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

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    Saturday, March 01, 2003

    Baghdad Batteries: Science ahead of its time or medicinal jolts? Cronaca has the details.

    posted by Sydney on 3/01/2003 11:13:00 AM 0 comments

    Superslime for Superbugs: A company called AquaPharm claims to have found a new antibiotic that works on the antibiotic resistant superbacteria, methicillin resistant staphylococcus aureus (MRSA). Like most antibiotics, it comes from the less-savory regions of nature. In this case, from slime found in tide pools:

    Several types of bacteria found by the five-person team produce an antibiotic that acts against the notorious hospital superbug, MRSA (Methicillin Resistant Staphylococcus Aureus.)

    One in particular is so effective it is already attracting keen interest from the big drug companies.

    Dr Jonathan David, technical director at the scientists' company AquaPharm Bio-Discovery Ltd, told the Press Association: "It appears to be very potent in terms of what concentration is required to kill MRSA.

    "It completely stops them dead, preventing any further growth and killing the existing bacteria."

    ..AquaPharm is keeping the identity of its MRSA-killing bacteria a closely guarded secret, and taken out patents on how they can be cultivated and used.

    The bacteria produce a natural powerful antibiotic to fight off other bugs that might want to invade their colony sites.

    They are collected by scraping off the surface slime from rocks, plants and invertebrates such as sea anemones.

    It’s ironic, but most antibiotics are derived from chemicals produced by other bacteria. The story of penicillin’s discovery in a mold-contaminated petri dish is well known, but what is less well-known is that other antibiotics have similar origins.The first-aid antibioitc, Bacitracin, for example, was discovered in bacteria growing in a compound fracture of a little girl named Margaret Tracy (the “traci” portion of “Bacitracin.”) Erythromycin was derived from soil organisms found in the Iloilo province of the Phillipines, hence the brand-name Ilosone, and the first cephalosporin was isolated from a fungus found in Sardinian sewers (forgive the broken English). We owe a lot to dirt.
    posted by Sydney on 3/01/2003 08:46:00 AM 0 comments

    What’s Wrong With This Picture? The FDA is forcing a very old, very useful, and very cheap decongestant off the shelves:

    The Food and Drug Administration stressed that the expectorant, extended-release guaifenesin, is not dangerous. Instead, the crackdown comes as part of the FDA's efforts to re-examine very old drugs that began selling before the government ever required proof that drugs worked well.

    In the case of this prescription cough ingredient, one company went back and found that proof. Last July the FDA formally approved sale of Adams Laboratories' Mucinex.

    Under FDA regulations, competing companies' unapproved versions then were automatically deemed illegal.

    Guaifenesin is the active ingredient in such old stand-bys as Robitussin. It’s been around for a long time, with no reports of serious adverse events. Yet, drugs like ephedra, which have been linked to deaths, can be sold freely with only a warning label (and that with some effort). Crazy world.
    posted by Sydney on 3/01/2003 08:44:00 AM 0 comments

    Shortage? What Shortage?: Is there a shortage of blood because of Red Cross greed or caution? Is there even a shortage? Depends on where you live:

    Despite the current Red Cross shortage, local hospitals said they have not yet experienced problems. Brownsville General Hospital gets its blood products from the Central Blood Bank and has not had any problems, according to Lisa Orris, the laboratory manager. Highlands Hospital is also doing well, though they are supplied by the Red Cross.

    "We've been fortunate. We haven't had to cancel any elective surgeries and we haven't had any problems meeting emergency needs. We aren't a big user of blood products here," said Denise McCloy, the director of quality and risk management at Highlands.
    Rich Hancock, the administrative director of the laboratory at Uniontown Hospital, said the shortage hasn't affected that facility either.

    "We have had no impact as of yet," Hancock said. "We're aware of what the Red Cross is saying and are aware that they are taking actions to maximize their reserves for hospitals."

    In Connecticut, hospitals are saying the same:

    Although, Dr. David Krugman, chief pathologist at New Britain General Hospital, said most hospitals, with the exception of those dealing with a larger volume of patients, usually order blood supplies when they are needed.

    "At New Britain we have a fair amount of elasticity on our shelves, and we have enough blood for day-to-day use, but we do have to make additional orders when the demand calls for it," Krugman said. "The Red Cross is doing what it has to to keep control of their supplies to make sure nothing, especially platelets go to waste."

    Krugman said regular donations are essential because platelets, extracted from both whole blood and through apheresis, a longer process when blood is separated and necessary components are withdrawn while a donation is being made, have a maximum shelf life of five days.

    "In some cases by the time the blood is screened and separated the platelets might only be used for two to three days," Krugman said.

    But, in the South, where a lot of blood was recently taken off the shelf because of clumping, and in parts of the country with recent bad weather that necessitated canceling blood drives, there is a noticeable shortage. Blood has a very short shelf-life, and as a result, the supply is always in a state of flux and vulnerable to the slightest interference with collection - whether by God or by man.
    posted by Sydney on 3/01/2003 08:42:00 AM 0 comments

    Friday, February 28, 2003

    Fascinoma: The anatomy of itching and scratching.

    posted by Sydney on 2/28/2003 08:38:00 AM 0 comments

    Dutch Euthanasia: In discussions of “death with dignity” and physician-assisted “suicide”, the Dutch are often cited as exemplars of advanced and civilized attitudes - a nation that does it right. But Wesley J. Smith points out how things really stand there:

    As proof, I referred to several studies on Dutch euthanasia revealing that about 1,000 patients who have not asked to be euthanized are killed by doctors each year. Though such killings are considered murder under Dutch law, I explained that those doctors who engage in "termination without request or consent" in the Netherlands are almost never prosecuted. Moreover, the very few who are prosecuted are usually found not guilty. And the exceedingly rare conviction, when it happens, never leads to criminal sanction, or even professional discipline against the offending doctor.

    A thousand patients a year who are killed without consent. That should give us all pause.

    (via Charles Murtaugh)
    posted by Sydney on 2/28/2003 08:28:00 AM 0 comments

    Pushing the Envelope: German anatomist/showman Gunther von Hagens, who turns autopsies into performance art and treats corpses as dolls, has even grander plans:

    His future plans include displaying corpses as though in the act of sex, for what he calls educational purposes to show how "easily disease can be transmitted, how an erection functions, showing all the blood vessels." He has some ideas on "how to do it so that even children can look at it and say `Isn't it wonderful?'"
    posted by Sydney on 2/28/2003 08:21:00 AM 0 comments

    Cost-Conscious Medicine: A British orthopedist recently lost his job because he objected to some of his hospital’s cost-cutting measures:

    During a hip replacement operation a scrub nurse offered the dessert spoon to Mr Charnley in place of the sharp curette normally used to scrape cartilage from hip sockets. "On several occasions I was offered the dessert spoon and rejected it. It was later alleged I threw it at a nurse, but that is not true. I simply lobbed it away hoping it would never be used again." He said nurses joked about the incident and later came into an operation with plastic spoons attached to their facial masks.

    Mr Terence Lewis, the hospital's medical director, said spoons were widely used in surgery at Derriford and were extremely useful. Hospital management arranged for an example to be brought before the tribunal by motorcycle courier. "I use one myself in cardiothoracic surgery. The spoon this tribunal was shown has saved a number of lives and is used to lift the sternum when we are stitching a patient."

    I suppose there’s nothing wrong with using a sturdy spoon as a retractor, but I’ve never seen a dessert spoon with an edge sharp enough to scrape cartilage from a joint socket.

    But this is about more than just substituting spoons for surgical instruments. The orthopedist got in trouble for failing to manipulate his patient lists to meet government targets. He wanted to operate on patients according to the urgency of their needs rather than their position on a waiting list:

    Mr Lewis acknowledged speaking to Mr Charnley about waiting lists. He said: "We had access to between 2 million pounds [$3.2m; 2.9m] and 2.5 million pounds, which would not be received by any trust which breached the target. It was a huge amount of money which the trust needed, and it was being put at risk by his threat not to cooperate in meeting targets."

    Mr Charnley's evidence was supported by his former secretary Rachel Payne and by Dr Rhona MacDonald, the editor of the BMJ's Career Focus section, who spent two months secretly interviewing staff at Derriford at the end of 2000. Her investigation followed the publication of a critical report into waiting lists at the hospital.

    Dr MacDonald said that management were "so driven by waiting list targets they did not have time for anything else, like quality." People who spoke out, she said, "were told to go on gardening leave, which was a euphemism for suspension."

    Ahh. The joys of government-run medicine.
    posted by Sydney on 2/28/2003 08:17:00 AM 0 comments

    Cellphones On: Recent research suggests that cell phones, contrary to universal policy, may be used safely in hospitals:

    Dr Saul Myerson, a cardiologist from the John Radcliffe Infirmary, told BBC News Online: "People who made the policy took what was the most defensive line and the easiest to implement - to ban mobiles altogether.

    "In practice, that has stopped people using them when they really need to."

    He said the ban had led to people being verbally, and sometimes physically, abused for using their phones in hospitals.

    "Interference occurs only in a minority of phones, about 5%, and at a very close range of less than a metre", he added.

    "It's sensible to ban phones from clinical areas, more because they could be disruptive than anything else.

    "But a sensible balance could be struck, and their use could be allowed in non-clinical areas."
    posted by Sydney on 2/28/2003 08:16:00 AM 0 comments

    Smallpox So Far: Only one adverse effect of smallpox vaccine among the few thousands who have gotten it so far:

    No "potentially life-threatening" reactions were experienced by any of the more than 7,350 people who received smallpox vaccinations in the four weeks that ended last Friday, the Centers for Disease Control and Prevention said Thursday.

    There was one "moderate-to-severe adverse event," a case of "generalized vaccinia" in a 39-year-old woman, the CDC said.

    Ten days after receiving the vaccine, she developed a rash on her chest and back that progressed to scattered pustules two days later, the CDC said. She was treated as an outpatient with antihistamines and the rash began clearing up in a few days. Tests are pending, the CDC said.

    A few people showed minor side effects, including fever, headache or "malaise," and probably several other such cases occurred but were not reported, the CDC said.

    Compare that to the headline in my morning newspaper today, Smallpox Vaccine Recipients Get Sick, and the opening paragraph:

    Officials are investigating medical problems in three health care workers who became ill after receiving the smallpox vaccine, though only one appears to have had a reaction to the inoculation.

    Of the other two, one with known coronary artery disease had a heart attack, and the other had an attack of gallstones. Neither illness has any remote connection to the vaccine. But you have to read through the whole article to find that out. Why even bother to mention them in the first place?
    posted by Sydney on 2/28/2003 08:15:00 AM 0 comments

    Thursday, February 27, 2003

    Pain in the ... A new treatment for hemorrhoids. Supposedly with fewer complications and less pain.

    posted by Sydney on 2/27/2003 08:46:00 AM 0 comments

    Foot Dragging: The public health community continues to find ways to avoid implementing smallpox vaccination. Now, they're claiming that the vaccination program will make it difficult to treat and identify a smallpox outbreak:

    The survey, published in New Scientist magazine, shows 59% of authorities have had to cut back on routine work.

    Ironically, if authorities are to have a hope of fighting the spread of smallpox in the event of an outbreak they need to identify any cases early.

    Public health departments aren't likely to be the ones diagnosing and identifying an index case of smallpox. That's far more likely to occur in a community physician's office or an emergency room. And, since the vaccination effort so far has been turned over to hospitals, just why, exactly, have the health departments had to cut back on their routine work? Have they stopped their childhood immunization clinics and STD clinics to go out and vaccinate the community? Of course not. What they have to do, is have their administrators come up with plans to address bioterrorism, and that's what they're really complaining about. Yet more evidence that bioterror preparedness shouldn't be left to the public health community.
    posted by Sydney on 2/27/2003 08:39:00 AM 0 comments

    Undoing the Damage II: The full text of the rebuttal to claims that growth hormone can reverse aging and enhance muscle performance is on-line now at The New England Journal, as is the reaction of the journal's editors to ads like this.

    Perhaps this will serve as a wake-up call to the Journal, and they'll rein in the tendency of authors' to exaggerate the importance of their research findings, and the duplication of those exaggerations in the Journal's press releases. Then again, maybe pigs will fly.
    posted by Sydney on 2/27/2003 08:15:00 AM 0 comments

    More Tort Reform Update: The Bloviator has a post on a proposal by an Illinois attorney/physician for tort reform in Illinois. The Bloviator, also a lawyer, isn't impressed. And rightly so. Apparently, the crux of the proposal (which isn't backed by any state medical organization) is that patient's should sign away their right to sue when they come in to see a physician. That does seem like a recipe for disaster, and I doubt the "act" will get very far. They did have at least one good protest sign, though: "Lawyers Need a Pro-State Check-up."

    UNRELATED: Ross also explains the origin of the term bloviate. Turns out it comes from the most famous son of my hometown, Warren G. Harding. I especially like the quote from Mencken on Harding's writing style:

    He writes the worst English that I have ever encountered. It reminds me of a string of wet sponges; it reminds me of tattered washing on the line; it reminds me of stale bean soup, of college yells, of dogs barking idiotically through endless nights. It is so bad that a sort of grandeur creeps into it. It drags itself out of the dark abysm of pish, and crawls insanely up the topmost pinnacle of posh. It is rumble and bumble. It is flap and doodle. It is balder and dash."

    That's all the more biting when you consider that before he entered politics, Harding published the town's newspaper, The Marion Star, still in print, and still the only newspaper in town. (And that's my old pediatrician on the front page today!) Thanks for the trip down memory lane, Ross.

    posted by Sydney on 2/27/2003 07:56:00 AM 0 comments

    Tort Reform Update: Congress is debating the issue of tort reform today, and the American Association of Trial Lawyers plans to use Jesica Santillan as a prop:

    Already, the Association of Trial Lawyers of America, which is lobbying heavily against the Bush plan, is working with Democrats in Washington to arrange for the Santillan family's lawyer to testify in Congress, where a hearing on medical malpractice is scheduled on Thursday before the House Energy and Commerce Committee. The lawyer, Kurt Dixon, sent a letter to the committee chairman today, asking to appear.

    "I urge you to save a seat for Jesica," Mr. Dixon wrote. "America deserves to understand how people like Jesica and her family would be affected by the legislation your committee is considering."

    Don’t be surprised if Mr. Dixon means that "save a seat" literally. One of the favorite ploys of trial lawyers is to display a picture of the deceased where the plaintiff would normally sit during a trial. They like to manipulate emotions that way.

    The argument they'll use is that this young life is worth more than $250,000. Indeed it is. Life is priceless. There is no adequate monetary award to compensate for loss of life. Or for injury. The Santillan family's pain and suffering isn't going to be alleviated by a multi-million dollar award.

    But the trial lawyer's aren't really interested in alleviating the pain and suffering of the family. They're interested in saving their personal gold mine that is the current tort system. As the president of the Trial Lawyer Association put it:

    Mary Alexander, the association's president, said it would be extremely difficult for the Santilláns to sue under a $250,000 cap, because it costs nearly that much to bring a case.

    If it does cost $250,000 to bring a case, which I very much doubt, you can bet that most of that is attorney fees. What Mrs. Alexander is really saying is that trial attorneys won’t make as much money if punitive damages are capped.

    Tort reform is an issue that must be addressed. Let's hope that Congress exercises some sensible judgement today and doesn’t let emotion rule the day.
    posted by Sydney on 2/27/2003 07:45:00 AM 0 comments

    Wednesday, February 26, 2003

    JAMA's weekly art history lesson.

    posted by Sydney on 2/26/2003 09:39:00 AM 0 comments

    Undoing the Damage: This week’s New England Journal of Medicine has a notice to readers (not up at their website yet) that deplores the use of one of their articles from 1990 to promote the sale of human growth hormone over the internet. Evidently, they get more hits to that article’s abstract in a week than other articles from 1990 get in a year. As a result, they’ve posted an accompanying link to the editorial they published in 1990 pointing out the articles’ drawbacks. Think anyone will read it?
    posted by Sydney on 2/26/2003 09:38:00 AM 0 comments

    Casting the First Stone: Evidently a North Carolina newspaper columnist has called for the dismissal of the surgeon who made the fatal transplant error in the Jesica Santillan case. An Indiana newspaper editor explains why that isn't the best response.

    The truth is, we learn from our mistakes. And a mistake like that is a lesson one never forgets.
    posted by Sydney on 2/26/2003 09:36:00 AM 0 comments

    AIDS Vaccine Protests: AIDS activists think that the recent research findings concerning the AIDS vaccine are over-hyped:

    The groups slammed VaxGen Inc. of Brisbane, Calif., saying the data does not back up the company's claims and could raise false hopes.

    "AIDSVAX fails to protect; VaxGen's claims of efficacy in black and Asian participants are misleading and premature," the groups said in the statement. "We call on VaxGen to submit the findings to a panel of outside experts assembled by the National Institutes of Health for a full examination of the data ..."

    The company said Monday that initial results of an important clinical trial of the AIDSVAX vaccine showed it did not prevent HIV infection better than a placebo.

    But it claimed "statistically significant" data showing that the vaccine might protect ethnic minorities, particularly blacks.

    ...VaxGen pins its assertions on nine infections among 111 blacks receiving a placebo and four infections out of 203 blacks who received the vaccine, according to the advocacy groups. The statement from the groups says the company's interpretation of the data could spur false hopes and stir racial divisions.

    Well, those are significant differences. And it could point to a genetic difference in the ability to respond to the vaccine. Is it overhyped? No more so than the warfari study (and plenty of others) have been. Perhaps less.
    posted by Sydney on 2/26/2003 09:28:00 AM 0 comments

    Rat Poison for Life: I’m late to this one, but the latest medical breakthrough is the story of warfarin and its ability to safely prevent blood clots when taken for life:

    Until now, there has been no proven long-term therapy that is safe for high-risk patients. When a clot develops, people are usually given warfarin for three to six months, but then the drug is stopped, because it increases the risk of severe bleeding. Without warfarin, however, almost a third of the patients will form another clot within eight years.

    The new study has found that after a few months of standard treatment with full doses of warfarin, clots can be prevented with lower doses, about half of what is normally used to treat someone with a clot. The lower doses provide a safe middle ground, reducing the risk of more clots without increasing the risk of hemorrhage.

    That certainly sounds wonderful. Warfarin has been around for over fifty-years, so it’s available in a safe and effective generic version, although in 1998 only 18% of users chose the generic. It was first discovered in the 1930’s when researchers investigated the cause of hemorrhagic illnesses in free-ranging cattle. What they found was a substance called coumarin that’s present in the stems of sweet clover. Coumarin gave rise to warfarin which is the active ingredient in most rat and mouse poisons, and in more refined form, available for human therapy under the brand name Coumadin.

    Warfarin has its drawbacks. Not only does it increase the risk of bleeding by inhibiting blood clotting, but its metabolism is easily influenced by outside factors, so that the amount of clotting inhibition that occurs at any given dose can fluctuate depending on what other substances a person has ingested - both in terms of other drugs and in terms of food. It’s so easily influenced, in fact, that someone’s written a Coumadin cookbook to help patients prepare meals that won’t interfere with their Coumadin therapy.

    This means that the drug requires very close monitoring to be used safely. When everything is stable, that usually translates into once a month blood tests to insure that the anticoagulation effect is within the therapeutic range - neither too high, nor too low. But, if a dosage change is required, or if a new medication is introduced, then that testing becomes more frequent, usually within a week or a few days of starting the medication. That can mean a major life-style hassle for the patient, as well as an expense. Most of my warfarin patients complain bitterly about being on it.

    And that’s what bothers me about this study. It only tracks the risk of taking warfarin over a mean of two years
    The trial was terminated early after 508 patients had undergone randomization and had been followed for up to 4.3 years (mean, 2.1).

    We don’t know how that risk pans out after ten, fifteen, or thirty years of warfarin therapy. That’s something that we should keep in mind before rushing to put everyone on it for life. But that doesn’t stem author Dr. Paul Ridker’s (
    of C-Reactive Protein fame) enthusiasm:

    "This really ought to change the standard of care overnight," said Dr. Paul Ridker, the first author of the study and director of the center for cardiovascular disease prevention at Brigham and Women's Hospital in Boston.

    But, as the accompanying editorial points out, not only is warfarin tricky to use, there is some conflicting data out there that isn’t getting quite the publicity that this piece is (In fact, I couldn’t locate a link to the article the editorial mentions):

    However,Kearon et al.have simultaneously reported in preliminary form the results of a different randomized,double-blind trial of similar size that found that low-intensity warfarin (INR,1.5 to 1.9 )was significantly less effective than conventional-intensity warfarin (INR,2.0 to 3.0)for extended prevention of recurrent venous thromboembolism, without significant differences in the rate of bleeding complications. It is difficult to reconcile these findings and to make definitive recommendations regarding the optimal intensity of anticoagulation therapy for long-term secondary prevention without data from a risk –benefit analysis in a three-way comparison of conventional-intensity,low-intensity,and no anticoagulation therapy following at least three months of conventional-intensity warfarin therapy for an initial episode of venous thromboembolism.

    In other words, curb your enthusiasm.
    posted by Sydney on 2/26/2003 08:44:00 AM 0 comments

    Tuesday, February 25, 2003

    Back to the Drawing Board: The first large trial of an AIDS vaccine was unsuccessful:

    The trial took place at 59 sites, mostly in the continental United States, with some in Canada, Puerto Rico and the Netherlands. It involved 5,400 volunteers, mostly men, none of whom were infected with H.I.V. at the start of the trial.

    About 5,100 of the participants were gay men who said they had had sex with many other men. The other 300 were women who were considered at high risk of infection through sexual contact.

    Two-thirds of the participants were given a series of seven shots over three years, while the other third were given the same number of placebo injections. The goal was to see if the people who received the vaccine would have a lower rate of infection. In the overall population of participants, 5.8 percent of those who received the placebo became infected, compared with 5.7 percent of those who received the vaccine. The difference was not statistically significant.

    But among black, Asian and other minorities the rate of infection was only 3.7 percent in the vaccinated group, compared with 9.9 percent in the placebo group.

    That meant, after statistical adjustments, that the vaccine reduced the infection rate in that group by 66.8 percent. The numbers were small, about 500 patients, but statistically significant. There was a less than 1 percent chance that the findings were the result of chance.

    Why the difference among minorities isn’t yet clear. But here’s how the vaccine works:

    The vaccine, known as Aidsvax, is made from a protein called gp120, the same protein that protrudes from the surface of H.I.V. and helps the virus dock with cells of the body's immune system. The protein in the vaccine is made in genetically engineered hamster ovary cells. Since the vaccine consists of only one protein and not the whole virus, it cannot give someone AIDS. But it is designed to provoke the immune system into making antibodies that will latch on to the gp120 protein in the real virus and the virus from infecting immune cells.

    Last week’s New England Journal had an article (Sorry. Requires subscription.) that explains why this approach isn’t such a good one. It turns out that the protein, gp120, is extremely flexible and difficult for antibodies to latch on to:

    The initial event in HIV-1 infection is the stable tethering of HIV-1 to a host cell. This interaction is mediated by a binding event between the glycoprotein (gp) 120 molecule that protrudes from the virus and a CD4 molecule on the host cell. (An accessory host-cell molecule, CCR5, is also involved in the binding event.) Stable binding leads to infection. The binding reaction can be blocked by neutralizing antibodies, but only two antibodies are known to bind glycoprotein 120 stably. The majority of antibodies fail to bind glycoprotein 120 and therefore do not neutralize infection. A recent study shows that glycoprotein 120 is refractory to the binding of these "impotent antibodies" because the molecule is unusually flexible, and the binding regions of the antibodies are specific to a particularly flexible part of it. (Emphasis mine.)

    Just a speculation, but it could be that minorities produce better binding antibodies. Anyway, the article predicted the failure of VaxGen’s vaccine. In an aside the author’s mentioned that the company might want to reconsider their approach. Turns out they were right. But give the company credit, they presented their findings honestly and didn’t try to use statistics to exaggerate them.

    posted by Sydney on 2/25/2003 06:06:00 AM 0 comments

    Healthcare Reform: Medicare and Medicaid reform is shaping up:

    Mr. Bush's proposals for Medicare and Medicaid, taking shape in recent weeks, would transform these pillars of the Great Society and their guarantee of health benefits to the elderly, disabled and poor.

    States would have far more power to determine who receives what benefits in the Medicaid program, which covers 45 million low-income Americans. The elderly would rely more on private health plans, and less on the government, for their health benefits under Medicare, which covers 40 million elderly and disabled people.

    The administration's vision for Medicare and Social Security moves away from the notion that everyone should be in the same government-managed system with the same benefits. It promises individuals more choices, including the option of picking a private health plan or investing some of their Social Security taxes in the stock market.

    I’m not sure about that investment of Social Security taxes in the stock market, but for Medicare to remain solvent as the baby boomers age, some sort of reform needs to happen. Today, the government program covers all seniors, regardless of how wealthy they are. Many of those could afford their own healthcare plan:

    Mr. Bush's Medicare proposal, being revised after an earlier draft drew fire on Capitol Hill, would encourage many beneficiaries to leave traditional Medicare and get their benefits through private health plans associated with the program.

    Administration officials assert such plans can manage care, tailor benefits and control costs better than traditional Medicare, one of the last bastions of fee-for-service medicine. The officials also argue that Medicare must be overhauled before Congress adds prescription drug benefits, a priority for each party.

    ...."When it comes to cars, and when it comes to health care, 1965 is not the state of the art," Mr. Bush has said.

    At least they see the need to put in some limits before offering drug benefits to everyone. Reform will be difficult, though. Elderly people of all backgrounds have come to see it as an entitlement. And people don’t like it when someone messes with their entitlement.

    For Medicaid, the Administration plans to give the states more power to determine who they would cover:

    The administration's proposal would offer states vast new power to reduce, eliminate or expand health benefits for low-income people, including many who are elderly or disabled. In return for the flexibility, and a temporary increase in federal assistance, states would eventually have to accept a limit on the federal contribution to the program's cost. The choice would be up to the states; they could stay with the existing program.

    Administration officials say the plan would allow states to stretch scarce resources during fiscal crises. Critics assert it would replace the poor's entitlement to health care with a block grant to the states, just when the number of uninsured is rising.

    It should be noted that the “number of uninsured” has no correlation with the number of people covered by Medicaid. Most of the uninsured make too much money to qualify for Medicaid, and those receiving Medicaid aren’t counted among the ranks of the uninsured. It’s actually fairly difficult, at least in my state, to qualify for Medicaid. Most recipients are either very poor, severely disabled, or single mothers.

    Most of the fat lies within Medicare, but reform of that will be extremely difficult. Not only have the elderly of all persuasions come to see it as an entitlement, but they have a very strong lobby in the AARP. I wouldn’t hold my breath for reform in our lifetime.
    posted by Sydney on 2/25/2003 05:52:00 AM 0 comments

    Monday, February 24, 2003

    Jesica Santillan Update: Monkey Media Report has more news on the Jesica Santillan case than you’re likely to find anywhere else, mainstream media included.

    Her “self-proclaimed godfather” only comes across as more obnoxious, having used his connections with Senator Dole to force the hospital to do things his way - including full access to the ICU and the right to take and publicize pictures of the girl as she lay dying. (Which if you think about it is disrespectful of the patient, who was not able to give her consent.)

    The hospital also comes across looking bad, but their side of the story hasn't been told in full. Certainly, it hasn't been told anyway near as freely as Mahoney has told his version.

    posted by Sydney on 2/24/2003 11:49:00 PM 0 comments

    Surviving the Fire: Thanks to advancements in on-the-scene emergency care, drugs, mechanical ventilators, artificial skin, and kidney monitoring systems, burn patient survival is improving dramatically:

    Two decades ago, burns over 50 percent of the body often meant death. At that time, doctors often added patients' ages to their burn percentage to calculate the chance of survival. So, a 40-year-old with 60 percent burn coverage would, by that formula, die.

    The odds have changed.

    ''You've taken something that was almost uniformly fatal and made it into something that we now expect we have a good chance to get the patient through this thing,'' said Cioffi. ''That's a pretty amazing thing when you can offer patients and their families this hope, when a few decades ago that wouldn't have been possible.'

    UPDATE: Here's a description of the Integra Dermal Template described in the article. (Includes an animated graphic that explains how it works.)

    posted by Sydney on 2/24/2003 07:42:00 AM 0 comments

    Conserving Blood: Two technological advancements to meet the blood shortage - "bloodless" surgery:

    In the St. Vincent operating room, the only outward clue that the hip replacement was a ``bloodless surgery'' was a bag of blood hanging near the head of the table.

    It was attached to the patient's wrist using a needle with a V-shaped connection. The blood had been pumped from the patient through one branch of the V before the surgery started. After the operation was over, the blood would be returned to the patient through the other branch of the V.

    It was one continuous loop, from the patient's arm in one line, into the bag, and back to the arm in the other line.

    In essence, said Dr. John Bastulli, chief of anesthesiology at St. Vincent's, the blood never lost contact with the body.

    A patient undergoing bloodless surgery is treated with a drug, such as Procrit, which boosts the production of red blood cells, in the three weeks prior to surgery.

    On the day of the surgery, one or two pints of blood are taken in the operating room before the surgery begins. The resulting loss of blood volume in the patient's body is replenished with saline.

    It's called hemodilution. And the result is that there's a supply of blood, rich in red blood cells, ready to go back into the patient after surgery. Plus, during the operation, the patient's blood is diluted, so fewer blood cells are lost from bleeding.

    Ultimately, it means the surgery takes place without using blood from an outside source.

    And double red blood cell collection:

    Double red blood cell collection -- called 2RBC -- could help balance the supply with that demand.

    As the name implies, the process collects twice as many red blood cells in one sitting -- two units as compared to the one unit collected in a traditional, whole blood donation.

    In 2RBC, blood is drawn into a special machine that separates the red blood cells from the plasma. The plasma is combined with saline and pumped back into the patient -- allowing more red blood cells to be harvested without severely lowering a patient's blood volume.

    Because most of the fluid is replaced, there's no dizziness that tends to occur with traditional blood collections. Plus, the needle used is smaller.

    Collection takes about 20 to 25 minutes longer.

    Neither procedure is widespread. The double red blood cell collection requires the use of a machine to concentrate the blood, and that machine costs thousands of dollars. Not exactly something that can be done in the local union hall during blood drives.
    posted by Sydney on 2/24/2003 06:14:00 AM 0 comments

    Abortion’s Legacy: According to this Washington Post story, the indiscriminate use of abortion has contributed significantly to growing infertility in Russian women:

    Russian health specialists call women like Esipova one of the more lasting legacies of a Soviet health system that for decades viewed abortion as the main form of birth control. According to Vladimir Serov, chief gynecologist at the Health Ministry, abortions are one of the primary causes of infertility in a country that is desperate to raise a plummeting birth rate.

    About 5 million -- or 13 percent -- of Russian married couples are infertile, and doctors report that diagnoses of infertility are on the rise. In nearly three out of four cases, infertility is attributed to the woman, typically because of complications from one or more abortions, according to Serov and other health experts.

    ...A study of mid-1990s data by a group of health researchers showed Russia's abortion rate was the fourth-highest of 57 countries, after only Vietnam, Cuba and Romania.

    "It's a habit, a tradition," said Serov. "It is a result of our low level of medical culture."

    Russian health and demographics experts say the abortion legacy has created a problem greater than the private trauma of childless couples, because the resulting infertility contributes to a low birth rate. That trend and a soaring death rate are helping reduce Russia's population at a rapid rate.

    U.N. population experts predict that in 50 years Russia will be the world's 17th-most populous country; it is now the sixth. Projections show Russia will lose more than a quarter of its population, dropping from 143 million people to 104 million by 2050.

    Like other countries in Europe, Russia has been experiencing a falling fertility rate for most of the last half-century. It is now the sixth-lowest in the world, according to U.N. studies. On average, Russian women now bear just more than one child.

    ....A study in 1994 found that the average Russian woman had three abortions by the end of her child-bearing years.

    After Abortion points out that most pro-abortion sites claim that there is no link between abortion and infertility. In truth, there may some complicating factors in the Russian cases. Because of their poverty, they may use less sophisticated techniques and equipment than in the States, which means that there may be more trauma to the uterine wall, and thus more scarring and subsequent infertility. They may also reuse instruments and operate under less sterile conditions, increasing the likelihood of infections. Still, abortion does involve scraping the uterine wall, and the more procedures you have, the more scarring there’s likely to be, and hence more infertility. And an average of three abortions per woman is awfully high.
    posted by Sydney on 2/24/2003 06:11:00 AM 0 comments

    Taking a Page from the Lawyers: More doctors are beginning to charge for doing paperwork:

    Doctors around the country have begun charging patients for services that have traditionally been free, according to the American College of Physicians.

    The fees range from per-page charges for copies of medical records to $10 or $20 for filling out the forms people need to apply for medical-leave benefits. A few doctors have begun charging patients up to $20 to respond to e-mail questions about their health.

    Dr. Allen M. Dennison of Barrington, R.I., said he charges patients $2 a minute to diagnose minor ailments over the telephone, and around $15 to fill out the health history forms parents need to send their children to camp.

    "We are really on the ropes financially," he said. "I think the patients know that if they are going to take a doctor's time, they are going to have to pay for it."

    This hasn't yet become widespread, but there's an awful lot of chatter about it in physician circles. A lot of people are hesitant to adopt it because it seems, so, well....greedy. Yet, all of those phone calls and paperwork add up:

    Most primary-care doctors now spend an average of two to three hours a day on tasks for which they are not compensated, such as returning phone calls and filling out insurance forms, he said.

    That means less time to see patients, and the fewer patients doctors see in person, the less they get paid, he said.

    Two or three hours a day of paperwork is about right, only in most of cases it translates into less time for our families rather than our patients. One of the greatest contributors to the paperwork burden has been the FMLA (Family Medical Leave Act) forms. The Act was meant to guarantee people time off to recuperate from a serious illness without running the risk of losing their jobs, but employers abuse it and make people fill out the forms for every mild illness they have. The forms are two pages long and require narrative descriptions of what’s wrong with the patient, how long it’s expected to last, what kind of therapy has been undertaken, how many times treatment will be needed, how long the illness is expected to last, etc. (I’m not sure how they square with the new privacy laws.) They are onerous.
    posted by Sydney on 2/24/2003 06:10:00 AM 0 comments

    Sunday, February 23, 2003

    First Tang, Then This: Thanks to the wonders of the space program, scientists are looking at ways to use nanotechnology to deliver drugs where they’re needed. Fascinating stuff.

    posted by Sydney on 2/23/2003 03:05:00 PM 0 comments

    Bayer’s Baycol Burden: Bayer, whose cholesterol drug, Baycol, had to be removed from the market because of death and muscle inflammation stands accused of ignoring the drug’s problems:

    But on June 27, 1997, the day after Baycol was approved by the Food and Drug Administration, Jerry Karabelas, executive vice president for pharmaceuticals at SmithKline Beecham, which later merged with Glaxo, wrote to David Ebsworth, president of Bayer's North American pharmaceutical operations, saying he had "serious concerns" about using the drug with some other medicines, according to excerpts of the letter included in court papers.

    Mr. Karabelas said that Baycol appeared to be no stronger than a competing drug called Lescol. But, he said, Baycol also caused "drug interactions that could be magnified at higher doses."

    "Simple and safe," Mr. Karabelas wrote, "no longer appears to be a viable promotional platform."

    ...In December 1999, Bayer added a warning to the drug's label saying that Baycol should not be prescribed with Lopid — a warning stronger than those on the labels of similar drugs. A drug's label, which is approved by the F.D.A., is a document included in a drug's package that often spans many pages, and doctors rely on these labels when they prescribe medicines.

    ...In May 2000, when Bayer was anticipating F.D.A. approval of the stronger version of Baycol in July, Dr. Richard Goodstein, vice president for scientific relations at Bayer, sent an e-mail message to Patricia Stenger, a manager in Bayer's scientific affairs division, about a meeting of the "Baycol Project team." Dr. Goodstein told Ms. Stenger that he saw "a false comfort factor in place across the company" about the drug

    ..That November, Bayer analyzed reports of side effects and found that patients taking Baycol alone had 5 to 10 times the chance of developing rhabdo as patients on the other medicines.

    Mr. Beck said Bayer then hired Pacificare, a managed care company, to more thoroughly analyze Baycol's risks among its members. The study did not include patients taking the highest dose of Baycol. It found that the drug at lower doses was no more risky than other statins as long as it was prescribed according to the label directions, Mr. Beck said.

    ...In December 2000, the Harris County public hospital system in Houston stopped using Baycol after seeing six cases of rhabdo in just nine months in patients taking the drug. The increase in rhabdo cases "was a noticeable thing in a hospital system our size," said Dr. David Hyman, chief of general internal medicine at Ben Taub General Hospital in Houston. "We made a decision we were uncomfortable with the drug."

    Eight months later, in August 2001, Bayer pulled Baycol from the market.

    None of that looks too good for the company. But the following doesn't make the lawyers look good, either:

    But approximately 100 deaths and 1,600 injuries worldwide have been linked to a muscle disorder caused by the drug, according to regulatory filings by the company.

    ....More than 10,000 patients who took Baycol or the families of those who died have filed lawsuits against Bayer and GlaxoSmithKline. The first trial, in Corpus Christi, Tex., began Tuesday.

    They know a cash cow when they see one. Bayer's being sued by about six times the number of people who were actually injured by the product. Maybe the company was negligent in not pulling it from the market sooner, but that’s no reason they should pay damages to people who weren’t harmed by it.
    posted by Sydney on 2/23/2003 02:58:00 PM 0 comments

    A Pill for Everything: Tamoxifen, a drug used to reduce breast cancer recurrence, is being touted for lumpy breasts:

    In the current study, Tan-Chiu and her colleagues reviewed the records of more than 13,000 women at high risk of breast cancer, who participated in an earlier trial designed to study the benefits of the drug in preventing the disease.

    The researchers discovered that women who took tamoxifen for an average of 49 months were 28% less likely to develop benign breast disease than women taking an inactive drug.

    Moreover, taking tamoxifen reduced the need for biopsy by 29% among the study participants, the authors note in the Journal of the National Cancer Institute.

    This is an important benefit of the drug, Tan-Chiu said in an interview. Going through a biopsy is often not a pleasant experience, she noted, and waiting for the result to see if you have breast cancer can be excruciating. "All that is nerve-wracking," she said.

    "If you can reduce that, it's wonderful."

    Except that tamoxifen isn’t without side effects. In addition to increasing the risk of blood clots, and uterine cancer and causing hot flashes, there’s some evidence that it might be associated with higher death rates. That’s a chance that’s worth taking if your goal is to avoid the recurrence of cancer, but not if it’s just to alleviate the minor inconvenience of tender and lumpy breasts.

    The authors suggest that the drug lowers the need for biopsy, but it fails to tell us how many women with benign breast disease undergo biopsies each year, and how that compares to those who take tamoxifen. The study's abstract doesn't give any more complete information, but just repeats those "percentage differences" that must have been in the press release. Not surprisingly, one of the study’s co-authors is financed by the makers of tamoxifen.
    posted by Sydney on 2/23/2003 02:44:00 PM 0 comments

    Requiescat in Pace: Jesica Santillan has died. Prayers for her family. Although her "self-proclaimed godfather" only grows more obnoxious. There have been few pictures of her family, but plenty of him leaning over her deathbed:

    Mahoney maintains that after the unsuccessful transplant, he was forced to battle the hospital's administration because it didn't want unflattering publicity about the error.

    Publicity is something Mahoney is quite good at. He raised the money for the transplant, and he’s inserted himself into the story at every possible moment. His point isn’t that the hospital denied their mistake, only that they didn’t mount a publicity campaign as soon as he wanted to get a second set of organs:

    He claims the hospital was more concerned about protecting its reputation than trying to find suitable donor organs from a compatible blood group.

    The delay damaged Santillan's brain and might have cost her her life, he charged. The administration needed to say it made a mistake "and not let a child lay on life support 10 or 14 days knowing that it's ruining her brain, it's ruining the other organs," he said.

    The hospital denies the allegation, saying it did everything possible to correct the error and give Santillan the best possible care.

    Doctors had said the second surgery would give the teen a 50 percent chance of survival. Without it, she would die, doctors had said.

    You can understand why they’d be hesitant to launch a publicity juggernaut. Not only because it would draw attention to their mistake, but because it would divert organs away from someone who might have had a better than 50% chance of benefiting from them.

    But now, the lawyers are involved (you knew they would be), and they’ve put the kibosh on Mr. Mahoney:

    Before noon Saturday, Mack Mahoney, the Louisburg home builder who had acted as the family spokesman and who had taken the story of the hospital's mistake to the news media, dropped out of the public eye.

    But I’m sure, having called the doctors “murderers”, Mr. Mahoney will be the driving force behind the lawsuit, too. In fact, you can't help but feel that the Santillan's are nothing more than pawns in Mr. Mahoney's grand publicity game.
    posted by Sydney on 2/23/2003 02:35:00 PM 0 comments

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