"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
Hormone Hysteria: A Canadian writer, Judy Gerstel, has a hormonal hissy fit over estrogen replacement therapy. She's the antithesis of the doctors who put patients on the drugs without discussing the pros and cons. To them, estrogen replacement was all pro, no con. To Judy Gerstel, they're all con and no pro:
The news in July that tens of thousands of heart attacks, strokes, breast cancers and pulmonary embolisms are caused by long-term use of combination hormones brings joy to no one.
It wasn't tens of thousands. It was tens (or less) per tens of thousands of users of hormones. She goes on to accuse women who feel better on hormone replacement of being weak-willed mental midgets:
Women who have been weaning themselves off HRT say they look in the mirror now and see their grandmothers. Of course, they don't really look any different at all.
It's the reverse placebo effect And thinking so can make it so.
It's the opposite of why women who take HRT to stay young probably do appear to be more youthful.
A woman who believes she looks and feels younger behaves in a way that reflects that state of mind.
She takes better care of herself, eats healthier, dresses and grooms herself according to a self-image of an attractive women who has not been relegated to the sidelines.
On the other hand, post-menopausal women who accept a role as "non-players"stop trying their best to maintain any superficial allure, any ability to attract the male gaze or male approval.
Dear Ms. Gerstel, have some compassion. You may not need estrogen to feel your best, but there are plenty of women out there who do. They aren't falling for some Madison avenue hype about estrogen and youth. Their bodies are simply not the same as yours. For whatever reason, when they go without estrogen they can't concentrate, can't regulate their body temperature approriately, can't get motivated, or have extreme vaginal dryness. They function better when taking estrogen. Not all women are this way, but a significant number are. For these women, the benefits of estrogen outweigh the risk. Stop belittling them, and have the decency to respect their choice.
UPDATE: A reader shared this email that she sent to Judy Gerstel. Since there's a good chance it'll never show up in the letters-to-the-editor page of the newspaper, I offer it to you here:
I read your article on the risks and benefits of treating menopause with HRT, and would like to comment. You seem to dismiss treatment of menopausal symptoms as a vain and trivial attempt to avoid the aging process, which I think ignores the more serious reasons some women seek treatment for symptoms of menopause.
There's more to menopause than hot flashes and wrinkles. Some of us experience severe menstrual problems as menopause approaches, the details of which I will spare you except to say that before HRT I was housebound for a week every month and now, with HRT (in my case low dose birth control pills) I am free to pursue a normal life. I am aware that there are risks to long term HRT, and I have discussed those risks with my doctor. We are both confident that this is the right choice for me.
It's great that you're evidently in good health, and it is my hope that you don't share my experience, and that of many other women, as "that special time" draws nearer for you. But please don't assume your experience is universal, or dismiss as neurotic those of us who experience problems that are beyond your imagination.
Doctor Bonuses: A reader alerted me to an article in the Boston Globe that discusses some insurance plans’ intentions to offer quality bonuses to doctors. Like the Institute of Medicine’s suggestion that physician payment be tied to qulality, there’s a lot wrong with this plan, much of which both myself and RangelMD have discussed before. But, this story unwittingly provided an example of the difficulty of assessing quality that neither of us mentioned.
One of the benchmarks that some insurance companies are using to assess quality of care, is the treatment of diabetics. To do so, they’re relying on the American Diabetes Association’s provider recognition program. If a doctor qualifies for the program, they get a bonus:
A physician receives $100 per patient if he becomes a member of the American Diabetes Association's provider recognition program, which awards the status to doctors who prove they do a good job of controlling blood pressure, cholesterol, blood sugar, and other dangerous indicators in most of their diabetic patients.
...Even so, the companies and health plans hope the incentives will be large enough to convince doctors to make the extra effort. Partners has hired an administrator to help its physicians qualify for the Diabetes Association registry. Only one doctor out of 5,000 in Partners, which includes the Harvard-affiliated Massachusetts General Hospital and Brigham & Women's Hospital, now belongs, said Dr. Thomas Lee, medical director for Partners Community HealthCare.
You’ll notice that being a “recognized provider” means that you achieve good lab numbers. It has nothing to do with the patient’s quality of life. They may be incapacitated from the side effects from their medications, but if their cholesterol, sugar, and blood pressure are within standard goals, the doctor gets a bonus.
There’s another problem with the program. They charge doctors for the privilege of being recognized as high quality providers. In this respect, it’s a little like the Who’s Who scam. Doctors pay a fee to get an application, then they pay a fee to process the application, and it isn’t a small fee, either:
There is an $80 charge for application materials. Once the application is completed, the data are submitted along with a fee of $375 per physician up to six physicians. Group applicants with more than six physicians must submit a fee of $2500. All Program fees are nonrefundable.
Now you know why only one doctor out of the 5.000 partners at the Harvard-affiliated hospitals have signed up for it. It’s silly to pay an outside organization to pat doctors on the back for doing the right thing by their patients. Which brings me to my next objection to “quality care bonuses.” They’re insulting to the profession. We’re physicians, not assembly line workers. It’s our duty and our obligation to make sure we do our best for each of our patients at all times. We shouldn’t require financial rewards to inspire us to that goal, nor should we accept them. posted by Sydney on
11/09/2002 02:27:00 PM
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Be Right Back: Have a lot to say, but no time to say it. Blogging will resume later this afternoon, if blogger's still working. (Lately it's been going on the blitz on weekends.) posted by Sydney on
11/09/2002 09:44:00 AM
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Rapid HIV: The FDA has approved a finger-stick, rapid HIV test, similar to the tests we use now for strep throat, infectious mononucleosis, and influenza. You have to have a government-certified lab to run it, though, so most doctor's probably won't be offering it in the office. That, however, may change:
But the test is so simple that Health and Human Services Secretary Tommy Thompson urged manufacturer OraSure Technologies Inc. to seek a waiver of that law allowing OraQuick to be sold in far more places - from small doctors' offices to mobile testing vans and maybe even HIV counselling centres staffed by social workers instead of health professionals.
It sounds promising. According to company promos, it’s pretty accurate:
In clinical studies performed to date on multiple specimen types covering approximately 950 HIV-positive and 1700 HIV-negative subjects, test sensitivity has been 100% and specificity has been 99.9%.
That sounds a little too good to be true, and in fact, the FDA site says it’s 96% accurate, but it doesn’t break that down into sensitivity (the likelihood that it will detect the disease if you have it) and specificity (the likelihood that you have the disease if the test is positive.) Still, it would be nice to have a means of testing people quickly. As things stand now, a lot of people skip HIV testing because of the inconvenience of going to the lab or health department and because they don't want their health insurance company or employer to know they had it done. If they could elect to pay cash for a simple, inexpensive test, a lot more may submit to testing. posted by Sydney on
11/08/2002 06:47:00 AM
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MMR vs. Autism: A definitive study of the MMR vaccine shows there is no link between the vaccine and autism. The study was a very good one. It looked at almost a half-million kids. The rates of true autism in vaccinated and unvaccinated children were the same (0.06% vs. 0.05%), and so were the rates of “soft” autism- those behavior disorders that get labeled as variants of autism ( 0.09% vs. 0.10%). Anti-vaccination activists, however, aren’t convinced:
Barbara Loe Fisher, co-founder and president of the National Vaccine Information Center, dismisses the Danish study as "numbers moved around on a piece of paper."
The issue "is not going away because Denmark has done an epidemiological study saying don't worry about it anymore," says Fisher, who claims her son developed neurological complications, though not autism, after receiving the MMR vaccine.
Which is why health policy decisions should never be driven by activist groups. posted by Sydney on
11/08/2002 06:44:00 AM
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Gender Bias: I received the following email n response to the Tech Central Station column about gender inequality, from a healthcare researcher and reviewer of grants:
...as someone who reviews NIH grants, and is and has been funded by NIH for
nearly 20 years (disclosure - none of it is gender related - I work the
neurophysiology of respiration & deglutition/swallowing in infants, and
mostly work with animal models), I think that perhaps the reality of what
gets funded, and what goes into clinical trials isn't quite that biased.
Grant proposals are required to show why sex ratios and race ratio (and
there are larger problems there, too, of which I am sure you are aware),
and in fact, whether it is appropriate to be including children in the
study. But with scientific justification, one can study males, or females,
or rats (more often). As is true of most of the extramural NIH research,
its PI driven. I've never seen that kind of PC bias govern a decision in
the funding process in the six years I've been involved, unless it was due
to a failure to justify the sample. While there may be bias in the
political promo, the substance of the research that gets funded is pretty
damn straight.
It’s true that basic science research isn’t influenced by gender quotas. And it’s true that a lot of clinical research funded by the NIH manages to avoid sexism, too. But, it’s also true that there are an awful lot of studies out there devoted to finding sex differences where none exist. The recent study of stroke symptoms in women compared to men, for example, was a study of dubious merit that not only got funded and published, but got a lot of unwarranted media attention as well, largely because the journal, The Annals of Emergency Medicine, gave it a feminist spin. We spend money on such studies thanks to departments like the Office of Reasearch on Women’s Health within the NIH - an office whose sole purpose is to make sure funds have been set aside for gender-specific research. So, while it’s true that there are many aspects of the NIH that probably don’t indulge in politically correct funding, it can’t be denied that there are also some funds within it that are specifically set aside for politically correct research, such as the recent $85 million for race-based medicine. posted by Sydney on
11/08/2002 06:37:00 AM
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Get a Clue: Well, this explains a lot. Ross, at the The Bloviator has a post (third one down), that details the public health sector’s own assessment of where their priorities lie. It’s the American Public Health Association’s report card on bioterrorism preparedness. Many of the areas they list as being priorities for bioterrorism preparedness are areas that aren’t within the realm of public health at all:
-Address poverty, social injustice and health disparities that may contribute to the development of terrorism. (#1 on the list) Grade: D
-Provide humanitarian assistance to, and protect the human rights of, the civilian populations of all nations that are directly or indirectly affected by terrorism. (#2 on the list) Grade: C
-Advocate the speedy end of the armed conflict in Afghanistan and promote non-violent means of conflict resolution. (#3 on the list) Grade: B+
-Prevent hate crimes, ethnic, racial and religious discrimination, including profiling; promote cultural competence, diversity training, and dialogue among peoples; and protect human rights and civil liberties. (#10 on their list) Grade: F
These are political objectives, pure and simple. They aren’t the province of physicians and nurses and social workers. The “report card” goes on, predictably, to criticize the Bush Administration’s policies at every turn.
Meanwhile, aspects of bioterror preparedness that are legitimate concerns of the public health sector, such as beefing up infrastructure, educating healthcare providers, coordinating efforts between public health officials and other responders, and providing adequate medication for bioterror victims are lower on their list. They also receive better grades (C’s and B’s) and much less criticism. But then, those are the areas that are the responsibility of public health officials. Evidently, introspection isn’t their strong point.
This isn’t as surprising as it may seem. The public health community is led chiefly by academics, and they, like other academics in other fields, are typically of a leftist bent. Witness this letter to The Lancet (May require registration, but it’s free, and it's the second letter down) signed by public health officials from American universities that puts the blame for Middle East violence solely on Israel. Of course, they have a right to their opinions, but when those opinions distort their world-view to the point that political objectives trump public health objectives, as it appears to in the report card, it destroys both their credibility and their effectiveness. And it means that they can’t be trusted with the charge of something as important as bioterror preparedness.
UPDATE: This email makes a good point:
I wouldn''t worry overmuch about that group. From their own letter:
"Sir--More than 50 public-health and medical workers in the USA and other countries have signed a statement1 that expresses our concern about the flagrant violations of medical neutrality accompanying Israel's military invasion of the occupied territories of the West Bank."
Fifty people world-wide? And they think that's persuasive? There are other groups (e.g. Reuters) I worry about more. posted by Sydney on
11/08/2002 06:06:00 AM
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Get a Clue II: Which brings me to my next rant. I don’t know how many times I’ve heard on public radio and read in the papers that the Republican victory means that the American people want tax cuts, or that Democrats didn’t do enough to “distinguish” themselves from the Republicans. Folks, this is not why the Republicans won so decisively on Tuesday.
I’m a medical pundit, not a political pundit, but I spend most of my day in close contact with people from all walks of life, of all ages, and that gives me a better idea than most political pundits of where “the people” are coming from. Let me tell you, since 9/11, there’s been a definite change in what they view as important. They don’t care so much about tax rates as about terrorism. They don’t care so much about prescription drug benefits as they do about preserving our country. The Democrats just never seemed to get that, or at least few of them managed to communicate it if they did.
Used to be, when I noticed someone’s blood pressure was higher than usual, they’d offer as an explanation that they were “rushed” or that they just had two cups of coffee before coming in. But since 9/11 they’ve been just as likely to blame it on the Democrats. No kidding. I get responses like, “I was just listening to the radio in the car on the way over, and that #!@*^ Daschle makes my bood boil. What does Congress think they're doing?” Or they’ll point to the news magazine they were just reading while waiting for me, and say “I was just reading about those politicians going over to Iraq and defending Saddam Hussein.” Then they’ll go on a long rant and when it’s all over, their blood pressure’s back to normal.
It’s the war that’s first and foremost on people’s minds. (And not in Susan Sarandon/Barbra Streisand sort of way.) Not the economy, not corporate malfeasence, and certainly not healthcare. And what they want is unity, not divisiveness. Unfortunately for the Democrats, all they had to offer was divisiveness. posted by Sydney on
11/08/2002 05:55:00 AM
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Preparing for the Future: The New England Journal of Medicine begins a series on genomic medicine today that's intended to educate physicians about the advancements in gene research and their applications to medical practice. The first in the series, Genomic Medicine - A Primer, is available today, for free, at their website. I read it last night in my snail-mail issue and highly recommend it. The authors are Alan E. Guttmacher and Francis S. Collins, the deputy-director and director, respectively, of the Human Genome Research Inistitute, the arm of the NIH that’s responsible for the Human Genome Project . The Journal plans to make each segment of the series available for free on-line. posted by Sydney on
11/07/2002 09:20:00 AM
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The Plague: Two people in New York City are hospitalized with what's believed to be the plague. But don't worry, they're just tourists from New Mexico, where bubonic plague is endemic among the rodent fleas:
This would be the first case of bubonic plague in New York City in over a century. But the origin of the disease may be less exotic. The U.S. Centers for Disease Control and Prevention say half the bubonic plague cases in the United States come from the state of New Mexico.
Bubonic plague gets its name from the bubos, or enlarged, infected lymph nodes that characterize its presentation. Terrorist attacks are not likely to be bubonic plague, but pneumonic plague, a respiratory version of the infection. A small percentage of people who have bubonic plague go on to develop pneumonic plague when the bacteria spreads to the lungs through the blood and lymphatic systems, but pneumonic plague can also be caused by inhaling the bacteria that cause plague. This doesn’t happen often in nature (it sometimes happens when people handle infected animals), but it’s the modus operandi of bioweapons. The couple from New Mexico are believed to have bubonic plague, not pneumonic plague. So, breath a sigh of relief. It isn’t a bioterrorist attack. (For everything you need to know, and more, about plague as a bio-weapon, click here.) posted by Sydney on
11/07/2002 09:00:00 AM
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This is Your Brain on Estrogen: Estrogen may decrease the risk of Alzheimer's:
Zandi and his colleagues analyzed medication history and health status for 1,357 men and 1,889 women living in Cache County who were 65 or older. They found women who used hormone replacement therapy had a 41 percent reduction in their risk of getting Alzheimer's compared with HRT nonusers.
Wow. That's impressive. But wait. Here's the real story:
Of the women who didn't use HRT, 7.3 percent were diagnosed with Alzheimer's.
Of those who used HRT, 2.4 percent got the disease, researchers reported, which was close to the men's Alzheimer's finding of 2.6 percent.
Not so impressive anymore, is it? There were also some confounding variables among the study subjects that need to be taken into account. The most important being the age and educational status of the women who used hormone replacement therapy. They were, on average, three years younger than those who didn’t take it, and they were slightly more educated. Age plays a big role, probably the biggest, in developing dementia, so it’s no wonder that the older group of non-hormone therapy users had higher rates of Alzheimer’s. Also, for some reason, the better-educated the patient, the better they do on Alzheimer’s testing. They’re able to cover up/ and or compensate for their losses better than the less-educated.
Estrogen isn’t yet ready to be a miracle brain food. If you’re interested, here’s a link to the raw data and here’s a link to the study. (available wholly intact for free without registration for a change.) posted by Sydney on
11/07/2002 08:14:00 AM
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Asbestos Follow-Up:The Cleveland Plain Dealer wrapped up its series on asbestos yesterday. I have to think that the timing helped elect conservative judges here after reading it all. Monday’s and yesterday’s pieces featured the justified cases and and the unjustified cases. (The series is a very well-done, unbiased piece of work. Read it all. It’s worth it.)
Here's what an asbestos litigator has to say about some of his colleagues:
Asbestos litigation has become a national nightmare as well as a national disgrace," said Steven Kazan, a lawyer representing victims of mesothelioma, a painful cancer caused by asbestos. "This has nothing to do with health anymore and everything to do with lawyers taking advantage of economic opportunity."
Another lawyer, who defends industry against the claims, made this observation about the explosion of suits filed by people without any disease at all against companies whose only involvement was that they later bought a company that once used asbestos:
"In this day and age, the burden of asbestos litigation has nothing to do with culpability," O'Connell said. "You've got people who are not sick suing people who never made the stuff."
Companies settle out of court rather than risk large punative damages. As a result, they often go bankrupt and end up unable to pay just compensation to people who actually deserve it:
As money is used to pay those who are not sick, dying claimants or their widows and children get a fraction of their due. Lynne Marion of Bay Village, for instance, will see no more than $150,000 of a $4.4 million award for the death of her 51-year-old husband, Dennis, a mechanic.
Ohio has one senator who is trying to get things changed:
The system has to change, said Sen. Mike DeWine, an Ohio Republican and a member of the Senate Judiciary Committee, which held hearings in September to consider a legislative solution.
"As things stand now, victims face a growing risk of never being compensated for asbestos-related illness, and many businesses face a growing risk of liquidation," DeWine said.
Twice, the U.S. Supreme Court has called on Congress to deal with the "elephantine mass of asbestos cases," saying a judicial remedy to the never-ending crisis is improbable if not impossible.
Yet the partisan fight seems unlikely to be resolved anytime soon. Democrats support trial lawyers who don't want changes; Republicans back corporate interests who do.
Cancer Vaccine? Researchers think they may have a vaccine against cancer. It works by attacking the healthy cells around the tumor and thus depriving the cancer of it's blood and oxygen. The problem, however, is what happens to the other cells of the body that rely on the same mechanisms to repair injury:
"It must be a concern if you deliver permanent immunity against the production of blood vessels that this will mean the body will not be able to repair itself after an accident, for example," he told BBC News Online.
"Ideally, what you want to do is to prevent the blood vessels from providing nutrients to the tumour in first instance but then for blood vessels to be able to regrow in other instances." posted by Sydney on
11/06/2002 08:23:00 AM
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UPDATE: The Oregonian has an astute observation about the defeat of both universal healthcare coverage and required genetic-engineered food labeling in their state:
Voters soundly rejected Measure 23, which would've raised taxes to guarantee universal health care, and Measure 27, which would've required labeling all genetically engineered food sold or distributed in Oregon. Passage would have given national momentum to these two concepts, but failure means a tough road ahead: If such ideas about health care or the environment can't pass in Oregon, they have a fruit fly's chance of surviving in most other states posted by Sydney on
11/06/2002 08:04:00 AM
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Nature and Nurture: There's a growing acceptance of the idea that both environment and genetics influence the development of our minds. It's a sensible position:
The brain is not primarily the product of genes, they say, but neither is it simply the sum of one's experiences. Rather, they say, each human brain is constructed of complex neural circuits that start taking shape before birth and continue to grow and change throughout life as genes and cells are influenced by environment, experience and culture
"The attempt to separate genes and environment is a mistake," said Dr. Steven R. Quartz, a scientist at the California Institute of Technology. "What makes us who we are is a complex interplay of early experiences, parenting, birth order, friends, genes and how these forces interact."
Requiem: Jonathon Harris, the actor who played Dr. Smith in Lost in Space, has died. He wasn't a formally trained actor, but he was a formally trained pharmacist:
Born Jonathan Charasuchin on Nov. 6, 1914, Harris grew up in the Bronx and graduated from Fordham University with a degree in pharmacology. But the lure of show business proved strong, and Harris joined a Long Island repertory company, where he performed in a number of productions before landing roles on Broadway, including one in 1946 with Paul Muni and Marlon Brando in ``Follow the Flag.''
MD Activism Pays Off: Ohio elected two politically moderate justices (and hopefully pro-tort reform) to the State Supreme Court yesterday, and swept the state with Republican legislators. Now, with luck, tort reform can be pursued successfully. I'm not sure how much of that can be credited to the activism of the state medical societies this election season, but I do know that without their efforts I wouldn't have been sure where a lot of the candidates stood.
In other Ohio news, James Traficant managed to get 15% of the vote while campaigning from his jail cell. People who voted for him were interviewed on the television last night as saying that their vote represented a vote for the working man. God help the working man.
Ohio voters also defeated a measure that would have required courts to send drug offenders to rehab instead of jail. posted by Sydney on
11/06/2002 07:30:00 AM
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Tuesday, November 05, 2002
Another Tale of Government-Run Medicine: Another reader sent in this example of a government-managed healthcare system - The VA:
My personal example of how the US government runs medical care is the VA.
Chicago's west side VA was still running an Allis Chalmers betatron for radiation therapy 20 years after the unit was obsolete. (I didn't believe a neighbor who was treated on the unit when he described the machine he was treated on, but was at the place a year or so later for a meeting, saw the unit, and was told, "Yea, we finally retired that unit early this year.)
I haven't been in a VA hospital in almost fifteen years, so things could have changed, but the one I did some of my clerkships in as a medical student was built right after the Civil War and hadn't changed much in the intervening years. They still had large open wards where twenty to thirty men shared a large room separated only by thin curtains around their beds. (This was in the mid-to late1980's.) They didn't have cardiac step-down units or telemetry floors, and their ICU was very primitive. It was a culture shock to do a rotation at one of the community hospitals and then go to the VA. It was very much as if you had stepped back in time. Things could have changed since then. DB would know. He works at one.
UPDATE: DB posted a reply about the current state of the VA system:
The VA has some major plusses. They have the best computerized medical record, bar none, in the US. It works in a physician friendly way. When I make rounds this weekend, I can review the labs, the pharmacy orders, the notes and even the X-rays from a single computer. I write my notes there, obviating the search for charts.
Our VA has state-of-the-art radiology equipment, but they have difficulty keeping enough technicians to do studies promptly. I believe they tend to understaff the wards, but the ICUs have good staffing ratios. They have improved greatly since my days of training in the 70s. I too trained with open 20 bed wards, today my patients either have private or semiprivate rooms.
He mentions some of the problems, too, but overall, it sounds like it has improved since the 1980's. posted by Sydney on
11/05/2002 01:14:00 PM
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Use With Caution: The FDA has just approved a new device for the sterilization of women. It's an alternative to tubal ligation. Tubal ligation involves going into the abdominal cavity through an incision to cut and mash the tubes that communicate between ovary and uterus, but the new procedure doesn't require surgery:
The device looks like a tiny spring. Doctors use a thin tube to thread one Essure device up the vagina, into the uterus and then into each fallopian tube. Flexible coils temporarily anchor it inside the tube. Dacron-like mesh embedded in those coils -- material widely used in medical procedures -- irritates the tube's lining to cause scar tissue to grow that eventually permanently plugs the tube.
The catch: It takes three months for the scar tissue to grow.
So in approving Essure on Monday, the Food and Drug Administration cautioned that women must use another type of birth control during those three months, then return for testing to ensure the scar tissue has fully blocked her tubes.
That's a crucial check, because not all women can be implanted successfully. In one study, doctors failed to block both tubes fully on the first try in about one of seven women, the FDA said. The test, performed at outpatient radiology clinics, consists of an injection of dye into the uterus followed by an X-ray to be sure the tubes are blocked.
In studies of more than 600 women, followed for a year, there so far have been no pregnancies in those whose Essure devices were implanted successfully.
The FDA did, however, require Essure's maker, Conceptus Inc., to continue studying those women for five years to ensure no long-term problems crop up.
I'd worry about the risk of tubal pregnancy after a procedure like that, too. Scarring isn't as trustworthy for blocking up passages as cutting and destroying is. Also, why go through an uncomfortable procedure twice - the placement of the implants and then the follow-up tests to check out the patency of the tubes - when you can go through a tubal ligation once for the same price? (To check for patency of the fallopian tubes, you generally have to inject die into the uterus and then follow its path up the fallopian tubes with x-rays. I've never had it done, but those who have tell me it's an uncomfortable procedure.) posted by Sydney on
11/05/2002 07:52:00 AM
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Bioterror Update: The White House has released a list of countries who have smallpox stockpiles:
A Bush administration intelligence review has concluded that four nations -- including Iraq and North Korea -- possess covert stocks of the smallpox pathogen, according to two officials who received classified briefings. Records and operations manuals captured this year in Afghanistan and elsewhere, they said, also disclosed that Osama bin Laden devoted money and personnel to pursue smallpox, among other biological weapons.
The other two are Russia and France.
UPDATE: The Bloviator has more on this. He's upset that the government didn't share this information with the CDC's advisory committee on smallpox vaccination this past summer. The knowledge just might have swayed their decision. Maybe the feds didn't trust the advisory panel with the information. Judging by some of the public comments that came out from the advisory panel members last summer, they seemed rather partisan. (Sorry, I would dig out the link but I've got to get back to the office.) The one piece I'm thinking of is a Washington Post op-ed by one of the panel members which accused the administration of using the smallpox issue for political purposes. It was hardly the voice of impartial science. As it is, the information we have now was "leaked." Maybe it was done this way to light a fire under public health officials when it became obvious just how laggardly they've been at preparing for biodefense.
UPDATE on the UPDATE: Here's the item I was thinking of. It's by Ruth Katz, associate dean of Yale School of Medicine and member of the CDC advisory panel. Here’s her take on the Adminstration’s attempt to get the ball rolling sooner rather than later:
"The Bush administration is now pushing hard on the smallpox vaccine, and it may well have valid reasons for doing so. But public health, not politics or public relations, needs to be the driver here. If the administration is only seeking to show that it is "tough on smallpox" and prepared for anything in the struggle against terrorism, health experts, elected officials and the American public should protest the hijacking of a carefully formulated policymaking process. Planning for a smallpox epidemic is not an event being staged for television."
While I was looking for that, I also came across two other pieces from last summer that are also pertinent. The first was one about political tensions between the CDC and the White House:
The tensions stem from a variety of factors, including fallout from widespread criticism of how federal health officials handled last fall's anthrax attacks, the absence of a CDC director since March, efforts by the new administration to change approaches to controversial issues such as sex education and HIV prevention, and a campaign to exert more control over the CDC from Washington, health experts said.
...Other factors have also contributed to the tension between the CDC and HHS, sources said. D.A. Henderson, who joined the department last November as head of HHS's new Office of Public Health Preparedness and is currently Thompson's principal science adviser for public health preparedness, once worked at the CDC but reportedly feuded with the agency on various occasions later in his career.
..Moreover, since the resignation of Jeffrey P. Koplan as CDC director in March, the agency has been run by a four-person interim team, leaving employees uncertain who will be the CDC's next leader. "If they appoint someone as the next head who is clearly a political hack, people will leave in droves," a former federal health official predicted.
The Administration can be forgiven if they felt less than trusting of the public health officials they had to work with last summer. There was obviously quite a bit of political animosity present there.
The second piece was from the early July issue of Businessweek, and it proves that the recent “leak” isn’t new news. I can’t link to it, but here’s the post:
"The risk of a terrorist attack can't be quantified. But homeland security experts note ominously that both Iraq and North Korea vaccinate at least some of their military, suggesting that they may have stockpiles of smallpox. And Russians once produced tons of highly weaponized forms of the virus, some of which may now be in terrorists' hands.".
But It's Natural: Apparently there's a trend among the teen-age set to try to get high with morning glory and moonflower seeds. The active chemical in the plants is similar to LSD, and in fact was used by the Aztecs as a hallucinogen centuries ago. Like most chemicals taken in their natural state, however, they're even more toxic than the manufactured LSD, as these kids have found out. posted by Sydney on
11/05/2002 07:31:00 AM
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News From a Single-Payer System: Doctors in England are set to walk. They can't come to an agreement with the government about their new NHS contracts. The health secretary is in a snit and refuses to negotiate with them anymore. The doctors are shocked at this behavior:
"I am very surprised that a senior politician is behaving quite so immaturely.
The Scoop on Zetia: Derek Lowe has all the dope on the new cholesterol-lowering drug, Zetia. He makes a valid point about that "cholesterolcentrism" we're suffering from these days. We're really not sure at all what good it does in the long run. posted by Sydney on
11/05/2002 07:20:00 AM
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Celebrity Medical Watch: The Osbournes are finally sick of all the attention they've brought on themselves and their family, especially since they have other issues to deal with:
"We agreed to do the show and so the cameras are here all the time," she said. "So it's a little bit invasive right now and we have no privacy. You know when you're sick, you want to be on your own? I can't throw up on my own and Ozzy can't get drunk on his own." posted by Sydney on
11/05/2002 07:20:00 AM
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Bird in Hand: A reader with relatives in Oregon had this to say about the state healthcare initiative on the ballot today:
My sister's place of employment told them that due to the increases in medical insurance premiums they couldn't afford a raise this year for the employees. However, if the Health Initiative passed then they would get a raise. And she bought into this! She's voting "yes" on the measure without thinking about how her state income tax will go through the roof wiping out any raise she might. I guess doubling the state budget (that currently has a deficit) didn't cause her to ask where the money would come from. My mother informed me after reading up on the ballot measure that it establishes a committee of 10 people that are allowed to raise the taxes without any other approval. I can't imagine this would go over well in Oregon since almost every single tax increase is decided by the voters.
Herta Flor, a German neuropsychologist, reported that when unpleasant electrical stimulation was applied to the backs of chronic back-pain patients, their brain activity associated with pain was almost three-times greater when their spouses were in the room.
The effect was not seen when the stimulus was applied to a finger rather than the back, or when the spouse was the type who distracts from the pain rather than focusing attention on it.
The explanation, Flor said, is ''a simple learning mechanism: If a behavior is followed by a positive consequence, the behavior will increase.''
The study was small, but experience bears it out. This behavior has a name in medical circles - "secondary gain," and it's another reason that the assessment and treatment of pain with a numerical "pain scale" is so inadequate. posted by Sydney on
11/05/2002 07:17:00 AM
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Uncertain Principles: The law is a sort of hocus-pocus science, that smiles in yer face while it picks yer pocket; and the glorious uncertainty of it is of mair use to the professors than the justice of it. -Charles Macklin, Love a la Mode, 1759.
The Cleveland Plain Dealer is running a series this week on asbestos. RangelMD has written eloquently about this before, but this series has a slightly different angle, so I’m going to add my two cents worth. Sunday's story was about a young man who was diagnosed with mesolthelioma at the age of fifteen. His family is suing the company his father once worked for, arguing that his father brought home the asbestos fibers from work that caused the boy's cancer.
There are several problems with that argument. First and foremost is that his father doesn't have any evidence of damage from asbestos exposure. Presumably, his exposure would have been much higher. Then, there's the fact that not every mesothelioma is caused by asbestos.
Mesothelioma is a cancer that grows from the cells that form the lining of the body cavities - the chest, abdomen and pelvis. The cells also cover the outside of the organs that are contained in those cavities - the lungs, the heart, the gut, the ovaries, the bladder, and the uterus. Something goes wrong in the cells making up this lining, it only takes one cell, and suddenly, there’s a cancer. Thirty percent of mesotheliomas occur in people with no exposure to asbestos. Radiation exposure, for example, can play a role. There is, in fact, a whole host of other possible causes:
Other factors that may promote DMPM (diffuse malignant pleural mesothelioma - ed.) include chronic lung infections, tuberculous pleuritis, radiation, and some mineral fibers. The simian virus 40 (SV40) has been implicated as a potential etiologic factor after sequences corresponding to its T antigens were isolated from human samples of diffuse malignant mesothelioma but not from adjacent normal lung. Furthermore, tumors histologically identical to malignant mesothelioma have developed when SV40 DNA material is injected into the pleural cavities of hamsters..
In fact, mesothelioma in children, which is what this story is all about, is not believed to be caused by asbestos at all.
Of course, none of this has stopped the lawyers. Do a Google search on “mesothelioma etiology” and you get an equal mix of medical and legal sites. It’s a boondoggle for the lawyers, but a travesty for businesses, most of whom were unaware of the health risks of asbestos when they used it:
More than 200,000 asbestos lawsuits jam dockets coast-to-coast and name 6,000 defendants. In Cuyahoga County, 34,000 claims monopolize the time of two judges brought out of retirement. Because of the glut of asbestos lawsuits - many filed by people who were exposed to asbestos but are not yet ill - some of the sickest victims will die before their cases are resolved.
The burden of paying asbestos claims has sucked billions from thousands of otherwise-healthy companies, pushing 62 into bankruptcy - more than 20 since Jan. 1, 2000.
I’ve written before about the patients I have who have been told by lawyers that they have evidence of asbestos exposure on x-rays - a claim that I usually can’t corroborate with independent films. The lawyers who are doing this are the very same ones responsible for the state of affairs in Cuyahoga county. Clearly, this is wrong. Now you know why Ohio so badly needs tort reform. posted by Sydney on
11/04/2002 08:25:00 AM
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Oregon Redux: Oregon's assisted suicide law is facing another legal challenge from John Ashcroft. Barbara Coombs Lee, executive director of the Compassion in Dying Federation questions his motives:
Lee accused Attorney General John Ashcroft of pursuing a "personal vendetta" against assisted suicide, based more on political and moral objections than legal principles.
Pardon me, but isn’t the law a codification of our moral principles? If we didn’t care about morality, we wouldn’t have laws. It’s immoral to steal, to murder, to act so selfishly that we put others in danger, and to insure that these immoral acts are kept to a minimum, we have laws.
The Compassion in Dying Federation has grown from an Oregon-focused group to a national advocacy group for the right of patients to kill themselves. Some suspect that their ultimate goal is to promote active euthanasia, once they’ve achieved general acceptance for the passive type, which is what “assisted suicide” amounts to. (Oregon voters should take note. A state that’s willing to allow euthanasia probably isn’t the best to ask to assume full financial responsibility for everyone’s healthcare.) They're the organization responsible for suing a doctor for elderly abuse because he wasn't able to adequately control a patient's pain without killing him. For the low-down on the goals and financing of this and other right-to-die organizations, click here.
posted by Sydney on
11/04/2002 08:24:00 AM
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Nicotine Lozenges: A pharmacist sent this email about the nicotine lozenge post from last week:
First, nicotine gum relies on buccal absorption of nicotine and the labeling of Nicorette instructs the user to chew until there is a peppery taste or slight tingling and then ""'park' the gum between the cheek and gum, and leave it there." Perhaps the gum is not releasing nicotine while it is parked, but it is in close contact with tissue.
Second, nicotine lozenges and "minitabs" (sublingual) are sold in the UK.
Thirdly and most important, my understanding was that nicotine itself is not carcinogenic. I did a little Web checking and found the following sentence at [this link]:
"Nicotine and cotinine are not cancer-causing agents, however."
The URL is for a press release from the University of Minnesota Cancer Center. Researchers at that center and I believe others have found that metabolites of nicotine can be carcinogenic. This certainly complicates things. However, the metabolism is in the liver and presumably would not have local effects in the mouth.
It’s true that nicotine gum releases nicotine in the mouth, too, but it only releases it when chewed. It’s also fairly bad tasting and causes an unpleasant tingling in the mouth, so people aren’t likely to chew it again and again as a substitute for smoking like they would normal chewing gum, or as they would for lozenges. Nicotine doesn’t have to be processed by the liver to cause cancer, not withstanding the claims of the Unviersity of Minnesota. There’s a significant increase in oral cancer rates among people who chew tobacco, for example. Finally, just because something is available in the UK doesn’t make it inherently good. They’re very loose and free with a lot of unregulated herbal substances, for example. Not to mention their attitude toward caesarean sections. posted by Sydney on
11/04/2002 08:17:00 AM
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We, The Underserved:Charles Murtaugh comments on the vibrator controversy at Cornell University's student health center. (Although it's probably not truly a controversy at Cornell.) He's exactly right that vibrators were invented by male physicians in an attempt to cure "hysteria." The gold standard of treatment was to induce an orgasm in the patient to release all of their sexual tensions. Oh, the irony.
He also points out a fact that escaped me when I first read about this. The doctor involved is a part of the Women’s Health Initiative, the research project at the NIH that’s responsible for the recent hormone replacement therapy storm of controversy. (They were a little hysterical themselves in their reaction to the small risk of heart disease and strokes in women taking estrogen. We’ll be living with the results of their hysteria for a long time to come.) She indulges in a little more hysteria when she calls women’s health “historically underserved.” This is a myth that deserves to be put to rest. With the exception of certain fundamentalist regimes who regard women as little more than chattle, women’s health has never been underserved. Textbooks of obstetrics were some of the first ever written. Some of the earliest medicines were designed with the intent to relieve menstrual ills, and to prevent conception. Doctors took specialized training in obstetrics and gynecology long before they did in urology. And today, the federal government spends far more to research women-specific diseases than they do to research male-specific diseases. They also spend more in outreach and education for women on health issues. We are and ever have been far from neglected. posted by Sydney on
11/04/2002 07:58:00 AM
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Among the lots on sale in New Bond Street was a woollen "stocking purse" still stained with Nelson's blood. A couple of years ago, at a Charles Dickens sale, Sotheby's sold the detachable collar the Great Inimitable was wearing when he died of apoplexy, still visibly discoloured with his last drops of sweat. Whoever bought those interestingly soiled articles has the DNA from which, a hundred years hence, the BBC will be able to clone two of its Great Britons. Happy thought.
Let's hope nobody takes that sort of thing seriously. Considering how difficult it would be to duplicate the 18th and 19th century living conditions and attitudes that shaped them into the men they became, there’s no reason to expect their clones to be anything near what the real men were. posted by Sydney on
11/04/2002 07:55:00 AM
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Voting Right: For the first time in my memory, at least in my state, physicians are getting out the vote to elect judges with moderate backgrounds. I have on my desk a mailing from one of my regional state medical societies that details the backgrounds of each candidate, judicial and nonjudicial, and the answers they gave to a questionairre on healthcare issues (they didn't send it to the candidates for judge.) It's the first time I've ever received anything like that. Usually the profession holds itself as "above the fray" when it comes to politics, but we're finally waking up to the importance of politics in life.
For an example of what we’re up against, just follow the money in the Ohio Supreme Court race. Two of the candidiates, Burnside and Black, have gotten significant chunks of change from law firms. Not many doctor’s practices could afford to funnel $5,500 into candidate’s purses the way legal firms can. In fact, neither individual doctors nor medical societies turn up as contributors to their opponents campaigns, Maureen O'Connor and Evelyn Stratton (although insurance companies certainly do.) posted by Sydney on
11/03/2002 11:44:00 AM
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Mad Doctor Alert: One California doctor's madness - and badness is detailed in The New York Times. This is truly a strange and bizarre story, something you'd expect to see in a supermarket tabloid. The doctor killed himself (or so they say) after someone tried to kill his business partner. But that's not the worst of it:
Buried next to his swimming pool they found canisters containing machine guns and C-4 plastic explosives. In refrigerators at his home and office, next to the salad dressing and employee lunches, were 266 bottles and vials of pathogens — among them salmonella, cholera, botulism and typhoid. The deadly poison ricin was stored, with a blowgun and darts, in a plastic bag in the family room. A compartment under the floorboards held medical files on 83 women.
He apparently had links to South Africa's biological weapons program and US militia groups. It's frightening to think of how many others like him might be out there. posted by Sydney on
11/03/2002 11:13:00 AM
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Litttle Lambs: Research has found that giving a hormone called prolactin to baby lambs helps them survive being born on a cold spring day. The same hormone may prove helpful in premature human babies, who have trouble generating enough heat to tolerate the world outside the womb. posted by Sydney on
11/03/2002 11:07:00 AM
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