"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
A Step Too Far: The American Heart Association is recommending we treat children for cardiovascular risk factors:
New guidelines developed by the heart association urge primary care physicians to consider family history of heart disease, diet and physical activity of their young patients and, if necessary, provide recommendations to families on changes that could forestall the future development of heart disease.
In some instances, drugs for hypertension and high cholesterol may be in order for children identified as being at high risk for early heart disease, according to the guidelines.
What will they think of next? In utero statins?
These aren’t by any means “evidence-based” guidelines, either:
There is no question that preventing cardiovascular disease is an important goal, Dr. Berg said, but there is also no solid evidence that interventions that work in adults will work the same way in children and adolescents. "It's hard to dispute that we would be better off if children exercise more and eat healthier diets. But on the other hand, when you get into issues like treating elevated lipids or blood pressure in 3-year-olds, the quality of evidence is different, and you might have a different take on those recommendations," he said.
Yes, it's much different committing a growing child to drugs that are taken for a lifetime, with no knowledge of how those drugs would affect growth and development, all to reduce the incidence of coronary artery disease by a few percentage points. What is the American Heart Association thinking? (Click here for more on statins. If archives are screwy, look for "Cholesterol Caution" post.) posted by Sydney on
4/12/2003 08:52:00 AM
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Hospital Looting: Much is being made about the looting of hospitals by the liberated Iraqis. But, we should remember how the Hussein regime used hospitals:
The French documentary filmmaker Joel Soler told me how his minder took him to a hospital, ostensibly to examine the effects of sanctions, but then called in a nurse with a long needle. "He said, 'Now we'll do a series of blood tests.'" Soler jumped on the table screaming: "I said, 'I'm calling my ambassador.' If I'd been American, forget about it."
The officer said special-operations forces found what looked like a ``prototype'' Iraqi torture chamber in the hospital's basement, with batteries and metal prods.
Briefing reporters at Central Command headquarters, Brig. Gen. Brooks said the hospital apparently was being used as a military command post...
Members of the strike force who stayed behind found ammunition, maps and a terrain model in the basement of the hospital. Brooks said that was proof the Iraqis are using civilian facilities to disguise and protect military installations. He said the troops found no evidence that the hospital was used to torture U.S. prisoners or opponents of the Iraqi government.
It might just be that ordinary Iraqis don’t view their hospitals as havens of rest, but as one more tentacle of the Hussein regime. Especially when you compare the above to the Iraqi secret police headquarters:
There was also a superbly equipped hospital, though Iraq has been telling the world for years that its medical facilities have been severely damaged by UN sanctions.
A U.S. Army medic showed off a cache of drugs and equipment he said was worth between US$2-million and US$4-million.
"It appears that Saddam Hussein reserved the best medical treatment for the Republican Guard," said Jack Graham, a U.S. Army medic. He said the supplies will be handed out to Iraqi hospitals.
Hospitals are military headquarters and military headquarters are elite hospitals - the topsy-turvy world of Saddam Hussein’s Iraq. posted by Sydney on
4/12/2003 08:51:00 AM
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Military Medicine: From the Department of Defense, the treatment of Iraqi patients aboard the Navy hospital ship, USNS Comfort:
Enemy prisoners of war enter the facility in no more the same means than our own coalition forces or Iraqi civilians. When they are brought to our casualty receiving, which is equivalent to civilian emergency rooms..
Medicine and Politics: A few months ago, the BMJ asked its readers, “How political should a medical journal be?” I think the standard should be the one upheld by American medical journals - not political at all. Their mission is to seek the truth with scientific method, not to promote agendas. The readers of the BMJ, however, disagree:
In all, 366 people responded to the question posed on bmj.com: How much space should the BMJ devote to political issues? In comparison with current coverage, 45% wanted more or much more coverage, 31% the same, and 22% less or much less.
Perhaps that’s one of the consequences of socialized medicine - medicine becomes hopelessly politicized. Not surprisingly, all of their affirmative letters to the editor were from physicians in public health. (Who, I must say, have a disturbing tendency to lean socialist politically worldwide.)
But the most interesting of all the letters was this one, which puts forth the theory that by publishing articles on bioterrorism, medical journals unwittingly helped promote the war, a la Lenin’s “useful idiots”:
I believe that most people in the United States and United Kingdom would have preferred not to launch a military attack on the people in Iraq. To persuade them to do so, they need to believe that they are being attacked. Medical journals have (unwittingly) had an important propaganda role in persuading the public that it is being attacked.
He must have missed the news about the 3,000 dead in New York and Washington, D.C., not to mention the anthrax mailings, or the ricin found in his own native England. Staggering.
The editors have taken the results of their survey to heart, and published several articles on the morality of war this issue. (Message: all war is bad, no war is just.) Perhaps the most astonishing is the “review” by an Oregon psychiatrist who claims to have identified a "9/11 judgment impairment" in physicians [Didn’t “9/11” top the BMJ’s list of words that should be banned? -ed. Yes, but they make exceptions if it’s used to sneer.] :
Good judgment relies on curiosity fostered by reflection. Certainly, fearful times are not conducive to reflection. We also know that the first casualty of war is truth, and without truth reflection is merely worry and fantasy - anything but good judgment. Judgment is a mental process demanding broad thinking, including reflection. Of itself, reflection does not, nor should it, lead to action. Rather reflection opens the mind to the free flow of curiosity, needed for exploring possibilities. Reflection produces questions that lead to appropriate action. Who can deny that an enhanced capacity to reflect is a necessary skill of a thinking doctor?
And how does that relate to 9/11? Does it impair our ability to make medical judgments? No. It impairs our moral judgment:
Undoubtedly doctors will discharge their duties in times of war. However, as community leaders our critical thinking establishes the nation's standards of health and, to a degree, our morality. Therefore, doctors' constructive curiosity must be preserved, not left until the war is over.
We may be able to set the health standards for our nation, but moral standards? We are but poor mortals, not gods, nor saints, nor prophets. Of course, what he’s really saying is that any physician who thinks this war a just war (i.e. any physician who doesn’t share his anti-war opinion) is suffering from impaired moral judgment. Goodness. You have to wonder how much success a man of such rigid thinking could possibly ever had as a psychiatrist.
But the broader question is why in the hell would the BMJ print such a piece of drivel? The answer, sadly, is that it suits their political agenda. Which raises yet a broader question - will the journal ever print any article that runs contrary to their political views? We may just be witnessing the beginning of the end of one of the world’s best medical journals. posted by Sydney on
4/12/2003 08:41:00 AM
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Caffeinol: A drug for treating strokes that combines two popular beverages - coffee and alcohol - is showing some promise:
Researchers from the University of Texas Houston Medical School gave caffeinol to 23 male and female stoke patients with an average age of 71.
They found they were able to give the patients lower doses of the drug than animal studies had suggested, while still achieving the same blood levels of caffeinol which had been shown to offer protection in rats.
In those tests, an artery supplying blood to the brain was blocked, mimicking what happens in an ischaemic stroke.
It was found the amount of brain damage was reduced by up to 80% if caffeinol was given within three hours.
Further research will now be carried out to test the drug's effectiveness in humans.
Caffeine is an active ingredient in many migraine therapies. It's supposed to improve blood flow to the brain. And alcohol? It does relax the types of muscles that make up artery walls, so it could theoretically increase blood flow to the brain, too. It isn't ready for real-world use, though. This study only looked at the safety of the drug, not its effectiveness, and it was only in a very small group of people. But, if it pans out, it would be the first drug to help reduce stroke damage once it occurs. Stay tuned. posted by Sydney on
4/11/2003 07:58:00 AM
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SARS Update: I don't have to blog about SARS anymore. It has a blog of its own. What the heck, there's still some stuff out there that needs posting.
Evidence continues to mount supporting the coronavirus as the culprit. And, reassuringly, the death rate still pales in comparison to the incidence. (Scroll down past the article links to the graph) But, more worrisome, the disease may have spread for the first time in the US from a co-worker to co-worker:
. Federal officials said Thursday the new respiratory virus that began in Asia may have spread for the first time in a workplace in the United States.
Dr. Julie Gerberding, head of the Centers for Disease Control and Prevention, said a suspected SARS virus patient who became ill after traveling to Asia may have infected a co-worker in Florida.
Gerberding said she was "very concerned" about the possible spread of the disease and said the Florida case is being investigated. Gerberding and Florida officials declined to name the location.
I'm not sure about the wisdom of keeping the location secret. When you're trying to control the spread of an infectious disease, transparency is an asset; secrecy, only an obstruction. (Evidently, this has become something of a policy)
Hormones, Again: The FDA is thinking about taking an estrogen replacement therapy off the market. The drug is Estratest, which combines estrogen and testosterone:
The Food and Drug Administration has begun proceedings to remove from the market the only estrogen-and-testosterone combination pill for sale in the United States.
The agency has asked the company that makes Estratest to produce evidence that the drug treats hot flashes in menopausal women who don't get relief from estrogen supplements alone.
The FDA approved Estratest in 1976. Research since then has suggested that there isn't good evidence that adding testosterone to estrogen provides better relief for hot flashes, an FDA source said.
It seems a little drastic to remove it from the market just because it isn't better than other hormones. Wouldn't it suffice to tell the company not to claim that the drug's superior, and save the market removal for drugs that have proven to be harmful?
Sometimes Estratest is used to try to enhance libido, but evidently that isn't a proven use, either:
In a statement, the agency said it is also concerned because estrogen-testosterone pills are being prescribed for "female sexual dysfunction" -- loss of libido -- which was not one of the uses approved in 1976. posted by Sydney on
4/11/2003 07:40:00 AM
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Cloning, Again: Another reason to doubt those who claim to have cloned a human:
Whether or not rogue scientists could clone a human is hotly debated. After 6 years trying, on over 700 monkey eggs, Gerald Schatten of the University of Pittsburgh says not.
The current technique, his team conclude, robs primate eggs of proteins they need to survive. The 'nuclear transfer' procedure used to create Dolly the sheep "paralyses the egg", Schatten says. Key proteins are sucked out when the egg is stripped of its DNA to be replaced with genetic material from another cell.
SARS Update: New theories developing include the idea that some people might be SARS superspreaders:
A "super-spreader" is a source case who has, for as yet unknown reasons, infected a large number of persons. Although transmission patterns of SARS remain incompletely understood, evidence suggests that such "super-spreaders" may have contributed to the evolution of SARS outbreaks around the world.
And that the very sick are the most adept at spreading the disease:
Until recently, all cases in Singapore have had good epidemiological links to their source. Further work is now required to establish similar links for the more recent cases. If confirmed, such linking of cases will show that transmission is limited to those who are symptomatic, and usually very ill. This hypothesis is supported by the observation that health workers continue to be the main group diagnosed with SARS. To date, investigation of the SARS outbreak in Singapore have revealed few signs of community spread beyond family members in close face-to-face contact with patients. However, these findings are based on limited data on exposures.
Still not sure why the Hong Kong hotel and and apartment complex had such a dramatic spread. One theory is cockroaches:
Hong Kong officials said yesterday they suspect cockroaches might have carried infected waste from sewage pipes into apartments in the huge housing complex, Amoy Gardens, that has recorded more than a quarter of the city's 928 infections.
"The drainage may be the reason. It is possible that the cockroaches carried the virus into the homes," Leung Pak-yin, the Deputy Director of Health, told a radio program yesterday.
Doesn't really fit in with the requires-close-contact-with-very-sick-people theory, does it?
Meanwhile, in Canada, they're having trouble keeping people in quarantine.
Cost Cutting? A new program to improve care and lower healthcare costs is underway, called Bridges for Excellence:
Under the program, participating companies will pay doctors thousands of dollars in bonuses for each worker whose care improves. For instance, a participating physician would get $100 yearly for each diabetic person whose blood pressure, blood sugar and lipid levels are sufficiently measured and controlled. Just 150 patients would net a doctor $15,000 extra a year.
The idea is that people with better lab values and blood pressure will be healthier, miss less work, and have fewer hospitalizations, thus save companies money. But, although patients who meet the parameters may have better long term outcomes (i.e. live longer and have complications later in life instead of early in life), it isn’t at all clear that they’ll be cheaper to take care of.
The program is set up to encourage doctors to use medication over lifestyle modification, and to use the medication aggressively. Expect patients to be on two or three blood pressure medications, two or three diabetes medications, and two or three cholesterol lowering medications to achieve all of the measurable goals. Not only is this expensive (easily hundreds of dollars a month), but it has great potential to increase side effects from drugs as well as drug interactions.
And it won’t completely eliminate hospitalizations due to diabetes and heart disease. It may decrease them, but it won’t eliminate them. By how much it will decrease them remains to be seen.
It will be interesting to see how this pans out. I give it about two to five years before it’s abandoned. posted by Sydney on
4/10/2003 07:56:00 AM
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The Problem With Cloning: One of two endangered Asian cows, cloned from twenty-three year old skin cells of a dead animal, has been euthanized because of cloning-related health problems:
The second of two cloned endangered cattle-like animals was euthanized Tuesday because it was abnormally large and had developed health problems, the scientist overseeing the cloning said.
Some of the problems associated with cloning:
To create the banteng, scientists inserted DNA from the dead banteng's skin cells into egg cells from closely related domestic cows, producing embryos.
The process created 45 embryos, which were transferred into the wombs of 30 cows at Trans Ova Genetics in Iowa. Of those cows, 16 conceived, and two pregnancies came to term.
...Abnormally large newborns are a common problem with cloned animals, and one of the many factors making scientists wary of cloning humans. Although the large banteng seemed healthy at birth, Advanced Cell Technologies told reporters, it quickly took a turn for the worse and was euthanized for humanitarian reasons.
Preparedness: The American Academy of Pediatrics endorses potassium iodide for children living near nuclear reactors:
Households, schools and child-care centers near nuclear power plants should keep potassium iodide pills on hand to protect children from thyroid cancer in the event of a release of radiation, the American Academy of Pediatrics has recommended.
...Potassium iodide, known by its chemical abbreviation, KI, can block the body's absorption of harmful radiation. The federal Food and Drug Administration has recommended that it be taken as soon as a radioactive cloud containing iodine is close by. The pills may still have some protective effect even three to four hours after exposure.
-All children at risk should receive KI before exposure, if possible, or immediately afterward. This will require that KI be available in homes located within 10 miles of a nuclear power plant. Child care facilities and schools within 10 miles of a nuclear power plant should plan to stockpile the agent. It may be prudent to consider stockpiling KI within a larger radius because of more distant windborne fallout, as occurred after Chernobyl; this will be determined by local and national public health authorities.
-Because radioiodines pass into breast milk, pediatricians should caution lactating mothers not to breastfeed their infants after the release of radioiodines, unless no alternative is available. The restriction is temporary, until public health authorities declare it safe to go back to breastfeeding. Public health authorities will also advise about the safe consumption of produce and milk after a radiation disaster.
A 65-year-old retired schoolteacher in India has given birth to a baby boy, and become the world's oldest mother, according to press reports.
If the claim is fully verified, then Satyabhama Mahapatra, from Nayagarh in Orissa, would beat the previous record holder by two years.
The boy, reportedly healthy and weighing 3kilogrammes (6lb 8oz), was born by Caesarean section at a private home, according to the Times of India.
...The pregnancy was not uncomplicated, say the reports - Satyabhama was hospitalised for the final trimester of the pregnancy.
A complicated pregnancy in an elderly mother, born by C-section in a private home in India. Unlikely. Especially since they seem more concerned about notifying the record books than anything else. posted by Sydney on
4/10/2003 07:27:00 AM
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Public Health Silliness: I was going to post something about last weekend’s announcement by the WHO that cancer deaths will be skyrocketing in the years to come, but Charles Murtaugh beat me to it. That’s the price I pay for being slow-witted. He’s right that the primary reason cancer will be increasing is that the population is aging. And he’s right, too, that the public health professionals are going to use it to push for restrictions on smoking, eating, and just about every other thing that can be related even remotely to cancer. This seems especially silly when we’re confronted with a very real public health threat in SARS. Public health is at its best when it concentrates on non-lifestyle issues like communicable diseases and proper sewage treatment. It's at its worst when it tries to make lifestyle choices public health problems. I like his suggestion:
If I were a university president, I would take our current heightened awareness of emerging diseases and bioterrorism, thanks to SARS and the anthrax attacks, and use it to leverage my school's public health faculty to get rid of its politically-correct, transnationalist, nanny-state crap-ass research, and focus on real problems. Does anyone know a university president sufficiently iconoclastic to take on the task?
A group of Democratic lawmakers and consumer advocates will propose legislation today to try to hold down skyrocketing health insurance costs by requiring state approval before insurers can raise their rates.
Consumer advocates say requiring state approval has worked well in limiting rate increases for auto insurance, the main target of Proposition 103, a ballot measure approved by California voters in 1988.
Before Proposition 103, ``We were having the same sort of problems with auto insurance rates that we're now having with health insurance,'' said Jerry Flanagan, a lobbyist for the Foundation for Taxpayer and Consumer Rights.
``Costs were going up,'' he said, and people were going without coverage. ``It became a crisis in the state. . . . You cannot allow the market to run away with itself.''
But William Wehrle, chief lobbyist for the California Association of Health Plans, says health insurance rate increases are due to rising health care costs driven by technology improvements, an aging population and other reasons.
``You can't get rid of those factors by passing a law any more than you can pass a law decreeing that it will always be 75 degrees and sunny out,'' he said.
Yeah. Health insurance is very different than auto insurance. Aside from inflation, I wouldn’t think there would be too many factors that would cause escalations in the rates of auto accidents (except maybe rescinding the speed limit.) But health care is subject to so many other forces - technological advancement and the ever-growing population of the elderly being the chief ones. The only thing this law is likely to do is cause health insurance companies to go out of business. (Thanks to H. Feinberg for the tip.) posted by Sydney on
4/09/2003 09:42:00 AM
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Eat Less, Exercise More: A study in this week’s JAMA says that low-carb diets have no advantage over other diets:
Among obese patients, weight loss was associated with longer diet duration, restriction of calorie intake, but not with reduced carbohydrate content. Low-carbohydrate diets had no significant adverse effect on serum lipid, fasting serum glucose, and fasting serum insulin levels, or blood pressure.
It was one of those hodge-podge studies that looks at trends found in a bunch of other studies, so it can’t be quoted as solid proof, but its findings do correlate with common sense. There’s only one known truth when it comes to weight loss - calories count.
In fact, this week’s JAMA is devoted to obesity. It also included this study, which found that structured programs (a la weight watchers) had more success than going it alone when it comes to shedding pounds:
Random assignment to either a self-help program (n = 212) consisting of two 20-minute counseling sessions with a nutritionist and provision of self-help resources or to a commercial weight loss program (n = 211) consisting of a food plan, an activity plan, and a cognitive restructuring behavior modification plan, delivered at weekly meetings.
At 2 years, 150 participants (71%) in the commercial group and 159 (75%) in the self-help group completed the study. In the intent-to-treat analysis, mean (SD) weight loss of participants in the commercial group was greater than in the self-help group at 1 year (-4.3 [6.1] kg vs -1.3 [6.1] kg, respectively; P<.001) and at 2 years (-2.9 [6.5] kg vs -0.2 [6.5] kg, respectively; P<.001). Waist circumference (P = .003) and body mass index (P<.001) decreased more in the commercial group. Changes in blood pressure, lipids, glucose, and insulin levels were related to changes in weight in both groups, but between-group differences in biological parameters were mainly nonsignificant by year 2.
There’s much more motivation in a group setting to stick with the regimen. So much easier to backslide when you go it alone. Take it from a repeat backslider.... posted by Sydney on
4/09/2003 09:36:00 AM
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Malpractice Caps: From a reader:
I think that your discussion of whether large malpractice awards make patients feel better misses something important: one of the primary purposes of malpractice lawsuits is to incentivize doctors to take the appropriate amount of care with their patients.
It's an extremely tricky economic problem to figure out what the appropriate level of award to provide an optimal incentive is, but it's not at all clear that the number would be lower than the current malpractice awards as opposed to higher. In particular, if only a small number of malpractice cases are ever detected, the level of the award needs to actually be higher than the patient's loss in order to have the average cost of malpractice to the doctor to be correct.
Although I’m not adept enough at statistics to critique the detailed analysis, I have reservations about the general premise that fear of lawsuits keeps doctors honest. I suppose that’s true to some extent. But, I think that far more often, fear of a lawsuit causes us to overtreat and to order unneeded tests to protect ourselves.
All doctors experience this, and not just occasionlly. Here’s another example from my own practice. A patient came to me after her sister was diagnosed with ovarian cancer. She wanted to make sure she didn’t have it. I discussed how we don’t really have a good screening test for ovarian cancer. She should have yearly pelvic exams to check for ovarian masses, but by the time those are felt, cancer is usually advanced. We could do yearly ultrasounds, but a cancer could still crop up in the intervening months, and be quite aggressive. We could do yearly blood tests for a protein that’s produced by ovarian cancer cells, but the test isn’t specific for ovarian cancer. It can be elevated for other reasons, resulting in a lot of worry and perhaps a needless surgical procedure. Again, a cancer could develop in the intervening months. Early diagnosis of ovarian cancer doesn’t necessarily improve outcomes, because ovarian cancer tends to be aggressive. We discussed genetic screening, which also can’t tell her with any certainty whether or not she’ll develop cancer, but only whether or not her risk is increased.
In the end, she looked at me blankly, shrugged her shoulders, and said, “I don’t know. You decide. I trust you to do what’s best for me.” But, in the case of screening tests like that, I don’t know what’s best for her. I don’t know if the false sense of security she gets from a normal screening test is worth the lower level of daily anxiety. I don’t know if she’ll think that a surgical procedure initiated by a false positive screening test would have been worth the risks it entails. But, I do know this. If I don’t do those tests, and she gets ovarian cancer, I’ll be the one who gets the blame. Maybe not by her, but certainly by her family. So, completely out of self-interest, I ordered the tests. They probably won’t make a difference in her life expectancy. They will certainly cost her insurance company a lot of money. But, they’ll keep me out of court.
I know that I'm not alone in this. Everytime I get a radiology report that hedges on the result and suggests more studies, I know the radiologist is doing the same thing. I suspect most of my mammogram call backs are due to this. There are times when exercise stress tests are equivocal for evidence of heart disease, the history not very convincing, yet patients get cardiac catheterizations "just so we don't miss anything." And there are plenty of times when we all order x-rays looking for fractures when we know full well the yield is likely to be small. All of this adds up quickly. And we all pay the price.
As one of my older, more experienced, colleagues once said, "It used to be that ordering a lot of tests was a sign of a doctor's inexperience. Now, it's the standard of care." posted by Sydney on
4/09/2003 09:15:00 AM
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Useful Illness Update: A reader sent this observation on recovery times, from a surgeon’s perspective:
As a general surgeon I see similar results about when patients can return to work. In a hernia repair that is worker's comp related it can be months before the patient will return to work. Otherwise it pretty much takes as long as they are given off from work by their employer. Dr. Ira Rutkow, who is widely published on the issue, made a similar statement when he gave grand rounds my intern year, and I thought he was stretching the truth a bit. However it has been my experience in pvt. practice that he was right on.
You would think that something like recovery from surgery would be fairly universal, all things physiologically being equal. Never underestimate the power of the mind.
But, there is another side to worker’s comp cases. There are those who spend their entire lives doing very hard, physical labor, rarely complaining about their daily aches and pains, but doing what it takes to get the job done. Then in their old age, they suffer the consequences in the form of degenerative joint disease. Professional athletes, some factory workers, construction workers, and the men and women of the armed forces are among them. But, unlike some star athletes, most of them don’t have the option of augmenting their retirement fund by hiring themselves out to drug companies for promotional purposes. As one reader emailed:
I just received a VA disability of 70% after fighting with them for ten years. The problem is, I spent most of my military service (26 years) doing whatever I had to do to get the job done. There were dozens of times I hurt myself, shook it off, and went on. Some of those injuries were minor, but a fair number were rather significant. I just didn't see the need to see a doctor about a "backache", and treated myself with painkillers, and went back to work. Frequently, the medical people would prescribe long periods of physical therapy, which took me away from my job or my family - or both - and which seemed to do absolutely no good (and frequently made matters worse).
Bottom line is, today I have a back that hurts most of the time, but rarely in the same way twice in a day, nearly constant headaches, a significant loss of fine-motor control that limits my doing several things that bring me pleasure and an additional income, I have a hard time socializing (noise bothers me, and people tend to be loud when they're having fun), and it's difficult to get the government to pay attention, because my medical records don't show a "prior condition" that occurred during military service.
Depending on circumstances, it seems that the military medical system tends to reward those that abuse the system, while punishing those that don't. Certainly, those people we used to call "malingerers" or "sick bay soldiers" tend to get better treatment from the Veterans' Administration than the people that put duty first.
SARS Update: Evidence continues to mount that SARS is caused by the coronavirus. This from The Lancet:
We analysed case notes and microbiological findings for 50 patients with SARS, representing more than five separate epidemiologically linked transmission clusters.
...A virus belonging to the family Coronaviridae was isolated from two patients. By use of serological and reverse-transcriptase PCR specific for this virus, 45 of 50 patients with SARS, but no controls, had evidence of infection with this virus.
And in China, officials are beginning to own up to their mistakes:
“Today, we apologize to everyone,” said Li Liming. “Our medical departments and our mass media suffered poor coordination. We weren’t able to muster our forces in helping to provide everyone with scientific publicity and allowing the masses to get hold of this sort of knowledge.”
But, their first response was not one of concern for public health, and it makes one doubt the sincerity of their apology:
Since the beginning of the outbreak last fall, Beijing has seen little of the panic that spread rapidly through southern China where the disease is believed to have first surfaced.
However, media coverage of frenzied shoppers in Guangdong buying face masks, vinegar and folk remedies did stir the Chinese government into early action — of a sort. The government closed at least one Beijing newspaper and advised others to restrict coverage of the SARS health crisis, according to reporters and editors in Beijing.
They’re now allowing coverage by the media, and investigation by WHO authorities. There was a Chinese doctor on NPR this morning, however, who said that the Beijing authorities aren’t being entirely truthful even now (transcript not available until after noon, but here’s their web page.) Are they being honest and open now? Who knows? As one Beijing resident puts it:
"First they tell us it doesn't exist here, then they say it's a disease imported from other places and everyone is quarantined," said a man visiting a local park with his daughter. He wore no face mask and had not taken any other precautions against the disease. "What should I do? Nobody tells us. And even if they did, how can we trust what they say?"
That’s the problem with lying. It destroys all credibility. And once in a while, a regime.
UPDATE: Here's a print version of the Chinese doctor's story. What does he think of the health ministry?
I think [Minister Zhang] wants very much to accomplish big things so he must tell lies." posted by Sydney on
4/09/2003 08:10:00 AM
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Another SARS victim, known only as Miss Tse, doesn't have to look beyond her own family to see the devastating effects of SARS.
Her mother, Sui-Chu Kwan, 78, was Toronto's first SARS victim and died in her Scarborough apartment March 5. Her older brother Chi Kwai Tse, 44, was the second to die here of SARS, passing away of respiratory failure March 13.
...Placed in isolation, too sick to make arrangements for her brother's funeral, Miss Tse became so weak she couldn't turn over in bed.
The article also details the way the disease was transmitted among healthcare workers, and necessitated the shut-down of the ICU and eventually the hospital. The Boston Globe has more:
At least three of the eight people killed by the disease in Toronto are believed to have contracted it while being treated for other illnesses at the hospital. And disease detectives believe a significant share of the people suspected of having SARS in Ontario are doctors, nurses, and other health care workers directly or peripherally associated with Scarborough Grace.
And the WHO says that the epidemic is straining hospitals in Southeast Asia:
Hong Kong SAR continues to report the largest number of new cases, placing some hospitals under considerable strain.
..The Singapore Ministry of Health has reported an unusual cluster of 29 suspected SARS cases in hospital staff from two wards of a single hospital.
...Though the case could be linked back to the French hospital, the absence of isolation and rigorous infection control at the provincial hospital suggests that many hospital staff, patients, and visitors could have been exposed, thus possibly seeding further waves of cases.
Healthcare workers should take note. Getting a smallpox vaccine now could prevent a much worse scenario than this if there should ever be a smallpox bioterrorist attack. posted by Sydney on
4/08/2003 08:25:00 AM
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Blood in the Battle: Spurred by necessity, and the change in a 1972 law that prohibited the Defense Department from participating or funding trauma research, artificial blood gets a chance:
The military, he said, supported the development of substances that might help in trauma, like a lightweight salt solution to restore fluids to injured soldiers, but it was never tested in the large clinical trials that are necessary before it can be sold.
"They couldn't get anyone to test it, and they couldn't test it themselves," Dr. Champion said. The standard salt solution, Ringer's solution, was developed at least 50 years ago to treat diarrhea.
"The standard of care is 1,000 c.c.'s of Ringer's, and if that doesn't work, give another 1,000 c.c.'s," Dr. Champion said. Each 1,000 cubic centimeter package weighs about 2.2 pounds. "That's quite a lot of weight when you're running up a hill under gunfire," he said.
... In Iraq, the Army is testing alternatives, like Hextend, a fluid that does not to be refrigerated and stays in the blood vessels, unlike Ringer's, which seeps out. It appears that a half-liter of Hextend may be the equivalent of three liters of Ringer's. But that equivalence, Dr. Holcomb said, needs to be tested in a large clinical trial, one of the many studies he and others are planning among civilians, who would be given the fluids in ambulances.
While hemostatic bandages can stem external hemorrhage, internal bleeding often requires massive amounts of blood transfusions to support life until the bleeding can be stopped. A lightweight alternative to blood would be very welcome, but there remains a lot of work to be done:
The concept was simple. Oxygen is carried in blood by hemoglobin, a protein in red blood cells. If you got rid of the cell and just used hemoglobin, it could in theory supply tissues with oxygen on its own. But when researchers tried that approach, it ended in disaster, with injuries to major organs, including the liver and kidneys. A likely reason is that hemoglobin disables a small molecule, nitric oxide, in blood vessels, preventing them from relaxing. With narrowed blood vessels, vital organs do not get enough blood.
"The last trial of unmodified hemoglobin was in 1978," Dr. Gould said. Researchers from Warner Lambert gave tiny amounts of the protein to six healthy volunteers. "They saw these toxicities," he said. "It happened 100 percent of the time, to every one of them." Dr. Gould called one of the drug company scientists. "He said: `It's worse than it sounds in the paper. It scared the daylights out of us.' "
But it appears that the toxicities disappear if the hemoglobin molecules are linked together in chains. The only problem, Dr. Gould said, is that virtually no small unlinked hemoglobin molecules can be in the mixture. "We gradually started to purify," he said, testing the substance in baboons and finding that he had to go below 1 percent unlinked hemoglobin or the artificial blood was dangerous.
With its solution of purified chains of hemoglobin, the company began small studies and was buoyed by success. Doctors have given as much as 20 units, or pints, of the artificial blood, PolyHeme, in 20 minutes, Dr. Gould said. An adult normally has about 10 units of blood. But with a severely injured patient, blood loss can be so rapid that it is lost as quickly as it is given, necessitating transfusions of 20 or even 30 units
Losing All Credibility: While manypeople, yours truly included, think the CDC is being alarmist at blaming heart disease on the smallpox vaccine, the Advisory Committee on Immunization Practices (the group that advises the CDC on immunization issues) thinks the CDC hasn't gone far enough:
The CDC's March 25 decision to temporarily defer smallpox vaccination of persons with a history of heart disease while investigating recent cardiac-related deaths of vaccinees doesn't go far enough, said the Advisory Committee on Immunization Practices.
What's needed, said ACIP in a March 28 recommendation to the CDC, is a ban on smallpox vaccination of adults with three or more major risk factors for heart disease. Such factors include high cholesterol, high blood pressure, smoking and diabetes.
The current CDC recommendation applies only to those with a known history of cardiac disease -- such as cardiomyopathy, previous heart attack, history of angina, or other evidence of coronary artery disease. If the CDC adopts the ACIP proposal, an estimated 6 percent of health care workers and 10 percent of the overall U.S. population would be ineligible to receive the vaccine.
The members of the ACIP have been against pre-attack smallpox vaccination since the beginning, you may recall. Their arguments back then - that ring vaccination would work to control an epidemic, that there wasn't any evidence of a credible smallpox threat, that the vaccine had too many side effects - although misguided, were at least credible.
This, however, is simply incredible. Three people out of over 100,000 vaccine recipients have had heart attacks. Two of these three people had known coronary artery disease. The other was a middle-aged man who smoked and had high cholesterol - all characteristics which increase the risk of heart disease. What was most likely responsible for the heart attacks - heart disease or vaccination? You don't need a medical degree to figure that out. posted by Sydney on
4/08/2003 07:35:00 AM
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Useful Illness Update:Jim Miller sends this observation:
Your post on illnesses disappearing when there is no compensation reminded me of a story that I read a couple of years ago. (In the Washington Post, I think.) Researchers from Norway had gone to Latvia to study the incidence of whiplash there, and found none. In fact, Latvians didn't even have the concept of whiplash. When the Norwegian researchers published these findings in Norway, they came under heavy attack from groups that had profited from whiplash. Some were even threatened, at least with legal action. Last I heard, Norway still has whiplash, and Latvia still doesn't.
Public Citizen Malpractice: Back in January, when the doctors of Pennsylvania were working hard to get their state legislators to take the malpractice crisis seriously, the consumer watchdog group, Public Citizen, released figures that accused Pennsylvania physicians of being the most negligent set of doctors in these United States. Turns out Public Citizen was giving out incorrect data:
In a January study, Public Citizen said that 10.6 percent of Pennsylvania's 39,000 doctors had paid off at least two malpractice lawsuit claims or settlements -- a rate that topped the nation. Moreover, the group said, 4.7 percent of the state's doctors paid off three or more malpractice lawsuits, accounting for more than half of all monetary payouts awarded in Pennsylvania's liability cases.
But Public Citizen now says that information was gleaned from a national database that tracks medical malpractice payouts, but which may have overcounted Pennsylvania statistics.
...Public Citizen now says that at least 5.4 percent of Pennsylvania doctors have paid off at least two malpractice claims, accounting for 52.5 percent of all payouts in the state. At least 2 percent of doctors paid off at least three cases, the group says.
The new numbers would rank Pennsylvania below other states with repeat doctor payouts in malpractice cases. West Virginia, where 9.3 percent of the state's 4,296 doctors have paid two or more malpractice payments, would now lead the nation, according to Sid Wolfe, Public Citizen's top medical liability analyst.
The doctors of Pennsylvania would like an apology:
"We would have hoped that Public Citizen would issue a public apology to the citizens of Pennsylvania for deliberately deceiving them on this issue," Moran said. "It's ironic that they initiated a report called 'Medical Misdiagnosis,' challenging the malpractice claims of the doctor's lobby, when, in fact, they are the ones that misdiagnosed the situation."
Those Ads, Those Ads! To those of you who stopped by yesterday and noticed those Blogspot ads advocating homeopathic cures for smallpox - I apologize. They cropped up for the first time yesterday, and I suspect they had something to do with my template problems. They're gone now, hopefully forever. And for the record, I do not advocate homeopathic medicine for smallpox. Relying on homeopathy for such a virulent disease would be deadly. posted by Sydney on
4/08/2003 07:23:00 AM
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Monday, April 07, 2003
SARS in China: How’s it going? Who knows? (Or does WHO know?)
Communist party sources in Beijing said the new leadership under President Hu Jintao and Premier Wen Jiabao had urged central and regional officials to issue words of reassurance to the international community.
Despite its upbeat stance, however, China's Ministry of Health announced Monday that the death toll from the virus had risen to 53, with 1,268 people infected.
It was also revealed that people had died of the mysterious illness in more of its provinces than previously reported, according to Reuters.
But that’s not what‘s happening in the universe inhabited by Chinese officials:
Most official papers on Monday covered a high-profile visit by Premier Wen to the China Disease Control Center.
Wen said the disease was "under effective control" in China, and that the great majority of provinces and cities had no SARS cases at all.
Useful Illnesses: We've all heard the phrase "useful idiots," as applied to people who unwittingly provide succor to the enemies of their own ideals (used most recently to describe war protesters and Peter Arnett), but there are also "useful illnesses," as described in a review (requires subscription) in the New England Journal of Medicine of the book Whiplash and Other Useful Illnesses:
Spine specialists have long known that patients with secondary gains — workers' compensation claims or lawsuits — have significantly worse outcomes than those who do not. In fact, in scientific studies designed to judge the efficacy of interventions, investigators must exclude such patients or report their results separately. Of course, such considerations are not limited to spine-related injuries. In a broad sense, Whiplash and Other Useful Illnesses is about the way in which illnesses for which patients may receive compensation are created and sustained for the benefit of a few at the expense of many.
Sounds interesting. There’s also this revelation:
Malleson draws parallels with other illnesses that were "fashionable" in other periods, such as "railway spine" and "repetitive strain injury," which reached nearly epidemic proportions in other countries until laws allowing compensation were rescinded. After the revocation of these laws, the ailments virtually disappeared.
There have been studies that show that injuries take longer to resolve when there are unresolved compensation issues - such as lawsuits and worker’s compensation. And although this is only anecdotal evidence and nothing to base public policy on, I’ve noticed in my practice that patients recover in a matter of days to weeks when they’re the ones at fault, compared to patients who are the victims of accidents, who take months to get better.
And the time for recovery does clearly seem to be related to compensation. This is what happens. A person has an accident, and as a result sprains their neck. As in any sprain, the pain is at its worst the first few days, then it gradually gets better. But, even when things are mostly better, there are still, on occasion, twinges of brief pain that come and go. For the person not involved in litigation, these twinges are barely noticed because they’ve moved on. Their injuries are no longer a major focus of their lives. They perceive these twinges as nothing more than the usual aches and pains that everyone suffers now and then.
But, the person who is trying to get compensation for their injuries, either through the legal system or the worker’s comp system, has the constant fear that things might get worse. Once they settle the case, that’s it. No future claims will be paid by the other party. So, when they feel those twinges, their inclination is to wonder if they might be harbringers of worse things to come, of disabilities that won't be compensated. That anxiety only serves to magnify the pain. Which keeps the case open. Which costs society a lot of money.
The reviewer also throws out this observation from the book:
A psychiatrist by training, he particularly faults physicians for publishing poor scientific work in an effort to advertise themselves as experts in the field. This advertising allows them to secure an additional lucrative source of income in the face of a contracting health care market.
Now that’s a criticism that could be fairly levelled at a great many researchers these days, and not just in the field of “useful illnesses.” It's a trend against which we should remain forever vigilant. posted by Sydney on
4/07/2003 07:53:00 AM
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The Origin of (Viral) Species: How the SARS virus may have come to be:
Experts say the new human coronavirus, if it causes SARS, probably arose when it managed to incorporate similar but foreign RNA, which, like DNA, can make up the genome or genetic code of microorganisms. Such alien RNA would make it a kind of natural hybrid.
Human coronaviruses, said Dr. Mark R. Denison, an expert at Vanderbilt University, are like the mild-mannered next-door neighbor with a proclivity for doing the unexpected. "It's always the quiet ones you worry about," he said.
....Coronaviruses, he added, "are ubiquitous and are relatively promiscuous" in their ability to infect different species. Infection of a single host with two different coronaviruses can easily lead to recombination and the emergence of new forms, he said, and "that's probably what happened here."
Guangdong Province in southern China, where the illness is believed to have emerged late last year, has dense concentrations of domestic waterfowl in close proximity to pigs and people. Experts say those are ideal conditions for transferring diseases among different species and for the emergence of a new strain of flu virtually every year. "It's no surprise that other viruses can take advantage of similar mechanisms," said Dr. Block of Stanford.
Housekeeping: I tried to update my links last night and somehow ended up altering the template to the point that none of the posts would show up. I stayed up too late fixing it, but in the process I may have lost some of my previous links. If I deleted your link to the left, I apologize. I will fix it, but not this morning. I'm afraid to do anything to the template until I have a block of uninterrupted time to fix any problems that might arise. In the meantime, here are the sites will soon be included in the list on the left:
Lagniappe, Farewell: Derek Lowe has moved (gone commercial). His new site is In the Pipeline. I’ll miss the old title, “Lagniappe” - Cajun for small, unexpected gift, but his content will be the same - pharmaceutical industry and research developments. posted by Sydney on
4/06/2003 11:26:00 PM
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MedMal in North Carolina: It's taken a back seat recently to SARS and the war, but the medical malpractice insurance problem isn't going away. In North Carolina, doctors are planning a rally to support tort reform. How bad are things there? This bad:
His firm, Senn Dunn Marsh & Roland, writes liability coverage for almost half the doctors in Greensboro, about 300 of them, and in recent months Ward three times has been unable to find insurance for local physicians — at any price.
"I had to tell those doctors to go home, shut their doors and tell the office they were sick," Ward said. "You have no insurance."
....There is no doubt of a problem. North Carolina providers saw an average premium increase on liability coverage of 50 percent last year, according to the U.S. Department of Health and Human Services. Only seven companies officially underwrite malpractice insurance in North Carolina right now — down from 10 just last year — and only four of them are truly active; no new players seem interested in entering the market, insurance observers say.
One doctor sums up the situation succinctly:
"If the insurance companies can't stay in business, then we can't get insurance. And if we can't get insurance, we can't practice," Amundson said. "If we can't practice, we can't provide health care. That's why this is a public issue."
As usual, the trial lawyer association argues that caps for noneconomic damages only penalize the injured. (Funny, they never mention how caps also penalize trial lawyers.) This idea that an award of millions of dollars somehow compensates for injury deserves to be challenged.
Whenever I hear that argument, I think of one of my patients who had a stroke during surgery. She sued and won a multi-million dollar award. It hasn't bought her happiness. It hasn't even bought her emotional adjustment. The stroke remains the defining moment of her life, and the source of a tremendous amount of bitterness and misery, which she inflicts not only on herself, but on all those around her. Sure, she lives in a beautiful new house now, complete with a lot of added features designed to make life easier for a person who can only use one hand. But, she doesn't use them. She prefers instead to require the assistance, and thus the attention, of her family members.
I've had other stroke patients whose illnesses were not the result of surgery, but rather of random events, who are much worse off, but who function better both on a physical and emotional level. The difference is in their spirit.
Putting caps on non-economic damages would not change any of this, of course. My patient would be equally bitter and dysfunctional no matter what the justice system did. And that's precisely my point - large monetary awards do not alleviate pain and suffering. They do, however, drive malpractice insurance companies - and doctors - out of business.
UPDATE: A rebuttal from a trial lawyer. Just have to say, though, that from cases that I've read about in the news and heard about from colleagues, I have trouble believing that the cost of bringing a case makes the majority of trial lawyers overly selective in the cases they take. I've heard too many tales of frivolous suits being filed and then dropped only much later in the game. Also, can't say if I'm "conflating economic and non-economic damages" in this case. I don't know the details of the award. But, I suspect that a significant chunk of it was for non-economic damages. posted by Sydney on
4/06/2003 10:10:00 AM
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Gupta Update: CNN's Dr. Sanjay Gupta describes what it's like to operate in the field:
It is hot, up to 110 degrees [Fahrenheit] here today and operating in non-air-conditioned operating rooms, sometimes in full garb and also a lot of dirt and sand. In addition to that -- the operating rooms are well-equipped, but for example today when we were doing this procedure for the gunshot wound to the head, we had to make do with the instruments that we had. So really, I was basically looking around the room saying, "OK, let's try these instruments over here. Let's try this particular material to try to create a closure over here."
It's trying to make the best of what you can with scarce resources, and having said that, I will say it is truly remarkable in a way what they do have. This is a totally mobile operating room and the operating rooms are designed to be mobile so they can move with the troops and support the troops as soon as they come off the front line.
So it's a little bit of both, but just every day, you look around and remember that you're in the desert. It's hot, there's lots of dirt and there are sandstorms and helicopters throwing up dirt coming in and out of here all of the time. If you think about that, it's really remarkable what they're able to accomplish, despite all of that.
And, by the way, he operated again on a patient, this time with good results. posted by Sydney on
4/06/2003 09:36:00 AM
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Journalistic Ethics: CNN’s doctor/medical correspondent, Sanjay Gupta, has sent media academics into a dither because he's been acting ethically, from a medical perspective. Gupta, who is a practicing neurosurgeon in addition to a reporter for CNN, is embedded with a group of frontline surgeons in Iraq, the Navy’s “Devil Docs”. They’re all general surgeons. He’s a neurosurgeon. When an Iraqi child was brought in with a schrapnel wound to the head, Gupta scrubbed in and performed neurosurgery. Unfortunately, the wound proved fatal, but the idea that a reporter would put his pen down long enough to try to help someone prompted the director of the ethics program at the Poynter Institute for Media Studies to tell the Boston Globe:
''I'm hoping and trusting that he and CNN set some thresholds,'' Steele said. ''I think it's problematic if this is a role that he's going to be playing on any kind of frequent basis. I don't think he should be reporting on it if he's also a participant. He can't bring appropriate journalistic independence and detachment to a story.''
And the director of Columbia’s Project for Excellence in Journalism agrees, saying that now that Gupta has performed surgery, his “objectivity” is in question, especially since the Navy surgeons he works with praised his surgical skills. Yet, this same director had this to say about Peter Arnett's cozy relationship with the Iraqi government:
"This is career suicide more than it is some great ethical breach," agreed Tom Rosenstiel, director of the Project for Excellence in Journalism, arguing that formerly strict rules against reporters commenting on stories they cover have softened in the face of media outlets' desire for publicity.
So, it’s only a bad career move for a reporter to be so entrenched with a foreign government that he can’t objectively distance himself from their propaganda, but it’s a breach of journalistic ethics for a reporter to attempt to save a life. Is it any wonder that people trust the media even less than they trust politicians?
