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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.''
    -Robert Ehrlich, drug advertising executive.

    "Opinions are like sphincters, everyone has one." - Chris Rangel

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    Saturday, September 07, 2002

    Reining in Drug Costs: The same reader had these thoughtful comments on drug price controls:

    If federal law constrains states' ability to implement the kinds of prior authorization programs that are routinely used in the private sector, then the law should be changed.

    Specifically, I believe Medicaid recipients with mild or moderate GERD should have to try an H2 receptor antagonist before being given one othe proton pump inhibitors. Medicaid recipients with osteoarthritis and low risk of GI problems should be required to try a generic NSAID before being given either a COX-2 inhibitor or a brand name NSAID. Medicaid recipients suffering from depression should be required to try fluoxetine HCl before being given a patented antidepressant like Paxil or Zoloft. After Claritin loses its patent later this year, Medicaid recipients who are suffering from allergies should be required to try generic loratadine before being given one of the patented non-sedating anithistamines. And if a number of competing drugs are very similar to each other with respect to both clinical efficacy and side effects (e.g., statins), it makes sense for the state to put the lowest-price drug(s) within the therapeutic class on its preferred drug list.

    There will be complaining from the usual suspects--e.g., doctors who believe their autonomy is being compromised, patients' rights groups who believe the restrictions will harm patient health, and of course the pharmaceutical industry, which will assert that the reduction in reimbursements will reduce innovation.

    But at the end of the day, I think these requirements would likely have little or no adverse effect on patients' health--any patient who does not respond well to the preferred drug could be switched to a more expensive non-preferred drug. And Medicaid drug costs would probably plunge. For example, according to a New England Journal of Medicine study published a few years ago, when Tennessee implemented a fail-first requirement for brand name NSAIDs, its NSAID expenditures dropped by about 50 percent.

    The evidence is not definitive--these programs have not yet been widely studied, and the NEJM study of Tennessee did not include a "control" state--but my guess is that these programs are as close as we can get in health care to a "free lunch": that is, dramatically lower costs with almost no adverse effect on patient health.

    I agree. I would like to be able to say that the majority of physicians choose drugs based on their efficacy rather than on detailing by drug reps, but the sad truth is that with each passing year I become more and more aware that the prescribing patterns of the majority of my colleagues are based on drug rep hype. Yesterday, a neurologist started a patient of mine with a normal cholesterol on a statin to treat her homocysteine level. I'm worried that she'll end up with liver problems or an interaction with her other drugs. My own husband came home last week from his doctor with a new, expensive antibiotic for pneumonia when a cheaper, older one would have been just as effective. All of my patients who see orthopedists or rheumatologists for their tendonitis or arthritis come back with Celebrex or Vioxx rather than ibuprofen or naproxen. Everyone wants to give the appearance of being on the "cutting edge" of medicine by prescribing the newest therapy, without regard as to whether or not it's actually any better than the old. The medical profession has abdicated a great deal of responsibility in this regard. The choices of the drugs we use to treat and prevent illnesses have far greater public health consequences than issues like obesity and alcohol use which have come to dominate the public health arena.

    posted by Sydney on 9/07/2002 06:32:00 PM 0 comments

    Drug Wars: A reader sent these comments about an earlier post on the drug company suits against state Medicaid programs:

    PhRMA argues that federal laws (e.g., the Omnibus Budget Reconciliation Act of 1990) requires states establishing a preferred drug list to include all drugs of manufacturers who participate in Medicaid unless the drugs are excluded for clinical reasons. The states' new cost containment programs exclude drugs solely or almost solely based on price. That is what PhRMA argues is prohibited by federal law. If PhRMA's legal case is so flimsy, why did the U.S. Supreme Court agree to review PhRMA's challenge against Maine's prior authorization program?

    If this is the law, which it apparently is, then the law is an ass, and it only goes to show how influential PhRMA is with our congressional leaders who make those laws. Fortunately, laws can be changed, and this one should be. It makes no sense to allow commercial healthcare insurance to choose drugs based on price and bar state-sponsored insurance programs from doing the same.
    posted by Sydney on 9/07/2002 10:27:00 AM 0 comments

    Mosquito Menace: This is shaping up to be the summer of the mosquito. Another case of West Nile virus has cropped up after a blood transfusion (but the patient also says she had a lot of mosquito bites), and the virus might now be in California. (It was always known that it would one day get there, it was just not certain how long it would take). More disturbing, there were two recent malaria cases in Virginia. (There are usually one or two cases of locally acquired malaria a year in the United States.) While the role of pesticides in controlling mosquitoes may be controversial, the role of standing water is not. Could it be that we’re beginning to reap the human costs of the wetlands protection program?

    UPDATE: Here's a new way to commit mosquito infanticide. (via Jim Miller)
    posted by Sydney on 9/07/2002 09:31:00 AM 0 comments

    An Hour a Day?!!!! Even DB, a self-proclaimed exercise fanatic, thinks the Institute of Medicine is off-base in their recommendation that we all spend one hour a day exercising. I admit to the same disbelief when I saw the headline in the paper yesterday morning. I put the question of who the hell has time to exercise an hour a day to my husband, but he smugly pointed out that “George Dubya” does, and so do his cabinet secretaries. There is, apparently, a cult of fitness in Washington.

    The guidelines writers, however, have evidently recognized their mistake in pushing the envelope for exercise so far. The stories today give the guidelines the spin that the exercise doesn’t have to be one continuous hour, but can be all the exercise you do in a day added up. Few people are so sedentary that they don’t move around for at least one hour in the day. Any activity, of course, is better than no activity, but exercise is most beneficial when it’s done as sustained exercise. Having gone too far in their enthusiasm for exercise for most of us, they’re now downplaying the recommendations to the point that they won’t be of much benefit. You have to wonder why bother?

    UPDATE: RangelMD thinks the recommendations are batty, too.
    posted by Sydney on 9/07/2002 08:28:00 AM 0 comments

    Misbegotten AIDS: RangelMD had an excellent post on the issue of HIV reinfection and complacency.
    posted by Sydney on 9/07/2002 08:27:00 AM 0 comments

    Friday, September 06, 2002

    Just a bundle of nerves

    posted by Sydney on 9/06/2002 06:11:00 AM 0 comments

    Debriefing Debunked: "Debriefing" people after a traumatic event evidently does nothing, according to a study in The Lancet:

    They covered critical incident stress debriefing (CISD), usually a one-off three-hour, group therapy session for trauma victims. (Note: I think that’s supposed to be “one to three hour” not “one-off three-hour”)

    Others looked at different methods of debriefing and how people fared who had no counselling.

    It was found that symptoms of post-traumatic stress disorder improved with non-CISD interventions and with no intervention at all.

    However CISD did not have any such positive effect.

    There was also no evidence it improved recovery from other trauma-related disorders.

    The study was one of those dreaded meta-analyses, but I've always wondered how effective those crisis-moment counseling sessions were. They always struck me as annoying and obnoxious in their assumption that anyone could salve psychic wounds in such a short time.

    CORRECTION: The phrase used by the BBC to describe one-shot debriefing wasn't a typo after all. A reader who knows put me right: "one-off is a Britishism that means single or one-time."
    posted by Sydney on 9/06/2002 06:05:00 AM 0 comments

    Four Down, 400 More to Go: A flight attendant who blamed second hand smoke in airplaines for her chronic sinus problems, lost her suit against the tobacco company. She's the fourth flight attendant to sue. So far, only one has won her case. But never fear, the trial lawyers have more in reserve:

    But Williams, whose law firm is preparing about 400 tobacco cases to be put before juries, said nothing should be read into the Janoff verdict.

    If nothing else, they are persistent.
    posted by Sydney on 9/06/2002 06:05:00 AM 0 comments

    Bioterror Preparedness: The CDC says that we are prepared.
    posted by Sydney on 9/06/2002 06:04:00 AM 0 comments

    Autumn's Child: Babies born in the fall live longer on average, but only by four to seven months.
    posted by Sydney on 9/06/2002 06:03:00 AM 0 comments

    Vested Interest: The Naderite healthcare group, Public Citizen, is campaigning against a government-funded Alzheimer's study which they claim is endangering patients. I don't know if the patient's are actually being harmed in the study. I would hope that they are being monitored closely for side effects of the drugs, but the group points out a worrisome aspect of the trial:

    Public Citizen alleges the trial is using Celebrex and Naprosyn only because the companies are supplying the drugs and not because of any evidence they will actually work.

    Receiving freebies like this only makes the researchers more likely to put a postive spin on their results, especially when the topic of the research is a difficult-to-measure variable, as memory is. Public Citizen is right to be concerned.
    posted by Sydney on 9/06/2002 06:02:00 AM 0 comments

    King Insurance: Health insurance premiums continue to escalate:

    The average family now pays about $8,000 a year on health costs.

    Barring some catastrophe, our family of six wouldn't spend this much a year on medical care if we paid for it ourselves. Our premiums for insurance, however, approach this. We would be better off if we just paid for our regular doctors visits ourselves. Could it be that insurance companies are making huge profits by charging more than they pay out in healthcare dollars? Maybe:

    Meanwhile, health insurers like UnitedHealth Group and WellPoint Health Networks Inc. have been delivering record profits to Wall Street, staying ahead of escalating costs.

    If I could, I would chose health insurance that only covered catastrophic illnesses - those requiring prolonged hospitalization, or one that had a high deductible, if the premiums were cheaper. But that sort of insurance never seems to be a choice for some reason. The insurance industry is so enmeshed in the managed care model now that they can’t come up with any alternatives, or maybe they don’t want to come up with any alternatives. As it is now, they hold all the cards. They call the shots on the premiums, they call the shots on the amount doctors and hospitals are paid. They rule the world. But, like Yertle the Turtle, they're going to come crashing down when the rest of us turtles can no longer support them.
    posted by Sydney on 9/06/2002 05:56:00 AM 0 comments

    Thursday, September 05, 2002

    Public Health Hyperbole: The lead researcher in a study on exercise in adolescent girls says of her findings that girls are less active as they get older:

    "It is a crisis. It is the new challenge in public health in the United States," said Sue Y.S. Kimm, a physician and epidemiologist at the University of Pittsburgh School of Medicine who headed the Growth and Health Study run by the National Heart, Lung and Blood Institute.

    When I read statements like that I thank God we live in a free country. Imagine if Dr. Kimm were the health officer in a totalitarian state. We would have exercise police forcing teenage girls to march around the block or play softball. It’s not clear why Dr. Kimm thinks this is a crisis. Both her study and the other one in the Washington Post article on exercise in older women are poorly written. Neither reveal their raw data, only ratios and percentages, so it’s difficult to say exactly how many girls in Dr. Kimm’s study exercised regularly and how many didn’t - and by how much those numbers declined over the years. Dr. Kimm made the same sort of overstatement in the article, saying that the results should “sound an alarm, given the current epidemic of obesity.” But is obesity truly an “epidemic”? Even by the end of the study when the girls were their least active their body mass index averaged 25.9 for blacks and 23.1 for whites. To be obese, it has to be over 30.

    What’s truly alarming about the study is that 50% of the black girls live in poverty (household income <$20,000) and 22% had been pregnant by the time they were 17. Those two problems are more worthy of public attention and resources than whether or not girls exercise every day.

    posted by Sydney on 9/05/2002 07:15:00 AM 0 comments

    West Nile: (Or, as one of my patients calls it, West of the Nile Virus.) It's looking more and more as if there is a link between the virus and organ donation, although it is by no means certain. Three organ recipients from the same infected donor ended up with the infection. As Dr. James Hughes, director of the CDC's National Center for Infectious Diseases, puts it:

    "There is clear evidence that organ transplantation appears to have been the source. Having said that, though . . . these patients all lived in areas where mosquito-borne transmission of West Nile virus is continuing to occur. This is complicated; it is important we not jump to conclusions."

    Stay tuned as our knowledge of the natural history of the virus continues to evolve.
    posted by Sydney on 9/05/2002 06:03:00 AM 0 comments

    Disabled Veterans: Truly disabled veterans are being squeezed out of the VA health system by their healthier frugal brethern. The VA administration wants to change that:

    More than 300,000 veterans cannot get appointments within six months of their requests, and thousands cannot get appointments at all, according to the department.

    The backlog stems largely from a decision in 1996 to open eligibility to veterans who were not disabled while in service, Mr. Principi said. Those veterans now make up about 33 percent of the patients enrolled in the veterans health care system.

    Robert F. Norton, a deputy director at the Retired Officers Association, said, "The severely disabled are now competing with all other veterans for appointments."

    The VA wants to stop advertising their services to the able-bodied and to give priority in appointments to the disabled. John Kerry thinks this represents a broken promise on behalf of the VA system and that Congress should appropriate more money to care for each and every veteran equally, but that seems a misguided use of resources. There are a lot of veterans out there who use the VA system to make themselves richer. They use it because it’s a few bucks cheaper than their private health plans. I have a significant number of patients who use both their very generous insurance packages from Ford and GM and their veterans benefits. If the drugs they take are five dollars cheaper at the VA, they go to the VA, but they use their private health insurance for convenience medicine - acute problems like injuries or sinus infections. They’re gaming the system, and we’re paying for their healthcare twice. Once in the price of our cars to cover their employer-financed insurance, and again in our taxes to cover their government-financed care.
    posted by Sydney on 9/05/2002 05:45:00 AM 0 comments

    Of Dr. Mudd and Captain Blood: The relatives of Dr. Mudd, the man who treated John Wilkes Booth for a broken leg after he assassinated Lincoln, are trying to redeem his reputation in the courts. The New York Times says that medical ethics is at issue:

    The case also raises questions of medical ethics and a doctor's responsibilities to a criminal who needs medical treatment, a question rekindled four years ago when Senator Bill Frist, the Tennessee Republican who is also a doctor, treated the gunman who killed two Capitol Hill police officers.

    Medical ethics isn’t the issue at all. If Dr. Mudd had contented himself with merely treating the assassin rather than giving both Booth and an accomplice shelter and transportaion, then it would be a matter of ethics. This is hardly a Senator Frist situation. The Senator provided care for a wounded man, without regard to who he was, which is what a doctor should do. He did not provide him a means to escape the law. Dr. Mudd can't even claim the moral high ground of Captain Blood. The fictional Captain Blood, you may recall, was a physician in 17th century England who was drawn unwittingly into a revolt against the King. He was summoned to treat a wounded man who turned out to be a rebel, was arrested with his patient, and sent to the West Indies as a white slave. Embittered by the experience, he became a pirate. (Although one with a good heart.) If Captain Blood had been written as a character who meant to aid the rebels in their cause, as Dr. Mudd did, the story would have lost all of its poignancy.

    There appears to be a common misconception these days that medical charity means sanctuary from the law. Witness the Seattle hospital that refuses to discourage criminal behavior within its own walls. That notion needs to be disabused. True medical charity is to provide medical care without prejudice, not to forgive sins and trespasses. No one benefits, not our patients, not society, when we enable bad behavior.

    As for Dr. Mudd, he clearly stepped over the line when he gave John Wilkes Booth horses to make his escape. He wasn’t acting as a doctor caring for a wounded man when he did that. His descendants claim that he hadn’t yet heard of Lincoln’s death. That’s hard to believe. He lived in Maryland, close enough to Washington for a wounded man to make his way to him without a horse. Word travels fast, even in those days - especially when it’s word of such import as a President’s murder. I happen to be reading the diary of Betsy Freemantle, the wife of a naval captain during the Napoleonic Wars. She records learning of the Battle of Trafalgar on November 7, 1805, one day after the Admiralty learned of it - even though she lived far from London. Surely the United States in the late 1860’s was capable of transmitting news just as fast, if not faster. Dr. Mudd was no Captain Blood.
    posted by Sydney on 9/05/2002 05:25:00 AM 0 comments

    Wednesday, September 04, 2002

    Smallpox Vaccine Update: The Department of Health and Human Services has given the Administration their smallpox vaccine proposal. They wouldn't go into the details, but it sounds like they are at least recommending more widespread vaccination than the CDC recommended. That's good. It will give them a chance to assess the true dangers of the vaccine, and the logistics of giving it to a large number of people. If it proves less of a problem than many think, then they could expand the program to a voluntary mass vaccination program.

    posted by Sydney on 9/04/2002 07:03:00 AM 0 comments

    JAMA's weekly art history lesson?
    posted by Sydney on 9/04/2002 06:36:00 AM 0 comments

    Contraband Bacteria: Derek Lowe has an excellent post about blackmarket bacteria.
    posted by Sydney on 9/04/2002 06:35:00 AM 0 comments

    Cholesterol Caution: Statins, a very popular class of cholesterol lowering drugs, have been linked to nerve damage:

    Researchers who studied 500,000 residents of Denmark -- about 9 percent of that country's population -- found that people who took statins were more likely to develop a form of nerve damage called polyneuropathy than those who never took the drugs. Polyneuropathy, also known as peripheral neuropathy, is characterized by weakness, tingling and pain in the hands and feet as well as difficulty walking.

    Taking statins for one year raised the risk of nerve damage by about 15 percent -- about one case for every 2,200 patients. For those who took statins for two or more years, the additional risk rose to 26 percent. The Danish study, published earlier this year in the journal Neurology, is not the first to implicate statins in the development of nerve problems, but as one of the largest statin studies to date it is regarded as significant.

    It’s really not all that impressive, though, as this synopsis makes clear. They looked at everyone who was diagnosed with nerve damage in the country without an obvious cause, and then found out how many had taken statins. Only 15 out of 166 people with idiopathic nerve damage had taken the drugs. The control group was made up of 4,150 people who had never had nerve damage. Of these, only 66 had ever taken a statin. There may be an association here between statins and nerve damage, but it isn’t a solid case based on these numbers.

    That’s not to say that statins should get a free pass. They shouldn’t. Their claim to fame is based on similar inflated numbers. They are among the greatest profit makers for the drug companies largely because physician groups like the American College of Cardiology and the American Heart Association have endorsed them as miracle drugs that are as safe as candy. In fact, here is their latest joint statement on the safety of statins:

    ...These agents reduce the risk of essentially every clinical manifestation of the atherosclerotic process; they are easy to administer, with good patient acceptance. There are very few drug to drug interactions

    Not true. There is a lengthy list of drug to drug interactions with statins.

    ..Statin therapy holds great promise for reducing the incidence of major coronary events, coronary procedures, and stroke in high-risk patients. At present, this potential has not been fully realized, because many patients at heightened risk are not being treated with these drugs. There is a well documented under-use of statins in clinical practice.

    Whether or not they are underused in clinical practice is a matter of debate. Many physicians aren’t as easily taken in by the claims for statins as the men and women who make up the scientific panels at the American College of Cardiology and the American Heart Association. Many of these panel members, not coincidentally, are dependent on the makers of statins for research grants. The American Heart Association, in fact, claims amongst its highest donors several drug companies that manufacture statins. (warning: pdf file). They’ve accepted claims that statins substantially reduce coronary artery disease based on comparisons of ratios rather than actual changes in disease incidence; which in all the studies, only amount to changes of 2 to 4 percentage points. See the results of the most lauded of the statin studies here, here, here, and here.

    Most recently, the American Heart Association and the American College of Cardiology have tried to expand the use of these drugs even further, by recommending that we screen and treat people as young as twenty for high cholesterol, possibly making statins the first drugs to be used everyday for a person's entire lifetime. What a market coup! They have plans to expand it even further. They're working on guidelines now that would recommend screening for markers of inflammation in the body that have a small correlation with heart disease risk. The buzz is that the inflammation can be successfully treated with statins, too.

    Not surprisingly, sales of statins are taking off:

    In fact, according to an article in the Wall Street Journal by Thom Burton, many insurers now grade doctors’ performances and dole out monetary bonuses and penalties based on measuring and “improving” patients’ cholesterol levels. And the fastest and easiest way for doctors to lower cholesterol is to prescribe a powerful statin like Pfizer’s Lipitor. As the new government guidelines are structured in such a way as to transform virtually every American into a candidate for cholesterol-lowering drugs, Pfizer’s profits are climbing. Income for the huge pharmaceutical company rose 38 percent in the last quarter of 2001 to $1.93 billion. Karen Katen, president of Pfizer’s human pharmaceuticals group, said Lipitor “still has enormous room to grow” because of “widespread under-diagnosis of high cholesterol.” (Wall Street Journal, 1/24/2002).

    The worst of it is that among all the statin boosterism not one study has been done to quantify the cost of long term statin therapy to society or to the individual. Shame on us.
    posted by Sydney on 9/04/2002 06:13:00 AM 0 comments

    No Surrender: Northeast Ohioans spit on West Nile virus:

    Mosquito bites line the legs of Cuyahoga Falls resident Wally Oelkers.

    Even a recent letter from the city announcing the discovery of mosquitoes carrying the West Nile virus in his neighborhood off Bath Road wasn't enough to scare Oelkers and his family.

    "I get bit all the time,'' he said on a recent afternoon.

    Oelkers and his wife, Tracy, also let their two children go outside to play at dusk.

    "Are we worried? No,'' she said.

    ...The threat of the West Nile virus also isn't scaring the senior citizens at New Horizons Adult Day Services, an adult day care program at Cuyahoga Falls General Hospital.

    About a dozen of the seniors listened on a recent morning as aide Bob Friend, a retired area disc jockey, read them a newspaper article about a 75-year-old Cleveland man who died last week.

    Still, no one at New Horizons said they were worried -- at least not for themselves.

    "I'm 95 years old. I'm not worried about me,'' said Elizabeth Culp of Akron.
    posted by Sydney on 9/04/2002 06:07:00 AM 0 comments

    Time Warp: Somehow, I thought this had long ceased to be. Judging from the report, it looks like the show never left the 'sixties, and is still more about Jerry than Jerry’s “kids.”
    posted by Sydney on 9/04/2002 06:06:00 AM 0 comments

    Tuesday, September 03, 2002

    Mammography Debate Continues: Fresh fuel has been added to the mammogram controversy fire. The US Preventive Services Task Force released the data it used to back up its continued recommendations that women aged 40 to 50 continue to get mammograms every one to two years, despite evidence last year that mammograms in this age group made no difference in breast cancer outcomes. (A good synopsis of last year’s controversy can be found here.) Meanwhile, at the same time, a Canadian study has been released that shows no benefit of mammography for women in this age group.

    The USPSTF is the government body that makes evidence-based recommendations on how preventive medicine should be practiced. Insurance companies and the government use their recommendations to monitor the quality of a physician’s practice. I routinely recieve notices from insurance companies informing me which of my patients, beginning at age 40 have failed to get their mammograms. The problem is, that all evidence is not created equal. The USPSTF data are based on a “metanalysis” of other studies, a practice which involves taking all the data from other research and mixing it in a statistical soup. The problem with this approach, is that published research tends to be biased toward studies that show a postive effect of treatment, so the combined analysis can be stacked toward treatment or, in this case screening. The other problem is that it can exaggerate the findings of a collection of poorly designed or border-line adequate studies by grouping them all together. It's one of the murkiest ways to come to conclusions about a test or a treatment, and not all that reliable.

    The Canadian study is the better and more reliable research. It looked at 25,214 women who had mammograms every one to two years, and 25,214 women who didn’t, ages 40 to 50 and followed them for eleven years. There were 105 breast cancer deaths in the mammography group and 108 in the non-mammography group. Essentially no difference.

    Yet, the controversy continues, and it probably will for some time, at least in this country. Breast cancer and mammograms have become so politicized here that decisions about it unfortunately tend to be made with the heart, not the head.

    For summaries of the two studies click here and here. This portion of the USPSTF summary is particularly apt:

    As better studies become available, recommendations about breast cancer screening may change.

    Looks like those better studies are already here.

    posted by Sydney on 9/03/2002 06:42:00 AM 0 comments

    Drink and Be Merry: Men who drank two or more glasses of wine a day after having a heart attack had fewer complications. The numbers involved in the study were small, though, so it's hard to say how valid the findings are:

    Dr. Michel de Lorgeril of the Joseph Fourier University of Grenoble, France and colleagues studied 353 men aged 40 to 60 who had just had heart attacks.

    ...Writing in the journal Circulation, published by the American Heart Association, De Lorgeril's team said the men had 104 cardiovascular complications such as a heart attack or stroke over the next year.

    Thirty-six of the complications occurred among men who abstained from alcohol, 34 among men who drank fewer than two glasses of wine a day, 18 among those who drank about two glasses a day, and 16 among men who drank an average of four to five glasses of wine a day, they found.

    No mention of what the drinking habits were of the 249 men who didn't have complications.
    posted by Sydney on 9/03/2002 06:40:00 AM 0 comments

    Daycare Debates: The daycare bogeymen are at it again, but this time they're trying to soften their message. There is a $10 million federal study of daycare and its effects on children which has been in progress for the past several years. They're releasing their latest data, although the story doesn't say exactly what the data are. It only reports the gist of them:

    Among the results was a potent trend: When they entered kindergarten, children who spent more time in day care demanded more attention, argued more, lied and cheated more, disrupted classrooms more, and were more likely to hit others, although all those behaviors fell within the normal range. The update supported similar data released 15 months ago.

    Fifteen months ago, the psychologsits participating in the study had a tift with one another about how to interpret the results, which means the trends they see probably aren't all that "potent". One psychologist, in particular was abrasive, and apparently still is:

    ''I grew up in a high-conflict family,'' Belsky said in a phone interview from England, where he teaches at the University of London. ''One of the things I learned is that you avoid conflict at your peril. Because we have struggled through our differences of opinion ... we could have this blow-up and I could be this disgusted and we can still go on. I have to tell you, after what I've seen, there are colleagues whose intellect I don't respect, whose intellect and scientific judgment could fit on the head of a pin.''

    He would not reveal whom he was referring to. ''We agreed not to name-call,'' he said.

    Evidently Dr. Belsky spent a lot of hours in daycare.
    posted by Sydney on 9/03/2002 06:36:00 AM 0 comments

    Monday, September 02, 2002

    Happy Labor Day

    posted by Sydney on 9/02/2002 11:23:00 AM 0 comments

    Flag Fervor: A British rheumatologist skewers the NHS, which even has its own flag.
    posted by Sydney on 9/02/2002 11:20:00 AM 0 comments

    Flag Fervor: A British rheumatologist skewers the NHS, which even has its own flag.
    posted by Sydney on 9/02/2002 11:19:00 AM 0 comments

    To Cover or Not To Cover: Researchers looked at the rate of use and success of in vitro fertilization in states that required insurance coverage of the procedure in contrast to states that required no coverage, but still couldn’t answer the question of whether or not it was to society’s benefit to have full insurance coverage for it:

    About 15,000 test-tube babies are born in the United States each year, at a cost of roughly $40,000 per child. More than 71,000 test-tube baby attempts were studied by the team, led by Dr. Tarun Jain.

    The team found that while 31.8 percent of the embryo transfers produced a baby in states with no coverage, the success rate declined to 28.5 percent when the insurance coverage was complete.

    Among the pregnancies, 11.2 percent produced at least three or more fetuses among women with no coverage, compared to 9.7 percent for women with full coverage. Women with full coverage were just as likely to have twins as those without.

    ..."The economic impact of multiple births on society is tremendous," the researchers said. In 1991, because of the higher likelihood of complications, the cost of delivering twins was 4 times higher than for delivering a single child. It was 11 times higher for triplets.

    Although fewer women would have multiple children if all states required insurance plans to cover in vitro fertilization, the researchers said, the additional women who took advantage of the coverage would probably mean more multiple births -- and their associated costs --in the long run.

    In an editorial in the Journal, Dr. David Guzick of the University of Rochester School of Medicine in New York said more work is needed "to quantify the benefits and costs of mandatory coverage."

    In truth, the differences are so small between the no-coverage states and the complete-coverage states, only one to three percentage points differences, you have to wonder if any of this even matters. Looking at population studies to determine whether an elective procedure like in vitro fertilization deserves full insurance coverage is in itself a questionable approach. The bottom line is that requiring such coverage only ends up increasing the insurance premiums for everyone else in the state.
    posted by Sydney on 9/02/2002 11:15:00 AM 0 comments

    Sunday, September 01, 2002

    Dream Editing: Escaping nightmares by rewriting them.

    posted by Sydney on 9/01/2002 12:44:00 PM 0 comments

    Pediatric Bioterror: The American Academy of Pediatrics has issued a statement on smallpox vaccine. Not surprisingly, they support the CDC’s ring vaccination approach, ignoring the effects of a smallpox outbreak on a non-immune population. (Many of the people who are part of the CDC’s vaccine vaccine advisory panel are also members of the Academy of Pediatrics, and three of them worked on the AAP’s recommendations.) No one under thirty, except for smallpox lab workers, has been immunized or exposed to natural smallpox. Ring vaccination is likely to be much more difficult and less effective in these circumstances, as I’ve argued before. Yet, the AAP isn’t entirely ignoring terrorism. They’ve included it in their disaster readiness kit for families, and they have a page now devoted to bioterrorism.
    posted by Sydney on 9/01/2002 12:43:00 PM 0 comments

    Gaining Their Hearts and Minds: Hamas is using medical charity to gain the support of average Palestinians:

    Ismail Abu Shenab, a Hamas political leader, said the group now supplied 15 per cent of all aid distributed in Gaza. 'This is an important factor in our growing popularity, combined with the success of our martyrdom operations and our pure image in contrast to the corruption of the Palestinian Authority.'

    Healthcare and suicide bombers must make for an interesting mission statement.

    posted by Sydney on 9/01/2002 07:58:00 AM 0 comments

    Into The Hormone Breach: Everything under the sun, including moistened towlettes to wipe the hotflash sweat from you brow, to take the place of hormone replacement therapy.
    posted by Sydney on 9/01/2002 07:50:00 AM 0 comments

    Chimp Genes and AIDS?< Dutch researchers are speculating that chimpanzees may have a gene that makes them immune to AIDS and that it was naturally selected for during a remote AIDS epidemic among them. The theory is based on a couple of wide speculative leaps:

    Dr. Ronald Bontrop, who led the Dutch team, said: "Chimps show more genetic variation than humans in all areas -- with this one exception, which is seriously condensed."

    He believes the most logical explanation was that a lethal epidemic had spread through the chimpanzee population and that only those with the correct genetic defences survived.

    And because modern chimps and largely immune to the HIV virus, Bontrop believes the ancient epidemic was AIDS-related.

    Or it could be some other explanation for the common gene, or a different disease that caused the epidemic, if there was one.
    posted by Sydney on 9/01/2002 07:25:00 AM 0 comments

    Family -The Knot You Can't Untie: Psychiatrists are seriously considering categorizing dysfunctional families as psychiatiric illnesses. Some see the bad relationships that underly some cases of situational depression (as opposed to chronic depression which is more of an innate condition than reaction to something) as a disease. They talk of them as something that might have a genetic basis or that could be cured with a pill. Thankfully, there are some voices of sanity from within the field:

    Trying to find the neural and genetic underpinnings of relationship problems to make the category fit the medical model of psychiatry is misguided, added Paul McHugh, former chairman of psychiatry at Johns Hopkins University.

    "You can't reduce everything to the idea that there is a brain flaw in every troubled situation," he said. "Perfectly normal people make mistakes in arithmetic. You don't look for problems in their brains, you look for problems in their arithmetic."

    UPDATE: Maybe some families do deserve to be classified as pathological.
    posted by Sydney on 9/01/2002 06:57:00 AM 0 comments

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