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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.

    "Opinions are like sphincters, everyone has one." - Chris Rangel

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    Saturday, February 01, 2003

    In Memoriam

    posted by Sydney on 2/01/2003 11:03:00 AM 0 comments

    Friday, January 31, 2003

    Insult: A report put out yesterday by the American College of Obstetricians and Gynecologists that summarizes the state of the research on cerebral palsy since 1985 concludes that most cases aren't preventable. They aren't all due to negligent doctors letting babies go through unwarranted stress during delivery. Most of them are due to problems the baby had in utero. The consequences for trial lawyers and obstetricians are immense:

    Obstetricians face more suits than any other specialty, more than two per career on average, and claims for neurologically impaired infants make up 30 percent of them, according to the American College of Obstetricians and Gynecologists. The average award by juries in such cases is about $1 million, the college says.

    About 8,000 babies are diagnosed each year with cerebral palsy, a chronic condition involving problems with muscle control that can include difficulty walking and speaking. Overall, about a half-million Americans have the disorder.

    That means that cerebral palsy is an $8 billion a year industry for malpractice lawyers. Predictably, they aren't happy:

    ''I see the sole purpose of this report as to give defense experts a document that they can cite in the courtroom in their efforts to convince jurors that negligent medical care does not cause cerebral palsy,'' said Dov Apfel, a Maryland-based plaintiffs' lawyer and specialist on birth injury cases. ''This is not a medical research paper.''

    Lee Tilson, another malpractice lawyer, called the report ''dangerous, intellectually indefensible, and morally irresponsible.''

    ''By promoting the argument that [fetal distress in labor] almost never causes brain injury to the fetus, this publication may cause obstetricians to ignore early signs of fetal distress in labor,'' he said in a statement.

    Well, that's not what the report says. It says that cerebral palsy is almost never caused by fetal distress in labor. The two aren’t the same. But then, distinctions like that are often lost on malpractice lawyers.

    posted by Sydney on 1/31/2003 06:39:00 AM 0 comments

    Vegan Warnings: Strict vegetarians who breastfeed may be putting their babies at risk of vitamin B12 deficiency, and developmental delays. (The details of the two cases can be found here.)
    posted by Sydney on 1/31/2003 06:06:00 AM 0 comments

    Consequences: About half of US doctors say they'll limit Medicare if cuts in reimbursement go through (requires registration):

    A total of 985 physicians completed the online survey, which was conducted in December 2002.

    If the cut occurs, 61% of primary care physicians and 44% of specialists surveyed said they would impose new or additional limits on their practice devoted to Medicare patients, according to the report. In addition, 60% of physicians said it has become increasingly difficult to find suitable specialists who will accept Medicare patients.

    Seventy-one percent of physicians surveyed said that they would make changes that could adversely affect treatment access, such as discontinuing certain patient services.

    I know it’s an online survey, and not to be trusted, but there you go.
    posted by Sydney on 1/31/2003 06:05:00 AM 0 comments

    Yikes: I like to think I have a fairly open mind, and I admit the importance of the topic of this story, but I really could have done without seeing that photograph. Not all nudity is beautiful.
    posted by Sydney on 1/31/2003 06:03:00 AM 0 comments

    Americanizing the NHS: In the wake of Dr. Shipman, the English doctor who so easily dispatched his annoying patients, the British are considering coroner investigations for every unexpected death. At least one doctor contemplates the possible consequences:

    General practitioners are faced each day with the possibility that a patient they are treating will die unexpectedly in the near future. Handling this uncertainty humanely and efficiently is part of our skill. If we as general practitioners are going to face regular medical coroner's investigations, looking for the all encompassing "incidents of medical error," our practice will change profoundly. We would be much more willing to offer further investigation or referral, even when the chances of benefit to the patient seem slim. We would also insist on long (probably 20 minutes) consultations to minimise the possibility of any medical error and to make very detailed records.

    We already practice medicine that way in the United States, not out of fear of the coroner, but out of fear of the trial lawyer.
    posted by Sydney on 1/31/2003 06:02:00 AM 0 comments

    Thursday, January 30, 2003

    Acrylamide Reprieve: Researchers say that acrylamide in food isn't a problem.

    posted by Sydney on 1/30/2003 08:44:00 AM 0 comments

    Self-Promotion: I have a Tech Central Station column up about technology, abortion, and life's dominion.
    posted by Sydney on 1/30/2003 08:39:00 AM 0 comments

    Cow Pox: With all the attention focused on smallpox vaccine, we forget that the virus in the vaccine, vaccinia, is still present in the natural world. The New England Journal today has a case study of girl who got cowpox (sorry requires subscription) from a cat who hung around cows:

    A nine-year-old girl living in a rural area who had no known exposure to cows presented with a two-week history of several painful lesions on her left forearm where she had been scratched by a free-roaming cat. Two days after the scratch, small vesicles had appeared. Within two weeks the lesions turned to pustules and then enlarged to painful, ulcerated nodules up to 2 cm in diameter and ulcers with black eschars. The patient had fever, malaise, and night sweats.... A serum sample from the child was positive for orthopoxvirus antibodies on neutralization assay and competitive enzyme-linked immunosorbent assay.

    She's doing fine now.
    posted by Sydney on 1/30/2003 08:36:00 AM 0 comments

    Giving Your All: Gruntdoc has an excellent post on the nuances of organ donation.

    And here’s a true story about live organ donation that turned out to benefit the donor as much as the recipient. My cousin donated his kidney. When the surgeons were placing it into the recipient, they felt a tiny nodule on its surface. He had been fully screened with all matter of scans and blood tests, and nothing had shown up. They biopsied it, sent it for a frozen section, and sure enough it was cancer. They had a dilemma. Both patients were under anesthesia. It was a small tumor. They were pretty sure they got it all, but couldn’t be certain the cancer wouldn’t come back in the future, especially in a recipient on immunosuppressive drugs. Did they put the kidney back whence it came, or go ahead and transplant it? They transplanted it. My cousin was most certainly saved from kidney cancer. And the recipient? Well, the recipient was his mom, my aunt. She’s glad to have a working kidney. And she says, if she gets kidney cancer, so be it. She figures it’s the second time she’s given him the gift of life.
    posted by Sydney on 1/30/2003 08:30:00 AM 0 comments

    Secrets of Life: The National Museum of Health and Medicine has an exhibit of MRI and CT scan images of the developing embryo. Here’s one at 44 days, and one at 56 days. And here’s the the moment of conception. They’re amazing images, and all very experimental at the moment. But, they pull back the veil from the secret life of the womb. Who knows, someday they might be as commonplace as ultrasounds are now.(These were done on preserved embryonic specimens, supposedly not the products of abortions. Except for the egg and sperm picture. That was done on a living patient at an in vitro fertilization clinic.)

    The creator of those images was interviewed last night on Fresh Air. Interestinginly, he mentioned that making those pictures changed his views about abortion, although he seemed afraid to come right out and say he was against it.

    UPDATE: Susanna Cornett has some trenchant observations on the sperm and egg link above.
    posted by Sydney on 1/30/2003 08:28:00 AM 0 comments

    No Language but a Cry:I linked quite some time ago to a review of The Happiest Baby on the Block, by California pediatrician Dr. Harvey Karp. I pointed out what some of the tougher critics had said about it, and what others who liked it said, and concluded that the truth was probably somewhere in between. Well, now I've read the book, and I can tell you the truth defintely lies somewhere in between.

    Dr. Karp would like us to believe that he's hit upon the absolute cure for infant colic. That after "exhaustive research" he's discovered the secrets that have alluded Western parents for ages. All we have to do is read his book, and watch his video, and do everything exactly right, in the right combination.

    And what is Dr. Karp's groundbreaking discovery? There are two of them - the "fourth trimester" and the "calming reflex". Both are based on pop anthropology - the belief that primitive societies are bastions of goodness and truth, where no baby cries and every parent is happy.

    Dr. Karp looks at primitive socieites and sees that they carry their babies around more than we do, which is true. They have to do more manual labor than we do and don't have the luxury of baby-sitters. He believes that babies in these primitive societies don't cry as much as Western babies. That may not be true. Their parents might just not be so bothered about the crying - they're too busy working hard to survive. He theorizes that human babies weren't meant to be born at forty weeks, but much later. Our larger brains have made it necessary for us to be born prematurely. Primitive socieites realize this and thus carry their babies around with them as if they were still in the womb.

    The first couple of months of life is his "fourth trimester" when we're really meant to still be inside the womb incubating. So, what newborns need is to have the environment of the womb recreated as closely as possible. Doing this will kick in his other invention, the "calming reflex."

    This "calming reflex", according to Dr. Karp, is a fetal reflex that keeps a baby from twisting and flailing around in the womb so they don’t get caught in their umbilical cords. It's supposedly brought about by the motion of the mother as she goes about her daily activities. There's only one problem. Dr. Karp offers no studies on fetal movement to back this up, and there are plenty of cases in which children are born with umbilical cords wrapped around their necks or their bodies. Sometimes, the cord is even tied in a knot. The reflex is a pure product of his imagination.

    Although the "fourth trimester" and the "calming relfex" are more theory than certitude, the suggestions that Dr. Karp offers based on these theories, do have some merit. They just aren't the groundbreaking revelations that Dr. Karp portrays them to be. He calls them the 5 "S's". First and foremost is swaddling, the ancient art of tightly wrapping a newborn. Although swaddling is a technique that hasn't been widely handed down in modern generations, it is something that every hospital nurse who cares for newborns knows how to do quite well. And it works. The others are placing the child on his stomach or his side; "shhhing", sometimes very loudly in their ear; swinging as in those infant swings or some other back and forth motion; and sucking as in pacifiers. Not much different than the advice of good old Dr. Spock. Or what you see many parents do as they try to calm their crying baby. The difference, Dr. Karp says, is that you have to do them in the right order and in just the right way, which he is happy to demonstrate for you in his video ($18). Of course, it may take a few weeks to work, he's careful to point out. Then again, colic usually subsides on its own after a few weeks, too.

    So does the Harvey Karp method work? Who knows. He offers many testimonials that suggest they do. But, it's difficult to take testimonials at their word. It's doubly difficult to take testimonials peppered with exclamation marks seriously. And when those testimonials are from celebrities? Forget about it.

    This isn't to say that Dr. Karp's book and video aren't useful. Life with a baby with colic can be a living hell. For parents living in such a situation, Dr. Karp provides help that they may not get anywhere else. Just don't expect miracles. And don't blame yourself, or the baby, if it doesn't work. In the end, no one really knows what causes colic. Not even Dr. Karp.

    (Also appearing at Blogcritics.)
    posted by Sydney on 1/30/2003 08:24:00 AM 0 comments

    Wednesday, January 29, 2003

    JAMA Break: JAMA is on vacation this week, so here's an art history lesson from an issue in 2001.

    ADDED BONUS: Microscopic pictures of snowflakes by Bentley, and Food As Art; Art As Food by 2blowhards.

    posted by Sydney on 1/29/2003 06:41:00 AM 0 comments

    Fighting Chance: Jane Brody has some sensible advice for children confronted by a would-be abductor (taken from this video):

    The tactics can make it possible for even a 5-year-old to get away from a full-grown man. For example, a child may be able to use her fingertips to strike a man in his eyes and follow that with kicks to the groin.

    If a child's mouth is being held shut, sometimes the man's fingers can be bitten hard. Or, if the child is being held with a rear bear hug, a head butt followed by a hand strike to the groin or a stomp on the top of the foot could give the child an opportunity to escape. Then, if the child cannot outrun an aggressor, it may be possible to avoid being captured by ducking under a parked car.

    Other tips include ways to avoid being shoved into a car or, if trapped in a car, how to disable the driver or the vehicle, causing an accident that would attract attention. Or, if abducted into a car, the child should try to jump into the back seat and escape through a back door. A child who is locked in a trunk should push out the taillights so that the wires hang outside the car.

    Tell children that if they are ever abducted, they should never stop fighting and looking for ways to escape. Several months ago, a 7-year-old girl was rescued after being tied up in a basement with duct tape over her mouth. She chewed through the tape, broke a window and called out for help.

    This has been our standard advice for the Medpundit children. In fact, last summer when my youngest went to Safety Town, the teacher asked the kids what they would do if a stranger tried to grab them. My son raised his hand and volunteered, “Fight to the death!” His teacher scolded him, “No, no, no. Run away.” But what if a child can't run away? I told him that if he can't run, he needs to fight. The school has evidently changed its approach, because just a few weeks ago, they offered something called “Escape School” to teach kids how to dodge and fight abductors. My kids didn’t get to go,they had other activities that night, so I can't tell you what it was like. But it sounds like better advice than my son got at Safety Town.

    As Glenn Reynolds would say, a pack not a herd.
    posted by Sydney on 1/29/2003 06:34:00 AM 0 comments

    Penmanship: Loxosceles was browsing the library when she found a book called The Physician Throughout the Ages and noted this:

    Chapter titles attempted to summarize the short chapters. I was amused to see that it was not until page 122 of Volume Two that "Doctors Develop Writing Abilities." Heh.

    Well, some of us developed them anyways.
    posted by Sydney on 1/29/2003 06:30:00 AM 0 comments

    Genetic Revolution: Researchers have coaxed liver cells to change themselves into pancreatic cells :

    A study using frogs hints that one day portions of diabetics' livers might be converted into pancreas tissue in the lab to restore healthy, insulin-producing cells, so that their bodies can store nutrients properly.

    UK researchers have made tadpoles grow pancreas tissue from their liver cells, and turned human liver cells into pancreas cells in the lab1.

    ...During embryo development, liver and pancreas cells grow from similar, adjacent tissues. In mice and humans the gene Pdx1 is essential for a pancreas to form. It codes for a protein that directs others in the cell - in a sense it gives the cell its identity.

    "We thought if we can find the master-switch gene for pancreas and somehow deliver it to liver cells, we could transdifferentiate liver into pancreas," Horb explains. So they put activated Pdx1 into frog embryos. Liver cells that had the gene converted into pancreas. In some tadpoles the whole liver was converted; in others just a few cells switched.

    Now, if they can just figure out if the effect lasts more than a few weeks, if it works in the human body, if they can control the amount of insulin and amylase the new cells produce so as not to overdose a person, and if the gene doesn't turn the cells into self-reproducing cancer cells, then this might work as a treatment for diabetics. Someday.
    posted by Sydney on 1/29/2003 06:28:00 AM 0 comments

    Second Hand Allergies: A liver transplant recipient caught a peanut allergy ( and a cashew and sesame seed allergy, too) from his new liver. This is the second case of peanut allergies being transmitted by a donated liver. In both cases, the donor died of his allergies. Guess that’s one more thing that needs to be screened for before organ donating. (Thanks to David at Cronaca.)

    And for the peanut-sensitive out there, don’t forget that kissing can be hazardous, too.
    posted by Sydney on 1/29/2003 06:26:00 AM 0 comments

    Narrow Window: Sleep too much, sleep too little, sleep just right and maybe lower your risk of heart disease:

    Researchers examined 10 years of data on 71,617 participants in Harvard's Nurses' Health Study, which tracked female nurses for a variety of studies. The women were ages 45 to 65 and had no sign of heart disease at the outset in 1986. Over 10 years, 934 of the women had nonfatal heart attacks or died of heart disease.

    The study relied on the nurses' recollection of their sleep patterns rather than directly measuring their sleep.

    The study expressed the results in terms of relative risk, not absolute numbers, but they found that more women had heart attacks who slept less than five hours and more than nine. What about those of us who sleep less than five hours some nights and more than nine other nights? Isn’t that the way most of us live?

    And that’s one of the problems with this study. They relied on the subjects' perceptions of how much they sleep, which for most of us varies from night to night. And perceptions are notoriously unreliable. I'm reminded every day of just how unreliable recall and self-evaluation is. Our practice has begun administering a nutritional screening survey to patients. One of the questions is "Have you lost or gained more than ten pounds in the past six months?" I'm constantly surprised at how many people answer that in the affirmative when their measured weight as recorded in their medical record hasn't changed at all. Our perceptions aren't nearly as reliable as we think they are, even when they concern something that should be wholly objective.
    posted by Sydney on 1/29/2003 06:23:00 AM 0 comments

    New Business: Now here's an idea, paying people to surf the net for you. In this case, it's to sort the good from the bad in medical information and trials. But how do you know they know what they’re doing? You don’t:

    "The whole concept is great if the people doing it are honest and not taking any kind of kickback," Dr. Logan-Young, the radiologist, added. "How do you know they are not paid to select certain articles over others? There is plenty of potential for problems."

    For those of you who don't want to fork over $150 for such a service, the NIH has a webpage that provides a good start for everything from finding clinical trials across the country to support groups, to basic disease information. And it's free. And it's more reliable than a stranger.
    posted by Sydney on 1/29/2003 06:11:00 AM 0 comments

    Tuesday, January 28, 2003

    Medical History: Lenin's stroke.

    posted by Sydney on 1/28/2003 07:17:00 AM 0 comments

    Reactive: C-reactive protein, that hot new test which is hyped so well by its lead researcher (and patent holder) has been scrutinized by the American Heart Association. Their recommendations? Depends on which account you read. ABC news (via the Associated Press) says the AHA proclaimed, "Docs Urged to Test for Heart Inflammation", but UPI gets the story right - "Experts downplay heart test value":

    A new and widely used blood test might be of only limited value in assessing heart disease risk, experts reported Monday.

    In an article to be published in the Jan. 28 issue of the journal Circulation, a panel convened by the American Heart Association and the Centers for Disease Control and Prevention concluded that the C-reactive protein, or CRP, test be used only in addition to cholesterol testing and blood-pressure screening and only in specific diagnostic situations

    ...The panel members emphasized they do not consider the new test as diagnostically important as cholesterol testing or high blood pressure screening. For most patients, they concluded, the emphasis must remain on detection, treatment, and control of the major risk factors, such as high blood pressure, high blood cholesterol, cigarette smoking and diabetes.

    To be fair, the ABC story mentions that the test isn’t recommended for widespread screening, but you have to read through five paragraphs to get to that part.

    The guidlines are here, and they mention the following drawbacks:

    -Current assays are not specific for atherosclerosis and thus are not useful in the setting of other systemic inflammatory or infectious processes.

    -..there remains much to learn about optimizing its application to risk assessment.

    -On the basis of the available evidence, the Writing Group recommends against screening of the entire adult population for hs-CRP as a public health measure.

    -At the discretion of the physician, the measurement is considered optional, based on the moderate level of evidence (Evidence Level C). In this role, hs-CRP measurement appears to be best employed to detect enhanced absolute risk in persons in whom multiple risk factor scoring projects a 10-year CHD risk in the range of 10% to 20% (Evidence Level B). However, the benefits of this strategy or any treatment based on this strategy remain uncertain.
    [emphasis mine]

    -These recommendations should not be interpreted to mean that the scientific evidence is fully adequate. Randomized trials in which inflammatory marker testing was the primary intervention have not been performed to provide Level A evidence, nor have cost-effectiveness analyses been completed to assess additional costs or cost savings through the use of such tests.

    Hardly an urgent call to test for heart inflammation. Someone at the Associated Press (and ABC) needs to take more care when reading press releases
    posted by Sydney on 1/28/2003 07:11:00 AM 0 comments

    New Antibiotic: And it’s all “natural” for it comes from the human gut:

    Researchers have found a potent antibacterial protein that is made naturally by the human body.

    The protein, dubbed Ang4, is created by cells in the intestines, according to a study published in the advance online version of the journal Nature Immunology.
    [it’s so advanced it hadn’t appeared online as of last night - ed.]

    ..."We showed that Ang4 kills many different types of gut bacteria," said Hooper, a researcher at Washington University School of Medicine in St. Louis, Missouri. "We think that Ang4 is part of the arsenal that use to keep bacteria from getting too close to the intestinal lining and causing damage."

    Hooper and her colleagues also found that Ang4 was a potent killer of a type of bacteria called listeria monocytogenes, which has been implicated in recent cases of severe food poisoning.
    posted by Sydney on 1/28/2003 06:58:00 AM 0 comments

    Life Stresses: A very small study of premature babies found that those stressed at birth don’t learn so well later in life:

    The small-scale study, from two universities in the US, aimed to provide some answers by comparing the progress of two sets of premature babies - all born at or before 36 weeks - based on a test taken in the first few hours after birth.

    This measures the acid levels of the blood, and higher levels are a good indicator that the baby has been starved of oxygen at some point during delivery.

    Half of the 52 children had normal blood test results after birth, and half had "mild to moderate acidosis" - a slightly higher reading, but not one usually associated with a longer-term impact.

    At the age of six, however, these children scored lower on verbal and "visuospatial" tests than the unaffected children. Researchers described it as "a large discrepancy".

    The article doesn’t say how low those children scored. Neither does the abstract. It’s hard to say how significant the difference in intelligence testing was. Researchers, you know, are prone to note “large discrepancies” in statisitcally small differences to boost their papers’ visibility. Reading this, you come away with the impression that premature babies end up stupid. This isn’t necessarily true. The same sort of findings could be equally applicable to babies born at term. They undergo the same stresses during birth. The only difference is that no one measures their acid levels (unless they come out really sick.)
    posted by Sydney on 1/28/2003 06:51:00 AM 0 comments

    Little Big Prince: King Edward (the one who married a divorced American and gave up his crown) had a brother who had evidently been forgotten by the public. He had epilepsy, and possibly autism. And he was very large:

    Prince John was born on 12 July 1905 and at first appeared to be a normal child Unlike his rather nervous elder brothers Edward, the future King Edward VIII , Albert, the future King George VI, Henry, Duke of Gloucester and George, Duke of Kent, John possessed a happy disposition., and was a plentiful source of the quaint and amusing childish sayings parents love to treasure. But before long, it was clear that John was growing too quickly. By the time he was 12, he could be fairly described as a 'monster boy'. He was already severely epileptic and was therefore subject to a frightening disorder which struck and felled its victims without warning.

    When his parents celebrated their Silver Wedding anniversary on 6 July 1918, six days before his thirteenth birthday, Prince John was notably absent from the family photograph taken at Buckingham Palace for the occasion. Instead, since 1916, he had lived in his own separate establishment, Wood Farm at Wolferton near Sandringham in Norfolk. There, he was cared for by his nurse Mrs. ' Lalla ' Bill and a male orderly, separated from his family and safely out of the public eye.

    Sounds like the prince may have had a pituitary tumor. How horrible it must have been to suffer from disease in the days before safe mass-produced drugs, MRI scans, and easy chemical assays for testing hormone levels in the blood. Prince John died at the age of 14 after a prolonged seizure.
    posted by Sydney on 1/28/2003 06:31:00 AM 0 comments

    Monday, January 27, 2003

    MedAct Malpractice: Re: "The Usual Suspects" item I posted yesterday. Howard Fienberg is ahead of the game. He debunked Medact back in November.

    posted by Sydney on 1/27/2003 01:02:00 PM 0 comments

    Happy Birthday: Today is Mozart's birthday. I don't know if it's true, but I just heard on the radio that he almost died in infancy because doctors thought that water was better than mother's milk.
    posted by Sydney on 1/27/2003 08:20:00 AM 0 comments

    Cloning Kooks: Clonaid says a third clone has been born. (Sure it has.) And Italy's cloning doctor is being investigated by Italian police for some reason.
    posted by Sydney on 1/27/2003 08:09:00 AM 0 comments

    Doing Their Bit: Sperm banks are showing their support for our troops:

    California Cryobank in Los Angeles is offering military men a year of free storage and discounts on sperm processing. The lab fielded about 80 calls and scheduled 37 appointments in the past three weeks, client manager Nolberto Delgadillo says.
    posted by Sydney on 1/27/2003 08:06:00 AM 0 comments

    Buying Blessings: Bill Gates is donating $200 Million to help solve the world's health problems. Those would be real health problems, not silly hand-wringing problems of prosperity like obesity:

    Mr. Gates said he hoped "to draw in a lot of talent that hasn't been aware of what could make a huge difference in terms of world health." For example, he said, "even scientists who work in different realms will now see that things like preventing mosquitoes from being a delivery vector" for diseases like malaria, dengue and West Nile fever "would be a phenomenal thing."

    Among the challenges the panel will consider are these:

    -Identifying an "Achilles' heel" to block reactivation of tuberculosis.

    -Finding innovative approaches to protect children from life-threatening diarrhea and respiratory infections.

    -Seeking ways to deliver combinations of micronutrients to improve child nutrition, cognition and survival.

    In the second phase of the Gates program, the Foundation for the National Institutes of Health will award grants of up to $20 million each over the next three to five years. The grants are expected to go mainly to coalitions of scientists from different disciplines and institutions, although individual scientists are eligible.

    They say that health is a blessing that money can't buy. But maybe it's a blessing that can be bought for others.
    posted by Sydney on 1/27/2003 07:50:00 AM 0 comments

    Med Mal Update: A thousand of doctors in Florida will be taking the day off today and tomorrow. But it isn't a strike. They're all going to a conference about the med-mal situation. And Georgia doctors clear their throats.
    posted by Sydney on 1/27/2003 07:41:00 AM 0 comments

    Pitty Wanting Pain: An account of Munchausen from the patient's perspective.
    posted by Sydney on 1/27/2003 07:29:00 AM 0 comments

    Breath Deep: A pulmonary physician had this to say about asthma control medications, especially cromolyn sodium:


    No, no, NO! We do NOT want people using cromolyn. Cromolyn is a trade name for "placebo." It doesn't control asthma in adults. Its effects are minor, and no good pulmonary doc or allergist I know of would use it as a first-line controller.

    Singulair: not as a first-line controller, though many FPs and pediatricians use it that way. It simply does not have the anti-inflammatory suppressive effect that corticosteroids have, and
    patients switched to leukotriene receptor antagonists may lose their asthma control. Singulair (or Accolate) is appropriate when a patient won't/can't use an inhaled steroid, but
    shouldn't be a first controller. It's a very useful second controller, and good data from the IMPACT trial shows that it can be about as useful as Serevent. The Glaxo people disagree, of course, and have funded a number of studies to dispute this (too many to attach!!).

    Singulair gets used in the pediatric world because pediatricians are still afraid of inhaled steroids, though the CAMP study showed that inhaled steroids are indeed safe in children. And better than nedocromil, another trade name for "placebo." Mothers of asthmatics are very afraid of inhaled steroids.

    Personal story: I teach, talk and treat asthma. My 10-year old has asthma, and it was really interfering with her life. I'm an asthma doc. I really, really know these drugs. It only took me EIGHTEEN months to convince my wife that an inhaled steroid would be okay.

    Back to the drugs. Serevent should not be used as a first controller in any circumstance. It has no significant anti-inflammatory effect except (perhaps) on airway edema. It might actually worsen the numbers of eosinophils in asthmatic airways. It's a great bronchodilator, and combined with an inhaled steroid makes a very useful contribution. But multiple studies have shown that asthma control worsens with Serevent alone.

    My bottom line: inhaled corticosteroids should be the first controller used in asthma, adults and children alike. Leukotriene blockers are okay as a second controller or when one can't/won't take steroids. Serevent should ONLY be used as a second controller, where
    it can make a substantial contribution. For my severe asthmatics, I use all three.

    Whew. Let me clarify. I didn’t mean to imply that these other controller medications should be first line therapy, only that they are still considered appropriate alternatives according to current guidelines on asthma therapy. And lets face it, surveys of therapy like the one GlaxoSmithKline did don’t take into account the nuances of patient preferences and fears. It’s far better to put someone fearful of steroids on the Cromolyn or Singulair than to do nothing at all, or to bully them into accepting a steroid inhaler only to have them go home and put the prescription or the medicine away in a drawer never to use. And none of this changes the fact that GlaxoSmithKline issued their statement based on findings that weren’t statistically significant.
    posted by Sydney on 1/27/2003 07:23:00 AM 0 comments

    Sunday, January 26, 2003

    Super Bowl Sunday: According to a letter in the New England Journal of Medicine this week, for the past 27 years, traffic fatalities have gone up in the hours after the game, especially in states with losing teams. The authors looked at traffic fatality data for Super Bowl Sundays from 1975 to 2001:

    We observed a 41 percent relative increase in the average number of fatalities after the telecast (24.5 vs. 17.3, P<0.001). In contrast, we observed no significant difference between Super Bowl Sundays and control Sundays in fatalities before the telecast (68.9 vs. 67.0, P>0.20) and a marginal decrease during the telecast (15.7 vs. 17.7, P=0.036). The increase in fatalities after the telecast was evident for 21 of 27 years and amounted to about seven added deaths on the average Super Bowl Sunday as compared with the average control Sunday.

    The increase in fatalities after the telecast also applied to nonfatal injuries and was generally larger in states with a losing team than neutral states and larger in neutral states than states with a winning team (68 percent vs. 46 percent vs. 6 percent, P=0.003). New York and Colorado had the most losses (five and four, respectively) and showed a 147 percent increase for the nine relevant years (95 percent confidence interval, 1 to 510). California had the most wins (eight) and showed no evidence of an increase (change, –4 percent; 95 percent confidence interval, –24 to 22) during those eight years.

    The increase was larger than that seen on New Year's Eve, but what surprised me was the small number of extra deaths:

    The increase in fatalities after the telecast was evident for 21 of 27 years and amounted to about seven added deaths on the average Super Bowl Sunday as compared with the average control Sunday.

    Even one needless death is a tragedy, of course, but seven extra deaths in a nation of 280 million is hardly a public health hazard.

    Super Bowl Sunday II: I have one patient who will be savoring this day more than anyone else on earth. I saw him last week for a cold and was surprised to see that he hadn't had the blood work done that I ordered last September. He's usually very diligent about that sort of thing. This particular blood work was to monitor for side effects of his medication, and he knows that, so I was especially surprised that he hadn't followed through with it. When I asked him why he hadn't, he said he had expected to be dead by Christmas so he didn't think it mattered. He has an aneurysm in his abdominal aorta which he's decided not to have repaired. Repair would be difficult - it's in an area of a previous graft for vascular disease, and he has severe emphysema to boot. His vascular surgeon told him last fall that he'd probably be dead in a few months.

    We discussed that statment when I saw him in September. I had tried to reassure him. That was just statisitcal guess. No doctor can predict when a patient will die. My advice didn't have the same dramatic impact as the surgeon's, though, and it pretty much fell on deaf ears. Now here it is, a month after his expected demise, and he's joyously surprised to still be here. As he left the office, he turned to me and said, "I thought I'd never get to see a Super Bowl again." Enjoy it, Mr. C.

    posted by Sydney on 1/26/2003 09:39:00 AM 0 comments

    Art History Lessons: Is the obesity "epidemic" really a modern phenomenon? I've always had a nagging feeling that it isn't, that obesity, or being overweight, is a hazard of prosperity and aging. According to a recent analysis of portraits from the 14th to 20th century, that's probably true:

    In the identified group, overweight was more common in men than in women (44%, 811/1844 v 30%, 346/1145; 14%, 10% to 17%). In the unidentified group [individuals whose identities were unknown - ed. note] the difference in overweight between men and women was smaller (43%, 136/316 v 34%, 106/310; 9%, 1% to 16%). Overall, overweight in identified sitters was higher in people aged over 40 than in people aged 40 or younger (53%, 394/742 v 34%, 763/2247). The association between overweight and higher age was most pronounced during the 17th and 18th centuries (see Table C). During the 18th century among people over 40, 79% (166/209) of identified men were overweight compared with 51% (30/59) of identified women. From the 18th to the 20th century the prevalence of overweight decreased in men over 40.

    Portraits, of course, could only be had by the wealthy and prosperous, as could plenty of food. We no longer tolerate starving or medical neglect of the poor, so naturally as a whole we're all living longer and growing fatter. It isn't necessarily a measure of our laziness or gluttony, but of our general health and prosperity. We are, as Jane Austen would have put it, stout.

    ADDENDUM: Here's a gallery of portraits with goiters from the same paper.
    posted by Sydney on 1/26/2003 09:23:00 AM 0 comments

    Preparedness: The NHS bioterrorism preparedness page.
    posted by Sydney on 1/26/2003 09:10:00 AM 0 comments

    The Usual Suspects: The "peace movement" has found a voice in academic medicine, and here it is. Not surprisingly, it comes from England's school of public health:

    Medact estimates that if the threatened war on Iraq ensues, "total possible deaths on all sides during conflict and in the following three months will range from 48 000 to over 260 000. Civil war within Iraq could add another 20 000 deaths. Additional later deaths from postwar adverse health effects could reach 200 000. In all scenarios the majority of casualties will be civilians." The report calculates that "the aftermath of a `conventional' war could include civil war, famine and epidemics, refugees and displaced people, and catastrophic effects on children's health and development." Knock-on effects could include exacerbation of international conflicts, inequalities, and divisions.

    The most recent UN report also estimates substantial and wide-reaching humanitarian impacts: "As many as 500 000 people could require treatment to a greater or lesser degree as a result of direct or indirect injuries," on the basis of the WHO's estimates of 100 000 direct and 400 000 indirect casualties. It indicates existing shortages of some medical items, "rendering the existing stocks inadequate" for war increased demand, and exacerbated by the "likely absence of a functioning primary health care system in a post-conflict situation."

    The report also "estimated that the nutritional status of some 3.03 million people countrywide will be dire and that they will require therapeutic feeding [according to Unicef's estimates]." Finally, "it is estimated that there will eventually be some 900 000 Iraqi refugees requiring assistance, of whom 100 000 will be in need of immediate assistance [according to the United Nations High Commissioner for Refugees (UNHCR)] . . . An estimated 2 million people will require some assistance with shelter." For 130 000 existing refugees in Iraq "it is probable that UNHCR will initially be unable to provide the support required."

    But the most worrying impact of the use of force in Iraq and internationally is in its role as an escalator of collective violence. The WHO defines "collective violence"by states or non governmental groupsas: "The instrumental use of violence by people who identify themselves as members of a groupwhether this group is transitory or has a more permanent identityagainst another group or set of individuals, in order to achieve political, economic or social objectives." The WHO reports that such collective use of force has long term negative impacts on stability and social wellbeing. International violence has been steadily increasing and "overall a total of 72 million people are believed to have lost their lives during the 20th century due to conflict, with an additional 52 million lives lost through genocides." Conflict escalates after use of collective force, as violence becomes a more common and legitimated form of political or social action.

    Didn't they say the same thing about Afghanistan? That's Afghanistan, where children are now finally getting immunized against measles, and efforts are finally under way to help women get prenatal care and safe deliveries of their babies. And don't these same people advocate laws that protect abused women and children from their abusive families rather than turn a blind eye to "maintain the status quo"? They should think of Iraq as an abusive family.

    UPDATE: Howard Fienberg is ahead of the game. He debunked this back in November.
    posted by Sydney on 1/26/2003 08:50:00 AM 0 comments

    Drug Dodge: Oncologists are coming under fire for making money off their chemotherapy:

    Medicare, which does not cover most prescription drugs, does pay doctors about $6.5 billion a year for drugs they personally administer, largely cancer drugs. Under the current system of determining what the appropriate prices for these drugs are, the government is paying, by some estimates, more than $1 billion more than what the drugs actually cost. Many private insurers say they are also overpaying for these drugs.

    In some cases, patients make a much larger co-payment for the drug than a cancer doctor paid to buy it. Some patients paid about $150 out of pocket for Toposar, a cancer drug, for example, while doctors appear to have paid closer to $60 after various discounts from Pharmacia, the manufacturer, according to the Minnesota attorney general, who is suing Pharmacia, accusing it of pricing fraud.

    The General Accounting Office, which studied federal payments for cancer drugs in late 2001, discovered that doctors, on average, were able to get discounts as high as 86 percent on some drugs.

    Dr. Thomas Smith, an associate professor of oncology at the Medical College of Virginia Commonwealth University, has estimated oncologists in private practice typically make two-thirds of their revenue from the chemotherapy concession.

    Ah, but how much do oncologists get paid to administer the drugs? Most likely very little. Administering a chemotherapy drug is much different than adminstering, say, a Depo-Provera shot for contraception. Chemotherapy agents often take hours to adminster intravenously, and patients have to be watched closely for side effects. Most oncologists have nurses who are with the patients constantly as they receive their infusions. This sort of careful management doesn't come free of charge:

    But oncologists say they need the profits from the drugs to make up for high costs in the rest of their operations. They say they spend enormous sums to have the facilities and employees that enable patients to receive chemotherapy outside a hospital, under close supervision.

    ``It seems to be a wash right now,'' said Dr. Larry Norton, an oncologist at Memorial Sloan-Kettering Cancer Center in New York and a former president of the American Society of Clinical Oncology. He argues that oncologists treat patients who demand more care and therefore have higher expenses.

    ``We're just trying to break even,'' Norton said.

    What's happening here is that the third-party payer accountants are seeing a large expense on their spreadsheet for chemotherapy. Their natural instinct is to do everything they can to bring that expense down. They have no idea what's involved in the delivery of those drugs. But if they refuse to pay for them, or lower reimbursement for them to the point that oncologists can't afford to administer the drugs safely, then access to cancer treatment will suffer.

    UPDATE: The Times has more detail, including the revelation that oncologists' earnings have outstripped every other specialty since they've been dispensing their chemotherapy drugs. Makes me more suspicious about that "just breaking even" defense.
    posted by Sydney on 1/26/2003 08:39:00 AM 0 comments

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