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

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

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    Saturday, January 18, 2003

    Blog Tours: Charles Murtaugh has a post explaining the molecular mechanics of gene therapy and what has gone wrong with the two patients who developed leukemia after receiving it.

    Chris Rangel continues his lawyer rant.

    Both Derek Lowe and and Jane Galt take on the economics of those low-priced Canadian drugs. (By the way, Jane’s right about what it means for most seniors to “not be able to afford” their drugs, at least if my patient population is any indication. Most people who send to Canada for their drugs have plenty of money for discretionary spending. They just don’t want to pass up a good bargain.)

    And Cronaca has the tale of a witch being sued for malpractice.

    posted by Sydney on 1/18/2003 01:15:00 PM 0 comments

    Art History Lessons: An angel with Down’s syndrome (the littlest angel, next to Mary) from the 16th century. The BMJ has the analysis.

    And check out Out of Lascaux today. She has some links to new art blogs, a discussion of artist’s portraits of each other (Freund and Hockney; Gaugin and Van Gogh), and a rant on the removal from a US exhibit of artwork that combined the Buddha and the Koran.
    posted by Sydney on 1/18/2003 08:36:00 AM 0 comments

    Setting Limits: The Administration has told states that they can place limits on the amount of emergency care they cover under Medicaid. Critics decry the change:

    "It seems too weird . . . to say to a kid with asthma, you can only stop breathing three times a year,"

    But is that what they’ve said?

    In the four-paragraph letter to the states first reported by the New York Times, Dennis G. Smith, Medicaid director at the Centers for Medicare and Medicaid Services (CMS), wrote that the agency previously had told states that they may not limit Medicaid patients' emergency room visits and must pay for all days those patients remained in the hospital following emergency care.

    "This letter is to inform you that [the agency] is removing both of these requirements," Smith wrote.

    That’s not quite the same as telling someone they can only have an emergency so many times a year. That’s just telling them they can't expect the state to pay for every treatment sought through an emergency room. As many a busy ER doctor will tell you, not every treatment sought in an ER is an emergency. That’s why you sometimes have to wait seven or eight hours for treatment.

    But what about that bit about limiting the reimbursement for hospitalization? You would think that if someone needed hospitalization, then it was a legitimate emergency. Well, unfortunately not always. Sometimes people are admitted for "social reasons" - i.e. their family just doesn't want to deal with them anymore. Sometimes no medical ailment can be found but they insist that they're too sick to go home. With private insurance, unnecessary admissions like that can be avoided by pointing out to the patient and their families that they'll be responsible for the hospital charges. That doesn't fly with Medicaid patients, because Medicaid covers everything.

    Consider the case of Medicaid managed care, those programs that were touted in the 1990's as the solution to runaway costs. Previous rules said that Medicaid programs had to pay for ER services that any “prudent lay person” would acknowledge as justifiable. The problem is defining what a “prudent lay person” thinks. That has been difficult for Medicaid managed care companies to determine, so they end up paying for everything, then opting out of the Medicaid business, or worse, going bankrupt.

    I remember when Ohio began forcing Medicaid patients into managed care plans about six years ago. One of the managed care plans that our office accepted decided to give it a go, and it was a disaster. They stayed in it for about two years. They were admirably committed to access. Not only was I expected to do my usual duties - providing medical care, being available in the night for emergencies - but I was to call a cab for patients if they needed to go to the ER in the middle of the night. (The fare was paid by the managed care company.) The problem came in sorting out the emergencies from the non-emergencies. There were definitely a lot more calls in the middle of the night from the Medicaid patients. Calls for things like “I want to be checked out for VD” or “I think I have a yeast infection,” or “My child has had a runny nose all week.” Most of those calls quickly became adversarial when I tried my usual line of questioning about the symptoms to decide if it could wait for an office visit in the morning, or if they really indeed had an emergency and just weren’t expressing it as such. It was obvious that the callers’ one goal was to get authorization to go the ER, not medical advice, and my questions were seen as obstructions to that goal. (You see, it’s so much easier to go get care right now, when you’re thinking about it, you’re awake, and you’re not doing anything else at the moment. It’s quite another thing to call the office, make an appointment and to show up on time.) If I refused to authorize a visit, I usually got a call from the patient advocate at the managed care company the next morning, demanding an explanation. After a while, I gave up. I authorized everything. So did my partners.

    We still have Medicaid managed care here, but I don’t get those types of phone calls as much. That’s because the managed care companies have given up, too. They no longer require authorization for ER visits. Now, I just get ER reports documenting treatments for yeast infections and runny noses. I also get nagging letters from the managed care companies pointing out the ER abusers who have signed up with me. I want to know, how am I to change their behavior when none of them have once bothered to call the office or to stop by to set up an appointment?

    One thing for sure, if Medicaid is to remain solvent, they have to set some sort of limits.
    posted by Sydney on 1/18/2003 08:18:00 AM 0 comments

    Friday, January 17, 2003

    The Customer is Always Right: But the patient isn’t. A man in England is trying to force his doctors to give him a pap smear and he’s being aided and abetted in the attempt by the NHS administrators:

    A family doctor has been summoned to a formal hearing over his refusal to put a 34-year-old male patient on the list for screening for cervical cancer.

    The complaint has caused doctors in the west country practice to spend hours in meetings and writing replies to the local primary care trust over the complaint which began two years ago.

    ...One doctor in the practice said: "We are worried that the PCT is so falling over backwards to be patient-friendly, that it has gone too far the other way. Silly things are starting to happen."

    ... "The refusal of one of the doctors to put Mr X on the recall list for cervical sceening has resulted in a complaint and, as a result the doctor, practice manager and other practitioners have spent many hours, at the expense of the care of other patients, answering written inquiries.

    "My suggestion would be to accede unquestioningly to the patient's demand and carry out the procedure requested. Provided of course that a representative of the primary care trust could indicate the necessary part of this gentleman's anatomy, and was able to give the learned medics a clue as to how they could access it."

    Just goes to show you what happens when the healthcare system is run by people who haven’t a medical clue.

    posted by Sydney on 1/17/2003 08:00:00 AM 0 comments

    Lawyerly Reflections: Some reflections on the law and lawyers, from a lawyer:

    Musings such as yours on lawyers kept me in hot water during law school. The law in america is a 12th century construct with overlay of high middle ages guild thinking and a religious gloss over it. Lawyers can best be thought of as "free companies" ie mercenary knights of the 12-14th centuries. It believes in trial by combat(the adversarial process), the duty to zealously defend the client, no duty of the attorney to tell the truth(they are not under oath), a referee who can reverse any decision if it does not feel right ( equity taking the role of the archbishop), protection of the professionals
    (lawyers and judges) from the rules imposed on the rest of society(the serfs or us), and a refusal to acceed to control from outside the caste (the supreme court is always right, especially when its wrong). I often contended that the legal cannons are an almost perfect definition of evil, ie no
    responsibilty for any of your actions no matter how reprehensible(I was only following orders). The legal process has not yet come to grips with the enlightnment or scientific revolutions. Most legal process is indistinguishable from the process of the middle ages. A telling point on legal ethics is that all law reviews check each footnote in a legal article because of how commonly lawyers lie about facts. Anglo-american law holds that the highest right anyone has is the right to sue anyone else for anything. That actually trumps everything else. The judges view law written by the legislature as suggestions, after all only the judges can say what it really means. A bad legislative law can be reversed, reversing a bad supreme court is almost impossible.

    Yeah, and no one seems to be interested in reforming the legal profession. They cry foul at attempts to reform the tort system, but make no sort of motion to rein in the lawyers who abuse the system for personal gain. Consider, for example, the lawyer’s oath:

    I solemnly swear (or affirm) I will support the Constitution of the United States and the Constitution of the State of (insert state);

    I will maintain the respect due to courts of justice and judicial officers;

    I will not counsel or maintain any suit or proceeding which shall appear to me to be unjust, nor any defense except such as I believe to be honestly debatable under the law of the land;

    I will employ for the purpose of maintaining the causes confided to me such means only as are consistent with truth and honor, and will never seek to mislead the judge or jury by an artifice or false statement of fact or law;

    I will maintain the confidence and preserve inviolate the secrets of my client, and will accept no compensation in connection with a client's business except from the client or with the client's knowledge and approval;

    I will abstain from all offensive personality, and advance no fact prejudicial to the honor or reputation of a party or witness, unless required by the justice of the cause with which I am charged;

    I will never reject, from any consideration personal to myself, the cause of the defenseless or oppressed, or delay any person's cause for lucre or malice.

    So help me God.

    Now, how does that square with the legal advertisement on the back of my local phone book? The ad has in big bold lettering across the top: “Medical mistakes kill thousands,” and “Wrongful Death,” then underneath in bold letters - “Fight Back.” And, the lawyer says he makes free hospital visits. Of course, in the oath there’s plenty of wiggle room for a good lawyer. There’s an awful lot of “which appear to me” and “which I believe” in it. Perhaps the legal profession should set standards to which it could hold its lesser brethern.
    posted by Sydney on 1/17/2003 07:56:00 AM 0 comments

    Egregious Headline Award: Surgery tools left in estimated 1,500 patients a year. In reality, there were 54 patients in Massachussettes hospitals insured by the same malpractice insurance company who had sponges and surgical instruments left in them from 1985 to 2001. Or, put another way:

    Overall, the retention of a foreign body was a rare event. The incidence varied from 1 in 8801 to 1 in 18,760 inpatient operations at the nonspecialty acute care hospitals (the four principal hospitals and one other) insured by CRICO for which complete data on inpatient operations and claims and incident reports on retained foreign bodies were available throughout the period from 1990 through 2000.

    The 1500 per year figure comes from this unfortunate extrapolation:

    Overall, our results suggest that, given the 28.4 million inpatient operations performed nationwide in 1999, more than 1500 cases of a retained foreign body occur annually in the United States.

    It isn’t really valid to apply the findings of a small group of physicians and hospitals in one state to the entire nation. Nor is it valid to extrapolate data gathered from 1985 to 2001 to to all surgeries performed nationwide in 1999. From 1985 to 1999 there has been an explosion in surgical technology. Surgeries that were once routinely performed by opening the abdomen, such as gallbladder surgery and appendectomies were routinely done with laparoscopic techniques by 1999. Laparoscopes require only small incisions and the insertion of fiberoptic scopes into the abdomen. It would be extremely hard to leave behind a sponge or an instrument in those. The paper doesn’t reveal in what years their retained instrument cases occurred. It would be very interesting to see how many occured in the late 1980’s and early 1990’s before the widespread adoption of laparoscopic techniques.

    Of course, it’s important to make sure that nothing is left behind in any surgery. Counting instruments and sponges before and after a surgery is one inexpensive way to prevent this, but the study found that even in cases where the pre-surgical and post-surgical counts agreed, the stuff was left behind. The authors’ suggest that all emergency surgeries, open body-cavity surgeries, and all fat people have x-rays before leaving the operating room. They argue that the $100 cost of an abdominal film is far cheaper than the average $55,000 cost of settling a lawsuit. But, of course, it would cost far more than $100 per lawsuit avoided. It would cost $28.4 million X $100, or $2.8 billion to avoid $82.5 million in lawsuits. (at the high end). Limiting it to only the valid statistical estimate within the hospitals themselves would mean spending $1.9 million dollars in abdominal films to avoid one malpractice case settlement of $55,000. Of course, that cost would be passed on to the patient in higher surgery bills and eventually higher healthcare premiums.

    ADDENDUM: RangelMD has some thoughts on this, too.

    UPDATE: And here's a tale of medical equipment technician:

    When I was working on service of medical equipment, the machines were my "patients." I made it a point that the tool kits had "a place for everything and everything in it's place.." I learned this the hard way early on.

    One RT called me down to one machine and said, "When I started to set up for the first patient, there was a big 'Klunk' when I rotated the machine, so I brought the patient out of the room and called you.

    I checked things and quickly found that I'd left a flashlight in the machine when working very late the previous night. Carrying the offending instrument out of the room, I was asked by the waiting patient, (an old lady, with an accent reminding me of borcht,) "Is everyting ok now?"

    I explained that I'd left the flashlight in the machine the previous evening and she floored me with a statement I never forgot. "It's a good ting you're not a surgeon!"
    posted by Sydney on 1/17/2003 07:41:00 AM 0 comments

    Smallpox Vaccine Update: Liability protection, no federal compensation for side effects (that would have been a gold mine for trial lawyers), and offering the vaccine to war correspondents. All the smallpox vaccine news that's fit to print.

    And then there's this leaked report on the smallpox vaccine from the Insitute of Medicine, not exactly known for its lack of bias:

    A confidential draft of its report was obtained by The New York Times. A final, revised version is expected to be sent to the disease centers and made public next week, a panel member said.

    The panel member added: "I think it's saying the decision to vaccinate was essentially a political one, and there are a lot of scientific reservations about it. We were not asked to talk about the policy, but we're saying there are a lot of reservations and safeguards that need to be put in place."

    Hmmmm. Now who's being political here? The Bush Administration in offering the public the means to protect themselves from a potential bioterrorist threat, or the IOM member who leaked a confidential report to the Times before anyone at the CDC had a chance to read it? One more mark against the IOM's credibility.
    posted by Sydney on 1/17/2003 07:23:00 AM 0 comments

    Thursday, January 16, 2003

    Outrage: Iain Murray of The Edge of England's Sword has been fired for blogging. Just reinforces that management truly lives in a Dilbert world. Visit him and show your support.

    posted by Sydney on 1/16/2003 01:29:00 PM 0 comments

    What The...? What on earth would motivate a physician with a post at a university to lie about his bubonic plague specimens?

    Dr. Thomas C. Butler was arrested Wednesday on a complaint of giving false information to the FBI. According to U.S. Attorney Dick Baker, Butler said Tuesday that vials containing bacteria obtained from tissue samples from East Africa were missing when "truth in fact, as he well knew, he had destroyed them prior to that."

    According to the story, Butler is the chief of infectious disease at the medical school and has been working on bubonic plague for 25 years. You would think he'd know better than to pull such a stunt.

    UPDATE: This is why. Oh, what a tangled web we weave.
    posted by Sydney on 1/16/2003 08:34:00 AM 0 comments

    Healthcare 2004: South Knox Bubba has some thoughts on healthcare reform for the 2004 election. I would just add that we should keep in mind the advice of DB:

    ...as I write ad nauseum, the true cost of health care is increasing. The focus of our struggle with the health care crisis must be the TRUE cost. Improved technology, survival, medications all have costs. Are we willing to address them?
    posted by Sydney on 1/16/2003 08:21:00 AM 0 comments

    Correction: Charles Murtaugh emailed to say the Washington Post article on bubble boy gene therapy and leukemia was incorrect:

    I've been meaning to post something myself, but I wanted to look into the experimental details to see if, as you suggest, they might explain why this group seems have such bad luck compared to others. One thing that probably does not play a role is the nearness of the SCID gene to a potential oncogene. The viral vector integrates at random, not necessarily anywhere near the gene that causes the disease. However, if the virus (which carries the wildtype SCID gene, to cure the disease) lands near an oncogene, it can turn up expression of that oncogene and lead to leukemia. But this should work just as well in non-SCID cells, and with any virus, not only one used for gene therapy. In fact, researchers have recently had a field day using retroviral mutagenesis in mice (here and here.)

    It seems that that’s probably what happened. The researchers have a letter to the editor in today’s New England Journal of Medicine that they wrote before the second patient developed leukemia:

      One proviral integration site was found, located on the short arm of chromosome 11 within the LMO-2 locus, as determined with the use of linear-amplification mediated polymerase-chain-reaction analysis. This proviral integration within the LMO-2 locus was associated with aberrant expression of the LMO-2 transcript in the monoclonal T-cell population. Aberrant expression of LMO-2 has been reported in acute lymphoblastic leukemia arising from T cells with / receptors, usually with the chromosomal translocation t(11;14). Tests for replication-competent retrovirus were repeatedly negative in our patient's lymphocytes.

    After the child developed leukemia, they discovered a different translocation which may be responsible for the disease. Here’s the original paper describing the therapy. They mention in it that there were three different insertion sites for the gene in the patients treated, but don’t say where those sites were. They also used a “defective Moloney murine leukemia virus” as the vector for gene insertion. Could that have anything to do with the leukemia? I would have to defer to Charlie on that one.

    UPDATE: Charles Murtaugh says the retrovirus probably has nothing to do with it:

    Probably the fact that it was a leukemia virus isn't relevant -- I'm not sure about this particular human virus, but in mice, leukemia viruses cause the disease mainly by virtue of the genes they themselves carry, i.e. viral oncogenes. But as the researchers point out, if the genome of even an innocuous retrovirus integrates near a so-called "cellular oncogene," it can cause that gene to be transcriptionally upregulated, and drive uncontrolled proliferation. Cellular oncogenes are generally genes that promote normal replication, and as such they are under tight regulatory control to prevent abberant growth. If you pop a virus in there, this regulation can be disrupted. One unfortunate property of blood cells, actually, is that it is very easy to turn them cancerous, compared to solid tissue cells. I strongly doubt that gene therapy directed to, say, the liver would ever give rise to a spontaneous tumor.

    FINAL UPDATE: Charles Murtaugh emailed again to say the Moloney leukemia virus does cause cancer. (We should note that the research team used a defective version of it, that is one that's not supposed to be able to reproduce.) But, how defective are those samples used in gene therapy? Are they 100% defective, or are there a small percentage of active virus particles in the mix? For more on the Moloney virus click here.)
    posted by Sydney on 1/16/2003 08:08:00 AM 0 comments

    Wednesday, January 15, 2003

    JAMA's weekly art history lesson. (Bonus: Out of Lascaux’s art history lesson)

    posted by Sydney on 1/15/2003 09:23:00 AM 0 comments

    Condom Caper Update: More on the condom controversy.
    posted by Sydney on 1/15/2003 09:18:00 AM 0 comments

    Parenting Points: A report that more infants are sleeping in adult beds has apparently caused some consternation: .

    The results delighted advocates of families' sleeping together, who say it makes for closer parent-child bonds and more secure children. The same results worry safety experts, who say the practice causes suffocation.

    Is it just me, or does it seem strange that there are groups out there who make it their business to tell people how to sleep?
    posted by Sydney on 1/15/2003 09:16:00 AM 0 comments

    Gene Therapy Set Back: Another bubble-boy treated with gene therapy has developed leukemia:

    For the second time in four months, a child treated with an experimental gene therapy in France has developed a form of leukemia apparently caused by the treatment.

    The new cancer case, in a boy who was given new genes to cure a severe immune system deficiency, undercuts scientists' initial hopes that the first case was a fluke, and calls into question the value of the radical treatment, which had been promoted as the first successful use of DNA to cure a disease.

    At least it calls into question the use of gene therapy for this particular disease. Other gene therapies don't necessarily have the same risk:

    Nonetheless, Glorioso and others noted, no cases of leukemia have been documented in any of the thousands of other people who have received some form of gene therapy, which suggests that the risk may be specific to this particular disease or treatment plan. Researchers said they held out hope that they will learn how to modify the treatment so it can still be used in children born with the boys' life-threatening disorder -- severe combined immunodeficiency, or SCID. Affected children can die from even minor infections, and the only cure -- a bone marrow transplant from a well-matched donor -- is unavailable for many.

    One reason that it might be a particular problem for SCID therapy is that the gene for the disease is very close to a gene that helps prevent cancer. In both cases the cancer gene was disrupted by the gene therapy.
    posted by Sydney on 1/15/2003 09:01:00 AM 0 comments

    Improvements: Data suggest that the medical care of Medicare patients is improving, at least as measured by changes in certain treatments:

    Among the biggest gains were those made in the percentage of heart attack patients being sent home from the hospital with prescriptions for beta blocker drugs; that figure rose on average from 72 percent to 79 percent.

    Another notable improvement was in the percentage of Medicare patients receiving pneumococcal vaccines -- up from 55 percent to 65 percent.

    No cause for celebration, though, according to those who make their living following such trends. For example, why isn’t that rate of immunization against pneumonia higher?

    "All you have to do is give the darn vaccine, you can give it any time of year, there isn't a shortage, and we're still not there," Jencks said. "Health care systems are still far too tuned to treating the acute illness rather than prevention."

    That may be, but immunization rates against pneumonia will never be 100% simply because some patients refuse to have it. They aren’t Barbie dolls, after all, or even infants whose parents can be coerced with mandatory immunizations for public school entry. I have no idea how many elderly people decline the vaccine when offered, but I know in my practice it’s significantly higher than parents who refuse to immunize their children.

    (The full study can be had for free here.)
    posted by Sydney on 1/15/2003 08:52:00 AM 0 comments

    Tuesday, January 14, 2003

    Even the Bad Can be Good: Anthrax's possible role in cancer treatment.

    posted by Sydney on 1/14/2003 08:15:00 AM 0 comments

    Dodge: The story of a convenient religion that people can join to be exempt from state-required childhood immunizations. Members don't actually congregate. They just get a letter saying their church doesn't believe in immunizations. Other aspects of their founding theology:

    He founded the Congregation - which does pay taxes, he said - with three other chiropractors, who have since died. The most radical was Dr. Daniel J. Dalton, who preached that physicians were agents of Satan, pharmacy was witchcraft, and Western medicine evolved from worship of the Greek god Hermes and adopted his symbol, the caduceus, a snake-entwined winged wand.

    "I wouldn't say he was a fanatic, but that would give you a sense of him," Dr. Schilling said. "What other people see as Western medicine, we see as a state-imposed pagan religion.

    Yeah, right.
    posted by Sydney on 1/14/2003 08:02:00 AM 0 comments

    Small World: A couple of months ago I wrote a letter for a patient to persuade his insurance company to allow him to get some artificial ears from this guy. I didn't know anything about the company or the man at the time. My patient had just heard that he was less expensive and better than any other prosthetic maker. Turns out, the man used to make disguises for the CIA. Here's how he got his start:

    Pious and churchgoing as a kid (he's still both), he was also a bit of a hell-raiser -- a duality he dealt with by enlisting in the Marine Corps in 1965.

    He got out in 1968 after serving in Okinawa and went to work as an illustrator of military magazines at the Pentagon. One day, upset because his parking space was so far from the building, he forged a special permit and began parking up close with the generals. Someone turned him in, and at the trial the judge called him to the bench and whispered:

    "Damn good forgery." Two weeks later, the CIA called.

    And now he’s doing work like this:

    One of Barron's most challenging feats was helping Zahida Parveen, a pregnant Pakistani mother of four whose jealous husband, in a 1999 spasm of "honor violence," cut off her nose and ears and poked out her eyes.

    With Dufresne and maxillofacial prosthodontist Michael T. Singer -- the dentist Barron is working with on Bev's nose -- he helped restore her former beauty.

    (She'd never see her baby, Parveen was quoted as saying, but at least the child would see her mother as almost normal.)

    Trivia: What famous scientist also wore a facial prosthesis? (Click here for more.)
    posted by Sydney on 1/14/2003 08:00:00 AM 0 comments

    Celebrity Medical Watch: Queen Elizabeth's knee surgery and the Bee Gees' pain.
    posted by Sydney on 1/14/2003 07:59:00 AM 0 comments

    East Meets West: Legend has it that Japanese women don't have menopausal symptoms because they eat so many more soy products than we do in the West. That legend is myth:

    Many Japanese women have shocking stories to tell. At 51 Yuriko Yasuda started having terrible stomach pains, cystitis and dizziness. Her feet and hands became so stiff and numb that she could not even hold a pencil. She developed claustrophobia and fear of heights and speed. The first doctor she saw prescribed a different medicine for each ailment. The next gave her Chinese herbal medicines, but the symptoms continued. After much searching, she found a women’s hospital and was prescribed a variety and dosage of HRT that relieved her symptoms. Only women with extreme symptoms would think of visiting a doctor. Many suffer in silence.

    When Satsuki Kagiyama was 45, she began to feel weak, listless and suicidally depressed. She suspected the menopause but told herself to stop being self-indulgent. The last thing she wanted to do was to see a doctor. “Japanese gynaecologists are very rude,” she explains. “They are mainly men and talk very loudly so everyone can hear.”

    Eventually she developed cystitis and vaginitis and was forced to consult a doctor. “He said loudly, ‘It’s because you’re an old woman, it’s an old person’s disease’. The patients were all in one room, in curtained-off sections, so everyone could hear. Then he said, ‘I’ll prescribe something.’ He never told me what was wrong. Last May I had a breast cancer check. The doctor asked me what medicines I was taking. He had never heard of HRT and looked it up in a book.”
    posted by Sydney on 1/14/2003 07:56:00 AM 0 comments

    Cloning: Eve Tushnet has about the best reasoned argument against therapeutic cloning that I've seen:

    Now the fun begins. When it comes to reproductive cloning, pro-cloners are quick to argue, "A clone is just a twin!" After all, identical twins have identical DNA, but they're obviously two people, not one. We shouldn't worry that clones would have "previously lived genomes," because we don't worry that twins have "somebody else's genome." I agree that clones won't lead "somebody else's life." They won't be replacements for lost loved ones. They won't be drones or Xerox copies; they'll be distinct individuals, just as identical twins are distinct.

        But then doesn't the twin analogy work for therapeutic cloning as well? When it comes to therapeutic cloning, we're not supposed to even worry about when life begins, because after all, I'm just getting a kidney with my DNA, so it's a part of me. Sorry, that's just not true. The blastocyst from which I got the kidney, busily dividing and growing, is no more an appendage of mine than my identical twin would be. I can't offer it to science the way I might offer my fingernail clippings or my foot. If a twin is a clone, a clone is a twin, end of story.

    Read it all, including her piece on reproductive cloning.
    posted by Sydney on 1/14/2003 07:42:00 AM 0 comments

    Law and Medicine: DB's Medical Rants has the latest waves in the med mal crisis - now it’s New Jersey that’s starting to feel the pinch. (His comment section has a lot of good points, too.) Chris Rangel has a series of letters from a lawyer

    Lawyers have been on my mind a lot lately, and not just because of the medical malpractice crisis. It seems that everywhere I turned last week I was hearing about lawyers. First, I had a patient who was trying to get an auto insurance company to cover the physical therapy he had after an auto accident. The insurance company’s lawyer says his xrays show a chronic condition that’s responsible for his back pain. Trouble is, the “chronic condition” is nothing more than an anatomic variant. It isn’t a disease. It certainly didn’t cause his back pain after the accident. Don’t lawyers have an obligation to make sure their allegations are based on reality?

    In stark contrast, later day another patient came in who had been in a car accident a month ago. He said he “was told to get himself checked out.” (I’m guessing he answered one of those mailings that people get from personal-injury lawyers after accidents.) He really had no physical findings on exam, and had minimal complaints. Yet, as he left, he said he hoped to “get something out of it.” Grrrrrrr.

    But the most nettlesome case is a patient who I suspect is getting ready to sue me. She doesn’t realize it yet, but that’s what’s going to happen. She thinks that she’ll just be suing the hospital. But my name’s on that hospital chart, and sure as shootin’ I’ll be dragged into it. She’s angry about a recent surgery she had. I haven’t been able to get a good grasp of what it is that she’s so upset about, at least not medically. She had some respiratory complications afterwards, but she was treated appropriately and nothing bad happened to her. Her surgery resulted in the desired outcome. No problems there. Yet, every time she comes into the office for something she vents about the hospital. She got her records. Her son is going over them with a fine tooth comb. Her daughter-in-law says this. Her pastor says that. The only consistent complaint I hear each time is that “they” were rude to her pastor. (I’m not sure what “they” did, but I think that a nurse tried to explain to her pastor that she wasn’t at liberty to divulge any information about the patient, since he wasn’t a family member.) Yet, that is the crux of the matter. Her final salvo is always, “Besides, they were rude to my pastor.” This is the sad truth about many, perhaps most, malpractice cases. They begin in anger over something that usually has nothing to do with medical care. Or, they have their origins in second-guessing by relatives and friends.

    So why is it that one lawyer can misuse medical information to thwart a valid claim, and another can file suit where there is no injury? Why is it that they can exploit misplaced anger so easily? Shouldn’t they hold themselves to a higher standard?
    posted by Sydney on 1/14/2003 07:38:00 AM 0 comments

    Monday, January 13, 2003

    Genomic Primer: Chapter Three in the New England Journal of Medicine's primer on genomic medicine. (It appeared two weeks ago, but I forgot to link to it.)

    posted by Sydney on 1/13/2003 08:33:00 AM 0 comments

    Blame Mom: Researchers say that moms who eat high-fat diets in pregnancy damage their kids. Oh, wait. Their work didn't actually involve people or the food we eat:

    Researchers found that rats fed a diet rich in lard - and similar to that provided by an over-reliance on fast food - were more likely to produce offspring that developed cardiovascular problems.

    The rats were fed either a standard breeding diet or a diet rich in animal fat before and during pregnancy.

    Their offspring were fed a normal healthy diet, and were closely monitored for changes to their heart rate and blood pressure.

    By middle age, both male and female offspring showed signs of blood vessel damage, with abnormal levels of fat in the blood.

    High blood pressure was only recorded in female offspring.

    Can't assume that applies to people. After all, the majority of people with heart and blood pressure problems today were in the womb long before McDonald's was the rage.
    posted by Sydney on 1/13/2003 08:30:00 AM 0 comments

    Seeing is Believing: A British electron microscopist makes the argument that electron microscopy could be used for identification of smallpox (free registration required.):

    Unequivocal laboratory confirmation is essential when far-reaching decisions depend on it and such diagnosis has been based on electron microscopy, gel diffusion, and egg or cell-culture inoculation, backed up in recent years by nucleic acid amplification methods. To get a reliable answer, and anything less is virtually worthless, all these methods except electron microscopy require time, mostly measured in days to complete, and all require skill and current experience in doing the procedure. Moreover, all except electron microscopy require the prompt availability of reagents or systems not now in routine use.

    ...Electron microscopy can provide a specific answer either way ("This is definitely a poxvirus", or "Definitely a herpesvirus") and the result can be available within 30 min from receipt of the specimen. This method, therefore, answers both requirements fully and should be the method of choice. All other techniques demonstrate, with varying but less than 100% certainty, the spoor of the virus rather than the culprit itself.

    Not a bad idea, although I don’t know how easy it is to distinguish the two types of viruses. Electron microscopes are much more plentiful across the nation than special virology labs. The operators would just need training to correctly identify a pox virus. And training the operators would be much cheaper than building labs.

    He also provides this chilling account of what could happen when the diagnosis is missed:

    Making a clinical diagnosis, and, in particular, differentiating smallpox from varicella, is difficult even when those concerned are seeing both diseases regularly. On at least two occasions (Knightswood, Glasgow, in 1950, and Burnley in 1956 [A W Downie, personal communication]), smallpox was incorrectly diagnosed clinically as varicella, with tragic consequences in Knightswood when 17 nurses and other contacts caught the disease and five died.

    Pretty sobering.

    UPDATE: Here’s an electron microscope image of a herpes virus and here’s the cowpox virus.
    posted by Sydney on 1/13/2003 08:21:00 AM 0 comments

    Dr. Death: Australian suicide doctor, Phillip Nitschke had his suicide machine confiscated by Australian custom officials as he tried to leave the country for the Hemlock Society conference in the United States. I'm surprised they let him leave. Isn't he being investigated for a suspicious death?
    posted by Sydney on 1/13/2003 08:19:00 AM 0 comments

    Cure or Cause? The New York Times Magazine had an excellent article on rebound headaches yesterday. These are headaches that are caused by taking pain medication, usually ironically enough for headaches, every day. When the drug wears off, the headache gets worse, so more drugs are taken, in a viscious cycle. (For a brief synopsis of rebound headaches, click here. For a more detailed account of treating rebound headaches, click here.)
    posted by Sydney on 1/13/2003 08:19:00 AM 0 comments

    NHS in the End Times: I've been reading P.D. James's
    The Children of Men
    , which imagines life in a world where everyone is infertile. Here's her imagined NHS solution to the problem, (in addition to mandatory semen testing and periodic gynecological exams of people of childbearing age):

    Our interest in sex is waning. Romantic and idealized love has taken over from crude carnal satisfaction despite the efforts of the Warden of England, through the national porn shops, to stimulate our flagging appetites. But we have our sensual substitues; they are available to all on the National Health Service. Our ageing bodies are pummelled,stretched, stroked, caressed, anointed, scented. We are manicured and pedicured, measured and weighed. Lady Margaret Hall has become the massage centre for Oxford and here every Tuesday afternoon I lie on the couch and look out over the still-tended gardens, enjoying my State-provided, carefully measured hour of sensual pampering.
    posted by Sydney on 1/13/2003 08:18:00 AM 0 comments

    Sunday, January 12, 2003

    The Other Foot: Stuart Buck at The Buck Stops Here, shreds the New York Times editorial that claims there's a war against women going on in this country. (Condom Wars? War Against Women? The editorial board of the Times could be accused of war-mongering.) And he imagines how a similar editorial would be written about the pro-choice political agenda.

    posted by Sydney on 1/12/2003 04:56:00 PM 0 comments

    Condom Capers Continued: Justin Katz has dug up the old condom fact sheet. As suspected, it's overly enthusiastic about condom efficacy. In fact, it cites in detail the paper from The New England Journal that I linked to in the original post. You know, the one that the editors cautioned shouldn't be used to justify making condoms the mainstay of STD and HIV prevention because of the inconsistent use even among motivated couples? Justin also has a biting analysis of the Kristof column.

    (Ed. note - Yes, I came back later and changed "sites" to "cites".)
    posted by Sydney on 1/12/2003 08:22:00 AM 0 comments

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