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

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

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    Saturday, March 29, 2003

    Smallpox Vaccine UpdateSmallpox Vaccine Update: Two states have decided to stop their smallpox vaccine programs because of heart attacks in some recipients, all of whom had heart disease or other risk factors:

    Altogether, federal health experts are investigating at least 18 cases of possible cardiac reactions, including three fatal heart attacks in recently immunized military personnel and civilian health care workers. But William Winkenwerder Jr., assistant secretary of defense for health affairs, said the heart attack death of a 55-year-old National Guardsman was more likely related to the man's high cholesterol and smoking than the vaccination.

    "That is very noteworthy in this case," Winkenwerder said in an interview. The evidence at this point, "indicates smallpox vaccination was not likely to be the cause of his death." More than 350,000 Defense Department employees have been inoculated since December.

    That qualifying statement has been made with every announcement of a heart attack in vaccine recipients, and yet the hype goes on and on. In the mind of the media and the public, and apparently in some health departments, there is a link between the vaccine and heart disease:

    Illinois and New York suspended immunizations entirely, as did some individual hospitals such as Dartmouth Medical Center in New Hampshire. Other states, such as Florida, postponed inoculations until they could update volunteers on new safety measures relating to heart risks.

    At the CDC offices in Atlanta, staffers were fielding nervous phone calls from people who had been vaccinated and worried they may be at risk for heart failure, said Dixie Snyder, associate director for science at CDC.

    The CDC really needs to be much more careful in their approach to releasing their figures. It's one thing to collect information on every illness, no matter how remote the chances are that it's related to the vaccine, for purposes of epidemiological analysis, it's another thing to make press releases detailing each of those outcomes. They wouldn't be doing this for tetanus or influenza immunizations, yet I'm sure many more people die of heart attacks within a few weeks of getting immunized for those diseases than have died of heart attacks after smallpox vaccination.

    posted by Sydney on 3/29/2003 11:44:00 AM 0 comments

    Got Lice? Better to spring for the over-the-countermeds than use the riskier perscription medication, no matter how much money it saves you by having your insurance company pay for the prescription treatment:

    Using too much Lindane to treat lice infestations can cause deadly brain or nerve damage, federal health officials warned yesterday, stressing that the prescription drug should not be used on babies and "with great caution" on children.

    The Food and Drug Administration took new steps to limit how much of the controversial drug people can slather on. Once sold in large bottles, Lindane now is to come only in one- or two-ounce packets for one-time use, and doctors are told not to prescribe more.

    I try to avoid lindane as much as possible. There are much safer alternatives now, but patients continue to pressure me to prescribe it. Their insurance co-pays for prescription drugs are often less expensive than the over-the-counter price of Rid. I have even, sad to say, lost some patients over this. (Lost in the sense that they left my practice because I wouldn't use it as first-line therapy, not in the sense that they died because I caved into consumer demands.)
    posted by Sydney on 3/29/2003 11:36:00 AM 0 comments

    Meanwhile...: The WHO physician who first realized there was a new infectious disease brewing in Asia has died from SARS:

    Italian Dr. Carlo Urbani, 46, a World Health Organization expert on communicable diseases, became infected while working in Vietnam, where he diagnosed an American businessman hospitalized in Hanoi, Vietnam, the U.N. agency said. The businessman later died.

    Forty-six year olds usually don't die from complications of a cold or the flu. Make no mistake, this is a more deadly and more contagious virus than we've become accustomed to. And it certainly has the citizens of Hong Kong spooked:

    Today, thousands of Hong Kong residents were wearing surgical masks around town, but many were not going around at all, slowing down an already feeble economy.

    Taxi stands where people normally line up during rush hour had few customers in sight. Schools were closed, and the Hongkong and Shanghai Banking Corp., the biggest lender in town, shut part of a floor in its main office today because a worker became sick.

    The Bank of China also closed a branch today for a thorough cleaning after a staff member fell ill. Several other companies have done the same.

    Anti-war protesters in Hong Kong cancelled a peace rally.

    Some airplane crews on Cathay Pacific Airways, Hong Kong's largest airline, were wearing masks, and spokeswoman Maria Yu said some flights might be cut.

    Other places are reacting, too:

    Nations across Asia are fighting to contain the illness. Singapore, which has had two deaths, nearly doubled the number of people quarantined to more than 1,500 on Friday.

    Australia advised its citizens today to reconsider traveling to Hong Kong, Singapore, China and Vietnam - the four places in Asia that have suffered SARS deaths - if they were worried about the disease.

    Taiwan said today its SARS cases had risen from 10 to 12. Officials handed out 100,000 free surgical masks to travelers and employees at its main international airport, which was being disinfected.

    ...In Toronto, health officials declared an emergency and said Friday that international travelers flying out of the city will be screened for SARS symptoms.

    The U.S. State Department has urged American travelers to watch for symptoms of the disease, including a fever above 100.4 degrees and signs of respiratory illness such as cough or shortness of breath.
    posted by Sydney on 3/29/2003 11:18:00 AM 0 comments

    Perspective: Michael Fumento puts the SARS outbreak in perspective:

    At this writing, SARS appears to have killed 49 people out of 1323 afflicted according to the World Health Organization, a death rate of less than four percent. In Hong Kong, that alleged "worst medical disaster" has killed ten people out of 316 known victims. But since this only takes into account those ill enough to seek medical help, the actual ratio of deaths to infections is certainly far less.

    In contrast, the 1918-1919 flu pandemic killed approximately a third of the 60 million afflicted.

    Further, virtually all of the deaths have been in countries with horrendous health care, primarily mainland China. In the U.S., 40 people have been hospitalized with SARS. Deaths? Zero.

    Conversely, other forms of pneumonia kill about 40,000 Americans yearly.

    But he downplays its tranmissibility too much:

    Each year millions of Americans alone contract the flu. Compare that with those 40 SARS cases and – well – you can't compare them. Further evidence that SARS is hard to catch is that health care workers and family members of victims are by far the most likely to become afflicted.

    If SARS cases were allowed to go unchecked without the quarantine measures that have been taken, their could well be millions of Americans who get infected with it each year, too. The mortality of the average influenza case is also significantly lower than the 4% figure for SARS. Only 1,765 people died in 2000 from influenza, the majority of them elderly patients whose health was already compromised. (There are usually around the order of 95 million cases of influenza annually in the United States.)

    And he overestimates the effectiveness of Ribavirin. It isn’t clear that it’s all that effective:

    In SARS, numerous antibiotic therapies have been tried with no clear effect. Ribavirin with or without use of steroids has been used in an increasing number of patients. But, in the absence of clinical indicators, its effectiveness has not been proven. It has been proposed that a coordinated multicentred approach to establishing the effectiveness of ribavirin therapy be examined.

    Although he makes a good point that there are other already well-established infectious diseases that kill far more people and are deserving of more budgetary attention (such as tuberculosis and malaria), the global health community is right to be concerned about a viral pneumonia that appears more deadly and more contagious than the run-of-the-mill cold and flu. Every fifty years or so, the influenza virus undergoes a mutation that makes it especially lethal, such as occurred in 1918. It’s that sort of thing that the public health community is most concerned about. When a new infectious disease appears on the scene, they’re right to take a cautious approach.
    posted by Sydney on 3/29/2003 11:08:00 AM 0 comments

    New Blog Alert: At least it's new for me. T. Crown's Musings offers this advice for physicians:

    A note to doctors who are worried about medical malpractice insurance premiums, and indeed about lawsuits in general:

    If your patient, or former patient, asks you why you did something, answer it. Forty percent of our cases -- yes, I'm keeping track -- come from people who wouldn't've bothered, except the doctor replies to questions like that with (I'm not making this up): "I don't have to answer that," or "You wouldn't understand."

    Look, I know that your patients won't understand most of what you tell them. Trust me; they end up in my office with some regularity. But you can stop a lot of them before they go anywhere near the "Attorneys" section of the Yellow Pages by tamping down the God Complex just a bit.

    Telling the truth is always the best path, no matter how painful it might be.
    posted by Sydney on 3/29/2003 10:16:00 AM 0 comments

    Friday, March 28, 2003

    Laugh for the Day: Sex advice from Donald Rumsfeld. (via Dr. Alice, who I have also now added to the links column to the left.)

    posted by Sydney on 3/28/2003 08:41:00 AM 0 comments

    Asian Virus Update: Hong Kong steps up its contagion control efforts:

    At least three Hong Kong universities will shut their doors temporarily from Saturday, and another hospital chief was admitted to hospital on suspicion of having caught the disease.

    But It’s hard to quarantine a free people:

    Singapore newspapers said that instead of staying home and avoiding crowds, schoolchildren are now clogging up shopping centers and cinemas.

    And, many countries are closely scrutinizing travellers from Southeast Asia (on the advice of the WHO):

    Malaysia on Friday reported its first suspected SARS case, a nurse working in neighboring Singapore, and said it would post health inspectors at a causeway it shares with the city-state to screen out infected visitors.

    In the Philippines, the government will ask those arriving from infected countries to voluntarily quarantine themselves by staying at home for seven days after arrival.

    ..In Taiwan, where 10 people have been infected, the government began stringent health checks requiring passengers to declare if they had been to Hong Kong, China, Singapore and Vietnam in the past 10 days. They will need to say if they had contact with patients of the disease.

    In Hong Kong, travelers will be required to fill out health declaration forms at all checkpoints from Saturday.

    More government staff will also be posted at checkpoints to detect those displaying symptoms of the disease -- high fever, cough, chills and breathing difficulties.

    The CDC has advice for families in the midst of international adoptions, and the World Health Organization, which organized doctors from the around the world who were caring for people with SARS, says they can now confidently describe the disease's progression:

    What we were able to establish is that within the SARS group of patients, there are two groups. One group makes up the majority, about 90%, who will have all the characteristic symptoms upon presentation, will progress to about day 6 or 7 and then will spontaneously start getting slowly better. The other group, the remaining approximately 10%, has a more severe form of the disease and progress to acute respiratory distress syndrome, many of whom will require mechanical ventilatory support. The mortality among this second group is quite high and early indications from my clinical colleagues suggest that most of these who do succumb actually have significant other illnesses at the time of presentation.

    So, it is like having a really a bad flu. And, it looks more and more likely that the cause is a coronavirus:

    The first phase of the hunt for the causative agent of this disease nears completion. The majority of the laboratories in our network find corona virus in specimens from patients with SARS. At the same time, the second phase is beginning. The second phase is the development of a diagnostic test. These two phases overlap. We have to double and triple check that the corona virus is the causative agent and that takes place. At the same time, a diagnostic test has to be developed for the corona virus. These tests will be used tomorrow or beginning tomorrow, in Hong Kong. Three laboratories in Hong Kong will use two different tests and will identify SARS patients in Hong Kong. These tests will then be further rolled out to other countries quickly.

    But perhaps the greatest lesson in all of this is the difficulty in stemming an epidemic once healthcare workers have been infected in great numbers:

    But the difficulty in Hong Kong is that because they are so many health workers infected, who are the pillars of the health care system, it’s very difficult now to find all the extra health workers they need to increase their measures.

    We should take that lesson to heart. Imagine if this were smallpox, which instead of a 4% mortality rate has a 30% mortality rate. Which instead of lasting 6-7 days, lasts two or three weeks. And which has many more nonfatal complications than this virus. Many of those who don’t die are critically ill with smallpox. Yet it could be prevented by pre-attack vaccination. That is, it could be if our healthcare workforce were willing to make the sacrifice. (Which is a small sacrifice not withstanding all the hyped up reports you read in the media.)

    By the way, as pointed out at Instapundit, The Gweilo Diaries has a lot of good first-hand accounts of Asia in the time of the virus.

    UPDATE: CharlesMurtaugh has a nice rundown on SARS, too, including the possibility of developing a vaccine. (And I don't say that just because he nicely mentioned me twice.)

    A Different Virus: The war is taking its toll on San Francisco's psychology patients. (September 11 did, too. A year later this same paper had a story about psychologists being swamped with patients still stressed out by the terrorist attacks.) At least one San Franciscan says she’s been infected by a “Republican virus”:

    "I find myself lashing out at my husband -- and he agrees with me!" Ruth said. She ascribes her current health problems to the intense emotions the war has provoked. "Just as Iraq was invaded by the viral Republican administration,

    I have been invaded by these viral Republican conditions," she said.

    I’ve heard all sorts of excuses for being grouchy and mean (hormones,chronic pain, etc.), but this is the first time I’ve heard it blamed on the Republicans.

    (via Best of the Web)
    posted by Sydney on 3/28/2003 08:33:00 AM 0 comments

    Anti-Semitism Watch: It’s alive and well in the British medical establishment. Witness these letters to the editor of the BMJ regarding an academic boycott against Israeli researchers. Even when they're against it, they're for it.
    posted by Sydney on 3/28/2003 08:32:00 AM 0 comments

    In the Spotlight: Last week's New England Journal of Medicine had an article about the Jesica Santillan death that's worth noting. Among its revelations is this description of the publicity circus:

    When patients and their supporters fear that something has gone very wrong, they may see the news spotlight as a rescue strategy or as a form of protection - almost as insurance. The spotlight can also offer an opportunity for revenge. Suddenly, an institution and its physicians are on trial before the public. And in this type of trial there are few rules. Physicians at Duke describe a disruptive, chaotic scene, with an invasion of excited lawyers, photographers, reporters, and family supporters around the pediatric intensive care unit. Dr. Duane Davis, surgical director of the transplantation program, said, "The worst aspect was that the patient became secondary to the conflict between caregivers and the patient's supporters." As the patient died, there were wild accusations charged with animosity.

    The patient became secondary. Secondary to her “self-proclaimed godfather’s” desire to garner as much publicity as possible. Secondary to the lawyer’s desire for a well-publicized case. Secondary to the photographer’s desire for a heart-wrenching photo-op. Secondary to the reporters desire for a human interest story of great magnitude. Bad form all around.
    posted by Sydney on 3/28/2003 08:30:00 AM 0 comments

    Coded Cough: A British man is on trial for allegedly coughing the answers to a friend on Who Wants to be a Millionaire:

    The Crown claims Mr Whittock used a total of 19 strategic coughs to let the Royal Engineers officer know which of the four options in the ITV quiz was the correct answer to a question.

    He says he has allergies and asthma. Expert testimony backs his claim:

    Professor Morris, head of both academic medicine at Hull University and the European Respiratory Taskforce on Chronic Coughing, said a medical examination showed Mr Whittock suffered from perennial rhinitis - a year-round dust allergy - "overladen" with seasonal hayfever.

    He told the lecturer's barrister, David Aubrey, QC, that changes in temperature and atmosphere as well as "nerves" could trigger a bout of coughing in someone like Mr Whittock.

    Fittingly, the expert testimony was interrupted by a coughing juror.
    posted by Sydney on 3/28/2003 08:30:00 AM 0 comments

    Good Grief: How is this possible?

    A consultant gynaecologist who inadvertently removed parts of a woman's kidneys, ovaries, and fallopian tubes during an abortion has been found guilty of serious professional misconduct by the General Medical Council but is allowed to continue working, under conditions.

    Dr Andrew Gbinigie, 47, was working his first day at the private Calthorpe Clinic in Birmingham in November 2000 when the abortion took place. During his first three abortions in the morning theatre staff had became concerned at his technique, and senior staff spoke to him at lunch time, but he reassured them that he was competent to tackle more developed fetuses. His first operation after lunch was on a 21 year old patient referred to in the case as Miss A, who was 20 weeks into her pregnancy.

    During the operation staff saw Dr Gbinigie remove various pieces of tissue that he seemed unable to identify. After he pulled down a segment of bowel his colleagues took serious fright, and an ambulance was called to transfer the patient to Birmingham Women's Hospital, where her life was eventually narrowly saved, but at the cost of a kidney.

    It's possible because at 20 weeks he probably thought it was fetal guts instead of adult guts he was removing. Who could tell the difference?
    posted by Sydney on 3/28/2003 08:29:00 AM 0 comments

    Thursday, March 27, 2003

    Helpful Hints: Prescription drug safety tips from The Onion.

    posted by Sydney on 3/27/2003 08:37:00 AM 0 comments

    Tort Reform Holdup: Tort reform has stalled in the Senate:

    The Feinstein bill is a compromise intended to win Democratic support, which is crucial in the closely divided Senate, where 60 votes are needed to prevent a filibuster. But the $500,000 cap is drawing complaints from the American Medical Association, which lobbied heavily for the House bill and is strongly opposed by the association's affiliate in California. So Mrs. Feinstein said she intended to hold her bill "in abeyance."

    "There is no way that I am going to introduce legislation that is going to be fought by my own doctors, who I am trying to help," she said in an interview on Tuesday.

    The physician groups are concerned by studies that suggest that caps of $500,000 are too high and unlikely to stop rising malpractice premiums. There are other problems with the compromise, too:

    Mrs. Feinstein's compromise would include what she calls a "catastrophic exemption," for cases involving severe disfigurement, severe physical disability or death. In those suits, jury awards for pain and suffering would be limited to $2 million or $50,000 times the number of years the victim could be expected to live, whichever was greater.

    That's a lot of money and it does nothing to curb the enthusiasm for "jackpot justice." And then, there's the usual political shenanigans:

    Dr. Lewin said he hoped senators could be persuaded to support a measure more like the House bill. But that appears unlikely. One Senate Democratic aide said that while several Democratic lawmakers were working on an alternative Democrats were angered that Dr. Frist and other Republicans were planning to bypass the Senate's committee process by bringing a bill directly to the floor.
    posted by Sydney on 3/27/2003 08:33:00 AM 0 comments

    Celebrity Medical Watch: Rolling Stones cancel concerts in Hong Kong due to mystery pneumonia. (Probably not a bad idea. A rock concert crowd would be an ideal place for easy transmission.)
    posted by Sydney on 3/27/2003 08:16:00 AM 0 comments

    Hair and Pain: There are some advantages to being a redheaded stepchild, at least if your a woman - better response to pain medications:

    “While we believe pain is the same in all women of all hair colours,” explained Mogil, “our study shows women with red hair respond better to the pain-killing drug we tested than anyone else -- including men.”
    posted by Sydney on 3/27/2003 08:09:00 AM 0 comments

    Guitar Nipples: Some of the health hazards of being a musician:

    Musicians' injuries are as numerous as their instruments: fiddler's neck, tuba lips, violinist's jaw, horn player's palsy -- even guitar nipples and harpist's cramp. The poor bagpiper is threatened by fungus that often grows inside the instrument. And the flutist? "The flute is a biomechanically impossible instrument to play," says Scott Brown, chief of the department of physical medicine and rehabilitation at Sinai Hospital in Baltimore and a musician himself.

    I’ve always suspected that about the flute. But, what I want to know is, what are “guitar nipples”? I couldn’t find anything on a Google search. Anyone out there know?
    posted by Sydney on 3/27/2003 08:03:00 AM 0 comments

    Something to Hide? DB is, rightly, incensed by this:

    A team of five experts sent to China by the World Health Organization to investigate a mysterious respiratory illness there has not been allowed to visit the province where the disease is thought to have originated in November, agency officials said yesterday.

    It is the second World Health Organization team since early February to be denied access to Guangdong Province, just north of Hong Kong.

    By now, the world knows the disease began in China, so it can’t be a case of trying to save face. So why are they stalling? Are they ashamed to show the world the state, or lack, of Chinese medicine? Or was this a bioweapon experiment gone awry? Similar events have happened before, but with agents less contagious. The Soviets had an accident at an anthrax plant that sent particles into the air and sickened people for miles downwind. But, with only a 4% mortality rate, this agent would be a poor choice as a bioweapon. More likely, they just don’t like scrutiny of any sort by outsiders.

    On an ironic note, one of the chief Hong Kong investigators has come down with the disease, motivating them to take it more seriously:

    Hong Kong officials played down the seriousness of SARS earlier this month. Dr. Yeoh Eng-kiong, Hong Kong's secretary of health, welfare and food, who has managed the SARS outbreak with Dr. William Ho, the chief executive of the Hong Kong Hospital Authority, accused the World Health Organization of being too quick to sound an international alarm.

    Dr. Ho, who is one of two doctors overseeing the government's response to SARS, was confirmed as a SARS case yesterday after having been admitted to a hospital late Sunday night.

    Now that they’re taking it seriously, maybe they’ll try harder to contain it.

    Meanwhile, Singapore is taking it seriously enough to close schools and quarantine all contacts:

    Singapore announced it is to close all its schools for more than two weeks in a bid to contain the spread of a the virus which has killed at least 50 people around the world.

    All primary, secondary schools and junior colleges will be closed until April 6, an official in the government press office told CNN.

    The move to close Singapore's schools came after the city-state reported its first death from the condition.

    Hospitals in Singapore say they have at least 60 confirmed cases of the illness.

    The government has ordered more than 700 residents suspected of coming into contact with the virus to quarantine themselves at home for 10 days.

    And the WHO figures have jumped to 1,323 cases worldwide, but that jump is due to the addition of 792 cases now admitted by the Chinese, figures they were previously keeping secret. Still no word on whether or not they'll allow WHO authorities to enter the province,although it does look like they're being a little more helpful.
    posted by Sydney on 3/27/2003 07:49:00 AM 0 comments

    Timidity Rules: The Bloviator mentioned this study yesterday, but it needs some closer inspection. A couple of researchers in New York looked at discharge diagnoses across the state and concluded that vaccinating healthcare workers will endanger a lot of people:

    The researchers examined data on 2.4 million patients discharged from New York hospitals in 2001; about 1.3 million of them had conditions that may put them at increased risk for contact vaccinia.

    Those at increased risk include: newborns; patients with immune system diseases; those with skin conditions including eczema; and cancer patients and others on immune-suppressing medication.

    The CDC has estimated that between 15 percent and 18 percent of the general population has an at-risk condition. The percentage among hospitalized patients naturally would be higher.

    CDC immunization specialist Dr. Walter Orenstein said the risk of doctor-to-patient transmission is very small if precautions are taken.

    One of the problems with the study is that it overestimates the numbers for each condition because it only looks at discharge diagnoses compiled over the year, not at the number of individual patients with those conditions. Some of the conditions, such as emphysema, cancer, and diabetes, often result in multiple hospitalizations over the course of the year for the same patient. The researchers didn’t make that distinction.

    The other flaw is that it assumes that hospital patients are going to come in direct contact with an employee's vaccination site. That’s extremely difficult to do, especially if it’s covered with a bandage.
    posted by Sydney on 3/27/2003 07:43:00 AM 0 comments

    Every Willing Provider: The state of Washington is reconsidering the wisdom of requiring insurance companies to cover alternative medicine. It's proving to be prohibitively expensive:

    Regence BlueShield says its cost for alternative health services totaled $44.5 million in 2002. Most worrisome is the annual rate of increase in these costs, said Regence spokeswoman Jodi Coffee.

    Increases ranged from 16 percent to 50 percent during the past few years. "We expect this trend to continue," she said.

    In 1999, Regence paid out nearly $20 million for alternative services. In 2000 the cost was about $30 million, in 2001 roughly $35 million, and last year $44.5 million.

    That’s the thing about a lot of alternative therapies - things like massage therapy, chiropractic manipulation, and acupuncture - they don’t aim to cure, they only aim to relieve symptoms. There’s nothing wrong with that, but it gets pretty expensive to pay for someone’s weekly or monthly chirorpractic manipulation or massage. One thing that insurance companies do around here is to limit the number of chiropractic visits they’ll pay for in a year, just as they limit the number of physical therapy visits.

    But, what I found most astonishing was this observation:

    "In 2003, we expect to pay out about $2 million more to chiropractors and massage therapists than we expect to pay out to pediatricians," Coffee said.

    Sounds like it’s time they starting setting some limits.
    posted by Sydney on 3/27/2003 07:40:00 AM 0 comments

    Wednesday, March 26, 2003

    Museum Watch: Cronaca has the very interesting story of the Alexander Fleming Laboratory Museum - the birthplace of penicillin. Hygiene wasn't Dr. Fleming's forte, much to our benefit.

    posted by Sydney on 3/26/2003 12:42:00 PM 0 comments

    Wanted: Medscape is looking for a military doctor stationed in the Mideast to provide a special war feature - "Tales from the Front." Details can be found here.
    posted by Sydney on 3/26/2003 12:32:00 PM 0 comments

    Medpundit’s psuedo-art history lesson. (Here’s a larger image of the portrait.)
    posted by Sydney on 3/26/2003 10:16:00 AM 0 comments

    Scrutiny: Some Congressmen feel that physicians should be doing complete physicals on deployed troops every so often to avoid another Gulf War Syndrome:

    The Kansas City Star reported this month that the military was conducting neither physical or mental examinations, nor blood sampling, as Congress required.

    "What's so difficult about all of this?" asked Rep. William Janklow, a South Dakota Republican. "We're talking about elementary data? What is so mysterious about giving everyone a physical exam?"

    Well, I can think of a few difficulties. How do you centrifuge and store blood samples in the field? Where do you send the samples for testing? What kind of tests would you run? Is it wise to take resources away from treating the wounded to do screening exams of limited value? Evidently, the military has some of the same reservations:

    Throughout most of the hearing, Winkenwerder insisted the Pentagon was doing the appropriate amount of medical testing.

    Winkenwerder said the questionnaire would provide a baseline for medical information about the troops. Certain answers could trigger more detailed questions, he said, adding that "hands-on" physical examinations provided limited value.

    He said that the blood samples from the troops were part of the military's standard test for HIV, and that samples older than a year would not be used.

    "We feel we are following the law and doing it in a way that makes sense," Winkenwerder said.

    This idea that a physical exam can find any and all lurking diseases is highly over-rated. Physicals are extremely limited in their ability to find problems, unless there’s something very obvious going on. There are very few silent diseases that can be effectively screened for with blood tests - such as diabetes. There are a few silent cancers, such as colon cancer and cervical cancer, that can be found easily with exams and screening tests, but physical exams wouldn’t do much to find those “mystery illnesses” such as Gulf War Syndrome that consist largely of subjective complaints.
    posted by Sydney on 3/26/2003 10:09:00 AM 0 comments

    Cause and Effect: Woman dies of heart attack, makes ABC News headlines because she had been vaccinated against smallpox:

    A Maryland nurse recently vaccinated against smallpox died over the weekend of a heart attack, and health officials are trying to determine whether the inoculation contributed to her death, an official familiar with the case said Tuesday.

    Smallpox vaccine does not cause heart attacks. People who die from the vaccine die from infectious complications, such as encephalitis. What's next? Vaccinated woman dies from auto accident, vaccine being investigated as cause?

    No, the next is a warning by the CDC that people with heart disease should avoid smallpox vaccination:

    Federal health officials ordered last night that no one with a history of heart disease be vaccinated against smallpox, after seven health workers with a history of cardiac disease developed severe health problems after being vaccinated.

    One of the seven vaccine recipients died, and one is on life support.

    The seven had clearly defined risk factors for heart disease or had heart problems. But heart problems are not known to put people at greater risk of adverse reactions to smallpox vaccine, said Dr. Julie L. Gerberding, the director of the Centers for Disease Control and Prevention.
    [emphasis mine]

    So, why put out this warning? I understand the need from an epidemiology perspective, to collect all data on everyone who had the vaccine to track side effects, but not every event that occurs after the vaccine is caused by the vaccine, and to present it to the media as if that is the case only further undermines efforts at bioterror defense.

    UPDATE: Chris Rangel says it's like warning people off shopping malls because a few had heart attacks after shopping.
    posted by Sydney on 3/26/2003 09:56:00 AM 0 comments

    Mystery Bug Update: 487 cases worldwide, the vast majority still in Hong Kong, and who knows how many in China. Number of deaths worldwide is 17. That's still a very small number out of billions, and the number of countries with true outbreaks remains small. (The cases in other countries are in travellers who aquired it in those listed countries.) It still seems that the WHO’s efforts are paying off in keeping the outbreak localized, though air travel does seem to be playing a troubling role in its spread. It’s tempting to criticize the hype about the illness, but in the long run, it’s probably helping to keep the disease as limited as it has been.

    Meanwhile, the cause is still in doubt:

    Some confirmed the CDC's report Monday that a previously unrecognized coronavirus, a relative of the viral family responsible for many colds, is present in patients' tissues and body fluids. Others continued to find a member of a different family of viruses, paramyxoviruses, which also cause upper respiratory tract infections.

    "There is consistent finding of both pathogens in individual patients or of either of the pathogens in other patients," said Dr. Klaus Stohr, a WHO virologist.

    Leading hypotheses, he said, is that either of the infectious agents causes the disease, or both are present, coincidentally, because they are common viruses. But a third possibility, he said, is that both viruses work together in a previously unrecognized way.

    That last possibility seems most likely. Two viruses working in synergy.

    Other Viral News: Researchers think they may have found a link between multiple sclerosis and the Epstein-Barr Virus, the virus that causes infectious mononucleosis:

    The Harvard researchers wanted to know whether there was a way to demonstrate an association between Epstein-Barr and multiple sclerosis. They reviewed blood samples routinely drawn from US military personnel, identified 83 men and women with definite or probable cases of MS, and compared them with military personnel not diagnosed with the disease.

    They found that the MS patients had dramatically higher levels of Epstein-Barr antibodies, immune-system cells that target the virus. In fact, some of the patients had 20 times as many of those immune cells as people without MS. The researchers also discovered that those markers of elevated immune-system response were evident in the patients' blood years before they were diagnosed with MS.

    They can't say for sure why some patients' immune systems churn out a stronger response to Epstein-Barr, although researchers have suggested that people infected with the virus later in life have a more robust immune response.

    Harvard researchers and MS specialists said the findings do not establish a definite link between the virus and MS; rather, the data provide another valuable path of investigation.

    In fact, multiple sclerosis has many and varied risk associations:

    Scientists know that genes influence whether someone develops MS, but the role they have in the disease is not nearly so striking as in other conditions. That has led researchers to investigate what else might be involved.

    Along with theories about viruses and bacteria, there's the geography factor. MS occurs more frequently the farther someone lives from the equator, where the disease is virtually nonexistent. Scientists theorize that a sunshine deficit, and the resulting dearth of vitamin D, in colder climates might explain the phenomenon.

    ''There's lots of complexity here,'' said Dr. Patricia O'Looney, director of biomedical research at the National Multiple Sclerosis Society. ''But knowing more about the disease will help us understand the disease more, answer more questions, and perhaps lead to more treatments.''

    It is a complex disease. It’s one of those diseases that may take time to manifest itself, and even then its symptoms and signs can come and go, making diagnosis difficult. And our treatment isn’t any better. There’s still a long way to go in understanding it well enough to improve our treatment approach.
    posted by Sydney on 3/26/2003 09:47:00 AM 0 comments

    Tuesday, March 25, 2003

    The Book-Film-TV-Video Critiquees is up at Blogcritics.

    posted by Sydney on 3/25/2003 12:31:00 PM 0 comments

    Mystery Bug Update: There's a new viral suspect as the cause of the mystery pneumonia:

    While more research is needed, the evidence that a coronavirus is involved comes from several sources, U.S. officials said. Scientists have been able to grow coronavirus from tissue from two patients. In at least one sample, scientists using a powerful microscope have seen the distinctive crown-like shape of a coronavirus. In addition, scientists have found evidence of a coronavirus in lung and kidney tissue from patients, as well as antibodies to coronaviruses in the blood of three patients. A procedure known as polymerase chain reaction has also isolated some genetic material. A preliminary analysis indicates it may represent a fourth, previously unknown, type of coronavirus.

    "We're getting information in from a variety of different kinds of testing, all of which are pointing us in this direction," Gerberding said. "This, in scientific terms, is very strong evidence."

    Before, the speculation was that it was a paramyxovirus, also a virus that causes cold symptoms. Now, evidence is pointing toward the family that most commonly causes colds, the coronavirus, which takes it name from its resemblance to the corona of the sun.

    Sad to see that the infections continue to spread to close contacts, despite admirable efforts to quarantine people with the symptoms. But, then that's the way with coronaviruses. They spread quickly and easily. Things may have been much worse if not for the efforts of the WHO and its regional counterparts.
    posted by Sydney on 3/25/2003 07:36:00 AM 0 comments

    New Canada Twist: Now the internet-deprived can import Canadian drugs without leaving home. Storefronts that serve as fronts for Canadian pharmaceutical firms are springing up to act as local middlemen. Trouble is, it’s illegal:

    FDA officials say the stores are illegal. Business owners say they're providing seniors a way to reduce their drug bills. On Friday, the FDA faxed a letter to an Arkansas affiliate of Rx of Canada, warning that it had 15 days to close or face legal action.

    Rx of Canada's Laguna Hills store is the seventh branch -- offering discounts of 20% to 80% below U.S. prices -- it has opened within two months. It is surrounded by 18,000 seniors living in Leisure World. Three weeks earlier, the company, owned by professional soccer player Joe-Max Moore, opened a store in La Mesa in San Diego County. Five more are scheduled to open today, in Woodland Hills, Colorado, Florida and Oklahoma, with still more to come.

    Just as ambitious is Earle Turow, a former clothing manufacturer who owns Discount Drugs of Canada in Delray Beach, Fla. He said he has signed deals to open 40 franchises next week, 40 the week after and an additional 100 in three months, including one in Palm Springs.

    Seems to me, if they’re going to enforce the law in this case, they’ll have to enforce it for the internet sales and the across-the-border sales, too. It won’t be politically popular, either, with more and more people turning to Canada for cheaper drugs.
    posted by Sydney on 3/25/2003 07:30:00 AM 0 comments

    Military Medicine: Now these guys really are a mobile surgical hospital.
    posted by Sydney on 3/25/2003 07:30:00 AM 0 comments

    Tort Reform of a Different Type: Having the patient pay for his own malpractice insurance:

    Americans are accustomed to purchasing insurance for disability, for death and dismemberment, for injuries sustained in an automobile, airplane or boat. Why not purchase insurance when one has to undergo the complex and sometimes risky treatments available today to deal with medical illness?

    The cost of this insurance would be small and could be funded by a small surcharge on every health and accident insurance policy.

    A similar plan was enacted by the federal government in 1986 in response to a crisis, when the few remaining vaccine manufacturers informed the government that they would cease manufacture of childhood vaccines unless the government solved the liability problem.

    The government's response was the National Childhood Vaccination Injury Act of 1986. A list of compensable events was developed and if a child experienced such an event after vaccination, a claim could be filed and, if appropriate, payment made through a compensation fund.

    This fund was established by placing a small surcharge on every dose of vaccine sold. The plan has worked very well and has allowed manufacturers of childhood vaccines to continue production.

    The medical injury insurance plan would work in a similar manner. It would compensate far more patients in a way that is more timely, efficient, and fair than our current system. It would be nonadversarial and would significantly reduce the cost of defensive medicine. It would take the financial pressure off many high-risk specialists and relieve the pending crisis of access to care for many Americans. It would promote the reporting of medical errors and near-misses resulting in a meaningful patient-safety system.

    Well, that's a different approach. But, it doesn't sound very feasible. Under the Vaccine Injury Act, it's the physician who decides if a child has been harmed by a vaccine. Who would decide if a patient had actually been harmed by malpractice?

    ADDENDUM: Thanks to Diablogger for the tip.
    posted by Sydney on 3/25/2003 07:28:00 AM 0 comments

    Back Early: Got back a day earlier than expected. While away, I was exposed to much more television than I am at home, and I just want to say that this twenty-four hour coverage of war seems extreme. The hotel we stayed in played it constantly - in the lobby, and in the restaurant. Sitting there eating breakfast while war coverage played was just too much like those people who took picnics to the Battle of Bull Run. This isn’t a Superbowl. It’s a war. And it doesn’t need play-by-play coverage. Just had to say my piece. Now, back to medical blogging.
    posted by Sydney on 3/25/2003 07:26:00 AM 0 comments

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