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

    ''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.''
    -Robert Ehrlich, drug advertising executive.

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    Saturday, December 14, 2002

    Smallpox Reasoning: The Administration reveals its calculations behind the smallpox vaccine recommendations:

    "We live in a new world," said Jerome M. Hauer, assistant secretary for emergency preparedness at the Department of Health and Human Services.

    In an interview, Mr. Hauer said Mr. Bush's decision was rooted in a calculus that looked at the smallpox threat over the long term — not just weeks or months but years and decades.

    The risks accumulate over a long time, Mr. Hauer said, and that drives officials to take prudent steps now to prepare for the worst. Medical experts estimate that the vaccine could give vaccinated individuals some protection against the disease for decades.

    By vaccinating millions of Americans, Mr. Hauer said, "you're testing your logistics, developing trained cadres, and protecting medical response teams. So in the event of an incident, you don't have to be concerned about vaccinating those groups." He added that vaccination could then begin of people who had come in contact with infected people "and, if necessary, mass vaccination."

    ...Dr. Alan P. Zelicoff, a physician and smallpox expert at the Sandia National Laboratories, said in an interview that the administration was engaged in no bluff or bluster, but had carefully weighed the long-term risks of a smallpox attack.

    "I think the administration has got it just about exactly right," he said of offering the vaccine to 10 million people. "The question is not what is the risk of attack in the next six months or year, but what is the risk over the effective lifetime of the vaccine, which is measured in decades."

    .."You have to understand the long-term benefits, which are enormous," Dr. Zelicoff said. "Thinkers in the administration are planning to make that argument publicly, and I believe the public will accept it once they see that the initial cadre of vaccinated people does all right."

    Sounds sensible. For all the news on the smallpox vaccine plans, visit The Bloviator.

    UPDATE: Here's what the Administration faces within the public health community as it tries to implement its plan:

    In a poll taken in June, 91 percent of members of the Association of State and Territorial Health Officials opposed any policy that would allow the general public to get vaccinated against smallpox before an attack.

    Why? Partly because of fear of risks, a reasonable objection. But vaccinating first the military, then healthcare workers, then the public allows those risks to be tested and measured. The Administration has acted wisely in deciding to offer the vaccine in increments.

    It's also partly a fear that side effects from smallpox vaccine will smear other vaccines. Here, the Administration has also acted wisely. They're doing everything they can to publicize the very real risks of the vaccine, (See all of The Bloviator's collection from yesterday.) and they aren't requiring, not even suggesting that everyone get it, unless they're a member of the armed forces. They're only allowing it to be available. In the other immunizations, the ones that people blame for autism and other ills, people aren't given a choice. They're told explicitly that these immunizations are safe, and they're told that their children must have them if they are to attend school. There's a world of difference in the two approaches. When people are told to they have to do something, they're naturally more distrustful and more likely to cast blame than if they're given a free choice in the matter. Look at the case of "alternative medicine" versus "traditional medicine." Much of what passes as alternative medicine is expensive and not effective, yet you don't hear about people suing its practitioners or supplement manufacturers the same way you hear about people suing their doctors or pharmaceutical firms. That's because most people use the alternative medicine with the full knowledge that its untested and unproven and risky. And their decision to use them is their own, not the suggestion of someone else in a position of authority.

    The other reason for the public health community's reluctance to offer the vaccine to the public is more disturbing, and more difficult to change. It's their ideology:

    It's the only human disease to have been eradicated -- a feat that many epidemiologists feel has never been fully appreciated by the public.

    To reverse that achievement through the intentional release of smallpox virus would be "a crime against humanity of unimagined proportions," says Georges C. Benjamin, executive director of the American Public Health Association and former head of the Maryland health department. Bringing back vaccination makes such an event thinkable -- and that's something many people have a very, very hard time accepting.

    That belief, that all men are inherently good, is a distinctly liberal ideal. It's that belief that prompts many to feel passionately that war is never acceptable and that fosters moral relativism. It's also extremely unrealistic. Hate is a powerful passion, it can blind and warp even the best of us if allowed to go unchecked. (Even those of us with liberal ideals.) Unfortunately, there are people out there for whom hate is the primary motivator, and there is a large segment of them who are organized and united and more than willing to act. Make no mistake, they would have no qualms about committing "a crime against humanity of unimagined proportions." Even if it would harm their own humanity.

    posted by Sydney on 12/14/2002 08:41:00 AM 0 comments

    Friday, December 13, 2002

    Diminishing Returns: A market analysis firm says that drug companies are making less per advertising dollar:

    In 2001, the top drug companies generated $17 in sales from each dollar spent on marketing, down from $22.20 for each $1 spent in 1998, the report said.

    Attracted by the lack of drug price controls and of marketing limitations in the United States, the pharmaceutical companies spend most of their promotional dollars in American markets. They spend 12 times as much to promote their prescription products in the United States than in Europe's largest medicine market, Germany, Datamonitor said.

    But to continue to finance the large increases in promotional expenses, some companies will be forced to decrease spending in areas like research aimed at finding new drugs, the report said.

    But the companies are loathe to give up old habits:

    Mariann Caprino, a spokeswoman for Pfizer, said that the analysis appeared "overly simplistic" and that Pfizer considered its promotional spending a "valuable investment."

    "We take our responsibility of educating physicians and patients seriously," she said.

    Do you suppose they really believe their mission is “education”?

    Datamonitor recommended that the drug companies reduce their promotional spending or find ways to make it more effective. But drug executives told the consultants that they planned to continue their rapid increases in promotional spending, saying they must keep up with competitors. "We are like a school of fish and no one is brave enough to go the other way," a pharmaceutical executive told the analysts as they researched their report, which was published last month.

    posted by Sydney on 12/13/2002 06:47:00 AM 0 comments

    Chickenpox Vaccine Update: There’s some evidence that the chickenpox vaccine isn’t as effective as we’ve assumed:

    Seven earlier studies found the vaccine protected at least 71 percent of the children who got shots from developing the disease and kept the disease minor in nearly all of those infected by the virus.

    But the latest study tracked by far the worst performance of a vaccine that has cut the number of U.S. chickenpox cases by 80 percent since it was introduced in 1995.

    The outbreak was at a day care center near Concord, N.H. A boy who had been vaccinated three years earlier came down with the virus Dec. 1, 2000. By Jan. 11, 2001, it had spread to 24 other children--including 17 who also had been vaccinated.

    It’s only one incident, in one community, in one daycare center, but it does make you wonder how well those vaccines will protect those kids when they become young adults - an age in which chickenpox infection is much more dangerous. (The original report is here.)
    posted by Sydney on 12/13/2002 06:40:00 AM 0 comments

    Liver, Liver on the Wall: Using livers to predict the future. (Thanks to Cronaca.)
    posted by Sydney on 12/13/2002 06:22:00 AM 0 comments

    The White Plague: Ancient tuberculosis in Britain.
    posted by Sydney on 12/13/2002 06:20:00 AM 0 comments

    Art History Lessons: Out of Lascaux has some beautiful examples of "candle painting," including a painting of St. Irene tending the battered body of St. Sebastian.
    posted by Sydney on 12/13/2002 06:19:00 AM 0 comments

    Of Drugs and Man: A pulmonologist sent along this explanation of why albuterol isn't an over the counter medication:

    About albuterol -- please, please don't make it available over the counter. Why? It will worsen asthma care substantially. According to published data, only about 30% of patients with persistent asthma take a controller medication (inhaled corticosteroid or leukotriene
    modifier, from the Asthma in America study, and also from the NHLBI National Asthma Education Program, see also Milgrom, J Allergy Clin Immunol, 1996). Many of the patients not on controllers over-use albuterol, with the result of unabated, persistent airway inflammation. This leads to continued poor control of asthma over time. That in turn increases substantially the risk of death (Suissa, NEJM, 343:332, 2000), decreases future responsiveness to controller therapy (Haahtela, NEJM, 331:700, 1994), and increases the risk of being hospitalized for asthma (Donahue, JAMA, 227:887, 1997).

    One of my colleagues... has examined public-aid health data in Chicago to look at albuterol over-use. He's examined public aid pharmacy claims databases for albuterol and controller prescriptions by zip code in Chicago. If you're properly treated, you should have (on average) one controller prescription per month, and at most, one albuterol prescription. If the albuterol:controller ratio is higher than that, it suggests that asthmatics in that zip code aren't properly controlled and are over-relying on rescue inhalers. In about 3/4 of the zip code regions, the albuterol:controller ratio exceeds 4. In none of the zip codes is the ratio less than 2. Either 1) asthmatics are using their inhaled steroid but still taking about 16 puffs of albuterol a day, or 2) you have a large number of asthmatics who are taking albuterol but no controller. Since the proportion of patients with intermittent asthma (no need for controllers) is only about 20% of all asthmatics, this suggests that we're doing a poor job of treating the persistent asthmatics.
    [ed. note - Controller medications are medicine like steroid inhalers or Singulair that prevent asthma attacks, or at least reduce their frequency.]

    The reasons why asthmatics are over-relying on rescue inhalers are many, from family and social disintegration, lack of access to medical care, apathy and acquiescence of chronic illness on the part of patients, poorly educated primary care providers (sorry, I'm a pulmonologist and I see this every day), insurance policies that force changes in medication based on preferred pricing for them which leads to confusion on the part of patients, and so on.

    If you make albuterol over the counter, the temptation is for an asthmatic to just buy it and skip seeing the doctor. That's the point of over-the-counter claritin, after all -- just take it and don't bug the doctor with your hay fever. In this way asthma remains poorly controlled, and we docs never see them to address it. Asthma control in the community is poor enough as it is, and I'm afraid this would just make it worse.

    For the record, I don't think albuterol should be over the counter, either, for the same reasons the author lists. My point was that it makes no sense for high dose hormone pills to be made available over the counter when other drugs, with less side effects, aren't. Holding the high dose hormones in emergency contraception kits to different standards than other drugs makes no sense medically. It only makes sense politically.
    posted by Sydney on 12/13/2002 06:07:00 AM 0 comments

    Thursday, December 12, 2002

    A Flower of our Public Health System: Got another hate mail today, this one by someone who attaches the initials MD, MPH, and MBA after his name. In response to this post:

    Emergency contraceptive kits, which are high-dose estrogen, are much riskier than asthma inhalers. If public safety and health were the real issue, they wouldn't be available over the counter. But the real issue isn't health and safety, it's politics.

    I received this:

    I am very surprised to learn that emergency contraceptive kits are high dose estogen, since the ECP [emergency contraception- ed. note]with the best record is levonorgestrel 0.75 mg X 2 (recently, ONE dose of levonorgestrel 1.5 is just as effective - Lancet 2002;360:1803-1810).

    I suspect you have never ordered emergency contraception or you would know better. If you have never ordered ECP, you MUST be a Roman Catholic who believes his Priest ahead of ACOG
    [American College of Obestetrics and Gyenocology - ed. note]. Yes, you are right, it IS politics. You and the other Right to Life people, who believe its OK to shoot an "abortion doctor" because of all the babies you will save. One death permits so many others to have life. Yes, a political shooting -- nothing personal, Doc.

    Whoa. I’m very surprised that someone whose on-line resume identifies him as an assistant professor of obstetrics and gynecology, and as a public health official, doesn’t realize that levonorgestrel (a progesterone) isn’t the only emergency contraceptive kit available in the United States. Maybe he never had to prescribe one. We also have Preven which consists of four tablets of 50 micrograms of ethinyl estradiol combined with 0.25 of levonorgestrel. The ethinyl estradiol is estrogen, and those doses are high. The dosage of progesterone in the progestin-only emergency contraception kits is also high. And they, too have a higher incidence of side effects than regular oral contraceptives, although they are better tolerated than the estrogen-containing emergency contraception.

    Now, to the truly objectionable part of the email. I have to say, this is about the most odious and bigotted barb that anyone has ever hurled at me. Perhaps I’m fortunate. I grew up white and Protestant in a white and Protestant town. I also happen to be a Roman Catholic - a Roman Catholic convert. And since I write this under a pseudonym, I’ll also honestly admit that I have prescribed emergency contraception - after a rape. I did it when two other doctors, not Catholic, refused to prescribe it because they had strong feelings about life beginning at conception. I did not do it lightly, and in fact, felt troubled enough by it to confess it to my priest. He didn’t think I had sinned. You see, Mr. MD, MPH, MBA, in real life people don’t fall into the narrow, stereotypes that exist in your imagination.

    How anyone could interpret my post about emergency contraception, or anything else I’ve ever written on this blog, as an endorsement of murder is beyond belief. I’m tempted to make a generalization about those in public health, but that would be stereotyping. Instead, I will just say that I have no confidence in this particular writer’s ability to evaluate without prejudice the merits of over the counter contraception, or anything else that doesn't agree with his particular ideology.

    posted by Sydney on 12/12/2002 07:40:00 PM 0 comments

    Cook County Closing: The hospital that was the model for the television show, ER, is closing its doors, but not shutting down. They're getting a new building because the old one was so badly worn out:

    With its intermittently operating elevators, funky smells, shortage of bathrooms, lack of sunlight, vast distances between wards and other nuisances, the building was declared too decrepit for modern surgery by the American College of Surgeons in the 1930s.

    Soglin said many doctors who come from developing countries say they like the hospital because it reminds them of home. "Being compared to the hospitals of the Third World is not exactly our goal," he said.

    Sounds like the new building is long overdue.
    posted by Sydney on 12/12/2002 08:44:00 AM 0 comments

    Health Insurance Reform: A couple of reader thoughts on health care insurance reform. First, a historical perspective on our current system:

    My understanding is that the rise of employer sponsorship of health insurance was largely an end run around wage price freeze laws. That is, health insurance was offered as an employment incentive by larger corporations in lieu of wages or other incentives.

    Foolish laws often lead to foolish, irrational behavior and often dangerous, unforeseen consequences. Poorly thought out tax and business laws have led to similar consequences. One reason some companies have over-used options grants has been to sidestep the cap on executive salaries. So, something once transparent to investors becomes opaque and easily abused. Laws curtailing the efforts of corporate raiders have led to mergers where the only clear beneficiaries are the newly gilded executives of the acquired firm. At least the raiders acted as sieves separating the chaff from the wheat in the aquired firm.

    And a plan to fix “the mess”:

    I have a simple plan to fix the health insurance system. First, get rid of all corporate and government health insurance. Secondly, all insurance providers would be required to provide insurance to everyone at the same price.

    The first step would bring the consumer back into the equation. I have worked for large employers all my life. My choices are limited, and my visibility into the true cost is almost nil. If I were responsible for the cost, I would select the appropriate insurance AND the appropriate medical care.

    The second step would once again create a pooled risk. That has disappeared in the current insurance climate. I have a daughter that was born with a congenital nephrotic syndrome. She required dialysis from 1 1/2 months until her kidney transplant at 1 1/2 years. I have looked at private insurance. She is un-insurable given our current system. I have to stay continually employed with large employers until she is 21. Or go bankrupt. Pool the risk - isn't that what insurance was for. Then everyone could be covered.

    Government's function should simply be to assist low income people to purchase insurance. Not to provide insurance. And maybe that shouldn't be government's function at all. Maybe charitable organization could provide that function. The incredibly reduced tax burden would surely make more monies available for charity.

    At least if I were king for a day, that's what I would do.
    posted by Sydney on 12/12/2002 08:19:00 AM 0 comments

    Medical Tour of the Blogs: Jane Galt noticed something I overlooked in The New York Times article on contraception yesterday. In some states emergency contraception is available over the counter. She points out that this makes no sense when drugs like albuterol require a prescription. I have to agree. Emergency contraceptive kits, which are high-dose estrogen, are much riskier than asthma inhalers. If public safety and health were the real issue, they wouldn't be available over the counter. But the real issue isn't health and safety, it's politics.

    Glenn Reynolds reports that his state is getting ready for smallpox, and so is Oklahoma. (Meanwhile, my state still isn’t reaching out to practicing physicians.)

    RangelMD has an excellent rant on jackpot justice juries. If you haven’t heard, in a move worthy of Monty Python, two jurors from Mississippi are suing 60 Minutes for insulting them. Not them personally, just juries from Jackson County, Mississippi, the national center of jackpot justice. Does it get any better than that?

    Medrants has a post on pharmaceutical company influence in physicians' prescribing habits, especially among teaching programs. There really is no such thing as a free lunch. He also points out in the next post, that his hospital’s electronic entry for drug orders hasn’t eliminated errors, something I’ve always suspected. It seems to me that data entry errors would be harder to catch than hand-written errors. Hand-written orders have to be read by two or three people to fulfill them, and if an error is made, it’s more likely to be caught in one of those readings.

    Ross at The Bloviator has the latest update on the Israeli smallpox vaccination experience.
    posted by Sydney on 12/12/2002 07:58:00 AM 0 comments

    Peeling Away the Fig Leaf: Well, I finally got around to reading the The V Book: A Doctor's Guide to Complete Vulvovaginal Health. If you remember, I was taken to task, and rightly so, for criticizing it without reading it a couple of months ago. I have to confess, I was wrong to characterize it as an effort to gain attention by being titillating, a la the Vagina Monologues. In fact, it’s a very well-done book on a subject that’s in much need of attention. And I don’t just mean that from a public health perspective, but from a physician education perspective.

    The truth is, the nether regions of our bodies are too often slighted by everyone, patient and doctor alike. Sure, there are gynecologists and urologists who are supposed to take care of those parts, but their knowledge tends to be concentrated on the inner workings of the reproductive system. Develop a skin problem “down there” and you are often hard-pressed to find anyone who’s comfortable handling it. A dermatologist will squirm and say he’s not comfortable performing a biopsy of the labia or the penis. But the gynecologist or urologist may just as likely squirm and say he’s not comfortable diagnosing rashes. The external genitalia are the red-headed stepchildren of medicine.

    The V-Book is an attempt to correct that. Written by Dr. Elizabeth Stewart, a specialist in vulvovaginal medicine, it’s a comprehensive guide to the anatomy and the disease of female external genitalia. Very well written, I suspect due to the efforts of co-author Paula Spencer, and well-organized, the book lays out the ground work for understanding diseases of the external genitalia by first ably introducing their normal anatomy and development. Interspersed throughout are little interesting sidebars to keep things from getting too dull - a timeline of vulvovaginal art, menstrual period facts, and descriptions of conditions in sufferers' own words.

    Most important, the book provides good, sound advice on various vulvovaginal conditions, both common and uncommon. It was refreshing to read Dr. Stewart drive home again and again that all that itches is not yeast, and that telephone consultation alone is inadequate to diagnose vulvovaginal problems. (The same is true for most health problems, actually.) She provides very good and understandable explanations of the meaning of pap smear results, of the natural history of herpes, and of skin conditions that often plague that area of the body, making sex painful and difficult. The chapters on vulvodynia, or as the author(s) call it, “depressed vagina” are excellent, and I would highly recommend them to anyone who has been diagnosed with this difficult problem. In fact, I recently recommended the book to a patient of mine who had been given a diagnosis of lichen sclerosis by her gynecologist but was having trouble understanding exactly what it was or what it meant for her future health. Come to think of it, it’s a book that a lot of doctors would benefit from reading. I know this doctor did.

    Having said all of that, I do have two quibbles with the book. Both are small. The first is a medical issue, and that is the recurring advice in the section on yeast infections to use cornstarch instead of talc or baby powder to keep the area dry. Cornstarch should not be used on skin rashes, especially in moist dark areas like the groin. It’s a starch, and the fungi that cause yeast infections can feed on it and make the skin version of a yeast infection (jock itch) worse.

    The other is a philosophical complaint. It in no way detracts from the book's value as a reference on vulvovaginal complaints. That is this - the author(s) have a bad case of penis envy. The book is peppered throughout with envious references to men, as in “I feel pretty sure that a man would not allow some important part of his terrain to go uncharted for so long,” or this quote from a patient with a precancerous lesion, ”But by not understanding all my body parts, I really lost it for a little while. I bet a guy would never do that.” But men have and do. They are just as ignorant of and just as frightened by diseases of their genitalia as women. Perhaps even more so because they don’t have articles in popular magazines or books like The V-Book to help explain things to them.

    At least one doctor has attempted to address this issue in men. The result is Under the Fig Leaf: A Comprehensive Guide to the Care and Maintenance of the Penis, Prostate, and Related Organs, by Angelo S. Paulo, a Florida urologist. Like The V-Book it’s a comprehensive catalogue of the ills that can befall the male genitalia. (The prostate’s included, too, even though it’s internal. No urologist could pass up the chance to write about their most beloved organ.) Unfortunately, unlike Dr. Stewart, Dr. Paulo didn’t have the help of a professional writer, and it shows. The book lacks the polish and the organization of The V-Book, although the medical knowledge it contains is just as comprehensive, and just as sound. It reads, unfortunately, like a medical textbook, with frequent references to “the patient,” and frequent lapses into medical lingo. Because there are no chapters on the normal anatomy and development of male genitalia, it’s often difficult to understand the doctor’s explanations - unless you have a background in medicine or are exceptionally well-read in matters genital. He does provide a helpful glossary, but it’s a bit of a pain to keep going back and forth from text to glossary.

    The book is also hampered by its illustrations. Dr. Paulo’s book was put out by a small publishing company, Health Information Press, and as a result, the illustrations are very basic and schematic. The V-Book, on the other hand, has very well-done pen and ink drawings as well as an occasional photograph to illustrate its points. But then, The V-Book was put out by a major publishing house.

    Here’s an idea. Maybe Paula Spencer could collaborate with Dr. Paulo and bring Under the Fig Leaf up to the caliber of The V-Book. Then we could see some equality of the sexes.

    (Ed. note: Amazon says Under the Fig Leaf is out of stock, but you can order it from the publisher here.)
    posted by Sydney on 12/12/2002 06:25:00 AM 0 comments

    Strange Puppets: Now I've seen everything. (Warning: Graphic image)
    posted by Sydney on 12/12/2002 06:24:00 AM 0 comments

    Crud-Causing Bugs: We've been seeing a lot of vomiting and diarrhea around here this week. My son said he only had eight out of twenty-two kids in his class yesterday because of it. So, in honor of my community's outbreak, and those on the ship cruises, here are images of two viruses often implicated in the "intestinal flu" or "intestinal virus" also known as viral gastroenteritis - the Norwalk virus and the Rotavirus. (Scroll down to see the pictures.) - from The Big Picture Book of Viruses (via The Eyes Have It)
    posted by Sydney on 12/12/2002 06:22:00 AM 0 comments

    Wednesday, December 11, 2002

    Breaking News: Charles Johnson at Little Green Footballs says that Bush has announced the government will allow voluntary public smallpox vaccination ....in 2004:

    “I think it ought to be a voluntary plan. ... I don’t think people ought to be compelled to make the decision,” Bush said in an interview with ABC’s Barbara Walters.

    ABC said the vaccine would be given first to military personnel, then to emergency workers, including hospital employees, paramedics and police. It would be offered to the general public in 2004, when newer stocks of vaccine become available.


    posted by Sydney on 12/11/2002 08:57:00 PM 0 comments

    JAMA's weekly art history lesson.
    posted by Sydney on 12/11/2002 08:59:00 AM 0 comments

    Mapping the Mind: Researchers think they may have found a clue to diagnosing schizophrenia before it becomes symptomatic:

    In the new study, the researchers used magnetic resonance imaging to scan the brains of 75 people who were deemed "at high risk" for psychosis because they had a strong family history of severe mental illness or had other risk factors, including transient or mild symptoms of mental disturbance or a decline in mental functioning.

    Over the next 12 months, 23 of the subjects developed a full-blown psychosis and 52 did not fall ill, the researchers found.

    A comparison of the brain scans from the two groups revealed significant differences in the volume of gray matter in areas of the frontal and temporal lobes and the cingulate gyrus. All three regions have been linked to schizophrenia by previous research, Dr. Pantelis said.

    When the researchers conducted additional brain scans on some subjects who developed psychoses, they found further reductions in gray matter not seen in the scans taken before the illnesses were diagnosed.

    The study (pdf file) was a small one, done among selected high-risk people. Before brain sizes can be used to screen for schizophrenic tendencies, we need to know how many people in the general population have a similar brain structure without ever developing psychosis. The other aspect of note is that the researchers looked at psychotic episodes in general, not just schizophrenia. Some psychotic episodes can be caused by severe depression, which is much easier to treat than schizophrenia, and which doesn’t have the long term poor prognosis that schizophrenia has. It's inaccurate to describe the areas of the brain in question as being responsible for schizophrenia. They are, more accurately, areas implicated in one of its symptoms.
    posted by Sydney on 12/11/2002 08:50:00 AM 0 comments

    Home Testing: In England, you can buy home tests to screen for colon cancer, osteoporosis, and Alzheimer's. That's amazing. We don't even have a doctor-ordered test here to screen for Alzheimer's. They don't really have them in England, either:

    One Alzheimer's test, for example, is simply a selection of "scratch and sniff" cards, in which various scents have to be identified.

    A consultant psychiatrist asked by Health Which? said that while losing sense of smell was a symptom of Alzheimer's, smell testing did not figure in scientific evaluation of possible cases of dementia.

    The osteoporosis screen is also of dubious merit:

    The "osteoporosis risk indicator" looked for the presence of high levels of a particular protein in the urine.

    However, experts confirmed that levels of this protein fluctuated naturally.

    There's something to be said for the FDA. It protects us from scams like this.
    posted by Sydney on 12/11/2002 08:15:00 AM 0 comments

    Banning Alcohol: The AMA wants to put tighter restrictions on alcohol advertising so kids won't be tempted to use it. They have data to back up their concerns:

    A study highlighted at the AMA meeting indicated that alcohol abuse may shrink teens' brains. That study found that the part of the brain that handles memory and learning was 10 percent smaller in 14- to 21-year-olds who abused alcohol than in those who didn't drink.

    It also cited reports that children now take their first drink on their own at the age of 12, on average, and that nearly 20 percent of 12- to 20-year-olds report binge drinking--four or five drinks in a row.

    What they don't have is data showing that teens drink because they see commercials for it on television. Like smoking, kids are more influenced by what they see at home, or among friends, than what they see on the television.
    posted by Sydney on 12/11/2002 08:09:00 AM 0 comments

    More Celebrity Medical News: Maybe Christopher Reeves really is Superman:

    He started a concentrated program of exercise and electrical muscle stimulation in 1999 and doctors announced this year that he has enjoyed a slow rebirth of limited sensation and movement. At the time, some doctors called it "an unprecedented amount of recovery" for a patient with such an injury.

    Corbetta said the new studies show Reeve may be exceptional in another way -- his brain has remained receptive to signals from the paralyzed portion of the body even though most of those signals were interrupted by the injury.

    Some researchers, based on the animal studies, have suggested that repairing the spinal cord would do little good because the brain has effectively given up on the paralyzed portions of the body and has changed so it could no longer process those signals.

    "The usual argument is that the brain has reorganized so what good is it going to do (to repair the spinal cord)," said Corbetta. "At least in this case, some of the responses are more normal than we would have expected. So there is new hope."
    posted by Sydney on 12/11/2002 07:42:00 AM 0 comments

    Blaming our Fathers: In an otherwise very good review of new contraceptive developments, the New York Times offers this explanation for slow innovation in the field:

    The lack of variety in birth control for Americans can be traced to a tangle of issues, Dr. Finer and other experts said, including the length of time it takes to develop any new medical product and a deeply rooted Puritanical culture.

    A "deeply rooted Puritanical culture"? Would that be the same culture that sells pornography on news stands, has naked actors on stage, tolerates "art" made from the Christian cross and the artist's urine, and attaches no stigma to single motherhood?

    The "lack of innovation" is more likely due to the fact that we have a method that's safe, well-tolerated, and favored by many people already - the pill. All of the innovations discussed in the article are really nothing more than new delivery methods - a cap that goes over the cervix, a hormone-coated ring that goes into the vagina, a patch, and a new version of Norplant that involves implanting a rod under the skin. All of those, with the exception of the patch, are more intrusive and bothersome than taking a pill. It's no coincidence that of all of those, the patch is the only one that's really catching on among patients. It's biology, not heritage, that limits the variety of contraceptives we have to use.

    Oh, but then, that reference to the Puritans was probably a sly jab at the failure of the abortion pill to catch on, wasn't it?
    posted by Sydney on 12/11/2002 07:35:00 AM 0 comments

    Celebrity Medical Watch: Courtney Love is upset that she’s mentioned in the California Medical Board’s report on cosmetic specialist Dr. Jules Lusman. Lusman had a habit of charging patients $1,000 for visits without documenting why he was seeing them and giving them prescriptions for various narcotics and sedatives, often along with prescriptions for syringes and needles. (This is not common medical practice.)

    I don’t blame Love for being upset. The Medical Board should have done more to protect the identity of the patients it mentions in the investigation. It should have been enough to identify her as “C.L.” rather than “a fairly well-known musician, age thirty-six when she first saw Lussman on June 25, 2001,” and then go on to mention that she’s also known as “Ms. C.-L.C., as she had at one point been married to Mr. C., who passed away,” and that the year of her birth was 1965. Then, too, it appears that someone at the Medical Board leaked her identity to the media:

    While a spokesperson for the board could not reveal the identity of "C.L.," two sources familiar with the investigation told the Los Angeles Times it was Love.

    They could have used more discretion in the report. It’s a very detailed rundown of the various maladies C.L. claimed to have when she saw Lusman. No one deserves to have their medical records hung out in public like that. Medical board reports are public documents, and they should be. But a case could have been made against Lusman without revealing so much about his famous client.

    Speaking of Celebrities: Courtney Love’s troubles began because her friend, Winona Ryder, used the same doctor to get drugs. The whole thing came to light during Ryder’s trial for shoplifting. When arrested, Ryder was found to have not only store merchandise in her purse, but a virtual pharmacopeia:

    On the day of her December 2001 arrest, officials say Ryder (or, Emily Thompson, as she was known around Rite-Aid) was found in possession of a syringe, a bottle of Aleve filled with Vicoprofen, Vicodin, morphine sulphate and Percodan (but, alas, no Aleve) and a yellow plastic pillbox containing Valium and Percocet.

    Her lawyers say she has a “pain management problem,” but it looks like her problem isn’t managing pain so much as managing to fit all of her drugs into her purse and to find ways to pay for them that can’t be traced.

    Courtney Love is also on record using a popular (and often overused) medical diagnosis to excuse Ryder’s behavior:

    In November, Courtney Love, a famous female rocker herself, told the New York Daily News that Ryder didn't deserve jail time for shoplifting because "she's got [attention deficit disorder] almost as bad as me." Love spoke of previous shopping trips when the two lost track of what had been purchased and what hadn't.

    posted by Sydney on 12/11/2002 06:30:00 AM 0 comments

    Tuesday, December 10, 2002

    CORRECTION: The earlier post on healthcare in the United States had a faulty link. It was the link to a paper criticizing the current state of health of America in the body of a reader's email. It's fixed now. If you don't want to comb through the post, but you wanted to read the paper, here it is.

    posted by Sydney on 12/10/2002 06:25:00 PM 0 comments

    Statins: Jane Brody has a good article on the side effects of the cholesterol-lowering drugs, statins, but she gives the drugs a pass when it comes to overinflated claims of their effectiveness:

    Statins have been hailed as miracle drugs for their ability to prevent deaths from heart attacks by lowering cholesterol.

    Some doctors go so far as to say the statins have had a greater effect on heart disease than anything else introduced in the last 50 years.

    Last year, a national group of experts issued guidelines saying statins should be prescribed to some 36 million Americans, three times as many as were taking them then, to reduce their risk of heart disease.

    In addition to protecting people at high risk, statins protect people who have already suffered one heart attack. Three large studies have shown that statins reduce the risk of second heart attacks by 30 percent and the risk of death from second heart attacks by 40 percent.

    Those studies (here, here, here, and here) actually consistently show that taking statins decreases the incidence of heart attacks by about three or four percentage points. From around 15% to 12%. It’s questionable whether their costs, both in terms of side effects and money, are really worth the surge in their use, a point I’ve made before.
    posted by Sydney on 12/10/2002 07:22:00 AM 0 comments

    Wow: An Oxford physicist has developed self-adjusting glasses:

    The physicist, Dr. Joshua Silver, calls them adaptive glasses. Their lenses are filled with silicone oil and form a chamber bounded by polyester film. Turning a knob on a small frame-mounted pump changes the amount of oil in the lens, altering the curvature of the lenses and, therefore, the power of the glasses. Users adjust the oil levels on each side until they can see clearly, a process that takes about 30 seconds.

    The glasses do not correct astigmatism, but they are effective against nearsightedness and farsightedness. Citing W.H.O. data, Dr. Silver estimates that all but about 15 percent of potential patients can be treated with his glasses.

    And they only cost $10!
    posted by Sydney on 12/10/2002 07:04:00 AM 0 comments

    Hush, Little Baby: Advice for sleep-deprived parents.
    posted by Sydney on 12/10/2002 06:58:00 AM 0 comments

    Stupid Pill Tricks: A woman who calls herself "America's Favorite Nutritionist" is selling herbal weight-loss pills for kids on the internet. They're called, rather unimaginatively, the "Skinny Pill for Kids":

    The marketer of the supplement, called "Skinny Pill for Kids," said her company had not done safety tests on children. The pill is being marketed to children age 6 to 12, and contains vitamins, minerals and herbs. A similar pill regimen is available for adults, as well.

    Pediatric experts told CNN they're especially concerned about three herbs in the "Skinny Pill" that are diuretics. Uva ursi, juniper berry, and buchu leaf all cause the body to lose water. The Physicians Desk Reference, a doctors' guide to drugs and alternative remedies, states the uva ursi should not be given to children under age 12.

    "Diuretics in children can cause kidney problems and electrolyte imbalances if taken long term," said Dr. Alison Hoppin, chief of the pediatric obesity clinic at Massachusetts General Hospital.

    In addition, the PDR says the herb could cause liver damage in children.

    Diuretics, herbal or otherwise, should never be used in healthy children. (They’re sometimes used in children with heart failure, but those kids are few and far between.) For that matter, diuretics shouldn’t be used for weight loss in adults, either.
    posted by Sydney on 12/10/2002 06:43:00 AM 0 comments

    You Can Say That Again: Ross at The Bloviator says that public health officials haven't been communicating with the physicians who actually treat the public when it comes to smallpox preparedness. And I was beginning to think that I was the only one being ignored.
    posted by Sydney on 12/10/2002 06:42:00 AM 0 comments

    Health Insurance Debate: Fresh Air covered the health care insurance debate last night. It's worth listening to. The program featured Marcia Angell, former editor of the New England Journal and Quentin Young, an internist who is the national coordinator of Physicians for a National Health Program. (Marcia Angell is also a member of the group.) Although his bio doesn’t mention this, Dr. Young cut his public activism teeth in the civil rights era. He views the need for medical care reform with the same passion. In fact, he told Terry Gross that what this country needs is a groundswell protest movement for a single-payer system like the one that won the civil rights cause.

    There’s nothing wrong with being passionate about a cause. In fact, it’s admirable to care so deeply about something. But the problem with passion is that it is also blinding. Dr. Young assumes that 1) medical care is a public good, and 2) that all medical care is equally good. Neither assumption is correct. To some extent, medical care is a public good, but only in the sense that a healthy nation is a vital nation. But this applies to the basics of health - clean water, control of infectious diseases, curing the curable. It does not apply to treating obesity, lowering cholesterol levels, freedom from arthritis pain or from the discomfort of indigestion, or the right to have the latest and most expensive drug for whatever ails you.

    Marcia Angell acknowledged this when she added, sotto voce, that her ideal of expanding Medicare to all “would have to have price regulations.” Note that she didn't say "rationing of benefits," but "price regulations." Good care costs money, whether it's spent on proper staffing levels at nursing homes, hospitals, and doctor's offices, or on research for better medicines. "Regulating prices" too often means cutting reimbursements to unsustainable levels. Only doctors, hospitals, and nursing homes feel that pinch now. Expand the government programs to include drugs, and the pharmaceutical industry will feel it, too. You can bet that would lead to fewer research projects into new and better drugs.

    Dr. Young expounded on Dr. Angell's idea of expanding Medicare. He often referred to Medicare as “flawed” and “in need of reform,” but the flaws weren't what most of us consider its flaws to be - poor reimbursement, Byzantine rules and Draconian enforcement of those rules. He thinks its flaws are that it doesn't cover enough - not mental health, not nursing home care, and not drugs. The reform he has in mind is to increase Medicare spending and then to increase it further by covering everyone regardless of age and need. What he wants, is a world without limits.

    The third guest on the program was Karen Davis, an economist and member of the panel that wrote the recent Institute of Medicine report on health care reform. She advocated a much more realistic approach to the problem. When asked about the possibility of a “protest movement” to force a single-payer system, she pointed out that surveys the IOM had done showed there wasn’t much support for that sort of system. In fact, most people are satisfied with the coverage they have now, as long as they aren’t in any danger of losing it. That’s why the IOM report favored letting states experiment with different methods for universal coverage that incorporated private insurance as well as government programs. Of the two, her approach is the more sensible and practical.

    The Mote in My Eye: A reader pointed out that my own passion on the subject of Medicare/Single-Payer system may be blinding me:

    As a faithful reader I fear you have gone over the hill and confused ideology with facts and common sense--you said referring to a post on Medicare: "The same thing would happen if we shift every man, woman, and child, regardless of age, to a single-payer system. Instead of taking up 20% of our GNP, healthcare will end up taking up most of it. Where will that leave us for defense and infrastructure?" . On what possible basis would you say that?

    I should have said “20% of the federal budget”, not the GNP. I meant to correct that before I posted it, but somehow it slipped by. Physician error.

    I say that from experience. I have no confidence in the ability of our system to ration care as long as the patient is left out of the loop when it comes to cost decisions. Managed care companies weren’t able to do it. They came under pressure politically and legally to expand coverage, and they got a lot of bad press for “denying care” when they tried to limit benefits. The government is no better at limiting benefits. No one wants to shoulder the politically distasteful task of rationing care. It's much easier to just cut back and delay payments to providers.

    Not only that, our lawmakers are already notorious for inserting themselves into treatment issues. Senators declare illnesses an “epidemic” if they or their family members have it (autism, most recently), they make pronouncements on the efficacy of mammography screening (In favor of, of course. Don’t want to alienate women voters) and they badger the NIH about its educational material (from both sides of the aisle). There’s no reason to think they would remove themselves from the debate when they have control over how every healthcare dollar should be spent, and there’s no reason to expect that they would exercise restraint in that spending. They’re too easily influenced by advocacy groups.

    But, back to the letter:

    I am submitting this link which accurately, and with out a partisan bent (I think), offers comparative date on health costs, mortality, etc. among 14 industrialized countries.

    A few observations. Data is current (1998-2000). Of 14 industrialized nations:

    1) The U.S. health care cost per capita is the highest ($4,178) versus a median of $1,783--Most of the countries have a much simpler, if not single payer, system

    2) The U.S. commits 13.6% of its GDP to health care versus a median of 8.2%

    Yes, but that’s because we use more high-tech medicine. As I mentioned above, not all medical care is equally worthy, but we aren’t very discriminating in our choices. We do more coronary bypass surgery, for example, than other nations, without much gain in life expectancy. We spend a lot on cholesterol lowering drugs to decrease the rate of heart disease by 3 or 4 percentage points. We spend money on newer, more expensive antihistamines and arthrititis drugs that aren't any better than older, cheaper drugs. Yet, if an insurance company, or Medicare, denied coverage for those treatments, they would be accused of denying needed care. Having a single-payer system isn’t going to change that. Not in our political system, anyways, and I’m not willing to give up our political system. I think it works pretty well for other things besides doling out health care.

    3) The U.S. life expectancy is the second lowest ( 70 years) versus 71.7 for other countries.

    Our life expectancy is 77 years, or at least it was in 2000. I don’t know how that ranks, but here’s an excellent explanation of why life expectancy isn’t the same as life span, and why you can’t put much stock in those WHO figures.

    4)The U.S. infant mortality rate is 7.2--the highest of all countries by a wide and significant margin.

    In 2000, our infant mortality was 6.9 per 1,000 live births, 28th among nations. The majority of those deaths were due to congenital anomalies and low birth weight. That doesn’t necessarily mean that we have deficient care. It could reflect our better prenatal care. Pregnancies that would end in miscarriages elsewhere, end in live births here, but live births with sicker babies.

    5) The US is rated number one in responsiveness, last in system performance and near the bottom in percent satisfied with the health system.

    I understand that each statistic can be rationalized--however--there is a message and it is not hard to find--costs can be contained and do not need to take over a nation's budget, quality of life has many dimensions and need not be substantially compromised by reducing total expenditures, and satisfaction is not necessarily driven by expenditures.

    That’s true. Satisfaction isn’t driven by expenditures. It’s driven by perceptions of quality. As I said earlier, though, I have no confidence in our political system’s ability to contain cost. No one wants to deny care, and no matter how marginally beneficial a treatment may be, there will be groups out there prepared to fight for our right to have it, and to have it for free.

    Also--regarding charity care--I doubt if you can find any provider who ran into trouble with Medicare because they provided charity care--to over simplify--one must generally charge all patients the same--this does not mean that there is the same expectation for payment. As for discounting to friends, professionals, etc. Since your Medicare or Medicaid rate is significantly driven by your costs, not your income--if you offer discounts to colleagues what you are essentially doing is having the tax payer subsidize the services you are giving away.

    This is absolutely true. The idea of professional courtesy never made sense, except in the case of medical students. They have no money, and deserve charity care. And, it’s true that you would be hard pressed to find someone who was penalized for offering charity care. However, the fact remains that a lot of doctors have interpreted the Medicare rules to mean that no one can be charged a lower rate than the Medicare rates, and that to do so means to incur stiff legal penalties. That perception, right or wrong, has had a definite impact on charity care.

    ADDENDUM: I have more to say on the subject here.

    Better Said: More eloquent dissertations on the issue of health care coverage can be found in this Cato Institute paper, and in First Do No Harm, by the Cascade Policy Institute.
    posted by Sydney on 12/10/2002 05:55:00 AM 0 comments

    Monday, December 09, 2002

    Imitating Christ: The man who lived the answer to "What would Jesus drive?"

    posted by Sydney on 12/09/2002 08:30:00 AM 0 comments

    Med-Mal in PA: The malpractice insurance crisis continues to affect doctors, and their patients, in Pennsylvania:

    Cynthia Roback, a registered nurse with Mercy's home health division for 22 years, said the number of patients being served by nurses has dropped from 200 to 100. She formerly had a caseload of 25 patients. Now, she has five. She blamed this decrease on doctors not seeing new patients.

    The home health services office in Wilkes-Barre will close, and services will be consolidated in one office in Scranton. Services in the nine counties Mercy home health nurses serve will remain intact, Mercy spokesman Jeff Lewis said.

    In Scranton, Community Medical Center laid off 15 employees this week as a result of lower reimbursements and fewer patients. The trauma center at CMC, the only trauma center in Northeastern Pennsylvania, remains in danger of closing.
    Delta Medix, the largest surgical practice in Scranton, will close next month as a result of rising malpractice insurance premiums. The practice comprises about 40 percent of Lackawanna County's general surgeons.

    Over the last few weeks, dozens of physicians throughout Luzerne and at least 40 physicians in Lackawanna County have announced plans to scale back services or stop accepting new patients.

    posted by Sydney on 12/09/2002 08:17:00 AM 0 comments

    Trying to Even the Field: Doctors in Cincnnati are suing health insurance companies for colluding to lower reimbursement fees. I don't know if their case has much merit. Our system is lopsided on the side of insurance companies, but I doubt there's anything illegal about it. Doctors are forbidden by anti-trust laws to join together and bargain collectively for better reiumbursement. Big companies who purchase health care insurance thus have much more influence with the insurance companies. If they want lower rates, the insurance companies try to give them lower rates, usually at the expense of doctors. Which leads to cases like this:

    Harry Fry, 60, was a Cincinnati cardiologist for 25 years before he retired last year. Fry, who now spends time driving a tractor on his farm east of Cincinnati, said reduced reimbursement for his services was a major factor in his decision to quit.

    He said that in 1990, for every $100 in services he billed for, he was reimbursed $92. In 2000, the year he decided to retire, his reimbursement per $100 billed was $29.

    "To stay even, I had to work three times as hard," Fry said. "And no businessman would be willing to put up with that."

    No, they wouldn't. And neither would most doctors.
    posted by Sydney on 12/09/2002 08:08:00 AM 0 comments

    Healing Hands: A sculpture from St. George's Hospital, London.
    posted by Sydney on 12/09/2002 07:46:00 AM 0 comments

    No Kidding: Government Report Says Some
    Drug Companies Use Deceptive Ads

    The government says that ads with deceptive images - such as an ad for the arthritis drug Celebrex that depicts an elderly woman rowing a boat and riding a scooter - often exaggerate the benefits patients can expect from a medication.
    posted by Sydney on 12/09/2002 06:38:00 AM 0 comments

    Genetic Revolution Update: It may be possible to predict a cancer's tendency to spread to other parts of the body by mapping its genes. Researchers looked at the gene mutations in cancers that had already spread, then looked for the same mutations in cancers that were diagnosed early, before they spread:

    They began by comparing 64 primary tumors with 12 other unrelated cancers that had spread. The metastasized cancers contained 128 specific DNA mutations that the primary tumors did not. But the scientists noticed another peculiar fact: Some of the simple tumors already contained the 128 specific mutations. Could these tumors be predisposed to spread, they wondered.

    Next, the team looked at 62 lung cancers, many of which contained the 128 mutations. They found the patients who had the mutations had cancers that were more likely to spread. Careful study of the data revealed that they only needed to identify 17 specific gene mutations among the 128 to predict a cancer that would spread.

    The team then tested more than 200 tumors: breast cancers, prostate cancers, brain cancers, and others. The pattern held: Patients whose tumors had the 17 mutations fared worse.

    ''We had no reason to believe it was this broadly applicable,'' Ramaswamy said.

    Large-scale tests on thousands of tumors, now underway, must support these results before doctors consider applying them on patients.

    posted by Sydney on 12/09/2002 06:25:00 AM 0 comments

    Testing Lullabies: Researchers are trying to find out if lullabies can help premature infants go home faster:

    During the next two years, 300 premature babies at Children's, the Cleveland Clinic, Rainbow Babies and Children's Hospital and MetroHealth Medical Center will participate in the study.

    The study is limited to babies who are born at 25 weeks' to 30 weeks' gestation or those weighing from 1 pound 2 ounces to 2 pounds 12 ounces at birth.

    All participating newborns will have a $300 digital music player known as a ZZZBox in their isolettes, but only half will actually have music pumped through the speaker for eight hours daily.

    If music therapy works, everyone wins.

    Babies go home faster. And those who foot the bill save money by reducing intensive-care stays, which cost $1,000 to $2,000 a day.

    ``It saves health-care dollars,'' said Kathleen Bailey, a registered nurse in Children's neonatal intensive care unit and co-director of the study. ``It saves pain and suffering on families.''

    The Kulas Foundation, a nonprofit philanthropic organization in Cleveland that supports music programs, is funding the $275,000 study.

    The music selected for the study is from the ``Baby-Go-To-Sleep Series,'' developed 17 years ago by songwriter and producer Terry Woodford.

    The tunes are familiar childhood classics: London Bridge, Rock-A-Bye Baby, Hush Little Baby and others.

    But each has a heartbeat in the background to simulate the sound babies hear in utero.

    An earlier, smaller study found that infants who listened to music in their isolettes went home an average of eight days earlier than music-free babies. No small potatoes when you consider one day in the neonatal intensive care costs around $1,000.
    posted by Sydney on 12/09/2002 06:07:00 AM 0 comments

    Sunday, December 08, 2002

    Dr. Smith’s Prescription for Holiday Stress


    Conquering holiday anxiety without resorting to drugs.

    Yesterday, I was cruelly reminded of just why it is that so many people hate the holidays. Usually, I steer clear of malls this time of year. It’s not that I dislike Christmas, it’s just that I’m not much for crowds. But yesterday, I had a quick errand to run - just a trip in and out of one department store to buy gift certificates for the office staff. I thought it would be so quick that I decided to do it after picking up my daughter from a birthday party. So, seven year old in tow, I whisked into the store. Everything started out great - easy parking, daughter subdued and well-behaved. But then, I encountered THE SALE.

    There, just a few feet from the sales counter which was my destination, sat lovely holiday china embroidered with green holly leaves and red holly berries in a very tasteful design. Now, holiday china is something that I’ve always wanted to own, but never felt worth the price. This holiday china had a sign next to it proclaiming 60% off. I quickly did the math. At that discount, I could buy enough plates for a family dinner at just a little above the usual cost of one set of plates. Suddenly, they were worth the price.

    With my daughter’s help, I took the plates to the sales counter. No line. Sales person available. What a great day. I purchased the nine gift certificates for the office staff and the holiday china, and was feeling pretty good until I looked at the receipt. The computer hadn’t registered the sale.

    What happened next can only be described as the epitomy of holiday hell. The sales clerk was very gracious about the mistake, but the cash-register/computer refused to admit any error. It refused her every attempt to correct it, and no one could come to her aid. Meanwhile, more customers were coming to the counter, and growing more and more impatient by the moment. Before my eyes, my daughter transformed from a polite, well-behaved little girl to a whirling, eye-rubbing human tornado, to a jelly-like life form that suddenly had no skeletal system to support her. Her energy and patience depleted, she unfortunately still had the strength to reach up to my watch, announce the minutes that had passed, and ask in her most pitiful voice, “Why is it taking sooooooo loooooong?,” which only served to further agitate the very cranky and very vocal lady next to me. I could see the tension increase in the poor clerk’s neck muscles with each passing minute. In desperation, I tried to cancel the purchase, but the cash-register/computer wouldn’t allow it. Finally, just as my daughter announced that forty-five minutes had passed, and just when I thought the lady next to me was going to kill us all, the clerk announced success, but at what a price. She handed me the receipt, her hands shaking, her eyes brimming with tears. There was a long line at the counter now, and somehow I knew that her evening was only just beginning. God help those who work in sales, and God help the rest of us who make their lives miserable.

    I left the department store with my budget intact, but my Christmas spirit in shreds. It’s time to take back the season, and to that end, I offer Dr. Sydney Smith’s prescription for holiday cheer:

    1) Tell your kids they can only ask Santa for one present. If that present is the hottest, hard-to-come-by toy of the season, tell them they have to ask for a different one. Don’t explain why, and if they whine about it, point out to them that Santa only brings toys to good children. Good children don’t whine.

    2) Avoid the malls. Shop online.

    3) Don’t knock yourself out trying to find that perfect gift for aquaintances and relatives. If nothing comes easily to mind, nothing will ever come to mind. Everyone likes food and drink, so send them something from Henry and David or Wine.com. Added bonus: You don’t have to worry about gift wrapping or schlepping to the post office.

    4) If you must go to the malls, go the second weekend after Thanksgiving. The stores are still amply stocked, the crowds aren’t as bad as the weekend right after Thanksgiving, and the store clerks aren’t at the end of their patience yet.

    5) If you feel the urge to watch a holiday movie, watch National Lampoon's Christmas Vacation, not It's a Wonderful Life. Watch it and realize that the dysfunctional Griswold family is closer to reality than the Baileys. Closer to the reality for all families, not just your family.

    6) Don’t bake unless you really want to, and then just bake for your immediate family. Send everyone else something from Harry and David.

    7) Reserve the last weekend before Christmas for yourself. Kick off your shoes, pull up a chair by the fire or the furnace vent, poor yourself a glass of wine, and relax. Christmas will come whether or not the gifts are wrapped, the cookies baked, or the cards are all sent. Just like the Christmas in

    That’s my plan this year, anyway. Now, if I could just think of a gift for my husband.
    Maybe I could persuade his favorite radio host to return to the airwaves....

    (Ed. note: This has also been posted at Blogcritics)

    posted by Sydney on 12/08/2002 10:25:00 PM 0 comments

    Man or Nature: Looks like things are warming up at the North Pole, and it isn’t because Santa has been working overtime:

    The northernmost reaches of the Earth are warming, reducing the sea ice across the Arctic Ocean, melting the ice sheet in Greenland and spreading shrubs into the Alaskan tundra, scientists said Saturday.

    Taken individually, the changes only suggest the region's climate is undergoing a warming trend. Together, they provide dramatic evidence the change is real, a panel of scientists said during at a meeting of the American Geophysical Union.

    "If you look at all the data sets together, they do provide compelling evidence something is changing over a great area," said Larry Hinzman, of the University of Alaska, Fairbanks.

    Natural variability may be behind the changes, but human activity might also be to blame, scientists said.

    Why is it that no one ever blames those submarine volcanoes under the polar icecaps? They produce enough heat to support life on the Arctic ocean floor, might they not also melt the ice?
    posted by Sydney on 12/08/2002 08:16:00 AM 0 comments

    Norwalk Virus Update: The Norwalk virus has been busy these past few months. Not only has it been shutting down cruise ships, it's been shutting down Toronto hospitals.
    posted by Sydney on 12/08/2002 07:41:00 AM 0 comments

    In the "He's still with us?" Department: Art Linkletter - still going strong.
    posted by Sydney on 12/08/2002 07:37:00 AM 0 comments

    Retiree Bust: It's getting harder for employers to afford heatlh care benefits for the retired:

    Faced with escalating health costs, more than half of employers plan to raise premiums and increase copayments for retirees over the next three years, and nearly a quarter say they are likely to eliminate health coverage for future retirees, a new survey shows.

    That can only get worse, with the baby boomers approaching retirement age. Another reason to divorce health insurance from employment and make it affordable enough for individuals to purchase.
    posted by Sydney on 12/08/2002 07:33:00 AM 0 comments

    Mormon Galileo: A Mormon scientist is being threatened with excommunication for disproving a central tenet of the Mormon faith:

    Anthropologist Thomas W. Murphy set out to test a key principle of his Mormon faith with the latest technology.

    He wondered: Would DNA analysis show -- as taught by the Book of Mormon -- that many American Indians are descended from ancient Israelites?

    His finding: negative.

    The result: excommunication -- if a church disciplinary panel today finds him guilty of apostasy.

    Well, at least he doesn't have to face the Inquisition.

    UPDATE: Susanna Cornett at Cut on the Bias has more thoughts on this.
    posted by Sydney on 12/08/2002 07:18:00 AM 0 comments

    Industry-Driven Reform: This may just be what we need. Health insurance reform from within the industry:

    Many health plans are developing or offering insurance with lower premiums and slimmer coverage to attract customers who cannot afford more comprehensive policies. Executives at Blue Cross Blue Shield of Montana are pressing state legislators to raise the cigarette tax to subsidize basic coverage. Another insurer, Blue Shield of California, proposed a plan this week for health insurance for all state residents. And Dr. William W. McGuire, chief executive of the UnitedHealth Group, the largest private insurer, has written to every member of Congress calling for "essential health care for all Americans."

    Sure, their motivation is to save their butts, but this is a welcome move nonetheless - especially the “lower premium, slimmer coverage” insurance policies. Right now, very few insurance companies offer catastrophic insurance. People are stuck with an “all or none” choice. The danger is if the companies persuade Congress to pass a law mandating that everyone have health insurance and then fail to provide affordable coverage to make that possible.
    posted by Sydney on 12/08/2002 07:10:00 AM 0 comments

    Good Old Days: A doctor remembers Medicare in its infancy:

    I often tell my residents that one of the most remarkable things about Medicare in its early years was how the claims were handled. My wife would sit at our kitchen table every evening, filling out the Medicare forms -- they were all hard copy then, no computer forms. And after three or so months, we'd get a check -- for the exact amount of the claim we had made. The exact amount! How often does that happen nowadays?

    What did happen, however, was something that the AMA had predicted. The costs of treating all of those people became prohibitive -- it actually turned out that the costs were up to 10 times worse than we had predicted. That's when the hassles started -- when the regulators came in. Then came the restrictions, the price controls and all of the complicated regulations.

    The same thing would happen if we shift every man, woman, and child, regardless of age, to a single-payer system. Instead of taking up 20% of our GNP, healthcare will end up taking up most of it. Where will that leave us for defense and infrastructure? And with the increased costs will come increased regulations and government interference.
    posted by Sydney on 12/08/2002 07:10:00 AM 0 comments

    Genetic Revolution Update: Researchers have transplanted cloned immune system cells back into the original owners, and boosted their immune systems in doing so. They were only cows, though, and no word of the long-term consequences of the procedure. Remember the bubble boy. He ended up having cells that ran amok after an initial success. The same could happen here. It might help in the short-term, but in the lung-run leave the person with leukemia or lymphoma or some other proliferative disease of the immune system.
    posted by Sydney on 12/08/2002 07:05:00 AM 0 comments

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