"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
Hysteria Revisited: Ross at the The Bloviator says that the public health community isn't just acting the role of hysteric in the "money for smallpox" stories:
And it's not as if the public health departments can give out smallpox vaccinations the same way they distribute flu vaccines. The need for pre-vaccination screening, the need for appropriate training of personnel in both vaccine delivery and delivery of informed consent to the patients, the real but remote chance of infecting others, and the pressure the federal government is putting on public health departments to get the vaccines distributed within 3 weeks beginning at the end of January, would necessitate a far more elaborate, more structured and, yes, more expensive system be put in place.
Three weeks isn't much time to implement any program, that's true. And their inability to do that with advance notice only drives home the impossibility of a post-attack vaccination plan. However, administering the vaccine shouldn't be as expensive as it's been made out to be by the media. It doesn't take that much time to get an appropriate history from a potential vaccination recipient, and it doesn't require much skill. The Red Cross does this sort of screening at their blood drives all the time. Nor is the administration of the vaccination a difficult skill to learn. It will take money to test people for HIV and other immunodeficiencies, but I don't think it will take the millions to billions the Post article was claiming.
There's a very real reluctance among the public health community to trust community-based physicians to administer the shots. That's understandable in the current approach that limits the vaccine to a chosen few. The vaccine has storage limitations that make it difficult to keep on hand unless a lot of it will be used in a short time. But, if public health officials are reluctant to assume the responsibility of certifying the health of vaccine recipients, they could simply require that a potential recipient's primary care physician vouch for it. Such a statement isn't unheard of. I routinely have to certify the health of my patients for third parties - for adoption agencies, daycare centers, and life insurance companies, with the patient's consent, of course. That would relieve the public health departments of the need to do extensive screening.
Public health departments don't have to go this alone. They can, and should, enlist the help of community physicians. It would make their task a whole lot easier.
posted by Sydney on
12/28/2002 05:34:00 PM
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Dissecting “Stem Cells”: Charles Murtaugh says those weren’t stem cells that grew into human kidneys in mice. They were cells from developing embryos - aborted embryos - at seven or eight weeks gestation. You know, I was totally pro-choice until I took an embryology course in medical school. Since then, I just can’t deny the humanity of a developing human being, no matter what the stage. (You can see all of those stages here.) posted by Sydney on
12/28/2002 05:06:00 PM
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Tempest in a Teapot: Political activists are charging the Bush Administration with subverting educational material on government health websites:
The National Cancer Institute, which used to say on its Web site that the best studies showed "no association between abortion and breast cancer," now says the evidence is inconclusive.
A Web page of the Centers for Disease Control and Prevention used to say studies showed that education about condom use did not lead to earlier or increased sexual activity. That statement, which contradicts the view of "abstinence only" advocates, is omitted from a revised version of the page.
Among the critics is the president of Planned Parenthood:
Gloria Feldt, president of the Planned Parenthood Federation of America, said the new statement on abortion and breast cancer "simply doesn't track the best available science."
Now, there's an impartial voice. Here’s what the website used to say about abortion and cancer, according to the Times:
The earlier statement, which the National Cancer Institute removed from the Web in June after anti-abortion congressmen objected to it, noted that many studies had reached varying conclusions about a relation between abortion and breast cancer, but said "recent large studies" showed no connection. In particular, it approvingly cited a study of 1.5 million Danish women that was published in The New England Journal of Medicine in 1997. That study, the cancer institute said, found that "induced abortions have no overall effect on the risk of breast cancer."
The Danish research, praised by the American Cancer Society as "the largest, and probably the most reliable, study of this topic," is not mentioned in the government's recent posting, which says the cancer institute will hold a conference next year to plan further research.
The Danish study (You can access the entire paper for free if you register, otherwise you just get the abstract.) compared Danish cancer registry information from 1973 to 1993 to abortion registry information from the same time period and found an incidence of breast cancer of 0.7% in women with no history of abortion, and of 0.4% in women who had one or more abortions. The study has its problems. It didn’t control for age, which is an important variable for breast cancer. The incidence of breast cancer is much higher in older women. Yet, by looking at data only after 1973, it effectively overlooked any abortions that the older women in the registries might have had as young women. And, as the editorial that accompanied its publication pointed out, there was an unexpected increase in breast cancer in women who had late stage abortions:
Among the women with late terminations, there were 14 cancers - almost twice as many as expected. Slightly fewer cancers than expected were diagnosed in women whose abortions took place before seven weeks of gestation.
....For the scientist trying to elucidate how pregnancy sometimes impedes and sometimes enhances one or more steps in breast carcinogenesis, puzzles remain, and this large study highlights some of them. The possibility of an increased risk with very late abortion, a decreased risk with very early abortion, or both must be seen as one of those puzzles. Neither the clear central finding that there is no overall risk nor the unresolved peripheral issues ought to influence the continuing public debate about abortion itself — a debate that is ethical and political in its essence. (emphasis mine)
In other words, the evidence is inconclusive, which is what the new National Cancer Institute post says:
The relationship between the varying levels of hormonal exposures over the course of a woman's lifetime and her risk of developing breast cancer has been the subject of extensive research. Certain reproductive events have been demonstrated to have protective effects (such as a full-term pregnancy), or in some cases can increase the risk of developing breast cancer (for example, early age at first menstrual period). For other events, the data have been inconsistent. Specifically, the possible relationship between abortion and breast cancer has been examined in over thirty published studies since 1957. Some studies have reported statistically significant evidence of an increased risk of breast cancer in women who have had abortions, while others have merely suggested an increased risk. Other studies have found no increase in risk among women who had an interrupted pregnancy. NCI is currently supporting mechanistic and population studies to gain a better understanding of the hormonal changes that occur during pregnancy and interrupted pregnancies and how they relate to breast cancer risk. (again, emphasis mine)
That’s an accurate summation of the state of affairs. What is there to object to? Nothing on the merits of science. Everything if you are operating under the assumption that the Bush Administration and all of its branches is single-mindedly devoted to the goal of thwarting a woman’s right to choose. (Although Pravda (!?) says our biased media is plotting to keep the truth from us.)
As for condoms, well, the Times says that the emphasis has changed:
As for the disease control centers' fact sheet on condoms, the old version focused on the advantages of using them, while the new version puts more emphasis on the risk that such use may not prevent sexually transmitted diseases, and on the advantages of abstinence.
The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual intercourse, or to be in a long-term mutually monogamous relationship with a partner who has been tested and you know is uninfected.
For persons whose sexual behaviors place them at risk for STDs, correct and consistent use of the male latex condom can reduce the risk of STD transmission. However, no protective method is 100 percent effective, and condom use cannot guarantee absolute protection against any STD.
This is unequivocally true. In fact, this is the standard advice regarding condoms when discussing them as a birth control method. Yet, you can bet that none of the critics of the condom as STD prevention information would criticize that advice when applied to preventing pregnancy, least of all Planned Parenthood.
To be fair, the Planned Parenthood people didn’t provide a quote about the condom issue. In fact, the paper couldn’t find any condom boosters to provide inflammatory quotes about the change. Instead we just get snippets of the website that aren’t very convincing examples of anti-condom bias:
"The studies found that even with repeated sexual contact, 98-100 percent of those people who used latex condoms correctly and consistently did not become infected."
But the recently revised page warns that evidence on condom use and other sexually transmitted diseases is inconclusive, though it says the uncertainty demonstrates that "more research is needed — not that latex condoms do not work."
It comes down to much ado about nothing. The breast cancer/abortion link, if there is one, is miniscule. The research is conflicted and uncertain (a good clue that there really isn’t a substantial link), and the website conveys an accurate description of that state of affairs. Condoms, while effective, aren’t 100% effective. Nothing is 100% effective. The advice on the website reflects that basic truth, and in no way disparages condom use.
It’s human nature to impute to others our own motives and failings. When someone does something that raises our ire, we suspect they’ve done it for the same reasons we would have done it - out of spite, or laziness, etc., even if the true circumstances are much more innocent. That’s what’s going on here. Those who are accusing the Administration of malice for changing websites are doing so only because they are the types who would change information solely to promote their agenda. And, of course, they hate everything the Bush Administration does. posted by Sydney on
12/28/2002 08:39:00 AM
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Hysteria: The public health community is estimating that it will cost states millions to billions of dollars to vaccinate healthcare workers against smallpox. Now, why would it cost them that much?
The one basic function that all public health departments universally perform is immunization. They have flu immunization clinics every fall. They're the places people go if they need odd immunizations for travel, such as the one for yellow fever. Surely, the simple task of administering a vaccine that's been supplied by the government, to a limited number of people, won't tax them that much. If they're worried about treating any potential complications from the vaccine, well, they should relax. It's the community physicians who would treat those, not the health departments.
Surely, their real complaint is the money needed for other bioterrorism preparedness issues - such as updating computer systems and lab facilities. It's just easier to blame the smallpox vaccine plan, since that's the most controversial of all. It also happens to be the one that is opposed almost universally by the public health community.
In Perpetuity: In just a half an hour the Canadian cloning cult plans to make an "announcement" about their human cloning project - is there a baby, or isn't there? Alas, I'll miss the announcement. My first patient is scheduled then, and I won't be able to post again until well after six tonight. The group's current goal is to help infertile couples conceive, and in so doing, perfect the cloning technique so they can one day achieve their ultimate goal:
Rael told CNN in July 2001 that the long-term goal for human cloning is to live forever. Rael says cloning a baby is only the first step: Eventually the group wants to learn how to clone an adult, then "transfer the brain to the clone."
UPDATE: Well, it's a girl. "Born in the country where she was born," they say. To an American mother. The scientist involved is a bishop in the Raelian movement, which CNN describes:
The Raelian movement professes that life on Earth was created through genetic engineering by extraterrestrials.
The Raelians believe their spiritual leader -- former French journalist Claude Vorilhon who now calls himself Rael -- is a direct descendant of these aliens. He says he has met with aliens and visited their planet.
I suppose it isn't that much stranger than most religions, except for the part about visiting other planets and choosing a journalist as a leader. Hard to believe their claim, but I suppose it isn't impossible. They've asked a journalist, Dr. Michael Guillen, and an independent panel of experts to check out the child.
Celebrex is one of the newer arthritis medications that is supposed to have a lower incidence of stomach upset and ulcers than the older arthritis drugs like ibuprofen or aspirin. The study compared the incidence of ulcers in people who used Celebrex alone compared to people who used diclofenac (brand name Cataflam or Voltaren), an older arthritits drug, paired with an ulcer prevention drug, omeprazole (brand name Prilosec).
The dose of Celebrex in the study was 200 mg twice a day. That costs $148 a month. The dose of diclofenac was 75 mg twice a day, which costs $27 a month for the generic version. Add omeprazole, and you add another $99 a month to the price tag, for a total of $126 a month. So, just what did they find? That the two treatments were comparable:
In the intention-to-treat analysis, which included 287 patients (144 receiving celecoxib and 143 receiving diclofenac plus omeprazole), recurrent ulcer bleeding occurred in 7 patients receiving celecoxib and 9 receiving diclofenac plus omeprazole. The probability of recurrent bleeding during the six-month period was 4.9 percent (95 percent confidence interval, 3.1 to 6.7) for patients who received celecoxib and 6.4 percent (95 percent confidence interval, 4.3 to 8.4) for patients who received diclofenac plus omeprazole (difference, –1.5 percentage points; 95 percent confidence interval for the difference, –6.8 to 3.8). Renal adverse events, including hypertension, peripheral edema, and renal failure, occurred in 24.3 percent of the patients receiving celecoxib and 30.8 percent of those receiving diclofenac plus omeprazole.
So, Celebrex may not be any better than the cheaper and older therapy when it comes to ulcer risk, but only if that cheaper and older therapy is taken with an anti-ulcer pill. Unfortunately, the addition of that anti-ulcer pill makes the regimen only marginally less expensive than Celebrex alone. There's another concern about using two drugs when one will do. The more drugs ingested, the greater the risk of side effects and drug-to-drug interactions. Omeprazole interacts with a long list of other drugs. So do Voltaren and Celebrex. In the end, it’s always best to try to simplify a medical regimen as much as possible and avoid using two drugs when one would do just as well. If the $20 a month difference is going to strain the pocket book, then by all means the cheaper combo would be fine, but otherwise, the one drug regimen of Celebrex would be the better choice. posted by Sydney on
12/27/2002 08:13:00 AM
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Sign on the Dotted Line: Forms for informed consent in cancer trials are OK, according to a study in the New England Journal of Medicine, although the authors suggest that researchers ditch the terms "treatment" and "therapy" and use more neutral words like "agent" or "drug". The question is, do people read the forms before signing them? posted by Sydney on
12/27/2002 08:11:00 AM
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Still the Season: A biology Christmas carol from Loxosceles, and some other great medical posts, too. (In case I didn't mention it before "Loxosceles" is the scientific moniker for the brown recluse spider, the most popular spider in medicine. Whenever someone comes in with a really nasty bug bite, the physician will inevitably scratch his chin and say, "Hmm...Looks like a brown recluse spider bite." Doesn’t matter whether it’s a spider bite or not. Any bad bite automatically gets blamed on the brown recluse spider. posted by Sydney on
12/27/2002 08:06:00 AM
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Thursday, December 26, 2002
Still a Holiday Elsewhere: In the United Kingdom, Canada, and Australia, it’s Boxing Day. In Ireland, it’s St. Stephen's Day. But here, it's back to work. Happy Respective Holiday to those of you in other parts of the world. posted by Sydney on
12/26/2002 08:28:00 AM
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Bedfellows: The feds have plans to breakup the cozy relationship between pharmaceutical companies and physicians, a move which is being resisted by both parties:
In contending that the proposed federal code of conduct would require radical changes, those opposing the change discuss their tactics with unusual candor and describe marketing practices that have long been shrouded in secrecy.
Drug makers acknowledged, for example, that they routinely made payments to insurance plans to increase the use of their products, to expand their market share, to be added to lists of recommended drugs or to reward doctors and pharmacists for switching patients from one brand of drug to another.
Insurers, doctors and drug makers said such payments were so embedded in the structure of the health care industry that the Bush administration plan would be profoundly disruptive.
Moreover, doctors said that drug companies were a major source of money for their professional education programs, and that the administration proposal could drastically reduce such subsidies.
"Without financial support from industry, medical societies would most likely be forced to curtail or stop offering these important educational activities," said Dr. Michael D. Maves, executive vice president of the American Medical Association.
Doctors of all types echoed that concern.
For "doctors of all types" read: "medical societies of all types." Much to the shame of the profession, our professional societies have become financially dependent on drug companies. They all rely on donations from pharmaceutical companies, not only to finance their educational programs, but to finance their day to day operations. Which makes me wonder what they do with all that money they charge for membership dues, which are usually several hundred dollars a year or more. (In the case of the AMA it 's around $2,000 which is one of many reasons I'm not a member.)
This is a practice that should give us all pause. The medical societies and associations are known for putting forth guidelines that set the standard of care. Last year, the American Heart Association disgraced itself by recommending the use of a drug of dubious merit for strokes when it was discovered that the drug maker gave hefty amounts of money to both the organization and to members of the guideline panel. More recently, the outgoing president of the AHA was reprimanded by the FDA for shoddy research practices involving drug trials. Then there's the American Pain Society which takes money from drug companies to finance the writing of "pain treatment guidelines" which - surprise! - are weighted heavily to the use of drugs for the treatment of chronic benign pain.
And I haven't even touched on the practice by "pharmaceutical benefits managers" of sending doctors faxes repeatedly to get them to switch drugs to their parent companies drugs, but the Times article covers it. The drug company and HMO dodge that it's just "common marketing practice" is ridiculous. It may be common practice but it's in no one's best interest - except the pharmaceutical companies and the HMO's. We have to recognize that drugs aren't like other consumer products. They have side effects, they have interactions, and they work differently in different people. Drug therapy has to be individualized. The decision of what drug works best in which situation has to be the decision of the patient and the doctor. It can't be driven by the same marketing techniques that are used for cars and widgets.
posted by Sydney on
12/26/2002 08:07:00 AM
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Christmas Miracle: It's hard to believe in miracles, but this story, about an Ohio woman's rapid and unexpected turn-around would seem to qualify:
"It's a miracle," said Bailey. "Just 10 days ago, I was on the critical list thinking I may never see Christmas and then I'm home with the heart of a 20-year-old. Not one of my doctors can explain it. No one at the hospital can explain it. I believe prayer and God stepped in and gave me my heart back."
Bailey said her heart was so damaged, it was only operating at 16 percent of its capacity.
"Now, it's at 57 percent," Bailey said, laughing. "What better Christmas present than to be able to come home to my five children, the youngest one is four, to my husband and spend the holidays. No better gift was ever given."
According to AP reports Mrs. Bailey's cardiologist says he’s been seeing more and more reversals of severe heart disease such as hers. He credits the drugs she has been on for a very long time (she had been in the hospital for seven months):
Binkley, 42, said increased doses of the intravenous drug dobutamine, which helps the heart contract, may have helped.
"Having that support for a prolonged period may have allowed the heart to rest and recover. That might be one explanation," he said.
...At his clinic, Binkley said he's following 57 patients whose heart functions have improved to an average of 55 percent, from 20 percent.
"We're trying to understand the characteristics of patients who will improve to that extent," he said.
I've had two patients in the past five years with severe heart damage caused by a viral infection who have bounced back this way, too.
Mrs. Bailey, though, has a different explanation:
At her church the following Saturday, there was a program in her honor. Members acted out poems from a book that a friend had written about Bailey's life.
"Around 7 p.m. that night, I got this heavy feeling in my heart," she recalled. On Monday, tests showed that her heart had improved to 57 percent.
Fishy Benefits: News is that eating fish in moderation will protect men from strokes:
Men who ate about 3 to 5 ounces of fish one to three times a month were 43 percent less likely to have a stroke during 12 years of follow-up. Men who ate fish more often did not reduce their risk any further, suggesting that a small amount works just as well as a larger one, said co-author Dr. Ka He of Harvard's School of Public Health and colleagues.
My goodness that does sound impressive. Unfortunately, the incidence of strokes in all groups was miniscule, and not at all that much different. In fact, this study is one of the most ludicrous examples of using statistics to inflate results. This is how the numbers break down for overall stroke, both the type that’s caused by a blood clot to the brain and the type that’s caused by bleeding:
Number of men who ate fish less than once a month - 2616. Number who had strokes - 40 (1.5%)
Number who ate fish one to three times a month - 4512. Number who had strokes - 57 (1.3%)
Number of men who ate fish once a week - 20,789. Number who had strokes - 282 (1%)
Number who ate fish two to four times a week -12351. Number who had strokes -174 (1.4%)
Number who ate fish more than five times a week - 3403. Number with strokes=55 (1.6%)
The authors, however, only make the claim for ischemic strokes - the kind that involves clots to the brain. But the numbers are even worse when you exclude the hemorrhagic strokes:
Number of ischemic strokes in men who ate fish less than once a month - 30 (1%)
In those who ate fish one to three times a month - 34 (0.8%)
In those who ate fish once a week - 169 (0.8%)
In those who ate fish two to four times a week -115 (0.9%)
In those who ate fish more than five times a week - 29 (0.8%)
The truth is, it doesn’t really matter how much fish men eat. (Probably doesn't matter for women, either.) You would think the study had been funded by a group of fishermen rather than the NIH. Maybe the researchers are just partial to fish. posted by Sydney on
12/26/2002 07:11:00 AM
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Dickens of a Diagnosis: Doctors have all sorts of hobbies that involve medicine. Some blog, others try to nail down the diagnoses of fictional characters - in this case, Tiny Tim. The wonderful thing about fiction is that you can make things up. It's impossible to say what Tiny Tim had. Dickens just wanted him to be a character that tugged at the heart strings.
Dickens does have a place, though, in medical history. There’s a disease, Pickwickian Syndrome, named after The Pickwick Papers:
Charles Dickens wrote a vivid description on what later became identified as a stereotypical, severe form of sleep apnea in a character called "Fat Joe" from The Pickwick Papers.
"Fat Joe" had such excessive daytime sleepiness that he fell asleep standing up, while in the process of knocking on a door! Thereafter, "Fat Joe" was referred to in clinical descriptions later in the 19th century of other hypersomnolent, obese patients with loud snoring, which came to be called the "Pickwickian Syndrome" in reference to Dickens' novel. Around this time, a case was reported with successful treatment by weight reduction. Later, the term "Pickwickian Syndrome" became supplanted by Obstructive Sleep Apnea, which includes a wider range of less severe cases without the daytime cardiorespiratory impairment of the Pickwickian syndrome. posted by Sydney on
12/26/2002 07:00:00 AM
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Housekeeping: I used some Christmas down-time to update some of the items to the left. ViewFromTheHeart is now included in the “Medical Blogs” category. If you haven’t visited the site, it’s a blog by a critical care nurse. Very good.
I also added a few new books to the “Recommended Reading” list. Three are first person accounts of illness. Two are by writers, Intoxicated by My Illness by Anatole Broyard, and Autobiography of a Face by Lucy Grealy. Boyard writes about his prostate cancer, and Grealy about living with the results of a disfiguring surgery. The other, Raising the Dead, is by a doctor who describes his own experience as a patient in intensive care.
The Man Who Mistook His Wife for a Hat is my favorite Oliver Sacks book. It’s a look at the sometimes odd presentations of neurological disorders. A Midwife's Tale is the story of Martha Ballard, a midwife in what is now Maine in the late eighteenth to early nineteenth century. The author, Laurel Thatcher Ulrich, builds upon Ballard's diary entries to vividly portray life in early rural America. Finally, The Sea and Poison by Japanese author Shusaku Endo, is a work of fiction that explores the ethical dilemmas of Japanese doctors in World War II - performing medical experiments on prisoners of war.
The other addition to the left is a link to Amazon.com. The books that will pop up there from time to time are all in the category of the history of medicine. Feel free to browse their links. posted by Sydney on
12/26/2002 06:54:00 AM
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I'm up early to bake pies and get the goose's stuffing going, but before I get lost in the duties and the celebrations of the day, I just wanted to say "Merry Christmas" to all of you who honor me with your visits. With that in mind, here is the music to a Christmas carol that’s especially apt for our times. The words were written by Henry Wadsworth Longfellow during the American Civil War, but - absent the verses about canon from the South (included in the above links) - they are timeless. It's been 2,000 years and we haven't yet achieved that “Peace on Earth” ideal. Here's hoping that one day we will:
I heard the bells on Christmas day
Their old familiar carols play,
And wild and sweet the words repeat
Of peace on earth, good will to men.
I thought how, as the day had come,
The belfries of all Christendom
Had rolled along th' unbroken song
Of peace on earth, good will to men.
And in despair I bowed my head
"There is no peace on earth," I said,
"For hate is strong and mocks the song
Of peace on earth, good will to men."
Then pealed the bells more loud and deep:
"God is not dead, nor doth He sleep;
The wrong shall fail, the right prevail
With peace on earth, good will to men."
Till ringing, singing, on it's way,
The world revolved from night to day,
a voice, a chime
A chant sublime
Of peace on earth good will to men. posted by Sydney on
12/25/2002 03:44:00 AM
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Lucy Grealy, the poet and essayist who wrote a noted 1994 memoir, "Autobiography of a Face," about her experience growing up with extreme facial disfigurement and repeated surgery to repair it, died at a friend's house in Manhattan on Wednesday night. She was 39.
No cause of death was announced. Friends said she had been despondent over operations she underwent two years ago.
NPR played a segment of an interview with her when her book was at the height of its popularity. She sounded so...accepting of her condition. But I suppose one would on national radio, at the height of one’s success. Ms. Grealy had a malignant tumor successfully removed from her jaw in early childhood. Unfortunately, the successful removal required the simultaneous removal of most of her jaw. Her memoir was a compelling and unflinching tale of growing up looking decidedly different, and of her attempts to correct that difference, not withstanding her remarks on NPR .She told the interviewer that writing the book gave her the confidence to walk into a room with “fluency,” and made her finally feel accepted. But fame is fleeting, and she never really gave up on trying to change her appearance - to grasp that elusive beauty that would give her the life she craved. At the end of her book, she was still looking toward the next operation, hoping that it would be more successful than the last. Sadly, she never got that satisfaction. posted by Sydney on
12/24/2002 12:18:00 AM
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Old Habits Die Hard: And apparently, so do old smokers. A nursing home resident in Ohio is fighting her nursing home's smoking ban:
Virgie Meade struggles with emphysema and a pulmonary disorder. She needs pure oxygen to breathe.
Now she says administrators at the Western Reserve Extended Care nursing home in Kirtland, about 15 miles east of Cleveland, are keeping her from the one thing she still enjoys -- smoking.
Meade, who has lived at the nursing home since 1998, and other residents were banned from a TV room they used for smoking and have been ordered to smoke outside, in an area protected from inclement weather with sheets of plastic.
That's not easy for Meade, who had a stroke seven years ago, lost a leg in her battle with bone cancer and uses a wheelchair. She has smoked for 37 years, since she was 20.
She’s not going to let anyone deprive her of the right to smoke while wearing oxygen. She's hired a lawyer.
Actually, I’ve got to admit, I feel sympathy for her. Smoking is probably the only enjoyable thing she has left in life. She’s already got all the illnesses that come with it. Stopping now isn’t going to reverse them. They should let her enjoy herself in comfort, somewhere away from other residents - and inside.
posted by Sydney on
12/24/2002 12:13:00 AM
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Sacrificing Others: Susan Sarandon will be starring in the made-for-TV movie about the doctor who discovered her breast cancer while working at the South Pole:
Sarandon, most recently on the big screen with Goldie Hawn in "The Banger Sisters," will star as Dr. Jerri Nielsen, who learned she had breast cancer while stationed at the South Pole in the dead of winter, making it virtually impossible for her to get out or for a medical team to get in to help her.
Neilsen was an emergency room doctor from Ohio when she joined a research team going to the remote Amundsen-Scott South Pole Station in Antarctica. Soon after the eight month winter of nearly total darkness began, she discovered a lump on her breast. She did a biopsy on herself, with limited resources and help only from others at the station, none of whom were doctors. She sent those results by email to specialists who said she had an aggressive cancer. The others at the station tried to give her chemotherapy with supplies air-dropped by volunteer pilots until Nielsen was finally brought back to the United States, where she underwent surgery and is now cancer-free.
The story of how the 46-year-old physician found treatment was the stuff of headlines in 1999 and is said to be an extremely inspiring one.
What's so inspiring about someone putting others at risk to assuage her own fear and anxiety? It always bothered me that Dr. Nielsen was portrayed by the media as a "hero" when she asked other, untrained, personnel at the station to perform her biopsy, then risked the lives of pilots - first to get her chemotherapy supplies, then to get her out of the South Pole in dangerous weather. She did this for a condition that was not immediately life-threatening. That isn't inspiring or heroic. It's selfish. posted by Sydney on
12/24/2002 12:08:00 AM
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Mouths of Babes: Can't resist sharing this. My nine year old was telling me about a movie he watched today. He was trying to think of the word for the occupation of one of the characters, which he described as, "Those people who accuse other people of doing bad things."
Mother Ginger: She may have danced elegantly in the Nutcracker but in real life, ginger has a history not only as a tasty Christmas spice, but as a medicinal as well. posted by Sydney on
12/23/2002 08:31:00 AM
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Tort Reform Update: How badly is tort reform needed in Pennsylvania? Very badly. The situation in Philadelphia alone is atrocious:
Last year, Philadelphia plaintiffs received more money from such lawsuits than all the malpractice cases in the entire state of California. Recently, a Philadelphia jury awarded $100 million in a malpractice case -- the largest in Pennsylvania history, and the third-largest in the nation. posted by Sydney on
12/23/2002 08:24:00 AM
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Smallpox Vaccine Update: So far, President Bush feels A-OK after his smallpox vaccination. It should be pointed out, though, that Bush is of an age at which he most certainly received a smallpox vaccine as a child. The incidence of side effects from the vaccine is substantially lower in people receiving it for the second time.
Meanwhile, Israel is now weighing the decision to vaccinate everyone, and the Brookings Institute along with researchers at Johns Hopkins, have put forth a proposal to re-vaccinate everyone who has already had the vaccine. It's an approach that will boost community immunity with the most minimum of side effects. The more immunity in a population, the better. (This is a pretty good alternative, actually.)
And while the Brookings Institute and Israel weigh risks and benefits, the American public health community continues to campaign against the vaccine. Here's the health officer for Nevada County on the incidence of side effects from the vaccine:
Johnson cited figures estimating that for every 100 million vaccinations, the vaccine would cause between 100 and 400 deaths and 2,500 cases of potentially fatal side effects.
That’s an interesting way of putting it. Most people express the incidence in per million not per 100 million. Expressing it per 100 million makes the incidence seem larger than it is, since we’re used to thinking in per million. The CDC website puts the estimate for serious, but not life-threatening side effects at 1,000 per one million, and the estimate for life-threatening complications at between 14 and 52 per one million. So, while he’s technically telling the truth, he’s telling it in a skewed sort of way.
This is one doctor, by the way, who plans to get the vaccine - if I'm ever allowed the chance. The risk of a bioterrorist attack with smallpox may be considered low, but in truth I don't think anyone can ever know what the chances of a terrorist attack are. Would anyone have ever bet that the chances of terrorists flying planes into the World Trade Center and Pentagon were high? I don't think so. No one ever cropped up afterwards saying, "I told you so."
And I'm not so confident about the medical community's ability to accurately diagnose, or to suspect smallpox in a patient. The man in the New England Journal'scase study from Cleveland went to two emergency rooms and one family practice clinic before being sent to the dermatologist who finally feared he might have smallpox. That was a false alarm, luckily, but there's no reason to think our performance would be better with the real thing. posted by Sydney on
12/23/2002 07:49:00 AM
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The Mummy's Curse: This must be the BMJ's week for humor. Not only does it have an article on the quality of the curves of Playboy centerfolds, it also has an article debunking the mummy's curse:
Among the 25 people exposed to the "curse", the average age at death was 70 years compared with 75 in those not exposed.
Reserving the Right to Refuse Service:RangelMD brings up an important point in a response to The Bloviator (scroll down to December 17’s post about a physician who requires waivers from his patients stating they won’t sue him ) - physicians have and always have had, the right to refuse service in nonemergency situations:
Except in certain situations (such as taking mandated ER unrefered call or in emergency cases) have the right to refuse service. This may come as a shock to the Bloviator and many others who seem to believe that they have absolute right to health care of unlimited expense and unlimited options independent of their ability to pay. They are confusing emergency care with regular office visits. Private physicians regularly refuse to take patients whose insurance (most notably Medicare or Medicaid) does not pay enough to even cover the operating expense of the practice. Why should physicians be required to take patients who ultimately cost the practice money? Physicians can and do "fire" patients from their practice who are regularly grossly noncompliant with their medical management and scheduled office visits or who are abusive of the physician and/or the office staff. On the surface a waver may seem unfair but patients have the right and every opportunity to see another physician.
Exactly so. You might think that patients who dislike their physicians would automatically exercise their right to choose and go elsewhere, but not all of them do. There are some people who thrive on conflict. They go to a doctor even though they think he’s a quack. They purposely ignore his recommendations and then blame him when things go wrong, just for the thrill and the drama of the fight. It’s these sorts of people that doctors routinely dismiss from their practice, and rightfully so. They represent an increased liability risk, not to mention the emotional exhaustion that’s involved in dealing with them. I’ve said this before, but it’s worth saying again. The cornerstone of the doctor-patient relationship is trust. If that’s missing on either side, the relationship is dysfunctional. It’s better for both parties to dissolve it. If the patient isn’t able to recognize that dysfunction, then it’s up to the physician to initiate the divorce. This isn’t arrogance, it’s just common sense.
This, of course, is a completely different issue than having patients sign waivers not to sue. That's just folly. It's like asking a fiance to sign a waiver not to divorce you once you're married. Disagreements are bound to crop up in any relationship, whether they're family, business, or medical. It's far better to settle those disputes in a court of law than to let things fester with no recourse. The latter is too likely to end violently.
posted by Sydney on
12/23/2002 07:37:00 AM
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Brush with Fame: Senator William Frist's father was Minnie Pearl's physician. (That little tidbit is buried deep in the long article on the life of the Senator.) posted by Sydney on
12/23/2002 07:34:00 AM
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The Cure: Hormones are certainly getting a lot of attention lately. Almost as much attention as smallpox. First, The New York Times ran a story about the dangers of anabolic steroids (read: testosterone), then Andrew Sullivan reacted with accusations that the Times was on an anti-drug crusade. Then, Reasonchimed in with a piece comparing their use by athletes to the use of batting helmets (?). Now, it's back to the Times with an article on hormones as a panacea for aging. At least the New York Times article is balanced. They present the views of steroid boosters and detractors. On the side of the proponents, there is this paper in The New England Journal of Medicine:
... he gave growth hormone to 12 elderly men for six months, reporting that they gained muscle and lost fat. Nine men who served as controls had no such body changes. In his paper, published on July 5, 1990, in The New England Journal of Medicine, Dr. Rudman concluded with this sentence: "The effects of six months of growth hormone on lean body mass and adipose-tissue mass were equivalent in magnitude to the changes incurred during 10 to 20 years of aging."
The study was small and brief and only looked at lean body mass, fat mass, bone density, and skin thickness. It didn’t bother itself with adverse effects of the growth hormone, or with quantifying any functional gain from the changes in body mass.
Then, as so often occurs with unproven therapies that cost a lot of money, there are the testimonials:
Dr. Ron Livesey was fat, tired and out of shape. At 49, he felt that his best years were behind him.
So one day seven years ago, on his way to a medical meeting, he stopped at a doctor's office in Palm Springs, Calif., for his first hormone injections.
Early the next morning, Dr. Livesey was at the meeting, sitting in a darkened auditorium watching slides of technical data. To his surprise, he found himself alert, taking everything in. He continued the hormone treatments.
Doctor Livesey now makes his living giving hormone treatments to others, at $1,000 a month, most likely paid for in cash -no insurance hassles, no Medicare hassles - since it’s unlikely to be covered by insurance.
She was depressed, gaining weight, feeling old and fatigued. But, she said, when she began taking growth hormone, estrogen and progesterone, she noticed an immediate change in her mood and energy. It gave her the stamina and enthusiasm to start dieting and working out at a gym and she dropped 10 pounds. She said her libido returned, her hair grew, and even her bunions regressed so she could wear high heels again.
Her bunions regressed? That’s extremely hard to believe. Bunions are bone deformities, usually caused by wearing tight-fitting shoes over a long period of time. The shoes press the big toes in toward the rest of the toes, and over time, the bones remold and the deformity becomes fixed. If anything, the regression of her bunions would make it harder to wear high heels since her foot would be wider at the toes. Sounds suspiciously like hype.
On the other hand, the skeptics have studies like this, which included adverse effects, and objectively measured functional improvements:
Dr. Papadakis set out to test growth hormone in 52 healthy men from 70 to 85. She designed the study so that the men did not know if they were taking the drug or a dummy medication.
Reporting in 1996, she found that growth hormone slightly increased muscle mass and decreased body fat but, paradoxically, did not make the men stronger. People had claimed it improved their mental clarity, but she found no such effects; if anything, those taking growth hormone did slightly worse on memory tests. They also suffered swollen legs and feet and achy joints, making them so uncomfortable that a quarter taking growth hormone had their doses reduced during the study.
Dr. Papadakis said her results were ignored by growth hormone enthusiasts. "They can't let go of the hypothesis because they like it," she said
Then, there are the animal studies:
"I agree that mice and rats are not people, but mice that don't make growth hormone live longer," Dr. Warner said. "Mice that overproduce growth hormone live shorter lives. The same principle applies in fruit flies and little worms called nematodes. It may be irrelevant, but it makes us wonder."
In fact, people who overproduce growth hormone live shorter lives, too. The condition is called acromegaly. Left untreated, it results in diabetes, hypertension, heart disease, and colon polyps that can lead to colon cancer.
As for testosterone, and other anabolic steroids they have their problems, too - especially when taken by growing adolescents. Excess testosterone closes the growth plates of bones prematurely, resulting in shorter stature. They suppress the growth of the testicles. Even adults can experience gonad shrinkage when they use them. They can cause hepatitis. In fact, Germany now compensates former East German athletes for the ill-health they’ve suffered as a consequence of forced anabolic steroid use under Communist rule.
So, while the use of anabolic steroids and other hormones has its place in known deficiencies, and in some chronic wasting illnesses (like AIDS), it isn't a fountain of youth and strength. posted by Sydney on
12/23/2002 07:25:00 AM
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Sunday, December 22, 2002
Smallpox Vaccine Update: As we continue to grapple with the issue of voluntary pre-attack smallpox vaccination, perhaps we should look to Israel for lessons. They also had to overcome fears of the vaccine:
Phase one of the program has gone pretty much as planned, though with a few complications. Probably the most surprising was the reluctance of many health-care workers to get the shots, which pushed back the deadline for the first 15,000 from October to December. "Part of it is a less than satisfactory communications effort. But it's mainly a reluctance to take a chance on getting severe side effects," says Ethan Rubinstein, the head of the infectious diseases unit at Tel HaShomer Hospital in Tel Aviv.
Those side effects can include high fever (which can hit 50 out of every million recipients of the vaccine), meningitis (15 per million), and even death (1 per million). The authorities pointed out, however, that most people who are affected in such ways are toddlers, the elderly, or those with weakened immune systems, none of whom would be given the vaccine during the initial inoculation.
So far, only four Israelis have been hospitalized in the course of the inoculation: a spouse and child came down with a mild case of cowpox -- from which on version of the smallpox vaccine is made -- and two people had heavy fevers. All are fine now. "My best advice is information, information, information," says Hadari. "Let everyone know exactly how little risk is involved and do everything you can to battle misconceptions."
With that in mind, The Washington Post today has a public information piece about the vaccine and the disease. It's not bad, although it doesn't do much to dispel fear of the vaccine, going so far to suggest that people with small children at home shouldn't get the vaccine. That would effectively eliminate vaccinating the most vulnerable segment of the population - those under thirty-five who have never been vaccinated, and would only undermine the goal of pre-attack vaccination. Whoever gave that advice to the Post, and surely they got it from someone in the public health community, should think twice about it before making it a policy. Especially in light of the review that will appear in the New England Journal of Medicine which shows that the vaccinia virus used in the vaccine isn't nearly as contagious as previously believed. This is what the paper's author told the New York Times:
In another article, Dr. Kent A. Sepkowitz, director of infection control at Memorial Sloan-Kettering Cancer Center in Manhattan, said that at first he feared there could be vaccinia epidemics in hospitals. But after studying the medical literature, he concluded that he had overestimated the threat and that medical workers could be vaccinated without endangering patients as long as the workers followed instructions like keeping the vaccination site covered and washing their hands often.
When he searched medical journals going back to the early 1900's, Dr. Sepkowitz said, "I think the key feature to me, looking back at these articles, is the paucity of outbreaks."
Dr. Sepkowitz said he thought hospital outbreaks would be far less likely today because patients with rashes are routinely isolated, and there is more emphasis on hand washing and covering vaccination sites.
The same goes with the home environment. With good hand washing and careful coverage of the site, it shouldn't pose a danger to normal children at home. posted by Sydney on
12/22/2002 11:22:00 AM
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