"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
Tales of Long Ago: A British physician sent in this account of a smallpox outbreak in Britain when he was a young doctor:
Of the 18 contacts who developed smallpox, those who had ever been vaccinated survived after mild to moderate illnesses. One severely ill 84-year-old man who had been vaccinated once in infancy also survived. Using a vaccine fully active in others, I vaccinated the exposed unvaccinated nurses. But by then it was over a week since possible exposure, and these vaccinations did not take. Presumably during the smallpox incubation period, the more virulent variola virus had already induced enough interferon to prevent vaccinia infection.
Previous vaccination protects well against severe or fatal illness, but cannot always prevent infection. Vaccination after exposure cannot be relied on, especially in the second half of the incubation period, when interference by the already established variola virus prevents the less virulent vaccinia virus from establishing itself.
Interesting. One of the arguments that those against pre-attack smallpox vaccination make is that post-attack vaccination can prevent the already-exposed from developing the infection. Evidently, that isn't necessarily true. posted by Sydney on
4/05/2003 08:51:00 AM
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The Spread of SARS:The Eyes Have It has collected two graphic representations of SARS and how it spread. The link to the Times graphic is the best - note the number of healthcare workers infected by just one patient.
Elsewhere in the news, SARS has been added to the diseases worthy of quarantine, which means if need be, the government can force you stay in your house until you’re no longer sick. The list is nothing new. It’s been around for some time and includes such diseases as smallpox and cholera, but it’s the first time in a while that a new disease has been added to it.
And, from the CDC press conference yesterday, we learn why the disease hasn’t been as fatal here:
We are using a very broad, very nonspecific, but quite sensitive surveillance case definition here to pick up these 115 suspect cases.
Now, having said that, though, why have we not seen one of these severely ill patients? I think we have been lucky, frankly. I mean, there is no better explanation at the moment, and we won't know until we get better information on risk factors, as they relate to exposure and individual susceptibility.
Translation: luck.
And there’s mounting evidence that the coronavirus is, indeed, the culprit - although it still isn’t certain:
Evidence for this previously unrecognized Coronavirus has been found now in at least 10 laboratories, including the laboratories here at CDC. The preponderance of the evidence continues to mount and continues to favor an etiologic role or this previously unrecognized Coronavirus in the cause of SARS.
So far, in looking at specimens from the suspect cases in the United States, we now have evidence of infection with this agent in a total of four people, and we are working with the state health departments in the states where these people reside, so that they are provided with the information and they, in turn, will provide the clinicians and the patients with the information.
Now, let me give a little more detail on the extent of the laboratory evidence. We have cultured this Coronavirus from a total of four patients. We have electron microscopic evidence from two patients of this virus. We have PCR results--that is the Polymerase Chain Reaction, the amplification technique--where we find evidence of Coronaviral nucleic acid in 11 patients.
Looking at the antibody tests, of which we have two--an IFA test and Allose test--there is evidence for infection in a total of five patients. And from the standpoint of histopathology, looking through the microscope at tissue from deceased patients, we have seen evidence of an entity that the pathologist call diffuse alveolar damage, which is the pathologic correlate for the clinical syndrome of Acute Respiratory Distress Syndrome, which has appeared in patients with severe forms of SARS.
This last bit about the pathological changes in the lungs is a key difference between this infection and influenza. The influenza virus doesn’t, for the most part, directly attack the lungs. “Influenza-related deaths” are usually caused by complicating factors - the development of a pneumonia super-imposed on influenza, or hypoxia that makes a heart condition suddenly fatal. This virus, in contrast, seems to attack the lungs directly and damage them enough to cause a critical illness in a significant number of its victims.
And, finally, is the CDC examining this outbreak for lessons in controlling and preventing a bioterrorist attack?
This is a fire drill for a number of things. It is a fire drill for an unexpected, severe acute respiratory disease. The one of those that we know is going to occur one day is the next worldwide epidemic or pandemic of influenza. So those of you who have been interested in following influenza preparedness in the past ought to pay very close attention to this. This has many similarities to the way the next influenza pandemic might begin.
Now, having said that, I am sorry, I have forgotten--well, let me,in terms of bioterrorism. Yes, I mean, we are operating through our Emergency Operations Center. That center was activated by Dr. Julie Gerberding, our director, back on March 14th, and it's been operating around the clock ever since.
We're using that now. If we have a bioterrorism attack, we will be using that emergency operation center and doing many of the same things that we're doing now, operating through multidisciplinary, headquarters-based and field teams.
So this a drill. We are building on our experience in dealing with anthrax, on the one hand, and also on our experience in dealing with West Nile encephalitis last summer as it swept across the country. And I would just remind everybody we're paying close attention to what's going on with West Nile Virus right now because, as things warm up, we're going to come back into West Nile transmission season before too long.
Bioterrorism? What’s that to us when we have West Nile virus to worry about! posted by Sydney on
4/05/2003 08:47:00 AM
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Not a JAMA Art History Lesson: I really miss posting the weekly art history lesson from JAMA. Why they decided to include it in the subscription-only part of their website is a little baffling, since their other entertainment items are free. But, since riding on their coattails is no longer an option, I’m going to try my hand at an art history lesson of my own. Call it Medpundit’s weekly art history lesson. (With apologies to Dr. Southgate)
Charles Willson Peale (1741 - 1827) was the pre-eminent painter of early America and the founding father of a dynasty of American painters (four of his seventeen children, the aptly named Titian, Rubens, Raphaelle and Rembrandt Peale, became painters in their own right). He was also the embodiment of the quintessential American can-do spirit. Initially a saddler by trade, he decided to try his hand at painting after seeing some badly done portraits and thinking he could do better. He read what instructional manuals he could find, and then traded his finest saddle to a fellow Maryland resident and painter, John Hesselius for painting lessons. His reputation grew quickly, and soon a group of wealthy patrons sent him to England to study under Benjamin West. He returned to the North American colonies in 1769 and set up a portrait studio. It became his business to paint the prosperous in their best light.
In 1772, he was commissioned to paint the portrait of a Virginia squire named George Washington. (Click here for larger image.) The retired colonel was forty years old at the time of the painting, and owner of a prosperous plantation. He stands before the craggy Virginia landscape wearing his old scarlet and blue British militia uniform, his gun in his hand and his sword at his hip. In his pocket is a letter with a visible signature. Although it is difficult to make out the signature, it was Peale’s habit to paint his lesser-known subjects with a letter or paper that bore their name for easy recognition. Standing there in that common 18th century pose, his right hand tucked in his shirt-front, the Virginia planter looks like a man quite satisfied and content with his lot in life.
Seven years later, Peale had occasion to paint Washington again, this time wearing the blue and gold of the American Army, and against the backdrop of the battlefield of Princeton. (larger image) The sword is still at his hip, but the gun has been replaced with a cannon. The Stars-and-Stripes waves proudly over his shoulder, while at his feet lies the British flag. No need for an identifying letter this time. Instead, there’s a column of captured British troops marching neatly into his right coat pocket. He stands looking directly at the painter, the complacency and satisfaction of seven years earlier replaced with an attitude of confidence and steely determination. The transformation from Virginia squire to conquering hero is complete.
Charles Willson Peale went on to paint over a dozen more portraits of Washington, and many otherpatriots. Like many men of his time, he didn’t content himself with the pursuit of one interest. He also branched out into science, dabbled in inventing, and founded a museum in Philadelphia (which his descendants eventually sold to none other than P.T. Barnum.) Yet, it’s for his portraits that Charles Willson Peale is best remembered, and rightly so. For it is through his work that so much of our history remains alive.
[ed. note - changed later to include the images in the site. Finally learned how to do that.] posted by Sydney on
4/05/2003 07:43:00 AM
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SARS Hysteria:Michael Fumento (who, by the way, has a very good article on biotechnology and bioterrorism) sends this note about SARS:
One thing people just can't get into their heads, whether it's Ebola or SARS, is that nothing kick's an epidemic in the butt like good medical care. As it now stands, we've had 85 SARS cases here and no deaths. If you've ever been to China, and I have on three occasions, you'd know why they have all the SARS cases but about 300. Meanwhile, today the WSJournal ran TEN SARS pieces. Yeah, that's my definition of hysteria.
Yes, that’s true about the quality of medical care having an impact. It impacts both the ability to take adequate care of the sick and to contain the epidemic with effective respiratory isolation measures. Here in the US, for example, we use disposable gowns and masks when entering an isolation room. I’m not sure that hospitals in every country can afford those sorts of measures. And, while there is hysteria - the school keeping students recently returned from a China trip at home, the State Department in China sending people home, etc., I still think the WHO is acting responsibly . Faced with an evolving, highly infectious disease, it’s wise to try to curtail it as much as possible. By one report, the disease results in a degree of respiratory distress severe enough to require critical care support in up to 20% of cases. That alone would put a tremendous strain on our hospital systems if the disease were allowed to go unchecked throughout the general population. And if the critical care services are taxed beyond their ability to respond, mortality goes up. In this case, an ounce of prevention really is worth a pound of cure.
Meanwhile, the disease seems to be on the wane in Singapore, Australia's cases have dropped, and China has allowed the WHO to investigate their cases.
Pap Controversy: Here in the United States, the standard of care when screening for cervical cancer is to use a “monolayer” method. A sample of cells and mucous are obtained from the cervix (the opening of the uterus) with a spatula and a brush, and swirled around in a preservative solution to put the cells into a suspension. The bottle is then shipped off to the lab and a sample of the suspension is sprayed onto a slide in a thin, evenly distributed layer for the pathologist to review.
This method is considered superior to the former method, the original Pap smear, in which the mucous and cells are smeared on a microscope slide, sprayed with preservative and shipped to the lab. The problem with this method being that sometimes the cells clump on top of one another or just get broken up in the process, making it difficult for the pathologist to properly assess their state of normality.
Now comes a study from France that says the new method is inferior to the old, contrary to previously published studies. The French team compared pap smear results done by both the old and new method with biopsy results and close inspection of the cervix with a magnifying lense (called colposcopy). Both biopsy and colposcopy provide more definitive results than the screening pap smears. They found that the conventional pap smear was both better at sampling cells and better at predicting true abnormalities than the newer monolayer method.
But, there is a major problem with the study. They were sloppy in the way they collected their specimens. Sloppy in a way that favors the conventional pap over the monolayer method:
Each woman underwent a standard conventional smear test. The remaining material was then used to prepare the monolayer slide and for human papillomavirus testing.
That means that far fewer cells were placed in suspension for the monolayer method than were placed on the slides for conventional evaluation. And, since pap smears rely on the quality and quantity of cells collected for their accuracy, it’s no surprise that the monolayer method faired worse. Fewer cells to examine equals less accuracy.
And in fact, the greatest difference in the two methods was in the adequacy of specimens. Only 75 conventional paps were inadequate vs. 235 of the monolayer paps. This says it all. The authors claim that their method of sampling isn’t biased toward the conventional pap because they used a mathematical model to compare the two. But, math models are just that - models. You can’t argue with reality. And the reality is that the sampling method was biased toward conventional pap smears.
A far better comparison would be between two groups of women - one of which had conventional paps, the other of which had monolayer paps. This would insure that neither method suffers from a diluted sampling of cells. posted by Sydney on
4/04/2003 09:02:00 AM
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Bad Outcomes: Buried in this USA Today article on medical mistakes is the impact that patient deaths have on physicians:
"One of the questions doctors ask themselves is, 'Did I kill this patient?' This is one of the most profound human experiences you can have, especially when you try to do good. For many of these people, it takes years to process this psychologically."
Some leave their professions after such traumatic experiences. Charles says the physicians involved in errors often do not seek counseling. But many develop depression and sometimes post-traumatic stress disorder.
In a report in the early 1990s, The Heart of Darkness: The Impact of Perceived Mistakes on Physicians, doctors described their emotions as angry, agonized, appalled, worried, guilty, fearful, embarrassed and humiliated. They have no place to turn, Barach says.
It's hard to escape those feelings even whenever there's a bad outcome - even if no mistake has been made. Every decision has its consequence - and sometimes those consequences aren’t what we expected. An antibiotic could cause a fatal allergic reaction. What looks like gallstones from every aspect defies all expectations and turns out to be a heart attack. Or maybe the one question that would have yielded the one vital piece of information to provide the correct diagnosis didn’t get asked. Even when we do everything right, patients die. Yet, most of us, in those circumstances, still question ourselves. Wondering if we overlooked something that another doctor wouldn't have missed. It's tough trying to be perfect in an imperfect world. (Thanks again to Howard Feinberg) posted by Sydney on
4/04/2003 08:47:00 AM
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Matter of Trust: Americans trust supermarkets more than hospitals, and just about everyone more than health insurance companies and managed care companies:
While no industries were mentioned by majorities as being generally honest and trustworthy ("so that you would normally believe a statement by a company in that industry"), results varied widely among the different industries. At the top end, relatively large numbers trust supermarkets (40%), banks (35%), hospitals (34%), computer hardware companies (27%), packaged food companies (23%), and computer software companies (22%).
On the other hand, only very few people believe that tobacco companies (3%), managed care companies (4%), oil companies (4%), and health insurance companies (7%) are generally honest and trustworthy. (thanks to Howard Fienberg for the tip.) posted by Sydney on
4/04/2003 08:41:00 AM
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Lawyer with Heart: The Iraqi who was instrumental in rescuing Private Lynch was a lawyer who didn't like what he saw when he was visiting his wife, a nurse at the hospital:
The friend walked him to the ground-floor ward, taken over by the feared Saddam Fedayeen at the start of the war, and past a window where he saw Lynch, an Army private first class captured after her convoy became lost near Nasiriyah in the opening days of the war.
Her head was bandaged, her right arm was in a sling over a white blanket and she had what Mohammed thought was a gunshot wound to a leg. But her real problem then was the black-uniformed Fedayeen commander who everyone addressed as "colonel."
The man slapped her, Mohammed said. "One, two," he added, making single slapping and back slap motions with his right hand. She was very brave, he recalled.
"My heart cut," Mohammed added, meaning stopped, putting his hand over his chest and grimacing. "There, I have decided to go to Americans to give them important information about the woman prisoner."
He walked through a combat zone to find the marines, then walked back to the hospital to make detailed maps of the place for them. He put both himself and his family at great risk to do so. (His neighbor had been shot for waving at a US helicopter.) In the end, the Fedayeen raided his house and took everything he owned. Now he and his family are refugees, at least until the end of the war. See, lawyers are capable of acting out of something other than self-interest. And how.
Miracle Vaccine: Is the flu shot a talisman against the grim reaper?
Men and women over the age of 65 stand to gain a host of health benefits from getting a flu shot, including a decreased risk of dying of any cause during flu season, scientists reported Wednesday.
...To see if a flu shot might cut the risk, Nichol's team looked at more than 140,000 men and women 65 years and older during the 1998-1999 flu season and again during the 1999-2000 flu season.
In 1999, 56 percent of the group had a flu shot; that proportion rose to nearly 60 percent in 2000.
Vaccination against flu reduced the risk of being hospitalized for heart disease by 19 percent, according to the report in Thursday's issue of The New England Journal of Medicine.
Additionally, those who got the flu shot reduced the chances of being hospitalized for cerebrovascular disease by 16 to 23 percent and the risk of being hospitalized for pneumonia or influenza by 29 to 32 percent.
Overall, a flu shot cut the risk of dying of any cause by 48 to 50 percent, according to the report.
That does, indeed sound like a wonder cure. The authors even use the phrase “protects against heart disease” in the original paper. But, the percentage of people - vaccinated and unvaccinated - who ended up dying or hospitalized for anything during the study was surprisingly small - 1.1% of vaccinated subjects were hospitalized for heart disease during the first study period compared to 1.6% of unvaccinated subjects. During the second period studied the figures were 1.2% vs. 1.4%. For death, the numbers were 1.2% for the vaccinated compared to 2.2% of the unvaccinated during the first study period, and 1.2% vs. 1.7% for the second study period. Hardly earth-shattering differences.
Not that I don’t recommend the flu immunization. I do. The elderly are particularly vulnerable to influenza, and it helps cut down on complications from the disease. It definitely saves lives. It just doesn’t prevent heart disease and death from all causes.
This sort of hyperbole only undermines the legitimate claims for vaccines. When you have researchers hyping the immunization as a preventive to heart disease in the media, it has the potential to cause substantial blow back when those expectations aren’t met. “What do you mean I had a heart attack? I had my flu shot this year!” Or, “Oh, no, my husband had one of those flu shots last year and he died anyways. I won’t have it.” We should be truthful about what our therapies can do. Taking the Madison Avenue approach to sell an immunization to the public is just wrong. posted by Sydney on
4/03/2003 08:04:00 AM
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SARS Reassurance: Here's a graph from the New England Journal of Medicine that helps put SARS mortality in perspective. (Scroll down past the article links) Notice that while cases reported have climbed steeply to over 2000, the number of deaths have remained quite small in comparison.
The same issue has the clinical details of the Canadian cases and a select few of the Hong Kong cases.
UPDATE: And MSNBC's Weblog central has a nice collection of all the Southeast Asian blogs that are reporting on SARS. Really makes you appreciate the power of blogs and other internet technology to disseminate information. posted by Sydney on
4/03/2003 07:54:00 AM
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Misleading Headline Award:West Nile was worse than thought implies that the West Nile virus was more contagious or made people sicker than we had been led to believe last summer, but that isn't the case. What the story is really about is that the people who had severe forms of it - specifically West Nile encephalitis - were left with residual neurological difficulties after their infections cleared:
Fifty-four percent of patients admitted to three Chicago hospitals last year suffered from symptoms including vision loss, paralysis of more than half the body, muscle weakness, abnormally slow movement, numbness and an unstable walk, the study released Monday found--symptoms similar to those of Parkinson's disease, stroke, polio and other diseases that damage nerves.
..In the new study, researchers followed 28 patients from Rush, Loyola, University Medical Center and Cook County's Stroger Hospital.
First of all, that's a very small number of patients from which to generalize about the disease. Secondly, encephalitis is, by definition, an inflammation of the brain, so neurological damage isn't unexpected.
But, the researcher quoted in the article can't resist indulging in hyperbole:
The findings indicate the virus might have mutated into a more dangerous form, Watson said.
"It's more severe than in past epidemics," she said. "It's presenting with more virulent and more aggressive symptoms."
The findings don't indicate any such thing, as Dr. Watson's partner points out:
But Dr. Sidney Houff, a Loyola University neurologist who co-authored the study, said it's unlikely the virus has mutated.
Clearly, Dr. Houff is the Holmes of the team. But, how else were they going to get the media to notice their paper amidst all the SARS news? posted by Sydney on
4/03/2003 07:52:00 AM
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HMO Deathblow? The Supreme Court has dealt a blow to the HMO’s in knocking down their right to pick and choose among providers:
Justices decided 9-0 that Kentucky can force health maintenance organizations (HMOs) to accept any qualified doctor who wants to join. About half the states have these so-called "any willing provider" (AWP) laws, and supporters say it gives patients greater choice and flexibility. The law was specifically designed to help low-income patients with limited health care options.
Not surprisingly, the HMO’s don’t like it:
HMOs and other groups call the policy "Bolshevik" health care coverage, arguing it increases patient costs because health care companies are prevented from choosing providers based on quality, price and volume.
If HMOs "can no longer be selective, there will be cost and quality implications affecting the level of care" they can provide, said Robert Eccles, the attorney representing the health plans.
The cased provided another example of the Court's continuing interest in federalism, testing the often conflicting balance of power between the national government and the states.
Well, this will make it a lot harder for HMO’s to control costs. It just could be the beginning of the end for them.
posted by Sydney on
4/03/2003 07:50:00 AM
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Contagion of Fear: We’re starting to get jittery. A Connecticut school has told students returning from a China trip to stay home for two weeks, for fear they could bring SARS to the school, and an entire airplane arriving in California from Asia was quarantined for two hours.
And from Hong Kong comes this curious report:
Fear of the spread of SARS caused Hong Kong officials recently to quarantine some 15,000 residents in a housing complex. Tuesday, some of those residents were being moved out so medical investigators could search for pockets of infection in the buildings.
How do you detect pockets of virus in a building? Do they have those Star Trek scanners that magically tell you what's in the environment - from life forms to the chemical compostion of the air? posted by Sydney on
4/02/2003 05:26:00 AM
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Joe Bob Does SARS: Joe Bob Briggs has about as good a description as any of the SARS virus:
Fortunately, we have crack microbiologists in rubber gloves and surgical masks studying cultures on three continents, and so what we know is ... well ...
In Hong Kong they say the disease is caused by the paramyxovirus family, which also causes measles.
But wait! The Canadians say it's caused by the metapneumovirus family, which is rarely found in humans and, when it is, normally causes respiratory disease in children.
But wait! The Americans say it's a coronavirus, similar to the one found in the common cold virus.
But wait! The Canadians counter that it could be two viruses, not one, and that the coronavirus part of it is a mutant animal strain of coronavirus. Listen to this quote from Frank Plummer, scientific director at the National Microbiology Laboratory in Winnipeg, "It's somewhere between a mouse corona, a bird corona and a cow corona."
Thank you for being specific, Frank. Isn't this the point in the 1950s sci-fi movie where the scientists huddle around the examining table and say, "But, Dr. Streubing, it's mutating! It's changing! By Jove, it's never been seen on Earth before!"
And he points out why it might have spread so easily in that Hong Kong neighborhood:
You know those neighborhoods in Hong Kong where everyone is so jammed together that Jackie Chan can run across the roofs of buildings and leap out one apartment window and land in the apartment across the street? It's one of THOSE neighborhoods. Some guy could sneeze four apartments away and you could get it.
Leave it Joe Bob. Only a chop-socky movie connoisseur would have picked up on that.
posted by Sydney on
4/02/2003 05:21:00 AM
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A Different View: The WHO has done an admirable job of tracking and containing the SARS epidemic. In just two and half weeks, they’ve identified the probable culprit, and they’ve kept the majority of the outbreak localized to southeast Asia. (The number of cases elsewhere is small and limited to recent Asian travelers and their contacts.) But the New York Times provides a different view from a former doctor and current columnist in Singapore:
As SARS spreads across the globe (Belgium reported its first case yesterday), many have been pointing their fingers at China, which has suppressed information about the illness after it first appeared there in November. The real problem is not how secretive China has been, but how ineffective the World Health Organization has been in creating and enforcing a public health policy suited for a global outbreak like this one.
Since its founding by the United Nations in 1948, the agency has overseen the monitoring and reporting of illnesses — but its rules are binding only on its members. Its membership now includes 192 countries but excludes some nations that are not members of the United Nations, like Taiwan, which has recorded five cases of SARS. Moreover, the only diseases that members are required to report are yellow fever, plague and cholera. And if a jurisdiction declines to report, there are no legal consequences.
What should we do to nations who fail to report their diseases? Hit them with economic sanctions, or invade them? The UN won’t even sanction military action against fascist dictators and rogue states with weapons of mass destruction who fail to comply with their disarmament resolutions.
The op-ed goes on in a similar vein, lamenting the inability of the WHO to enforce any sort of international health policy. It reads like a plea for more WHO power. But the author also unwittingly points out why it would not be wise to give the WHO unlimited authority:
...but the agency's definition of a public health emergency is so broad — whether an illness is serious, unexpected, likely to spread internationally, and restrict travel or trade internationally — that it could apply to almost anything, or nothing.
They’re doing the best job they can with the SARS epidemic, and it seems to be working, although imperfectly. I’d much rather have a spirit of cooperation among sovereign states than a dictatorial global public health regime. The appropriate role of the WHO is advisory. Each nation should be responsible for inacting their own public health measures within the constraints of their laws.
Give the WHO unlimited powers, and you never know what could happen. Once an infectious epidemic has died down and things are quiet again, there’s always the danger that they’d turn their attention to noninfectious diseases (as is their want) and declare an obesity emergency or heart disease emergency - and confiscate our french, er, freedom fries. posted by Sydney on
4/02/2003 05:17:00 AM
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NRO on Smallpox Defense: Jonathon Friedman’s piece on bioterror preparedness makes so many good points, it’s hard to know where to begin:
Strategy is the device through which we control our fate despite adverse circumstances and conditions of uncertainty.
Mass vaccination may be an imperfect policy with some risks - what policy isn't? - but it is a highly effective one, as it minimizes uncertainty and protects the public from one of the enemy's most potent weapons.
The conundrum of the mass-vaccination skeptics is how to deal with risk, a subject that many Americans obsess over. They want information on the likelihood of a smallpox attack, and whether there is a "specific threat." Perfect information is demanded in order to make a perfect decision. And there lies the fatal flaw in their thinking.
So true. We live in an imperfect world in which the complete elimination of risk is impossible. Yet, so many of us expect a world without risk that an entire class of lawyers has been able to make a very good living off that expectation, and it’s contributing to our paralysis when it comes to our self-defense:
..... Incredibly, lawyers frighten the bureaucrats more than bio-terrorists, lawsuits being a clear and present danger. We are more afraid of attorneys with files than of terrorists with vials. posted by Sydney on
4/02/2003 05:10:00 AM
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Accounting: The NHS is calling for a posh maternity hospital to account for its high rate of cesarean sections:
An exclusive London maternity unit used by celebrities including Victoria Beckham and Claudia Schiffer has been asked to account for its high level of caesarian operations.
The unit at the Portland Hospital for Women and Children performs nearly twice as many caesarian births as the English average, according to a report by the National Care Standards Commission.
And what will they say if the hospital just tells them their patients are too privileged to push? posted by Sydney on
4/02/2003 05:09:00 AM
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AIDS Entrepeneur: Bill Gates is investing $60 million in research to find an anti-HIV cream. It's hard to criticize such a noble gesture and cause, but you have to wonder if spending that money on clean needles for African healthcare providers might save more lives. Especially when you read statements like this:
Helene Gayle, director of HIV, TB and Reproductive Health for the Gates Foundation, said women were at greater risk of HIV infection than men.
Given the low availability of female condoms, it was important to find other way that women can protect themselves, she said.
"The imperative to find something that women can use to protect themselves from HIV is clear and urgent.
"The only technology we have is a male-controlled technology - a condom."
Is that true? That women are at the greater risk of HIV infection? I still don’t see this as often in women as I do other sexually transmitted diseases - say gonorrhea or chlamydia. I couldn’t find any reliable statistics (i.e. not from activist groups) about the sex distribution, though. Anyone who does have that information, I’d appreciate it if you could pass it along. posted by Sydney on
4/02/2003 05:07:00 AM
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SARS Update: Interesting development in Hong Kong. The apartment complex that had a surge of new cases, involved one block of apartments, and most of the cases were apartments that were stacked on top of each other (they were upstairs neighbors):
The Hong Kong Department of Health has today issued an unprecedented isolation order to prevent the further spread of Severe Acute Respiratory Syndrome (SADS). The isolation order requires residents of Block E of Amoy Garden to remain in their flats until midnight on 9 April.
The decision to issue the isolation order was made following a continued steep rise in the number of SARS cases detected in the building over the past few days. Concern about a possible outbreak in Amoy Garden mounted on Saturday, when 22 of Hong Kong's 45 new SAR cases hospitalized that day were determined to be residents of the estate. On Sunday, 36 of the 60 new patients admitted to hospital with probable SARS were Amoy Garden residents.
Hong Kong health authorities today informed the public that a cumulative total of 213 residents of Amoy Garden had been admitted to hospital with suspected SARS since reporting on the disease began. Hong Kong's outbreak began on 12 March when health officials first recognized a cluster of cases of atypical pneumonia in the Prince of Wales Hospital.
Of the 213 Amoy residents affected in the outbreak, 107 patients resided in Block E. In addition, most of these 107 patients from Block E lived in flats that were vertically arranged.
That suggests that this virus can be transmitted through air ducts, which in turn suggests that you don't need much of a viral load to be infected. For most viruses, like colds, you have to come into contact with respiratory droplets - either by someone sneezing or coughing on you, or from touching someone's contaminated hand or lips, etc. (That's why it drives me crazy to see someone lick a page before turning it.) But, highly contagious diseases (such as smallpox) can cause infection with a minimal of contact because they don't require a huge glob of viral particles to start the infection. Rather worrisome. posted by Sydney on
4/01/2003 08:25:00 AM
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Lessons of a Contagion:(self-promotion) There are lessons to be learned for bioterror preparedness in the SARS epidemic. My article at Tech Central Station has the details.(/self-promotion) posted by Sydney on
4/01/2003 08:19:00 AM
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Tupperware Mutants: Research suggests that plastic could cause gene mutations. In rodents. In cages where their plastic has been eaten away by strong solvent. They aren't really sure how that translates to people who eat out of plastic containers. posted by Sydney on
4/01/2003 08:15:00 AM
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Good News/Bad News: Doctors are prescribing fewer antibiotics than we did ten years ago, in an effort to avoid antibiotic resistance. But, we're prescribing more broad spectrum antibiotics (drugs that cover a wider range of bacterial species):
Researchers looked at data from the Centers for Disease Control and Prevention from outpatient clinics and found that the number of antibiotic prescriptions doctors wrote decreased roughly 17 percent from 1991 to 1999. However, prescriptions of broad-spectrum antibiotics roughly doubled - from 24 percent to 48 percent for adults and from 24 percent to 40 percent for children.
Overusing broad-spectrum antibiotics is just as bad as overprescribing antibiotics in general when it comes to fostering bacterial resistance to antibiotics. Yet, just as there's pressure from patients to be treated, there's pressure to select certain drugs. I can't tell you how often I've been told that "amoxicillin isn't strong enough," or that "only Cipro works for me." Those are beliefs that are very difficult to overcome, and trying to defeat them usually causes the "negative placebo effect" to kick in - when the treatment doesn’t work because the patient believes it won’t. posted by Sydney on
4/01/2003 08:13:00 AM
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Medicine By Email: Reservations about the privacy issue remain a problem for wide-spread use of email between doctors and patients. Some companies are marketing secure systems, but the price seems a little high:
MedStar Health, which owns hospitals in the District and Maryland, is offering a secure e-mail option to doctors affiliated with the hospitals. The pilot project is free for the first year. After that, doctors may have to pay an annual fee or $2.50 per e-mail they send. Other hospital corporations are considering similar moves.
$2.50 per email is pretty steep. Expect that cost to be passed on to the patient, and if people balk at paying it or if insurance companies won't reimburse it (which they won't,despite the few who are doing it in the article) then forget about email.
And then there’s the concern that patients will email with an emergency and go unanswered for a while:
"How can a patient be sure that I'm sitting by my computer when they are trying to reach me?" worries David Eisenman, an ear, nose and throat specialist with a group practice in Washington. That's especially a worry for pediatricians, who will often take prescription refill requests or appointments by e-mail but are often reluctant to communicate by e-mail [about other matters] lest a message about an emergency go unnoticed.
"If a parent phones in, we can assess the situation right away," says Jeffrey Bernstein, head of a four-doctor practice in Silver Spring, "but it's not possible to continuously monitor a computer screen to make sure we're not missing an emergency."
This may seem self-evident. Who in their right mind would email a doctor about an emergency and expect an answer right away? You’d be surprised. A colleague of mine had an asthma patient arrest waiting for her to call back on a weekend. She couldn’t reach her because the patient had given the answering service the wrong number. I’ve had other patients leave messages on the office answering machine that were clearly emergencies instead of waiting for the answering service to pick up. It’s much too likely to happen.
And diagnosing and treating via email? Not wise. Fewer and fewer people seem to believe this these days (including doctors) but you really do need to examine a patient to make an accurate diagnosis. Email is even worse than phone calls for this because it doesn’t have any real interaction (voice clues, the opportunity to get quick answers to a question about a symptom). In fact, most doctors who use email take their time in answering it:
But even if you tell your doctor you'd rather he e-mailed than phoned you, you may still find yourself waiting longer than you'd like for a reply. In a survey last year by Harris Interactive, doctors said they respond to patients e-mail questions within 18 hours of receipt. But patients said they received replies about 30 hours after their messages were sent.
I’d say that puts email somewhere between the fax and the phone for response time. posted by Sydney on
4/01/2003 08:10:00 AM
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Monday, March 31, 2003
SARS Update: Canada is having trouble keeping up with its small, but growing, case load, something which should give healthcare workers hesitant to receive the smallpox vaccine pause:
Swamped public health officials estimated Ontario has about 100 cases of severe acute respiratory syndrome, but admitted they had only been able to analyse data for 81 -- 42 probable and 39 suspect cases.
"There are very many more individuals provincewide who are cases that are under investigation," said Dr. Colin D'Cunha, Ontario's chief medical officer of health
Hong Kong health officials said on Monday that 92 new cases of a deadly pneumonia have been found in a housing estate, raising the total number of cases there to 213.
Health secretary Yeoh Eng-kiong said at a press briefing that the government decided to impose an isolation order in a block of Amoy Gardens estate on Monday as the number of new cases had risen sharply from 121 on Sunday.
He said out of 213 people, 107 were from just one block.
The women's world ice hockey championship, scheduled to take place in Beijing, has been cancelled because of SARS.
And, according to Instapundit, Taiwan is accusing the WHO of ignoring it. But, they really just seem to be a in a pique because Americans were sent to help them out:
''The CDC is an American institution,'' she said. ''It is not responsible for taking care of the health of other nations.''
Other Taiwanese noted that their island is one of Asia's most vibrant democracies and a major trading power. They felt the WHO insulted them by asking the United States to look out for their interests.
''Is Taiwan one of America's states?'' said Dr. Wu Shuh-min, whose Foundation of Medical Professionals Alliance in Taiwan sent the original request to the WHO for assistance in investigating SARS.
The U.N. agency has also irked some Taiwanese by lumping the island together with China on the WHO Web site, calling it ''China, Taiwan'' or ''Taiwan Province.'' Most Taiwanese are extremely sensitive about being considered part of what they view to be a backward, repressive authoritarian nation.
You can't blame WHO for asking for some manpower help. Although I suppose they could be more sensitive about listing them as a separate country from China.
posted by Sydney on
3/31/2003 06:35:00 AM
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Women Doctors: Why is it that newspaper reporters can never content themselves with being happy that women are now well-established in professions that were once the sole province of men? They always have to find something to complain about. Take, for example, this story about women in medicine:
Even when salaries are adjusted for all these variables, women still get paid less. Two Dartmouth researchers, writing in the JAMWA, measured the incomes of primary-care physicians between ages 36 and 45 and found that women earned only 60 percent to 85 percent as much as their male counterparts from 1989 to 1998 -- not much different from the Bureau of Labor Statistics' finding that women in the United States earn 76 percent of what men earn.
There’s a reason for this. Most doctors are paid on a productivity basis, even when they’re employed. See fewer patients, get paid less. A lot of women physicians make the choice to work fewer hours so that they can meet family obligations. Most married women physicians with families can afford to do that because they have a spouse’s income to fall back on. Those who choose to devote more time to work and see more patients make more money.
Then there’s also maternity leave, which again for a lot of us means six to eight weeks without pay (even when we're employed by someone else.) That brings down the average, too. The disparities in income between men and women physicians would probably fade away if unmarried women physicians were compared to unmarried men physicians.
Overall, the article overstates the impact of women on changing the face of medicine. We aren’t necessarily more humane and understanding than our male counterparts. We just benefit from the perception that we are.
But there were two items in it that just made me laugh:
``It really has been an amazing thing,'' said Leo B. Twiggs, medical director of the University of Miami's Institute for Women's Health. ``They have a uterus and have kids and many want flexible working patterns. Vive la difference!''
Imagine that. They have a uterus and a brain. Truly amazing. And he’s the director of the Institute for Women’s Health!
And then there was this statement by a 40 year old woman medical student:
``I didn't know any women in high school or college who thought of being doctors,'' she said. ``It just wasn't done.''
Goodness. I’m 40. I knew several girls in high school who wanted to be physicians. And my college? You couldn’t swing a cat without hitting a woman pre-med student. But then, I wasn’t a music major, like the woman quoted above was. Chances are, you wouldn’t find too many people of either sex even today in music programs who wanted to go into medical school. Not because it “just isn’t done” but because they just have no interest.
Kids Today: Boomer parents are shocked, SHOCKED! that their kids are anti-abortion:
"I was shocked that there were that many students who felt strong enough and confident enough to speak about being pro-life," said Nina Verin, a parent of another student in the class (whose oral argument was about war in Iraq). "The people I associate with in town are pro-choice, so I'm troubled — where do these kids come from?"
Teenagers supporting life. Crazy kids. What’s the world coming to?
Of course, experts have an opinion as to why support for abortion is declining among teenagers. Well, lots of opinions, really:
Experts offer a number of reasons why young people today seem to favor stricter abortion laws than their parents did at the same age. They include the decline in teenage pregnancy over the last 10 years, which has reduced the demand for abortion. They also cite society's greater acceptance of single parenthood; the spread of ultrasound technology, which has made the fetus seem more human; and the easing of the stigma once attached to giving up a child for adoption.
Ultrasound makes the fetus seem more human? Earth to experts: the fetus is human. Even a human embryo is human.
But the kids give the best explanation for their opinions. It’s far too easy for them to imagine having been aborted themselves:
One of them is Kelly Kroll, a junior at Boston College and president of American Collegians for Life, who says she is a "survivor of the abortion holocaust" because she was adopted. "Myself and my classmates have never known a world in which abortion wasn't legalized," she said. "We've realized that any one of us could have been aborted. When I talk about being a survivor of abortion, I am talking about it from a personal place."
Even kids who weren’t adopted, but raised by pro-abortion parents probably think about that from time to time. Thinking of an aborted fetus, wouldn’t they also think, “There but for the grace of God go I....”
UPDATE: The Cranky Professor used this approach when discussing abortion with students:
While in the throes of my dissertation I taught high school Latin. The abortion argument would come up at least once a year (for all people talk about public schools, if the teachers allow it real thought can go on). My showstopper was asking how many of them believed there was someone MADE for them, a one-and-only out there.
Then I asked them to look up the numbers and figure out the odds on whether their one-and-only had made it to birth.
Hospital Use: The difference between the US military:
Many of the patients treated have been Iraqis. "By Geneva Convention and NATO standards, casualties are taken care of in order of priority, based on injury and illness, not based on uniform," Dr. Jenkins said. "That's been the policy back to our own Civil War at least."
Now, investigators believe that the hospital was a den of horror rather than healing and was used by the fanatical Feyidah militia as a staging area and headquarters. Inside, the leathernecks found one room that was equipped with a bed and a car battery, indicating that it was used to electrically torture prisoners. posted by Sydney on
3/31/2003 05:58:00 AM
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RSS Feeds: I admit it. I’m still living in 2002. To those of you who wish I had an RSS feed, I haven't been able to get Bloggerpro to host it properly. Thinking about changing hosts, but not quite ready to make the jump yet. Be patient. In the meantime, I usually only post things once a day (usually before 9AM EST, unless blogger is down, then not until after 6PM), unless something really strikes my fancy, so you don’t have to keep hitting your bookmark to find out if anything is new. posted by Sydney on
3/31/2003 05:55:00 AM
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SARS Update: A doctor in Hong Kong describes what it's like to be in the midst of the SARS epidemic:
At noon, his chief of staff announced that the hospital's own doctors and nurses had begun filling up the emergency wards as patients. They reported trouble breathing, severe muscle pain and high fever. Their mystery illness wasn't responding to treatment. The healthy staff took to dressing from head to toe in protective gear. To avoid infecting his family, Cockram kept to a separate bedroom and wore a surgical mask at home. Many of his colleagues slept in their offices. In a few days, the wards filled up with more than 90 patients. "It was heartbreaking," he says. "This was a new disease, and we didn't know what to do. We felt so helpless."
In other news, the CDC released guidelines for patients and their close contacts to help minimize spread of the disease. Don't cough, don't sneeze, don't drink out of the same glass as others, wash your hands, and stay at home for ten days after you're feeling better.
And here's the WHO's summary of yesterday's developments:
The number of cases in Viet Nam remained at 58 for the sixth day in a row, indicating that the outbreak in Hanoi is well-controlled.
The largest increases occurred in Hong Kong Special Administrative Region of China, with 45 new cases, and Canada, with 8 new cases. The United States of America reported 8 additional suspect or probable cases.
It's reassuring that in Vietnam things have remained steady, with no new cases for so long. They may be near stopping the spread. It's also reassuring that such large countries as Canada and the United States have seen only small increases in cases (all the new cases were in travellers returning from southeast Asia), but Hong Kong, where healthcare workers were especially hit hard remains worrisome.
One of the reasons Canada has been able to keep local spread to a minimum is that they're practicing universal respiratory precautions:
In Toronto, all hospital workers should be issued protective gear to stop the spread of SARS. Dr. James Young, the Ontario commissioner of public safety, told reporters that hospital staff must wear masks, gowns, gloves and eyewear.
"We are all taking this disease very seriously," said Young. "Health officials and health care workers across the province have been working hard to prevent infection. Now, we are using all arms of the government needed to make sure the spread of this disease is controlled."
Health Canada, meanwhile, said it has received reports of 37 cases of SARS in Ontario, British Columbia and Manitoba. There have been three deaths in Canada.
Here's a tally of cases in the United States (still no deaths here, thankfully)
UPDATE: Canada has taken the unusual step of closing two hospitals that cared for SARS cases, and quarantining their workers:
Most cases involve health care workers at Scarborough Grace Hospital and York Central Hospital who became infected while treating initial victims, all of whom had traveled in Asia or had close contact with other victims.
"What we're seeing in the last week is mostly health care workers that are young, healthy people and we have to realize if we start to see individuals and families that are older, that they are more susceptible to a worse outcome," Low said.
Frank Lussing, president and chief executive of York Central, said anyone who has worked there since March 16 has been asked to stay home for 10 days. The hospital has a staff of 1,800 workers.
The quarantine advisory extends to those in close contact with the hospital workers posted by Sydney on
3/30/2003 08:07:00 AM
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Overzealous: Is it any wonder that young people don't want to go into medicine these days, when they see stories like this:
A prominent University of Washington kidney specialist pleaded guilty yesterday to a felony charge of submitting a fraudulent health-care bill but vowed he would not give up his position on the UW medical-school faculty.
That's right, felony charges, as in robbing-a-bank-type charges. His crime:
Couser pleaded to one count of mail fraud for submitting a $124 bill to a private health insurer in 1996 for a dialysis treatment at which he wasn't present. His plea came in the fourth year of a Justice Department criminal investigation of Medicare and Medicaid billing practices at the UW medical school.
Couser also admitted that from September 1991 to last April he submitted $100,000 in bills to Medicare, Medicaid and a U.S. Defense Department health-insurance program for dialysis treatments when he wasn't present.
Now, I don't bill for dialysis, but I have to wonder about the justice of this. I often walk past our hospital's dialysis department, and there aren't any nephrologists hanging out in there while their patients get dialysis. Yet, those nephrologists are responsible for writing the correct orders for that dialysis and for handling anything that may go wrong. They don't have to be physically present to have it administered, but it is their professional expertise that makes it possible. Shouldn't they be able to bill for that? posted by Sydney on
3/30/2003 08:04:00 AM
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Crafty Sperm: Researchers have discovered that human sperm cells use scent to find an egg:
German researchers trying to work out how sperm find their way to their intended destination have identified an odour receptor in testicular tissue, usually found in the sensory nerve cells of the nose.
In laboratory tests, the receptor kick-started a process where sperm were drawn towards concentrations of an artificial scent called bourgeonal, which triggers the receptor in nasal cells.
The results have implications for infertility treatment as well as the development of non-hormonal contraceptives. posted by Sydney on
3/30/2003 07:29:00 AM
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