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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Saturday, November 16, 2002

    Bias Watch: Reuters appears to have taken editorial control of The Lancet. In an editorial from this week’s issue, entitled (apparently without irony) “Keeping Scientific Advice Non-Partisan”, the editors of the respected medical journal say that “the Republicans seized control in the Senate and the House of Representatives,” then goes on to make dubious, and in some cases, inflammatory, assertions about bias in government funded health matters. All of the assertions are based on complaints by those who have their own sets of biases:

    On Oct 25 this year, ten academics wrote an editorial in Science bemoaning Tommy Thompson's, Secretary of Health and Human Services, "prerogative to hear preferentially from experts who share the president's philosophical sensibilities". The editorial describes how 15 of the 18 members of the Advisory Committee to the Director of the National Center for Environmental Health have been replaced, many with scientists with links to the chemical or petroleum industries, and that the Department of Health and Human Services' Advisory Committee on Childhood Lead Poisoning Prevention has been stacked with industry-affiliated scientists.

    Well, I suppose it’s only human nature to notice other people’s faults before recognizing your own. The phrase “ten academics” should have alerted the Lancet’s editors to the potential for bias right away. The academics are complaining that people who hold opposing views to theirs are being appointed to advisory committees. Goodness. As Henry Miller ( a former FDA official) pointed out a few weeks ago, biased members of scientific advisory committees are nothing new. Here’s a list of the people responsible for a recent National Academy of Sciences sponsored EPA advisory committee on biotechnology:

    The members of the committee and the invited reviewers for the EPA report were selected with disregard for apparent conflicts of interest and known bias. Three members of the twelve-person committee (Stanley Abramson, Fred Betz and Morris Levin) are former EPA staff who had helped to craft and defend a variety of process-based regulatory policies at the agency, and another (Rebecca Goldburg) has produced a succession of anti-biotechnology tracts over the past decade and half. Moreover, during the formal review process, the document was reviewed by another former senior EPA official (Lynn Goldman) who had been instrumental in crafting and defending the policy in question, and by an intractable anti-biotechnology activist (Jane Rissler). Three members of the USDA committee (its chairman, Fred Gould, and David Andow and Norman Ellstrand) ) are long-time skeptics about the safety of recombinant plants and have consistently advocated process-based regulation, and another (Ignacio Chapela) is the author of a discredited article on alleged contamination of indigenous gene-spliced varieties of corn in Mexico by gene-spliced varieties. Even the staff director of the Academy's Board on Life Sciences, Frances Sharples, is a long-time anti-biotech activist.

    This weblog has also detailed the biases of other supposedly “dispassionate scientists” within the public health community and the Institute of Medicine.

    The Lancet goes on to lambast Congressional conservatives for removing a web page at the National Cancer Institute that addressed the issue of whether or not there's a link between abortion and breast cancer:

    The political right's attempts to influence expert opinion does not stop at filling scientific advisory panels. In June this year, the prestigious National Cancer Institute removed a factsheet--Abortion and possible risk for breast cancer--from its website while it is reviewed. This factsheet, which discussed the risk of breast cancer after an abortion, was removed after some members of Congress questioned its validity.

    Now, this is an interesting issue, and in truth it probably reflects political biases on both sides. To tell you the truth, I wasn’t aware of the controversy swirling around breast cancer and abortion until I did a google search on it today. Evidently, there has been some research that suggests that having an abortion slightly increases the risk of breast cancer, and there have been other studies that show that it doesn’t. The only people who seem to be concerned about the implications of the studies are the pro-choice groups and the pro-life groups. Believe me, it isn't one of the burning issues for those of who actually practice medicine. I doubt that most doctors include it in their discussions with patients who are considering abortion ( I know I don’t.) So why would the NCI even have had a web page about the supposed abortion-cancer link? Probably because someone with a political agenda encouraged them to. Someone who attributed more weight to the matter than it deserved. Just as surely, the Congressional request to remove the web page was instigated by political activists against abortion. And now in the third round, we have Congressmen from the other side of the aisle joining the fray at the instigation of the pro-abortion activists. This game could go on and on forever. But of course, the Lancet editors only see political motivation on one side.

    They then turn their attention to Dr. David Hager, the controversial nominee for a position within the FDA:

    W David Hager is a nominee to chair the FDA's Reproductive Health Drugs Advisory Committee, the committee which, 2 years ago, approved the use of mifepristone as an abortifacient. Hager helped the Christian Medical Association last year to lobby for a safety review of mifepristone. But Hager's track record (at least in PubMed) as a researcher is sparse. His abilities as a doctor--voted "best doctor for women" by Good Housekeeping magazine--are lauded by his supporters, but his critics cite his religious views as a stumbling block to his nomination. The publisher's blurb on his book As Jesus cared for women describes biblical healings related to Hager's case studies and concludes that "Jesus longs to bring the same wholeness to today's women". This is not to decry faith in medicine: the perfect role model is C Everett Koop, US Surgeon General 1981-89, a devout Christian, and who maintained credibility by remaining impartial, especially in sensitive areas such as women's health and AIDS.

    This reads like a synopsis of the Maureen Dowd column on Dr. Hager. The Lancet sneers at his publication record, but it’s very difficult to search PubMed by author. A search for papers by “Hager, WD” does turn up several papers by the man, as well as those by a few other Hager, WD’s. In fact, he’s just as qualified as any other ob/gyn to be on an FDA advisory board. And, although the editors say that they don’t mean to “decry faith in medicine,” that’s exactly what their objection to Dr. Hager amounts to. If he were an Episcopalian rather than an evangelical, no one would be uncomfortable with him.

    Then, the (presumably) British editors deliver their final thrust. They tell us just exactly how we should be manning our government advisory committees:

    The current US Administration is certainly pro-industry, pro-family, and on the religious right. Any threat to impartial science-policy advice, especially advice that affects health and health-care choices, will harm most those whose voices are unheeded by the right-wing--the poor, minorities, those without health insurance, those living in the shadow of polluting industries, those at risk of sexually transmitted infection (especially young people), young people who need realistic contraceptive advice, single mothers, and intravenous drug users.

    Translation: These committees should be filled with people of the same ideological bent as the writer of this editorial, that is left. Only a biased mind would indulge in such stereotypical labels and use them to smear those with whom they disagree. Sadly, it appears that the same sort of fevered lunacy that has infected a significant portion of the Democratic faithful has also infected the editorial staff of the Lancet. And that, dear readers, should give us all pause. For if you can’t count on a scientific journal to be unbiased, who can you count on?

    posted by Sydney on 11/16/2002 01:50:00 PM 0 comments

    We Prepare: We might be getting a little closer to voluntary vaccinations for everyone everyone:

    President Bush is moving toward approval of separate plans to inoculate civilians and the military against smallpox, a disease eradicated decades ago but feared as an agent of bioterrorism, administration officials say.

    Mr. Bush was said to be closer to a decision on the military.

    At the same time, officials said the president was comfortable with proposals to eventually offer the smallpox vaccine to all Americans, beginning with health care workers most likely to come into contact with a contagious patient. He has not, however, signed off on key details or a final plan.

    Mr. Bush's top bioterrorism aides agree the vaccine should eventually be offered to the general public. At issue is how fast to move ahead.

    The decision about military vaccinations has been made (they’re going to get them.) and it looks as if steps are being taken to make it possible for civilians to elect to have it, too. Once the legal liability issues are taken care of, then the overall plan for smallpox defense can begin:

    Federal health officials have recommended that prior to any attack the United States slowly phase in smallpox vaccinations, beginning with about 500,000 military and 500,000 civilian health care workers who are considered to be at greatest risk of encountering the virus. After that, they suggest offering vaccine to as many as 10 million first responders and then the entire population some time in 2004.
    posted by Sydney on 11/16/2002 08:03:00 AM 0 comments

    Britain Prepares: British officials surveyed their hospitals and found them wanting in terms of bioterror preparedness, so the government is launching a public defense education offensive:

    Britain will start an education campaign using posters, mock-emergency drills and other devices to advise the public about how to respond to a biological or chemical attack, the government's chief medical officer said today.

    A report by the National Audit Office published on Thursday found that many of Britain's state-run hospitals and ambulance services do not have adequate plans or sufficient equipment in place to deal with an assault involving chemical, nuclear, biological or radiological weapons, or one with casualties of 500 people or more.

    I never thought I would say this, but at least in this respect there’s an advantage to a government-run health system. There’s someone in charge to force them to take the bioterrorism threat seriously.
    posted by Sydney on 11/16/2002 07:44:00 AM 0 comments

    Medical Activistism: Blogcritics had this item about pressure by the AMA and WHO to get movies that “glamorize” smoking rated R. Put aside for the moment, the thorny issue of what defines “glamorization.” Put aside the implications for freedom of expression and character development. Consider, instead, some of their other demands:

    Encourage R ratings for films that show smoking unless they also show the consequences.

    Stop identifying tobacco brands in all images.

    Run anti-tobacco ads before films that contain any tobacco presence, regardless of rating.

    Certify in on-screen credits that nobody on a production accepted anything of value from a tobacco company or its agents.

    Note to film production companies: Tell the AMA you’ll gladly do the last one when they do the same with JAMA and pharmaceutical companies.
    posted by Sydney on 11/16/2002 07:38:00 AM 0 comments

    Friday, November 15, 2002

    Celebrity Medical Watch: Winona Ryder's post-traumatic hippy disorder.

    posted by Sydney on 11/15/2002 08:46:00 AM 0 comments

    Smallpox Debate Continues: Not surprisingly, a mathematical model of smallpox spread finds that pre-attack vaccination would slow the spread of the disease:

    It found that if 80 percent of the people in close contact with a smallpox case were inoculated in a community that had no pre-existing immunity then there would be a death rate of about 19.6 per 1,000. With some pre-existing immunity, however, the death rate per 1,000 would drop to about 1.8 per 1,000.

    The argument within the article seems to be between mass post-attack vaccination and targeted post-attack vaccination, but the study clearly shows that there's a benefit to pre-attack vaccination. Relying only on post-attack vaccination, whether targeted or massive, is the worst choice. It would be almost impossible to locate and vaccinate everyone who came in contact with a smallpox case, and it's logistically impossible to vaccinate everyone in a community after an attack. I'd say this study stands as another argument in favor of voluntary pre-attack vaccination.
    posted by Sydney on 11/15/2002 08:34:00 AM 0 comments

    Wrong Turn: Al Gore says our healthcare system is in a crisis, and the solution is government-funded universal healthcare. I guess he didn't notice how the voters of Oregon responded to that idea.
    posted by Sydney on 11/15/2002 08:19:00 AM 0 comments

    Blowing Smoke: Peggy Noonan takes on the tobacco puritans today. Now, I believe that smoking is bad for you. I encourage my patients to quit and counsel teenagers to never start, but there's rude and bullying about the way we publicly treat smokers. As Noonan notes, there's no reason we should force them to stand outside in the cold:

    But you definitely wouldn't be harmed if the handful of smokers in your office were allowed to smoke only in a common room with good ventilation. Why wouldn't that be a civilized and acceptable compromise?

    A smoking room in public places and office buildings would definitely be a better alternative to having people clumped around the entrances to public places puffing away. It would be less annoying to non-smokers who have to walk through the smoke cloud to enter the building, and it would be more comfortable for the smokers.

    She's right, too, about liberals being the least tolerant when it comes to the foibles of smokers. I once belonged to a group practice in which one of the physicians, a vocal liberal, proposed we dismiss all of our HMO patients who failed to quit smoking. They were too much of a financial risk for the practice, she argued. The proposal was voted down, but the few who supported it were of the most liberal bent.
    posted by Sydney on 11/15/2002 08:11:00 AM 0 comments

    Alternative Parents: An Ohio family has found itself in court to defend their right to limit their child's healthcare to alternative medicine. According to the story, this is where the child, who has leukemia, currently stands:

    In June, Noah began the traditional treatment, which included a blood transfusion and drugs. He went into remission within 14 days. Later, his parents turned to holistic treatment -- addressing the body and mind -- through a medical doctor practicing in Lancaster.

    It's not clear why his pediatric oncologist took the step of reporting the parents to social services. If the child's in remission, then their choice to use alternative medicine, although probably misguided, isn't necessarily harmful. It's always better to work with a patient's belief system, even if it runs counter to the best medicine, than to be confrontational about it. If the child were acutely ill with leukemia, and his parents were denying him life-saving treatment, that would be a different matter.
    posted by Sydney on 11/15/2002 08:03:00 AM 0 comments

    Kidney Economics, Continued: Yesterday's letters page of the New York Times continued the kidney market debate, with some interesting suggestions:

    The fairest way to carry out an incentive plan for organ donation is through the tax code. A cadaver donation should result in suspension of the estate tax and the final year of income tax. A live donation should be rewarded by a lifetime income tax exemption.

    If the concept of paying for organs meets too much resistance, why not simply level out the pool? Those who commit to being an organ donor when the time comes will get first priority if they find themselves in need of a transplant

    I don't know about the donor pool, but the income tax suggestion isn't a bad idea.
    posted by Sydney on 11/15/2002 07:54:00 AM 0 comments

    Thursday, November 14, 2002

    Vaccination Promo: An ad promoting vaccination programs, circa 1941. (Note the inclusion of smallpox in the list of vaccine - preventable diseases.)

    posted by Sydney on 11/14/2002 08:04:00 AM 0 comments

    Inflammatory Screening: The C-reactive protein, the inflammation marker that seems destined to replace cholesterol as the most-hyped risk factor for heart disease, is in the news again:

    The latest research is likely to encourage many doctors to make blood tests for inflammation part of standard physical exams for middle-aged people, especially those with other conditions that increase their risk of heart trouble.

    The study, based on nearly 28,000 women, is by far the largest to look at inflammation's role, and it shows that those with high levels are twice as likely as those with high cholesterol to die from heart attacks and strokes.

    But what does “twice as likely” mean, exactly? Do ten percent of people with high cholesterol die of heart attacks and stroke? Do twenty percent? Five percent? Two percent? What percentage with high C-reactive protein die of heart attack and strokes? Five? Ten? One? Only the authors know. They haven’t shared that information with CNN, and they haven’t revealed it in their paper, either. They mention in the abstract, and in the paper that “77 percent of all events occurred among women with LDL [bad cholesterol - ed.] cholesterol levels below 160 mg per deciliter (4.14 mmol per liter), and 46 percent occurred among those with LDL cholesterol levels below 130 mg per deciliter,” but that isn’t at all the same as telling us what percentage of people with those cholesterol levels had “events.”

    The paper itself only portrays the results in terms of “relative risks” and “predicted events,” a statistical technique that inflates the signficance of findings. It never once gives absolute numbers. This is particularly maddening since it was sponsored by a grant from the NIH and since it’s being used to promote the widespread use of the test for screening purposes. As the CNN article points out, some doctors are already treating patients with expensive cholesterol-lowering drugs (the statins) on the basis of their C-reactive proteins, a move which would only further inflate overall medical costs in return for uncertain benefits.

    The main author of the paper, Dr. Paul Ridker, has a patent on the process of testing for C-reactive protein - a test that can cost anywhere from $25 to $50. Clearly, it’s to his advantage to give the data the most positive spin possible. The editors of the New England Journal of Medicine, however, owe their readers more. They should require that papers like this include the raw data so the results can be given the scrutiny they deserve, and they should be holding their authors to a higher standard of integrity.
    posted by Sydney on 11/14/2002 07:49:00 AM 0 comments

    Crystal Protein: There might be a protein marker that can predict the aggressiveness of breast cancer:

    The research team found that none of the patients with a low level of cyclin E had died from the disease. It was also noted that the proportion of tumours with high levels of cyclin E increased with the growing severity of the disease.

    Unlike the C-reactive protein study, this one doesn’t shy away from the numbers:

    Among 114 patients with stage I breast cancer, none of the 102 patients with low levels of cyclin E in the tumor had died of breast cancer by five years after diagnosis, whereas all 12 patients with a high level of low-molecular-weight cyclin E had died of breast cancer within that period.

    The authors also have a patent on testing for the protein, but they’ve been much more honest in portraying their results than Dr. Ridker was. Admittedly, the results were in their favor, but they were also careful to temper their enthusiasm in their conclusions. They point out that the data is based on a small sample, and they caution that more work has to be done before it can be applied to larger populations. Proof that you can hold patents on your research topics and still maintain your integrity.
    posted by Sydney on 11/14/2002 07:45:00 AM 0 comments

    Med Mal Update: At a conference on the medical liability crisis in Pennsylvania, one trial lawyer had this to say:

    Initially, admitted trial lawyer Kenneth Rothweiler, he did not think doctors were leaving Pennsylvania.However, his opinion has changed in the last year as he has seen physician friends move out of state.

    "It's not a doctor problem. It's not a lawyer problem," he noted. "It's all of our problem."

    It certainly is.
    posted by Sydney on 11/14/2002 07:31:00 AM 0 comments

    Trauma Drama: The Best of the Web had a link yesterday to a Boston Globe story about an attempt to create a new classification of post-traumatic stress disorder - post traumatic slavery disorder. Here's a description of the index case:

    Sekou Mims's son was 16 when he experienced a sudden psychotic breakdown. Over three months, the black teenager had a series of delusions - that white police were following him, that white strangers on a train were staring at him menacingly. He'd hyperventilate walking down the street. All his delusions revolved around racism.

    Mr. Mims is a social worker, and he’s convinced that his son’s fixation with racism stems from slavery, even though his son was never a slave. I had a similar sort of disorder when I was a young girl growing up not very far from a small liberal college town in Ohio, but my disorder involved a morbid fear of hippies. I was never harmed by a hippy, nor did I ever personally meet a hippy. But, in 1968, I was six years old, and I heard my parents and my grandparents talk repeatedly about “those damned hippies” and their drug use and the danger they posed to society, and I watched hippies riot on television. They scared me witless. I would duck and cover in the back seat of the car if I saw a long-haired, poorly-washed person on the street. I would cling closely to my mother and beg to go home if we encountered a sixties-era bohemian in the grocery store. I never reached the extremes of the young Mims, but I definitely had a hippy phobia. Clearly, the source of my fear was the anti-hippy sentiments of all those around me. Something similar is most likely the source of Mims’ disorder, especially when you consider his father’s bio:

    Mims, 46, grew up in poverty in Boston and spent a number of his adolescent years in reform school for petty crimes and assaults. Later, he joined the Nation of Islam and worked in human services for the court system and a halfway house, before earning a master's degree in social work.

    How much of the racist ideology of the Nation of Islam do you suppose the younger Mims was fed as a youngster? Probably a lot. Social worker, heal thyself.

    UPDATE: A reader sent along another example of social worker myopia.
    posted by Sydney on 11/14/2002 07:26:00 AM 0 comments

    Be Prepared: Glenn Reynolds has an excellent column at Tech Central Station on civil defense, including this observation:

    In addition, people trained in first aid (especially the specific skills likely to be useful in the aftermath of a terrorist attack), in recognizing the signs of chemical or biological attack, and in various other disaster-recovery skills could contribute a lot. Even in the case of such relatively "mundane" events as truck-bombings and shooting sprees, individuals on the scene will have to wait crucial minutes before aid even begins to arrive.

    Why is it that we aren't doing this? In World War II, the civil defense program was a community-based program that worked. We could, and should, do something along the same lines now.
    posted by Sydney on 11/14/2002 07:13:00 AM 0 comments

    Wednesday, November 13, 2002

    JAMA's weekly art history lesson.

    posted by Sydney on 11/13/2002 09:07:00 AM 0 comments

    Home Shock Therapy: For $2300 and a doctor's prescription you can now get a home cardiac defibrillator. If they're anything like the ones used in malls and other public places, they'll be easy to use with the most minimal of training. (You just turn them on and a computer-generated voice tells you what to do from there, step by step.) Although, there is some controversy regarding their effectiveness.
    posted by Sydney on 11/13/2002 09:02:00 AM 0 comments

    Menopausal Motherhood: A paper today in JAMA says that menopausal motherhood is medically safe, at least for the hand-picked heatlhy few. The study only followed seventy-seven women in their fifties and sixties who had gone through rigorous medical screening before undergoing in vitro fertilization. They had to rely on younger women’s eggs, and they had higher rates of C-sections, diabetes, and hypertension, but their wombs were able to carry babies to full term. It shouldn’t be assumed, however, that menopausal pregnancy is a cakewalk:

    ``They took the purest of the pure,'' Stewart said, referring to the women studied. ``One of the problems we have, we take these very selective groups and say, `This applies to everybody.'

    ``Eventually what's going to happen in my office is the diabetic smoker who's overweight and has high blood pressure is going to want to do this.''

    And eventually they’ll expect the rest of us to pay for it, too. Can it be very long before someone expects Medicare to cover their IVF procedures and pregnancy care?

    Then there’s a word to the wise from someone who’s experiencing late motherhood herself:

    But Stark County mother Cheryl Clifford said those contemplating later-life birth through in vitro fertilization need to seriously consider issues that can arise.

    Clifford, of Jackson Township, knows the subject well: Seven years ago, at age 48, she gave birth to Heidi, Paul, Robert and Ruth.

    ``I almost feel like I was so far at the end of the stretch for doing (in vitro),'' she said. ``I can't imagine starting that process now. Of course, if I had only ended up with one child, my perspective might be different.''

    Personally, I can’t imagine choosing to go through the trials of pregnancy and child rearing in the twilight years, but that’s my own personal bias. I do worry, though, that women succumb to a romantacized ideal of motherhood when they choose to have babies on their own or late in life. The reality is much messier and tougher than images of women cuddling their infants would have you think. Children are a lot of work and you can’t evade the effects of aging on endurance, even in the healthiest people. The comparison is always made in these cases to men who have babies late in life without raising any eyebrows, but more often than not, those men have young wives who take up the slack. How many of these post-menopausal women have young husbands to do the same?
    posted by Sydney on 11/13/2002 08:10:00 AM 0 comments

    Starry Night: A pretty picture of the ion channels in muscle cells.
    posted by Sydney on 11/13/2002 07:01:00 AM 0 comments

    Kidney Counterpoint: A reader points out:

    The moral argument against paying for kidneys is compelling--and we should be grateful that no profession makes all the rules (attorneys come too close for my comfort). But--yes,the interminable "but"--several years ago there was an article in the NY Times Sunday Magazine (I think) discussing this issue--An Israeli physician simply pointed out that in a transplant every one except the patient benefits financially--the surgeon, the hospital, the surgical team, the patient, the manufacturers etc.--No one, including myself,seriously suggests they should donate their time. An argument can be made that the donor plays a significantly different role in this transaction than does the professionals--however, equally persuasive is the fact in pure economic terms unbalanced transactions of this nature are not likely to be self generating and enduring--or--supply will not meet demand--I am sure there are examples of transactions similar to that articulated for transplants that are successful and enduring but I am hard pressed to identify them--I am not offering a solution and for that I apologize--however--In my own mind I think it is inappropriate to preclude a serious discussion of the economic exchanges in transplants.

    I can think of one system that comes pretty close to exemplifying a transaction in which people willingly and literally give of themselves to help others - the blood donation system. The same system also exemplifies the down side of paying people to donate parts of their bodies. You can give blood for either altruistic motives or financial motives in this country. People who donate their blood through the Red Cross do so altruisitically, although admittedly at less personal cost than an organ donation. You can go to almost any community and find people at schools, churches, and civic halls willingly giving up their time and their blood just to help others. However, the centers that buy blood are usually found in or near the poorest neighborhoods and are frequented by people who are desperate for cash. They usually sell their blood as a last ditch effort to get some money, often to feed a drug or alcohol habit. Desperate people make hasty decisions. A system of organs for cash would result in those who can least afford it sacrificing their health for those who may not be all that deserving. Does someone over sixty-five with hypertension really need a kidney transplant to live another five to ten years? Should they get that transplant to the detriment of some cash-strapped younger person? For, as the survey from India showed, the donor usually ends up with the shorter end of the stick in the transaction, both financially and medically.
    posted by Sydney on 11/13/2002 06:58:00 AM 0 comments

    Tuesday, November 12, 2002

    Kidneys for Sale: Nicholas Kristof is sitting in for Paul Krugman today at the New York Times and the topic is kidney economics. Here's one economist's take on renal failure, dialysis, and transplants:

    "We're losing 6,000 lives a year, more than twice the number killed in the 9/11 attacks," notes Professor Kaserman. "And if we were paying for the organs, federal expenditures would go down. So we're actually spending money to kill people."

    Well, people don't just get transplants and walk away healthy and happy ever after. They have to take medication that has its own set of complications, and they are always at risk for transplant rejection. It's hardly a panacea. Especially when you consider that a lot of the original kidneys had to be replaced because of systemic disease that's still present - high blood pressure and diabetes for example. This means that the new kidneys are at risk for the same damage that the old ones sustained. Their medical bills don't disappear after the transplant, and neither does their risk of death. Dialysis isn't "killing people", their diseases are. Dialysis only delays the inevitable; as does, in many cases these days, renal transplant.

    Over 50% of people on dialysis are over the age of 65. Their kidney disease is due to chronic illness. To encourage young, healthy people to sell their kidneys to the old and diseased is morally bankrupt. It subjects healthy people to the hazards of surgery merely for the hope of economic gain. It doesn't even confer any economic advantage, according to a recent paper in JAMA that surveyed kidney for cash donors in India:

    Ninety-six percent of participants sold their kidneys to pay off debts. The average amount received was $1070. Most of the money received was spent on debts, food, and clothing. Average family income declined by one third after nephrectomy (P<.001), and the number of participants living below the poverty line increased. Three fourths of participants were still in debt at the time of the survey. About 86% of participants reported a deterioration in their health status after nephrectomy. Seventy-nine percent would not recommend that others sell a kidney.

    Which is why we should thank God that economists don't run the world.


    posted by Sydney on 11/12/2002 08:01:00 AM 0 comments

    On a Wing and a Prayer: In the Ukraine (and other parts of the former Soviet Union) not only do patients have to pay for their care, they have to provide the supplies:

    The Rev. William M. Lyons was moved to action when he saw a newborn child with excess fluid on the brain, lying helplessly in a hospital in Mukacheve, Ukraine.

    During a conversation with the child's doctor, Lyons discovered that a shunt needed to drain the fluid was not readily available. Such a shunt is standard equipment in American hospitals.

    ``I was told that the family had to supply the shunt and that in most cases, the family is given a list of equipment that they need to provide before surgery can be performed,'' said Lyons, pastoral associate at First Grace United Church of Christ in Akron. ``This is in a place where the unemployment rate is 80 percent, and I can't use the words to describe what kind of medical resources are not available.''

    Sometimes we forget how good we have it.
    posted by Sydney on 11/12/2002 07:43:00 AM 0 comments

    Other Sperm News: Men in Boone County, Missouri have lower sperm counts than men in New York, LA, and Minnesota:

    Fertile men from mid-Missouri's Boone County were found to have a mean sperm count of about 59 million per milliliter, compared to 103 million for men in New York, 99 million in Minnesota and 81 million in Los Angeles. The sperm of the Boone County men also tended to be less vigorous, the study found.

    Why could this be? The people doing the study think they know the answer:

    Dr. Shanna Swan of the University of Missouri-Columbia, the lead researcher, said she and her collaborators believe that environmental factors such as the use of agricultural chemicals might contribute to the differences.

    CNN says that the paper is available on-line at the Environmental Health Perspectives website, but as I type this, it isn't. But, an association isn't proof of a connection. While it's true that farmers and people in rural counties are probably exposed to more fertilizer and pesticides than urban dwellers, it doesn't follow that they're responsible for any differences between the two populations. The difference in sperm count could just as easily be due to ethnicity, but without the paper itself to examine, it's impossible to say. Too bad CNN didn't provide the details.
    posted by Sydney on 11/12/2002 06:40:00 AM 0 comments

    Fertile Field: A new at-home fertility test for men is gearing up to a marketing campaign. The test isn't all that reliable, though:

    The whole thing (the chemistry, that is) takes about 30 minutes. Tests offered as part of the FDA approval process showed the FertilMARQ test matching professional test results 87 percent of the time, with home testers getting the same results as pros 141 out of 158 times when the FertilMARQ results were positive and 27 out of 36 times for negatives, according to Lake Consumer Products.

    It only measures, in a rough way, the quantity, not the quality of sperm, which is just as important when it comes to assessing infertility. It also costs forty dollars, which is the same price you pay to have a lab or physician's office count the sperm under the microscope. (Although sometimes the professional test can cost more if they do more testing on the specimen, such as pH and motility.) Of course, an over-the-counter test has the added advantage of privacy . But professional testing can also use samples that have been collected at home. Providing a specimen doesn't necessarily mean performing in a cold, sterile, exam room. In the long run, it's probably not going to prove that useful. Unless it's used this way:

    Stillman agrees that the product's biggest market will be women, but has a different take on how they'll put it to use. "I can see a lot of women using it surreptitiously" to check their partners' sperm concentration, Stillman says. "Kind of like a pre-nup," he adds.

    This prospect appears to dumbfound Dorman. "I never heard that," he says. "I don't know how to respond." After a moment, though, he adds, "If a woman's going to do that, you might want to think twice about marrying her."

    posted by Sydney on 11/12/2002 06:35:00 AM 0 comments

    Cheers: Two weeks ago the Washington Post ran an article about consumer-driven health care that made it seem much more expensive than it was. I had planned to do a check on their facts, but never found the time. Now I don't have to. They have very graciously, and very prominently, displayed a correction on their website. Looks like there is hope for big media.
    posted by Sydney on 11/12/2002 06:22:00 AM 0 comments

    Monday, November 11, 2002

    Alzheimer's News: A Republican effort to rename the disease.

    posted by Sydney on 11/11/2002 08:20:00 AM 0 comments

    Smallpox Vaccine Trials: So far, at least one smallpox vaccine trial, in Tennessee, has had no adverse effects:

    Approximately 150 Middle Tennesseans ages 18 to 32 have been inoculated with varying amounts of long-frozen Aventis Pasteur smallpox vaccine. The aim is to find out whether the vaccine is effective in full, 20%-strength and 10%-strength dosages, and whether the people to whose shoulders it is applied can be contagious to friends and family.

    So far, so good.

    ''With the volunteers, we haven't had any cases of spread to household contacts, spouses and so on,'' infectious diseases researcher Tom Talbot reported last week. ''That's because we are preaching meticulous hand hygiene.''

    The vaccinees have done well, too. And we still haven't had any stories of vaccine disasters from Israel where they've been vaccinating healthcare workers for months.
    posted by Sydney on 11/11/2002 08:15:00 AM 0 comments

    Tales from the North: Canadian senior citizens are up in arms in British Columbia because the government has to change their prescription plan from universal coverage for all to a means-tested one. The proposal seems modest, but it's needed if the program is to survive at all:

    However, the provincial government says that income testing is the only fair way to ensure the survival of Pharmacare, B.C.'s prescription-drug program.

    British Columbians can expect the government to draw its income-testing line somewhere between 2 and 4 per cent of annual income, Mr. Hansen, the Health Minister, said last summer.

    Currently, seniors pay a $250 deductible for prescription drugs and Pharmacare covers the rest. With income testing, Pharmacare will pay for drugs after the income test amount is covered by the user.

    Our Congressional leaders should take note as they prepare to consider a prescription drug benefit here. Providing coverage without means-testing will be a financial disaster, and it will be all the harder to change course once it's enacted.
    posted by Sydney on 11/11/2002 08:10:00 AM 0 comments

    Don't Bet on It: Motherhood may make women smarter. Well, it might make rats smarter, but my (personal) experience has been more kids = more work = sleep deprivation = stupid mom.
    posted by Sydney on 11/11/2002 08:04:00 AM 0 comments

    Frozen Demon: The New York Times Book Review had an excellent review of The Demon in the Freezer', the third in Richard Preston's "Dark Biology" trilogy. The first was the non-fiction Hot Zone about Ebola virus, and the second was a novel, The Cobra Event about manufactured infectious agents. This one is, unfortunately, nonfiction, and it's about the smallpox threat. The closing statement from both the review and the book is especially poignant, and true:

    ''All I knew was that the dream of total Eradication had failed. . . . We could eradicate smallpox from nature, but we could not uproot the virus from the human heart.''
    posted by Sydney on 11/11/2002 07:55:00 AM 0 comments

    Hormone Hysteria Update: The media can't get enough of the hormone replacement story. The New York Times gave front page treatment to it yesterday. One aspect that's relatively new and deserves comment is the idea that when stopped, hormone therapy should be "weaned off" to prevent hot flashes:

    Still other doctors are devising their own methods of weaning women from the drugs - suggesting they wear estrogen patches and gradually trim them down to nothing, or increase the interval between pills. In this, however, they are acting on their own. There are no practice guidelines, no rigorous studies on what works best.

    That's right, there are no guidelines, but there is a long history of women stopping estrogen in the past. We don’t need guidelines for everything. There's no reason to think that weaning gradually off of estrogen would prevent hot flashes. Women who are prone to hot flashes have them no matter how they stop them. And the bottom line of hormone replacement therapy is that it remains the individual's choice.
    posted by Sydney on 11/11/2002 07:53:00 AM 0 comments

    Love's Liability: Here's a woman who's the embodiment the stereotypical doctor's spouse - the person who marries a doctor with unrealistic financial expectations, and ends up living beyond their means. This woman takes it the nth degree :

    On Saturday, Dr Jones was cleared by the GMC of the main charge of failing to protect his patients' best interests. The professional misconduct committee decided he had taken all reasonable measures to keep records away from his current wife, who approached her husband's patients for loans of up to £10,000 after obtaining their details from her husband's consulting rooms at the Thames Valley Nuffield Hospital in Slough, Berkshire.

    The GMC heard that to satisfy her taste for expensive clothes, jewellery and make-up Sofi Jones, 38, allegedly approached four of his patients and asked for money, claiming her husband was "too proud" to ask them himself.
    posted by Sydney on 11/11/2002 07:52:00 AM 0 comments

    Genetic Revolution Update: Yet another gene story in the news. This one, the discovery of a gene responsible for cell death. Turns out that cancer cells have a defective gene that allows them to grow unchecked:

    Some of the body's genes apparently exist only to trigger cells to commit "suicide" - for instance when they appear to be about to turn cancerous - to keep the body's tissues in a constantly shifting equilibrium. But cells that do become cancerous either lack or ignore those genes. They keep dividing long past their intended lifespan and often beyond the point where they cause damage to the surrounding body.

    Ken Parkinson, who led the team at the Beatson centre, said that it had pinpointed one of the genes on a tiny section of chromosome four, which is just four genes long.

    And, thanks to the Human Genome Project, here's a map of chromosome 4.
    posted by Sydney on 11/11/2002 07:23:00 AM 0 comments

    Terrorism Gene: German scientists kept the brain of a long dead urban terrorist to look for a terrorism gene:

    German scientists secretly removed the brain of one of Europe's most infamous terrorists to look for a "terrorism gene".

    The brain of urban guerilla Ulrike Meinhof, who committed suicide in jail, has been found in a jar at a German university after years of investigation by her daughter, Bettina Rohl.

    They didn't find a gene for terrorism, but they did find she had a brain tumor whose removal caused her personality to change radically. The greater question, though, is why the Germans felt they had the right to take anyone's brain, even if they were a dead criminal. Haven't they learned anything about medical ethics since 1945?
    posted by Sydney on 11/11/2002 07:20:00 AM 0 comments

    Sunday, November 10, 2002

    Case Study in Preparedness: In May, two doctors in Cleveland had a patient that had all the classic symptoms of smallpox. What happened is a case study in how badly our public health system is prepared to handle this. The state health department was no help. It took twenty-four hours to get blood and skin samples tested, and they had to be flown to the CDC in Atlanta to do it. In the meantime, the patient had to be quarantined in the hospital, putting patients and staff at risk of exposure. Not only that, but during his illness, he had been to two emergency rooms and one health clinic, potentially exposing many more people to the infection. It wasn't smallpox, of course, but if it had been, there certainly would have been a public health disaster. The case highlights just how difficult a "ring vaccination" defense would be. How on earth could you gather up everyone who had been in all the places the patient had for vaccinations? It's a persuasive argument for voluntary pre-attack vaccinations. And it's proof of how inadequately prepared the state of Ohio's public health system is for an event.


    posted by Sydney on 11/10/2002 03:49:00 PM 0 comments

    One Lump or Two? A new study claims that drinking coffee boosts sugar metabolism, thereby decreasing the risk of diabetes. The benefit, however, requires pretty hefty doses of coffee:

    Individuals who drank seven or more cups of coffee a day, were 50 percent less likely to develop the disease. Fewer cups a day had less of an impact.

    People who drink seven or more cups of coffee a day are also more likely to have ulcers and palpitations, so I wouldn't go hog wild on the espresso yet. The original paper can be found here (requires free registration.)
    posted by Sydney on 11/10/2002 09:23:00 AM 0 comments

    Smoking Genes: Researchers may have identified a gene that plays a role in nicotine addiction. A defect in the gene translates into a faulty system for getting rid of nicotine. People with the defective gene have a harder time giving up cigarettes:

    During the study, Lerman's team worked with 426 white smokers who were trying to kick the habit. All participants smoked at least 10 cigarettes per day. They received either bupropion (Zyban)--an antidepressant known to help smokers quit--or an inactive drug for 10 weeks, and also participated in seven sessions of group therapy. All were told they had to quit smoking 2 weeks after starting medication.

    The investigators also took blood samples from the smokers and noted which type of the gene known as CYP2B6 they carried. CYP2B6 encodes an enzyme that research suggests plays a role in the metabolism of nicotine in the brain.

    Lerman and her colleagues found that people who carried a form of CYP2B6 that produces an enzyme with decreased activity reported a larger increase in their cravings of cigarettes after their quit-date than did those with the more common form of the gene. Carriers of the less active form of CYP2B6 were also 50% more likely to start smoking again during the treatment. About 25% of the population carry this form of the gene.

    The researchers also discovered that among women who carried the less active form of CYP2B6, 54% of those who took bupropion had continued to resist cigarettes by the end of the study, an achievement noted in only 19% of those who received the inactive drug. The findings will be published in the upcoming issue of Pharmacogenetics.

    This doesn't negate the role of the will in smoking cessation, however. (The article doesn't say what percentage of people with the defective gene successfully quit compared to those with the normal gene. It only comments on the effect of bupropion on their efforts.) The symptom reported by carriers of the defective gene was craving, and cravings can be safely ignored. It may make it harder to quit, but it certainly doesn't make it impossible.
    posted by Sydney on 11/10/2002 09:17:00 AM 0 comments

    Celebrity Medical Watch: Pop groups have been enlisted in an anti-smoking campaign directed toward European teenagers. The intention is to counter tobacco company ads that are targeted to the same audience. That's an admirable goal, but the EU's health commissioner thinks tobacco is more powerful than it is:

    "Tobacco multinationals are targeting our kids," Byrne told reporters. "It is well known that eight out of ten people who smoke start when they are between 12 and 18 years old. Once they are hooked on nicotine, these people no longer have a choice."

    It's true that nicotine is addicting, and that for some people it's hard to quit. But withdrawing from tobacco isn't a fatal proposition. All you have to do is stop buying the cigarettes. Choice is always a part of the equation.
    posted by Sydney on 11/10/2002 08:55:00 AM 0 comments

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