"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
Plague Times:Cronaca says that once upon a time, villages had plague stones where, in times of plague, farmers left food in exchange for vinegar-soaked money, to avoid the plague-infested villages. posted by Sydney on
1/04/2003 10:45:00 PM
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Clone Update: The Raelians say that they've produced another clone:
Boisselier, who heads the Clonaid firm that claims to have produced the first human clone, said the baby was born in northern Europe late yesterday to a couple from the Netherlands, but she did not specify the particular country in which the baby was born.
"It is a little girl. She is very well," Boisselier said.
"She is smaller than the first, at 2.7 kilograms," Boisselier said, adding: "It was a natural birth. Her parents are two lesbians from the Netherlands."
It remains to be seen whether they'll let this one be tested and examined. The first one, after all the hoopla, is now off limits. posted by Sydney on
1/04/2003 03:37:00 PM
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Measure for Measure: Yesterday, the London Times had a Q&A with their health editor about the trend for drug companies to take an active role in disease definition. The article was prompted by this essay in the British Medical Journal on efforts to define normal sexual behavior as dysfunctional. Here’s the Times’ editor on the various diseases whose definitions have been expanded lately:
More often these days the development of disease descriptions come from "consensus conferences" where a group of experts, often with financial links to drug companies, meet to produce guidance for others. Once a diagnosis exists, the tendency is for doctors to employ it.
The most obvious example of this is in autistic spectrum disorder - a wide-ranging diagnosis now used for many children who would previously have been diagnosed as subnormal. Another example is ADHD - attention deficit hyperactivity disorder. As soon as many patients are being diagnosed, it becomes possible to market treatments - such as Prozac for ADHD. So facilitating such conferences is a good way for drug companies to promote their wares.
And to expand their markets. And it isn’t just psychological diseases whose definitions have been broadened lately. Obesity is more broadly defined now, hence the epidemic. So is diabetes, another disease that’s often labeled as an “epidemic.”
These expansions can’t all be blamed on drug companies, though. In some cases, it’s a legitimate effort to improve health outcomes. This is the case with diabetes. By setting lower blood sugar levels for the diagnosis, the hope is that earlier treatment will delay even longer the complications of the disease, such as heart disease and kidney failure, and blindness. The same can be said of obesity, although the case is less clear-cut. Sometimes, as in autism, it’s the work of activists. The more people who can be counted as suffering from a disease, the more likely the government is to increase research funding, and other state-funded help for those suffering from it. Whether instigated by doctors, drug companies, or political activisits, however, the outcome is the same. As the BMJ article pointed out, we risk narrowing the definition of normal to such a degree that even the healthy are labeled sick.
For Example: A good example of just that phenomenon is what has happened with autism in the past ten to twenty years. Once upon a time, autism meant a severe developmental disorder that rendered its victims completely unable to communicate or interact with other people in any way. Now, the definition has been substantially broadened. But even that broad definition wasn’t enough for the recent survey of the prevalence of autism published in JAMA. Not content with the DSM-IV criteria that are generally now used for the diagnosis, the authors included more general, less debilitating disorders:
Throughout this article, the terms autism and autism spectrum disorders (ASDs) refer to autistic disorder, Asperger disorder, and pervasive developmental disorder - not otherwise specified (PDD-NOS).
Pervasive developmental disorder, not otherwise specified is a waste-basket term, used to classify those who don’t fit into any of the other categories. Asperger's disorder, sometimes called “high functiong autism,” was only defined in the 1990’s. Before that, we called such people “eccentric” or ‘geeky.” Of course, “eccentric” and “geeky” aren’t the sort of labels that get schools special education funds, but Asperger syndrome, having the blessing of the medical profession, does. It’s no surprise that it has caught on as a diagnosis .
Derek Lowe does a fine job of dissecting the media’s response to the JAMA article. In truth, the paper does not prove that autism itself has increased, only that the diagnosis of autism has increased, and it does that largely by including disorders that aren’t what most people think of as autism - that is the severe and disabling form of it. An accompanying editorial, although generally supportive of the claims that autism has increased, expresses reservations about them, nonetheless. One of those reservations is the way in which the classification of disabilities has changed:
.... during 1987 to 1994, diagnostic substitution occurred; thus, while the prevalence of autism increased from 5.8 to 14.9 per 10,000, the prevalence for mental retardation decreased from 28.8 to 19.5 per 10,000. These trends then cancel each other. According to the authors, new federal legislation (Individuals with Disabilities Education Act15) mandating that states provide early intervention programs for toddlers with developmental delays played a role in the increasing use of the diagnosis of autism.
The editorial also points out that there has been a disproportionate increase in spending on autism in relation to the scientific evidence of its prevalence:
Although claims about an epidemic of autism and about its putative causes have the most weak empirical support, the subsequent controversy has put autism on the public agenda. In recent years, children with autism, their families, and professionals involved in their care and in research have seen welcome and legitimate increases in public funding. Yet, ironically, what has triggered substantial social policy changes in autism appears to have little connection with the state of the science. Whether this will continue to be the case in the future remains to be seen, but further consideration should be given to how and to why the least evidence-based claims have achieved such impressive changes in funding policy.
Yes, indeed, we should give consideration to how and why claims of little evidence result in such impressive changes in public policy. Serious consideration.
posted by Sydney on
1/04/2003 03:26:00 PM
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Malpractice Extremis:The Bloviator has the latest on the West Virginia surgeon work-stoppage. He says the surgeons are angling to get the state to pressure insurance companies to pay them better. That's too bad. They weaken their cause. It would be far better for them to just cancel contracts with insurance companies they have problems with, rather than bringing the state into it. They have that option with health insurance companies. They don't have it with malpractice insurance companies. posted by Sydney on
1/04/2003 03:25:00 PM
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Friday, January 03, 2003
Clone World: Several months ago I posted an excerpt from a newspaper article about people who were seeking to have themselves cloned. One of those people was a man with cystic fibrosis. This was the original post:
Then there is the man who thinks that cloning himself will give him a second chance at life:
He was born with cystic fibrosis, an inherited lung disease that could easily kill him within the next decade. There is no cure, but by adding a healthy version of the gene that's defective in CF, scientists have been able to "cure" individual cells taken from patients with the disease. Now Colvin wants scientists to do just that, and a little bit more: Take one of the trillions of cells in his body, fix the tiny molecular mutation that causes the disease, and then clone that single repaired cell to grow a new and literally improved copy of himself -- a newborn Jonathan Colvin who would be free of the disease.
"In some respect, it would give me a second chance at life without CF," Colvin said. "It wouldn't be me, but it would be very similar to me."
I hate to break it to him, but it won‚t be his brain in that clone’s body, and it won’t be his life it’s living.
Recently, Mr. Colvin emailed me:
well duh, that's what I said ....."It won't be me, but it will be very similar to me".
The point is precisely that it won't be "my" life the clone is living; it will be a life that I might have lived had I not had CF.
What would be the point of living the same life again? I suppose this is why you are med-pundit, and not philosophy-pundit :)
Mr. Colvin also suggested in a subsequent email that if Steven Hawking could clone himself, then maybe the world would be graced with another physics genius. Or maybe not. That’s the point about cloning. Even though the baby has the same genes as its parent, it is still its own unique person. Just as identical twins are unique people, not the same person split in two. Our genes aren’t our destinies. Throughout our lives, we’re influenced by things beyond the control of our genes. Even our genes are influenced by factors outside our control, and can be expressed differently in different situations. That’s one reason identical twins differ from one another. There’s no reason to expect a cloned baby to live your life for you anymore than you should expect a traditionally conceived child to do so. (Many a parent has been disappointed in that expectation, and many a child made miserable.) And as for Stephen Hawking, there’s a good chance his clone wouldn’t even like physics, let alone be adept at it. posted by Sydney on
1/03/2003 08:43:00 AM
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Double Duty: A new drug aimed at treating inflammation at the cellular level, got not one, but two, papers in this week’s New England Journal of Medicine. The drug, Antegren, is an antibody that blocks receptors on cell surfaces that are involved in mediating inflammation. The two papers look at the responses of two diseases that are of an inflammatory nature,Crohn’s disease and multiple sclerosis:
In the MS study, 213 patients in the United States, Canada and the United Kingdom were given six monthly infusions of one of two Antegren doses or a dummy drug. Patients who received the dummy drug had about 10 new brain lesions, compared to about one new lesion in those getting Antegren, a reduction of about 90 percent.
The frequency of relapses was cut in half in the Antegren groups, to 19 percent from 38 percent in the comparison group.
However, once treatment was stopped, there were no differences in the rates of relapses and new brain lesions between the two groups. The drug looks more promising for Crohn’s disease:
The 248 patients in the Crohn's study in Europe received two infusions a month apart of either of two Antegren doses, a dummy drug or a combination of Antegren and the dummy drug. A scoring system measured their response over 12 weeks.
Overall, the patients who received only Antegren had higher remission rates and response rates. The highest remission rate was 44 percent at six weeks in the low dose Antegren group, compared with 27 percent in the dummy drug group.
In both studies, there were few serious side effects and there was no difference in side effects between the treatment groups.
The Crohn’s disease study, however, didn’t look at relapse rates beyond the twelve week treatment period. As the author’s conclude, “the longer-term benefit and safety of this treatment...remain to be defined.” posted by Sydney on
1/03/2003 08:25:00 AM
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Dehumanizing Medicine: The New England Journal of Medicine considers the legacy of Nazi medicine in this week's issue. They first appear in the discussion section of a research paper on the genetic characteristics of a neurological disorder called Hallervorden-Spatz Syndrome. Drs. Hallervorden and Spatz were distinguished German physicians - and committed Nazis. The authors suggest in their closing paragraph that the eponym be disgarded, as it has “fallen into disfavor”:
The eponymous term "Hallervorden–Spatz syndrome" has fallen into disfavor in view of the unethical activities of the German neuropathologists Hallervorden and Spatz during World War II. We encourage the use of the term "pantothenate kinase–associated neurodegeneration" for the majority of patients with Hallervorden–Spatz syndrome who have proved or suspected mutations in PANK2. For the remainder, we propose the term "neurodegeneration with brain iron accumulation."
In an accompanying essay, Michael Shevell argues the same. An eponym is an honor, and these two men are not worthy. Here’s a description of Hallervorden’s work:
At the outbreak of World War II, Hallervorden was the pathologist of the Brandenburg State Hospital, which included the chronic care institution at Brandenburg-Görden. This would be one of the six elimination centers established under the Aktion T-4 adult-euthanasia program. The program effected the transfer of institutionalized patients from all parts of Germany after a secret review of questionnaires based on their medical files by a central committee of physicians. After their transfer and a brief period of observation to verify the underlying diagnosis, patients were killed by gassing with carbon monoxide in disguised shower facilities. The operation was never legally mandated and was rife with deception of the affected families. A memorandum signed by Adolf Hitler, dated the opening day of the war, empowered physicians "to grant a mercy death to those judged to be incurably ill." In operation for less than two years (during the period from 1939 to 1941), the Aktion T-4 program resulted in the deaths of 70,273 persons.
To an academically oriented pathologist such as Hallervorden, Aktion T-4 provided an opportunity for the study of rare specimens on a previously unimaginable scale. Hallervorden's reports to the German Association for Scientific Research and the German Research Council detail his use of specimens derived from the Brandenburg-Görden killing center. Dissatisfied by the quality of medical information in the patients' dossiers for a funded project entitled "Inherited Feeble-Mindedness," Hallervorden himself selected and examined a number of living patients before personally removing their brains at the killing center. On the basis of these materials (and others he obtained through the child-euthanasia program and the Jewish Hospitals of Warsaw and Lublin in Poland), Hallervorden published 12 scientific articles (7 as sole author) in the postwar era on a variety of topics, including the effect of carbon monoxide exposure on the fetal brain.
Note those publications were after the war. In fact, Hallervorden was still very much admired and respected as late as ten years after the war. Here’s an interview with a prominent American neurologist who worked with him in 1955 in Germany:
Could you tell us more about Julius Hallervorden?
Well, I had great respect and fondness for him. However, I had no idea then about what had happened in the past. I wrote a small biography about him in a little book that I have right here, entitled The Founders of Child Neurology, edited by Stephen Ashwal, a pediatric neurologist. I said in the final paragraph: "He was of a quiet, reserved nature, wholly devoted to science and to neuropathology, and, at the same time, warm, friendly, and an inspiring teacher. He was one of the last great figures of the classic period of German neuropathology."
In recent years, his use of the brains of children that had been killed under the Nazis' euthanasia program has been heavily criticized.
When, in 1938, Spatz became Director of the recently established and well financed Kaiser Wilhelm Institute for Brain Research in Berlin, he invited his old friend Hallervorden to become head of the Neuropathological Division. Meanwhile, during the Nazi regime in Germany during the war, a systematic program of euthanasia was carried out on individuals officially not considered suitable for the kind of society the leaders were trying to create. In addition, there were the now well known horrors of the Holocaust. There is compelling evidence that Julius Hallervorden knowingly carried out examinations on anatomical materials from victims of these massacres, thus becoming part of a dehumanized regime that denied respect and dignity to those members of the society which, within the framework of its perverted ideology, were judged unworthy of living.
And here’s Hallervorden’s own account of the events:
"I heard that they were going to do that, and so I went up to them and told them, `Look here now, boys. If you are going to kill all those people, at least take the brains out so that the material can be utilized'"; "There was wonderful material among those brains, beautiful mental defectives, malformations and early infantile disease"; "They asked me: `How many can you examine?' And so I told them an unlimited number — the more the better"; and "I accepted the brains, of course. Where they came from and how they came to me was really none of my business."
Those were just brains and nervous systems to him, not human beings. And, since the people who owned them had already been deemed unworthy of life, what was it to him? Might as well make some use of all that discarded human tissue. It was for the advancement of science, after all. It was for the good of humanity.
Sound familiar? It should. The same argument is made today for fetal stem cell research, and for therapuetic cloning. Those aborted embryos (whether aborted surgically from a womb, or aborted during their growth and development in a petri dish) aren’t human, or if they are, they aren’t human in the full sense of the word, so the argument goes. They’ve already been denied the chance to develop fully, so why not use them for the benefit of humanity?
And if you think I’m stretching the analogy, consider this statement from pro-therapeutic cloning (yet also supposedly pro-life) Senator Orrin Hatch: (via Charles Murtaugh):
Sen. Orrin Hatch, R-Utah, is one of four sponsors of a bill that would allow the creation of cloned human embryos but would ban their implantation in a womb. On Feb. 5, 2002, Hatch testified, "No doubt somewhere, some, such as the Raelians - are busy trying to apply the techniques that gave us Dolly the Sheep to human beings. Frankly, I am not sure that human being would even be the correct term for such an individual heretofore unknown in nature." [emphasis mine]
See One, Do One, Teach One: The Wheeling, West Virginia doctor walk-out might be catching on with other West Virginia doctors, in other specialties:
Parkersburg-area doctors will consider a walkout during a meeting of the state medical association next week, said Dr. David Avery, a Parkersburg family practitioner and former association president.
"I'm afraid this is just the first bit," Avery said. "If the governor and the Legislature don't act, this will be spread quickly across the state -- and it will be all physicians, not just surgeons."
Michael Roberts, a surgeon at two Parkersburg hospitals, said Thursday there was "a good chance" the five surgeons at those facilities would stage a walkout in two weeks.
"We are basically in the same situation as the people in Wheeling," he said, adding that his malpractice insurance rates have jumped 140 percent. "We just can't keep up with the rising costs."
Meanwhile... at least one obstetrician had to close her doors in Huntington, West Virginia, because of the crisis:
Smith said she received notice from the state Board of Risk and Insurance Management Dec. 19 that she would have to pay four times her current premium for medical malpractice insurance. The increase was from $24,000 to $96,000, she said.
Smith appealed the increase and only decided Tuesday that she had to close, she said. The closure will be permanent unless she finds an affordable option for coverage, she said. Smith took a 30-day leave of absence, which would allow her to reopen if she finds a solution.
In March, Smith decided to give up obstetrics, hoping that it would reduce her premium. But coverage for practicing gynecology alone was still unaffordable, she said. Smith also gave up obstetrics because she couldn’t recruit a partner to share the workload, a problem she said was related to the medical malpractice climate in West Virginia.
Smith, like the surgeons who walked out in Wheeling, is insured by a state run malpractice program:
"The state developed this program; however, it’s not affordable," Smith said. "In my situation, I have never lost a lawsuit, but I have had suits filed against me that I had to defend against. The suits were dropped, but it still counted against me, which I think is unfair."
So, what’s a West Virginia doctor to do? Become a Virginia doctor:
"I can get insurance in all the surrounding states," Smith said. "I looked at North Carolina and Virginia, and they will insure me at half the cost, but I have no other alternative in this area."
..."You have one choice," Smith said. "You put your house up for sale, and you move."
Bluegrass Malpractice: In Kentucky, the state had to step in to keep the obstetricians at the University of Louisville insured:
A California company recently notified University Hospital late last year of plans to drop malpractice insurance for the hospital's Obstetrics Department. Then the state stepped in, preventing the company from dropping coverage.
Listening to the sound of an unborn heart, Dr. Daniel Edelstone breathes a sigh of relief after a near flatline for the Obstetrics Department at UofL. Edelstone is chairman of th department He says that without malpractice insurance, "we literally would have had to stop providing health care."
Once the state stepped in, "They were forced to provide us insurance," Edelstone is chairman of the department, and he says the company is providing coverage, but at a much higher rate. "They weren't forced to provide it at a reasonable rate -- our rates went up about 65 percent."
Costs for malpractice insurance have increased from $900,000 a year to one $1.5 million annually. The skyrocketing costs of malpractice insurance a dangerous threat.
"What you have is a system that is just running away with itself," Edelstone says.
And what happens next year when the rates go up even further? West Virginia redux. posted by Sydney on
1/03/2003 07:27:00 AM
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Illinois Malpractice: They aren't striking yet in Illinois, but the malpractice situation is beginning to strain the system:
Because Illinois law holds hospitals liable for actions taken by physicians affiliated with them, hospitals and especially academic medical centers have borne the brunt of an escalation in malpractice awards from juries in the past few years, the center's Max Brown said.
Last year Rush was self-insured for the first $4 million in liabilities, but this year, it must cover the first $15 million itself, with insurance companies only stepping in to cover awards that exceed $15 million.
"The London insurers have told us that no one is going to insure anything under $15 million and that will probably go to $20 million next year," Brown said. "Academic medical centers must set aside reserve funds to cover this liability, and that money has to come from other programs - from education and research."
And at least one malpractice insurance company says it can't afford to cover anymore doctors:
The agency that provides physicians with malpractice insurance in Illinois, ISMIE Mutual Insurance Co., has put a freeze on accepting new doctors for coverage. Rising malpractice awards could threaten ISMIE's reserves if it accepts more physicians, said the organization, which is an affiliate of the Illinois State Medical Society. posted by Sydney on
1/03/2003 07:23:00 AM
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More than 44 million Americans were obese and 16.7 million people had diagnosed diabetes in 2001, according to the study by the Centers for Disease Control and Prevention.
The researchers found the nation's obesity rate climbed to 20.9 percent in 2001 from 19.8 percent the year before, and the rate of diagnosed diabetes rose to 7.9 percent from 7.3 percent.
Of course, the population is getting older, too. Age is a factor in both weight gain and in diabetes. And then there's the matter of our prosperity. We do such a good job of providing food to the poor that the poorest states are no longer starving, but suffering from diseases of affluence:
The study confirmed previous findings that Mississippi is the state with the highest rate of obesity and Colorado the lowest. The highest rate of diagnosed diabetes was in Alabama; the lowest was in Minnesota.
I can’t dissect the study, since I haven’t received my issue of JAMA yet, and I don’t have online access to the full articles, but the journal does have an insightful look at the problem by an economist that’s available for free. posted by Sydney on
1/02/2003 07:41:00 AM
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Strike: Surgeons went on strike, but not in Pennsylvania, as feared. It was across the border, in West Virginia:
At least 39 surgeons walked off the job at four hospitals in West Virginia on Wednesday to protest rising medical malpractice insurance costs, officials said.
The hospitals are all in Wheeling, in the northern part of the state sandwiched between Ohio and Pennsylvania. They now must transfer emergency surgeries elsewhere and cancel planned procedures until the doctors end the strike, which they have scheduled to do at the end of the month, officials said.
The surgeons are of all types - general, orthopedic, and cardiac. They all asked for leaves of absences for thirty days from their hospital duties. No word on who's looking after their patients already in the hospital, but a West Virginia newspaper has these details about the walk-out:
Wheeling Hospital, Ohio Valley Medical Center, Weirton Medical Center and Reynolds Memorial Hospital all have surgeons who have requested leaves of absence to start the new year.
Eighteen surgeons at Wheeling Hospital, 12 from OVMC, seven at Reynolds and four at Weirton Medical Center have requested 30-day leaves of absence. The exact number of surgeons protesting is not known, as many doctors have privileges at more than one facility.
Wheeling Hospital has lost all but one surgeon, as three general surgeons requested leave on Monday. Unless something changes, the hospital will not offer any surgery after Wednesday.
You know, this kind of thing would have been unthinkable as recently as a year ago. Doctors in the United States just didn’t go on strike. Who would we strike against, after all? Most of us are self-employed. But, the malpractice insurance premiums have gotten so untenable, that there’s no choice for some of the high risk specialties. It’s ironic that a lot of the West Virginia surgeons are still doing surgery across the river in Ohio, where malpractice insurance premiums are also considered exorbitant. posted by Sydney on
1/02/2003 07:29:00 AM
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Desk Cleaning: While cleaning my desk of the latest unread journals, I came across this essay (requires a paid subscription) that reflects on the changes in healthcare over the past ten years:
The cumulative effect of the public-policy and marketplace changes of the 1990s has been the near-elimination of the system's reserve capacity and the exhaustion of available compensatory mechanisms. Each part of the health care system used strategies to maintain its own stability. Hospitals closed beds and tried to increase the productivity of their workers, particularly nurses. Physicians added staff and worked harder to maintain their income in the face of managed care. Employers passed on some health insurance cost increases to employees, with the average worker's single-coverage contribution rising from 11 percent of the premium in 1988 to 15 percent in 2001, and with even greater cost sharing envisioned in the future.
...Even the Federal Employees Health Benefits Program and the California Public Employees' Retirement System, two of the best-managed and most aggressive purchasers, faced premium increases of 13 percent and 25 percent, respectively, in 2002.
Use of emergency departments increased 14 percent between 1997 and 2000, and many emergency departments are reaching capacity, prompting diversions of critically ill patients to other facilities.
Over the 1990s, the number of students entering nursing school declined by 25 percent, and the age of the average nurse increased from 37.7 to 45.2 years.
...medical-school applications have decreased 15 percent over the past four years.
He paints a picture of a healthcare system straining under the burden. Overworked, dispirited doctors and nurses; hospitals with limited capacity, both in the sense of physical space and staffing levels, unable to handle any unexpected surge in patient loads, and patients being forced to use their retirement savings to pay for healthcare insurance. It isn’t pretty. posted by Sydney on
1/02/2003 07:28:00 AM
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Bias: Speculation on why women died by the Chicago health department of 100 years ago:
The abnormal preponderance of deaths among females, 305, to 293 males, in the week ended December 27, is accounted for by the health department by "the defective street car service, with its frequent breakdowns at a season of the year when thousands of women, at a high pitch of nervous tension over the holiday shopping, have been kept waiting for hours exposed to the inclemencies of the weather. posted by Sydney on
1/02/2003 07:23:00 AM
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Busy Bloggers:richard[WINTERS]md was busy with a bunch of excellent posts this past week. Posts on breaking bad news, on responding to lawsuits, and "Arse or Elbow?" are particularly recommended.
The Other Pox: The New York Times reviews a book about the role of syphilis in history:
Whatever its precise origins, syphilis reached plague proportions worldwide by the 16th century, when, Ms. Hayden writes, "each country blamed its neighbor for the malevolent import," the Russians calling it the Polish sickness, the Germans cursing it as the Spanish itch. The name syphilis comes from a poem written by the physician Girolamo Fracastoro in 1530, about a shepherd named Syphilus who offended the god Apollo and was punished with the world's first case of the pox.
The disease remained a pox on many houses for centuries to come, as it spread from person to person by sexual contact or other exposure to ulcerating sores, or congenitally, from mother to child. Treatments, like the consumption of high doses of mercury, were harsh, dangerous and only minimally effective. By the turn of the 20th century, perhaps 15 percent of the adult population in major cities like Paris and London had syphilis, though often the diagnosis was spoken of in the most euphemistic and obfuscatory terms.
The 16th century anatomist, Gabriele Falloppio described how syphilis may have been introduced to Europe. It was biowarfare. This is his description of the actions of a group of Spaniards holed up in a fortess in Naples while fighting the French army of Charles VIII in 1494 (his father was in the same fortress), as quoted in Combat Surgeons by John Laffin:
...under the pretext that food was short, they expelled from the fortress the whores and women, especially the attractive ones whom they knew were infected with the disease. The French, seized with compassion for the women and attracted by their beauty, gave them asylum.
And, presumably, some loving attention. The tides of war turned when others joined the fight, and a month later the French and their allies beat a retreat, carrying syphillis out of Italy to the rest of Europe.
At first, syphilis causes a painful ulcer at the site of infection, either in the vagina or the penis, but then that resolves and it manifests itself as a generalized rash, hence its name “The Great Pox.” Then, it gets tricky and hides in other parts of the body, quietly wreaking havoc. In the brain, it can cause dementia, in the aorta, an aneurysm, and in the heart, it can destroy the valves and cause narrowing of the coronary arteries. Understandably, it can be confused with many other diseases, hence its other name, “The Great Imitator.” The problem is, since its manifestations are so protean, many other diseases can be confused with it as well, making it all the more harder to accurately blame it for the erratic behavior of so many historical personages. posted by Sydney on
1/01/2003 10:23:00 AM
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Hope In Sight? Pennsylvania officials have come up with a temporary plan to help doctors pinched by the malpractice insurance crisis:
The first aspect of the plan is to reduce 2003 MCARE premiums. MCARE, or Medical Care Availability and Reduction of Error Act, was passed earlier this year. Rendell estimated that doctors will see at least a 30 percent reduction in their total insurance premium. The MCARE relief, estimated to cost about $220 million, will be funded through a one-time emergency assessment on surpluses held by all companies writing health insurance in Pennsylvania.
Rendell said he will also support the reintroduction of legislation that would compensate trauma centers for the higher costs of trauma care. Two eastern Pennsylvania trauma centers -- at Abington Hospital in Montgomery County and at the Community Medical Center in Scranton -- closed recently because they lost their staff neurosurgeons, a requirement for certification. The trauma center legislation would cost between $18 million and $22 million, Rendell said.
Reimbursement rates to doctors from insurance carriers should be increased, Rendell said. That, along with expected increased in Medicare and Medicaid reimbursements, will aid physicians' financial situations, he said. [Medicare payments are slated to decrease in 2003, not increase -ed.]
The last element of Rendell's plan is a new court rule that will be recommended to the state Supreme Court in early 2003. The rule would require every malpractice suit to have a certificate of merit. Tort reform experts predict such a rule could reduce the number of malpractice claims by more than 25 percent.
And it isn’t just the surgeons who are having problems:
In a further worsening of the insurance crisis, many insurance companies are no longer writing medical malpractice policies and will cease coverage beginning Jan. 1, Rovito said. About 60 percent of the state's 35,000 doctors will be without coverage as of Wednesday, Rovito said. Those physicians are either not taking new patients, not performing high-risk procedures or simply closing their practices, said Chuck Moran, spokesman for the Pennsylvania Medical Society.
"Doctors are really being caught between what their ethics tell them to do and what the law requires them to do," Moran said. State law requires doctors to have $1 million in malpractice insurance in order to be licensed to practice in Pennsylvania.
Scranton neurosurgeon Shripathi Holla said he will not work the first week of January, a move that would temporarily close Community Medical Center's trauma center.
Another Scranton surgeon said he'll temporarily stop work in protest of rising medical malpractice premiums, but he has no intention of closing his practice.
"I think it's foolish for people to say we're going to close if they truly do not mean it," said Dr. William Auriemma, a colorectal specialist.
Other FDA News: The Red Cross is in trouble for ignoring FDA rules and passing out hepatitis infected blood as a result. That’s pretty bad. If you can’t trust the Red Cross, who can you trust? posted by Sydney on
1/01/2003 10:20:00 AM
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Smear Campaign Fails: The campaign to stop the appointment of Dr. David Hager to an FDA committee on reproductive drugs based on his religious beliefs has failed. The FDA announced the new members of the committee last week, and Dr. Hager is included. posted by Sydney on
1/01/2003 10:17:00 AM
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Tuesday, December 31, 2002
How Cold is Scotland? Cold enough to warrant drinking anti-freeze?
Glennis Middleton, a councillor from Forfar, Angus, was not wearing her glasses when she reached for a drink after some strenuous home decorating, picked up the wrong bottle and drank three mouthfuls of what properly belonged inside her car radiator.
There was nothing on the bottle to label the antifreeze as potentially lethal. But Mrs Middleton's daughter telephoned the family GP, who recommended going to hospital. Doctors administered two drams of whisky, followed by a dram every hour through the night as they monitored the level of antifreeze in her blood.
This is actually a rather common event. Anti-freeze is a favorite of desperate whinos. In this case, the patient was given oral alcohol (Good Scotch whiskey, of course!) to counteract the ethylene glycol in the anti-freeze, but the most common form of administration is intravenously (doesn’t require the patient’s active cooperation), and there’s now an alternative, non-alcoholic treatment - fomepizole. posted by Sydney on
12/31/2002 07:43:00 AM
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In Praise of Uniforms: Some thoughts on the doctor's white coat. There are those don't like the white coat. Once they’re safely ensconced in their own practices, they discard it. They see it as a barrier between themselves and the patient. But I've been loathe to give up my white coat. Not only does it have all those handy pockets for my pens, prescription pad, Palm Pilot, and the thin filament with which I test the nerves of diabetic feet, but its bulk hides my expanding figure. Most important, putting it on each day is like putting on the mantle of my profession. I feel like a different person when I’m wearing it. I’m no longer Mrs. Smith, wife and mother, but only Dr. Smith. All of the pre-occupations of my private life vanish. My mind becomes focused only on my professional duty.
The white coat has its uses from the patient’s perspective, too. I recently realized its importance in that regard when my dentist became my patient. In his office, my dentist wears a white coat. He wears a white coat and dark-rimmed glasses and speaks passionately about dental technology. He is a solemn dental geek. And I like that. It makes me feel safe. It makes me trust him with that drill. But in my office he wears a black leather jacket, black turleneck, and gold chains. He he looks more like a used car salesman than my trusted dentist. I know in my heart that his clothing has nothing to do with his dental skills, but I'm still glad that when I go to his office, it's his white-coat persona I see. It’s so much more reassuring, even though I spend most of my time there with my eyes closed. posted by Sydney on
12/31/2002 07:37:00 AM
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Canadian Medical Journal Channels Reuters: The Canadian Medical Journal has either been taken over by Reuters writers or they're using the Reuters style book for their editorials, vis a vis the use of scare quotes:
Frustrated by the amorphous quality of the enemy, the campaign against terror has the hard target of Iraq in its sights. We cannot presume to second-guess "intelligence" or to judge the degree of economic self-interest in the West's goals of regime change and disarmament..."
And this:
...But "regime change" will not be sufficient to remove the risks to health and well-being that plague the people of Iraq...
The rest of it is mostly an argument for reconstruction following war (didn’t the US pretty much write the book on that?) and for a global welfare state financed by the West (read: United States).
Many's The Pint:The New York Times exhalts the benefits of drinking and describes the mechanism of its benefits. It also offers this observation:
Meanwhile, though, other studies were examining the drinking habits of individual subjects, a technique scientists usually consider more reliable than examining population averages. These studies found similar sizable benefits from a few drinks a day among Italian wine-drinkers, Japanese and German beer drinkers, and Americans who preferred hard liquor.
Lessons Learned: Efforts are being taken to eliminate laboratory stocks of polio, in anticipation of eradication of the disease:
"When polio is eradicated, every effort must be made to ensure that wild polio virus is not similarly transmitted from the laboratory," the CDC said.
Polio, which can cause paralysis and death, is not thought to be as dangerous as smallpox as a bioterrorist weapon because less than 1 percent of those infected with polio develop symptoms. People around the world also have been vaccinated against polio for decades.
Mission Massacre: Three hospital workers are dead in Yemen at the hands of an Islamic militant:
"One of the eyewitnesses there said that he came in the office as if he had a child beneath his jacket [but] it turned out to be ... a semi-automatic rifle that he used against them," he said.
The dead are William Koehn, the hospital administrator; Kathleen Gariety, the hospital business manager; and Dr. Martha Myers, an obstetrician, said Wendy Norvelle of the Southern Baptist International Mission Board, which runs the hospital.
He told authorities he did it to "cleanse his religion" and to "get closer to Allah." Ironically, according to the CNN report, it sounds like the hospital administration was about to be turned over to local authorities. posted by Sydney on
12/30/2002 08:36:00 AM
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Bend Over:DB has a post about Pennsylvania doctors receiving threatening letters - from the state government no less. The doctors in Pennsylvania are considering a work stoppage over their state’s malpractice insurance crisis:
"A stoppage of practice may be detrimental not only to your patients, but also to your practice, your standing amongst colleagues, as well as your license should your conduct be found to constitute abandonment," Weaver wrote. (Weaver is in charge of the office that licenses physicians)
In addition, some doctors got the following notice from the state licensing board:
Adding to the unease of Pennsylvania's doctors is a notice received by about 15,000 of them from the state's Bureau of Professional and Occupational Affairs.
The notification said that due to "unanticipated production problems" the doctors would not get their 2003 license, but rather "temporary" 120-day authorizations to practice medicine.
That would be unnerving - to be told on the one hand that if you limit your practice the state will consider you to be in violation of ethics rules, and on the other hand that your current license is only “temporary.” It’s all the more unnerving when you consider this:
Dozens of Scranton area doctors will effectively be off the job January 1st, when their malpractice insurance expires. According to state law, they can't practice medicine without it.
So, let’s see if I’ve got this straight. The physicians won’t have malpractice insurance come January 1, because they can't afford the premiums. They can’t practice legally without it, but if they follow the law and stop practicing, they’ll lose their licenses nonetheless. If politics is like an enema, then Pennsylvania just told its doctors to bend over.
If I were practicing in Pennsylvania, I know what my response would be. I’d be looking for a practice in another state. Preferably one with good tort reform laws on the books. Pennsylvania just insured that a work stoppage is going to be the least of their problems. Count on a surge of retirements and relocations in the coming year, and even worse, more long-term problems with access to care.
ADDENDUM: Meanwhile, in Mississippi, tort reform is a go:
Mississippi's medical malpractice reform law caps pain and suffering awards at $500,000, increasing to $1 million by 2017. Another law rewrites the state's product liability statutes, capping punitive damages at $20 million for the largest corporations. posted by Sydney on
12/30/2002 08:26:00 AM
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Right Start: Health insurance companies are offering more individual insurance policies:
Several insurers, including Medical Mutual, have recently started aggressively marketing their individual plans.
They're rolling out plans that give people choices. Consumers get to decide, for instance, whether they want a higher premium with more benefits or a lower premium with more out-of-pocket charges.
``It's about consumerism,'' said Kevin Lauterjung, Medical Mutual's market leader for individual products. ``It's about offering choices to folks.''
...Anthem recently expanded its individual health plan offerings and has seen enrollment jump 30 percent from last year.
One insurance executive explains why companies like to deal with employers rather than individuals:
Some insurers shy away from the individual market because it's less predictable and more labor intensive than group plans, which are typically offered through employers.
``It's much more predictable to enroll a group of 100 employees versus 100 individual contract holders,'' said Kevin Cavalier, vice president for sales and marketing for SummaCare in Akron. ``The margins skinny down a lot when you're working in the individual market place.''
But the individual market is showing some signs of growth, in part because more people are losing their jobs or choosing to open their own businesses.
And if you’re healthy, those individual plans are cheaper than employer-based ones:
For some people, individual plans can be more affordable than picking up the entire premium through COBRA, the law that protects people from losing their insurance when they lose their jobs.
One example: A healthy 30-year-old man with a family of three or more can get an HMO plan without a deductible for $357 a month or $4,284 per year.
By comparison, the average annual premium this year for an employer-sponsored health insurance is $7,957 for a family and $3,060 for a single person, according to Kaiser Family Foundation.
The problem is, if you're not healthy, the premiums are very high, because there is no "risk pool" for an individual. posted by Sydney on
12/30/2002 08:18:00 AM
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Surgery In Extremis: The writer who won a Pulitzer Prize for this World War II story, has died:
On Sept. 11, 1942, aboard the submarine Seadragon at a depth of 120 feet in the China Sea, Pharmacist's Mate Wheeler Lipes joined with a group of officers — none of whom was a doctor — for what was apparently the first major surgical operation ever in a submerged submarine.
In an operation that lasted 2 hours and 36 minutes, using a tea strainer covered with gauze as an ether mask and spoons as muscle retractors, they successfully removed the appendix of a crewman from Kansas, Darrell Dean Rector, who had been stricken the previous day.
"One by one, the sponges came out. One by one, the tablespoons, bent into right angles, were withdrawn and returned to the galley. At the end it was the skipper who nudged Lipes and pointed to the tally of bent tablespoons. One was missing. Lipes reached into the incision for the last time and withdrew the wishboned spoon and closed the incision.
"They even had the tool ready to cut off the thread. It was a pair of fingernail scissors, well scalded in water and torpedo juice.
"At that moment, the last can of ether went dry. They lifted up Rector and carried him into the bunk of Lieutenant Charles K. Miller of Williamsport, Pa. Lieutenant Miller alone had control of the ship as diving officer during the operation.
"It was half an hour after the last tablespoon had been withdrawn that Rector opened his eyes. His first words were, `I'm still in there pitching.' "
Cloning Update:The New York Times has this interesting revelation about the Raelian cult that claims to have cloned a baby:
Rael has also published a message from the Elohim asking "our last Prophet, Rael, to found a religious order that will bring together young women who wish conscientiously to put at the service of their creators and of their Prophets their interior and exterior beauty when we arrive at the embassy." "While awaiting our arrival," the message continued, "they shall prepare themselves for this day of such hope in placing themselves at the service of the Last Prophet, Rael, and in seeing to his well being when necessary." posted by Sydney on
12/30/2002 08:13:00 AM
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Adminstrative Efficiencies: In England, the NHS has gotten so top heavy that there are more administrators than hospital beds (link requires paid registration):
The National Health Service now has so many levels of bureaucracy that there are more administrators than hospital beds. Official figures reveal that for the 199,670 beds currently available
there are now 211,650 staff classed as managers, administrators or clerks ˜ an all-time high. Critics blame ministers‚ obsession with target- setting for the rise.
The growth of administrators employed to monitor NHS performance and progress towards the government's 300 targets, has seen the bureaucracy grow by almost 12,000 in the past year alone.
Figures released to Tim Loughton, the shadow health minister, show the number of senior NHS managers more than doubled in the past decade to 27,000, while the number of beds fell by almost 59,000.
“It is ridiculous. You cannot get through a morning‚s work without being interrupted by someone with a clipboard asking silly questions,” said a consultant at the Queen Elizabeth hospital in Birmingham which has more than 1,300 administrators for its 1,000 beds. (Thanks to a reader who must have subscription to the Sunday London Times)
More Consequences: And a lot of those administrators and appointees are of one political mind:
Some 599 – or 21.9 per cent of all appointees – were Labour, while 143 or 5.3 per cent were Tories, and 111 or 4.1 per cent were Liberal Democrats.
Liam Fox, the shadow Health Secretary, said there was still a "blatant bias" in favour of Labour. "It is everything to do with subservience to the party first, with a sense of duty to the local community a very distant second," he said.
...Dame Rennie Fritchie, the Commissioner for Public Appointments, issued a scathing report that described NHS appointments as "politicised in a systemic way".
She said political allegiance had been the "decisive factor" in the selection of a number of candidates as Frank Dobson, the former health secretary, sought to counter years of perceived Tory "cronyism" on trust boards. Between January 1998 and March 1999, the number of councillors on trust boards more than doubled, with 80 per cent being awarded to Labour supporters.
Another good reason to avoid both politicizing medicine and government-run healthcare systems. posted by Sydney on
12/30/2002 08:07:00 AM
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Choose Your Enema: The BMJ has an editorial in its most recent issue that posits the question of how political a medical journal should be. As medical journals go, the BMJ isn’t all that political, at least not by British standards. It is much more restrained than The Lancet which often publishes editorials of a decidedly leftist bent commenting on subjects that are only tangentially related to medicine - subjects like war and terrorism and the religious background of FDA commissioners. Compared to American medical journals, however, the BMJ is decidedly less restrained. The New England Journal of Medicine would never publish an editorial taking an active side in politics. They might comment on government health programs, but they would never comment on a decision to go to war, for example, or on the outcome of an election. And as for The Journal of the American Medical Association, its publisher fired an editor during the Monica Lewinsky scandal for publishing an old survey of no medical value that purported to show the majority of Americans thought oral sex wasn’t sex. They felt he had crossed the line between medicine and politics.
In contrast, here’s how the editorial staff of the BMJ feels:
Take the impending attack on Iraq, apparently over its possession of "weapons of mass destruction." How should we respond to the British and American governments' claims regarding Iraq's nuclear, chemical, and biological arsenal, or the Iraqi government's denials? Such weapons have undeniable consequences for health, which makes them our business. But taking the claims or counterclaims at face value, or declaring ourselves unconvinced by one side, or ignoring the dispute completely, are all equally political decisions. At a time when even National Geographic magazine is devoting 35 pages to weapons of mass destruction, readers might expect us to come to a judgment over the risks they currently pose. They might also expect us to beconcerned with the source of the anthrax used the last time a weapon of mass destruction was deployed.
It’s quite a stretch to take bombs and other weapons and make them a medical issue simply because we use them to hurt each other. By that logic, baseball bats would be medicalized. The editors must realize this on some intrinsic level, for to justify their very broad definition of medicine, they quote two old Prussians. The first is Karl von Clausewitz who famously said that "war is the continuation of politics by other means." The editors use him to justify their belief that the current war on terrorism ("phoney war" is the term they used) isn’t so much a matter of defense as of politics. They use the other Prussian to justify the politicization of medicine. That Prussian is Rudolf Virchow, the philosophical father of public health medicine, who said that “politics [was] nothing but medicine on a grand scale."
Interesting choice. Virchow’s philosophy of medicine was later taken to its logical extreme by his countrymen, when Prussia was no more. That philosophy became a central tenet of a German political movement that considered the state a biological unit and themselves its healers. One of its leaders described the political movement as “nothing but applied biology.” That leader was Rudolf Hess. That political movement was the National Socialist movement, more commonly known as the Nazis.
And, in fact, Nazi Germany is a good example of all that is wrong with politicizing medicine. Few German physicians opposed the politics of the Nazis. They enthusiastically embraced it. Many of its biological ideas were de rigeur in medical intellectual circles- eugenics and its spawn being chief among them. Those were the ideals of the times - and not just in Germany. In England and in America, the same sorts of ideas had gained hold. But thankfully in England and in America, medicine wasn’t politicized to the same extent as Germany. There was room to debate the issue in our journals and in our medical societies. There was no room for debate in Nazi Germany. For, when medicine is politicized, then the dominant political view wins all arguments. In Germany, doctors had one of the highest ratios for Nazi Party membership than any other profession, and their membership in the SS was seven times that of other academics. (Pretty sobering, isn’t it?) These were the doctors who were the heads of medical societies, the editors of journals, and the chairs of medical departments in the universities. They censured colleagues who disagreed with them. They even went so far as to supress research that contradicted their political beliefs.
In his book, The Nazi Doctors, Robert Lifton interviewed several of those German doctors. They aren’t monsters, but normal men who, guided by their politics, believed they were doing the right thing. They sincerely believed that their medical science upheld their political beliefs, when in fact it was their political beliefs that shaped their science. That’s how they became Hitler’s willing executioners. They had let politics trump medicine, and disgraced themselves in the process.
Granted, the editors of the BMJ and The Lancet don’t espouse the same beliefs as Nazis. But, the consequences of politicizing medicine are no different, whether the politics is right, left, or center. It clouds judgement, and it stifles dissent. It’s one thing to politicize a newspaper or a magazine - other newspapers and magazines, of different political bents, can challenge their views. It's quite another thing to politicize a medical society or a medical journal. Medical societies and medical journals aren’t the same as newspapers and magazines. It’s the role of medical societies to represent a wide range of physicians, of all political persuasions. It’s not their role to give a stamp of approval or disapproval to government policies - especially not policies that have nothing to do with the practice of medicine. It’s the role of medical journals to provide us with unbiased, well-done medical research on which to base our practice of medicine. It is decidedly not their role to serve as political mouthpieces - whether of the government or of its opposition, nor is it their role to serve as soapboxes for the political views of their editors. Leave politics to the politicians, for as another medicopolitical quotation puts it, “Politics is a choice of enemas. You’re gonna get it up the ass, no matter what you do.”
Choose Your Enema II: On a more local note, I received an email from my professional society, The American Academy of Physicians, suggesting that I discuss the importance of raising the Medicare fee schedule with my patients. The idea is that by lobbying my patients, I can get them to in turn lobby our Senators and Congressman to halt legislation that will lower Medicare reimbursement. I’m ashamed of them for suggesting it. The doctor’s office is not the place for political discussions. A doctor is there for one purpose and one purspose only - to serve the patient. Not to use his influence with the patient for his own political gains. It isn’t hard to imagine a patient interpreting that sort of lobbying as medical blackmail. If they don’t comply, or if they don’t agree, will the doctor continue to give them quality care? Or will he be prejudiced against them? Some things are just plainly wrong.Using the authority of the physician as a soapbox for what in the end is a purely political cause is one of them.
I’ll be more than happy to write my Congressman and my Senators. I’ll write a letter to the editor of the newspaper if they want. I’ll march on Washington if they ask. I’ll even volunteer to work on campaigns of sympathetic politicians. But I'll do all of that in my private role, not my professional one. And I’ll do all of that on my own time, not on my patients’ time. I refuse to beat them over the head with my politics. posted by Sydney on
12/29/2002 08:09:00 AM
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Rolling Over: A one month old baby in a British hospital was inexplicably found lying on the floor of her room:
Humara Ali was found with skull injuries, a broken leg and bruising, on the floor of the Airedale General Hospital.
Authorities aren’t sure what happened, but the hospital staff called police when they found her. I’m betting she rolled off the bed. Normally, the hospital beds for infants are big cribs, but the sides come down so you can examine the baby and take care of them. Someone probably neglected to put the sides back up. A one month old usually isn’t able to roll over yet, but I’ve seen this happen. Parents of newborns sometimes report they rolled off the changing table when their backs were turned. And one day, one of my partner’s patients fell off the exam table in the office. She was about two weeks old, and her mother got distracted by her other child while she was dressing the baby. Moral of the story: Even though newborns can’t roll over, they can still fall from heights. So don’t turn your backs on them. posted by Sydney on
12/29/2002 08:05:00 AM
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