the American Heart Association and American College of Cardiology recommended their use in all heart attack patients whose blood pressure could tolerate it. Insurance companies keep track of physicians’ rates of use of ACE inhibitors in these conditions as a “quality assurance” measure. Zestril is especially popular because of its once a day dosing. It was the number one prescribed ACE inhibitor in 2000. As the population ages, more and more prescriptions for it are written. Larger market, higher prices.

    Lipitor, a cholesterol-lowering drug, rose 13.5 percent (more than five times the rate of inflation). In 1999, a study was published in the New England Journal of Medicine that showed treatment with Lipitor was as effective as angioplasty for low-risk people with stable coronary heart disease. By 2000, Lipitor had jumped from the number three to the number one most prescribed drug. More customers, higher prices.

    Physicians could do their part to fight this upward spiraling trend by considering the true cost of our recommendations. We should be more critical of guidelines instead of embracing them as if they were God’s own word. Organizations like the American Heart Association, the US Preventive Task Force Services, and professional societies should consider the economic consequences as well as the public health consequences when coming up with them. As for pharmaceutical companies, I don’t hold much hope that their executives will ever have the moral compass to refrain from charging as much as they can get away with. Their covenant is with the stockholders, not the patients who rely on their drugs. While I don’t believe that complete socialization of the pharmaceutical industry is desirable, I do believe that some sort of measure is needed to reign in their greed. In a way, we are seeing an attempt at that within our system now, in the drug reimportation bill, and in the generic drug bill. They need to change their fundamental ethos, and if it takes a shake up via legislation or grass roots revolt, so be it.
    posted by Sydney on 7/28/2002 06:26:00 AM 0 comments

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