"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 chronically harassed, understaffed, underequipped system reaches reflexively for routine diagnoses, prescriptions. Did Kwan Sui-Chu's doctor, an Asian Canadian herself with many Asian patients, get the Toronto Public Health alert? Is it normal for coroners to mark "heart attack" as cause of death for elderly patients even when they've been prescribed antibiotics for a new condition in the last week? Why, after Scarborough admitted Mr. Pollack, whom they knew to have been infected during his previous stay with them, did they allow Mrs. Pollack to circulate among other patients? Why did Scarborough compound its own carelessness by infecting York Central?
Most of what went wrong could have been discovered by a few social pleasantries: How's the family? Been travelling recently? The so-called "bedside manner" isn't just to cheer you up, it's meant to provide the doctor with information that will assist his diagnosis. In Canadian health care, coiled tight as a spring, there's no room for chit-chat: give her the antibiotics, put it down as a heart attack, stick him on a gurney in the corridor for a couple of days. Maybe you could get service as bad as this in, oh, a Congolese hospital. But in most other Western health care systems the things Ontario failed to do would be taken for granted. There might be a lapse at some point in the chain but not a 100% systemic failure all the way down the line.
As tempting as it is to jump on that bandwagon, I’m afraid I can’t. The truth is that all of those things can, and do, go on here in our private healthcare system. Overworked doctors with crammed schedules, overworked coroners, reflex prescriptions for antibiotics - they aren’t unique to Canada. The truth is, it could have happened anywhere, even here.
It’s true that the WHO began tracking the illness that turned out to be SARS in mid-February, but it wasn’t until March 12 that they issued a health alert. The first Canadian patient saw her doctor on February 28 and died on March 5. No primary care doctor anywhere in the world (except maybe China or Hong Kong) would have suspected SARS then, even with a travel history. The second victim, son of the first, became ill on March 5 and died on March 13. Again, no one would have suspected SARS on March 5. No one would have known about it. Even the later case in which the wife of a victim wasn’t quarantined isn’t a terrible blunder. That was on March 16, when the WHO was still describing the disease as less communicable than it has turned out to be. Although, one would have thought that her son would have taken his respiratory symptoms a little more seriously and stayed home from that religious retreat.
The Canadian health system may have a lot wrong with it, but in the case of SARS, it was just a victim of unfortunate timing. posted by Sydney on
4/26/2003 08:10:00 AM
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Only in Michigan: Here in Ohio, Michigan jokes are a popular past time. Now, there's evidence that there might be some truth to them. Some Michiganders are afraid they'll get SARS from Canadian garbage:
"To advise that it is unsafe for citizens to travel to Toronto while it is acceptable for that city's trash to come to our county without inspection is unacceptable"
Maybe they’re just confused by the term “trash”:
Q: Why do they throw out a sack of manure at University of Michigan weddings?
A: To keep the flies off the bride
NOTE: Before you send me hate mail for insulting Michigan, please be aware that my one and only most beloved brother is a Michigander.(But not a University of Michigan fan.)
More SARS Humor: Then there's the Toronto mayor's rant about the WHO Toronto travel restrictions:
"There has been a humorous side, though. Mr Lastman, in his rage, mistakenly criticised the US Centres for Disease Control (CDC). A doctor, standing beside him during his speech, prompted him with: 'WHO'. The Mayor repeated: 'the CDC'. The doctor repeated: 'WHO' – trying to correct him. But he kept thinking it was a question. She eventually spelt out: 'No, the World Health Organisation'. The Mayor said: 'Yeah them too.' "
Here We Go: It's been two days since the publication of the obesity and cancer paper, and already the results are being misinterpreted:
Obesity plays a much bigger role in causing cancer than researchers had previously believed, accounting for 14 per cent of cancers in men and 20 per cent in women, according to a massive new study by the American Cancer Society.
An estimated 90,000 Americans die each year of cancer caused primarily by obesity and excess weight, according to the study, published on Thursday in the New England Journal of Medicine.
That makes weighing too much second only to smoking - which causes about 170,000 cancer deaths a year - as a preventable cause of cancer.
The study didn't say that being fat causes cancer. It said that fat people who have cancer die at higher rates than skinny people who have cancer. (Scroll down to Thursday’s post, which has been updated, for more on that.) For all we know, fat people get less cancer than skinny people. Ergo, you can’t say that being fat causes cancer. posted by Sydney on
4/26/2003 08:01:00 AM
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A Whale of a Fish: It’s been pointed out to me that I neglected to mention one of the key differences between whale meat and fish meat in my Tech Central Station column on mercury levels in fish. That difference is that whale meat is higher in PCB's than fish meat. For those of you who haven’t read the column, and who don’t want to, the EPA’s current standards for mercury levels in fish and humans is based on a study done in the Faroe Islands of the North Atlantic among people who ate not fish, but whales. That study found small, subtle declines in the intellectual performance of children with increasing blood mercury levels at birth. A similar study in the equatorial Seychelles Islands, where the people eat fish, not whale, found no intellectual decline, but it’s been ignored when it comes to setting standards. (If you want to know why, you’ll have to read the column.)
Anyway, it’s quite possible that the PCB level in whale meat was a confounding variable, but the authors of the Faroe Island study say that they controlled for that somehow and still found a decline in intellectual measurements. I’m sure the “control” involved stasticulating, but I didn’t mention it because it would have made the article a lot longer than it needed to be. Besides, there are a whole lot of other differences between whale and fish that can't be controlled for. Whale is fatter, for example. Whale is a mammal. Whales live longer, and is at the top of the ocean food chain, thus accumulating higher levels of all toxins than fish. And, according to this report, accumulate them they do:
A 1998 study by the International Whaling Commission determined levels of contamination among some marine mammals are so high that the animals would be classified as hazardous waste sites if they were on land.
Happy DNA Day: Today is the 50th anniversary of the “discovery” of DNA - when all of the information out there finally congealed into one theory, published fifty years ago today. In honor of that event, today has been declared DNA Day.
Over at Nature they have a whole web page devoted to the subject, including this playful essay about DNA and the meaning of life.
Watson and Crick get most of the credit, but it’s fitting to remember Rosalind Franklin, whose X-ray diffraction photographs of DNA were instrumental in pointing out the molecule’s structure. She died of ovarian cancer in her late 30’s, before she could share the Nobel prize. The New England Journal of Medicine has a book review (subscription required) of a recent biography about her, Rosalind Franklin: The Dark Lady of DNA which disclosed an interesting aspect of the education of women in pre-World War II England:
Franklin was born in 1920 into an upper-middle-class banking family, which "stood high in Anglo-Jewry" — part of the establishment to be sure, yet never fully English. She developed as an outsider. Early on, she declared herself a scientist (and, by implication, not a banker). Having been referred to as "alarmingly clever," she went up to Cambridge in 1938, where she found an institution that first admitted women in 1869 but would not grant them the degree of B.A. Two years after she received her Ph.D. in 1946 for internationally recognized research on coal, Franklin's undergraduate degree was awarded retroactively.
So what were those women expected to do there if they weren’t entitled to a degree? Hunt for husbands? Or just provide comfort care for the male undergraduates? We’ve truly come a long way.
By the way, that NPR link above also includes a lot of other great DNA links, such as a Talk of the Nation segment with James Watson. And CharlesMurtaugh has a post on why you can’t believe everything James Watson says. (scroll down to Thursday, April 24. Archive links are broken, as is the case throughout all of Blogspotdom. Why do we all stick with it? Because it’s free!) posted by Sydney on
4/25/2003 09:06:00 PM
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Fitness Craze: Jane Galt's Wall Street Journal Diet Tips. Everything listed is good advice, except that bit about excercising. As long as exercise isn’t used as an excuse to eat more, it is a definite aid to weight loss - and to keeping the weight off. posted by Sydney on
4/25/2003 08:52:00 PM
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Rest in Peace? Dr. Atkins may have moved on to a better world, but the debate about his diet will go on and on. Michael Fumento delivers an Atkins obituary like none other. posted by Sydney on
4/25/2003 08:50:00 PM
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Technical difficulties.... Was unable to complete my posting this morning because Blogger went on the fritz. Sorry for the delay. Posting will now resume until another malfunction occurs. posted by Sydney on
4/25/2003 08:46:00 PM
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Doctors and Drugs:DB has been ranting about the pharmaceutical industry, and debating the subject with his readers. It’s true that doctors have a love-hate relationship with the industry. We love the innovations they make in disease treatment. We hate their marketing techniques. Disease treatment should be chosen on the basis of its merits, not on the success of its advertising campaign. (And believe me, there are a lot of distortions in the ad campaigns of pharmaceutical companies, whether they’re aimed at the public or at the medical profession.) posted by Sydney on
4/25/2003 07:50:00 AM
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Scores of police officers and a squad of the People's Armed Police, wearing facemasks, fanned out around the sprawling confines of Beijing's People's Hospital today, wrapping it in yellow police tape and locking 2,000 health care personnel and patients inside. The facility is believed to have 70 patients stricken with severe acute respiratory syndrome. The semi-official China News Service said the facility, which is attached to Beijing University, was quarantined because it could not stop SARS from spreading so "it needed to be isolated from the rest of Beijing."
I feel sorry for those people. Now they’re stuck in there indefinitely with nothing but hospital food to eat. posted by Sydney on
4/25/2003 07:39:00 AM
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Readers on SARS: A reader sent in this interesting observation:
In spinning through some of the stats I see on SARS, the one thing I keep seeing (but about which I may be very wrong) is that the vast majority of deaths seem to be occurring in countries with socialized medicine. In fact, the bulk of the cases are occurring (at least for now) in countries with socialized medicine. I don’t recall anybody making that connection (but then, I may not be looking in the right places) and have to wonder.
Funny thing, I commented on just the same thing to my husband yesterday at breakfast, and was on the verge of blogging the thought when I had reservations. After all, Hong Kong is a hotbed of capitalism. Surely, they don’t have socialized medicine, do they? Well, if a second person had the same thought, it’s worth looking into.
So, with the help of Google, I learned that Hong Kong has a dual system - 90% socialized, 10% privatized. Judging from this analysis the socialized portion is quite popular:
The fees of public hospitals per bed day are cheap. The emergency service is free of charge, attracting many non-emergency patients in the evenings and on public holidays. The almost free-of-charge public hospital services provide few incentives for radical reform, apart from the expectations for continued improvements.
Of the others among the top four SARS nations, Canada has a socialized system. China, of course, has a socialized system. Singapore, like Hong Kong, has a hybrid system:
80% of the primary healthcare services is provided by the private practitioners while the government polyclinics provide the remaining 20%. For the more costly hospital care, it is the reverse situation with 80% of the hospital care being provided by the public sector and the remaining 20% by the private sector.
Hmmm. Seems to be a definite trend. However, China, Hong Kong, Canada, and Singapore also had the disadvantage of having SARS before it was recognized as a highly contagious new illness. The rest of the world had the advantage of their unfortunate experience. As a result, subsequently infected countries have been able to initiate infection control and quarantine measures as soon as a case was suspected, making it less likely to spread among the general population.
Another reader brought up two very good questions regarding the infection:
(1) Is it possible, or could it be theoretically possible to catch SARS more than once? (Or is it like Chicken Pox?)
Answer: We don’t know yet, and aren’t likely to know until it’s been around for a year or two more.
(2) Is it possible, and what is the current thinking of the medical community, on whether or not people can be contagious prior to exhibiting symptoms of SARS?
It does appear that people can be contagious before exhibiting symptoms. That may be one reason that it has spread so easily. Again, it’ll take more time and more cases to know exactly when someone becomes contagious, and for how long communicability lasts after infection. So much remains to be learned - and observed.
And from another reader, a link (subscription required) to a Wall Stree Journal article that suggests the mortality rate for SARS may, indeed be higher than stated:
The World Health Organization maintains that the mortality rate for severe acute respiratory syndrome is currently about 5.6%. That figure, often cited by public health officials and the media, represents the number of known SARS-related deaths divided by the number of probable cases world-wide.
But some medical officials believe the real mortality rate may be 10.4%, or nearly twice as high. That's because in its calculation, the WHO includes not just known cases of recovery from the disease but also patients who remain hospitalized -- in other words, people who may yet die.
A more accurate method of calculating the mortality rate for a disease, some disease experts say, is to use only known outcomes: divide the number of deaths by the number of recoveries plus deaths. That excludes sick SARS patients whose fate is still unknown, as well as those who are listed as "suspected" cases but may not have SARS at all.
Using that method backs up the contention that SARS is worse in countries with socialized medicine:
Calculating the mortality rate using only deaths and recoveries, the death rate for Hong Kong is currently 17.7%, according to data posted Monday on the WHO Web site. Canada's is about 18.2%, and Singapore's is around 13.3%. No deaths have been reported in the U.S. Some outlying areas of China, Dr. Niman says, appear to have mortality rates of nearly 50%.
Although in Canada, they’ve noticed a difference in mortality by age:
In Canada, some doctors support calculating the mortality rate by deaths and recovering patients, and excluding those in early phases of the illness. Using those criteria, Canadian doctors estimate that the mortality rate is about 1% for patients under 50, and about 25% for patients over 65.
And, they’ve noticed that the critical stage comes far into the illness:
"This is a three-week illness," with many patients hitting the most critical period from days 11 to 16, says Allison McGeer, director of infection-control at Toronto's Mount Sinai Hospital. Some patients who become critically ill or eventually die of the illness don't seem all that sick at first. "We don't have any good markers at onset to tell us how serious a case is going to get," says Dr. McGeer, 50, who is now at home recovering after spending almost three weeks being treated in the hospital for the illness.
The same reader sent along thisWashington Times column that says China needs to feel the heat from the international community for endangering the world:
The cover-ups have got to stop. No considerations of Chinese pride or special political circumstances can excuse this kind of behavior, which exposes the whole world to risk. Pressure should be brought on the Chinese government to guarantee that next time, everybody in the world hears about a new disease at the same time. How much pressure? As much as necessary.
But how do you change someone's basic nature? China, like most totalitarian regimes, seems to encourage the elevation to power of people for whom lying comes easily. It's so entrenched, only a complete shake-up would change it. posted by Sydney on
4/24/2003 08:38:00 AM
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Self-Promotion: Have a column over at Tech Central Station on fish and mercury. (Note: The fine in California for selling fish without warning about mercury is $2,500/day. I typed too many zeroes in the article.)
The Root of All Evil: Obesity gets the blame for diabetes, arthritis, and heart disease. Now it’s getting blamed for cancer:
Obesity appears to increase the risk of dying from cancer significantly and could play a role in more than 90,000 deaths from the disease each year in the United States, a study by the American Cancer Society released Wednesday reveals.
The study, which looked at hundreds of thousands of people over a 16-year period, found "the heaviest men and women in the study had 50-60 percent higher death rates from cancer than normal-weight people," Jeanne Calle, the principal author of the study and director of analytic epidemiology for the American Cancer Society, told United Press International.
Based on the results, Calle's team used the current prevalence of obesity in the United States to estimate "as much as 20 percent of cancer deaths in women and 14 percent in men" could be due to being overweight.
"This translates to more than 90,000 deaths from cancer each year that could potentially be avoided if we could maintain normal weight throughout adulthood," Calle said.
If we’d all just get off our fat butts the world would be such a better place. But the study has some problems that neither it, nor the editorial accompanying it, addresses:
-It doesn’t break down its findings by age. Everyone is lumped together by body mass index, a measure of obesity, instead. The authors don’t mention if heavier people tended to be older, a variable that would affect their death rate
-It doesn’t tell us the incidence of cancers by body weight, only the number of deaths from cancer. Did fat people get more cancer than skinny people, or less? The authors don’t say.
-It doesn’t reveal how many people were included in each weight group. There’s no indication of how many people were skinny, or how many were fat. That does make a difference, especially when expressing results as percentages. If the number of obese people was small compared to those of normal or average weight, then the comparison of death rates may not be valid.
Obesity gets the blame for everything these days, but this study doesn’t make it at all clear that it’s responsible for cancer deaths. I have to wonder, though, if California requires restaurants and grocery stores to post warnings about carcinogens in their food, will they read this study and require them to post warnings that their food contains calories?
I believe your criticism of the obesity/cancer study is somewhat off base.
(1) While it's true that they don't *break down* their findings by age, they did control for it as a confounder. See the footnotes on p 1631. So, while it's hard to tell when this is significant, it's not correct to suggest that the problem could just be age.
This is how the study says it controlled for age: "Age-adjusted death rates were calculated for each category of body-mass index and were directly standardized to the age distribution of the entire male or female study population." This still obscures the role that age could be playing in 1) the incidence of cancer and 2) the incidence of obesity. Most cancers are more common with increasing age - breast cancer, colon cancer, lung cancer, skin cancer, to name a few. Obesity is more prevalent with increasing age, too. It's quite possible that more of the "overweight" group also happened to be older and thus more prone to cancer.
(2) You're correct that it doesn't tell us the incidence. So, it could be that being fat just increases your chance of dying from cancer. But that would be pretty bad too.
Yes, it would be. But, incidence counts. If fat people are less likely to get cancer in the first place, then perhaps the ones who end up with it have more virulent forms of it, hence greater mortality. Not all cancers are the same. Although the study lumps all breast cancers together, there are subcategories of breast cancer, (and most other cancers, too) that each have different mortality rates.
(3) They don't say *directly* how many people are in each weight group, but you can work it out pretty easily from the data in Table 1. Just divide the incidence by the death rate. Clearly, there are a lot more people in the higher group. However, this isn't a problem for the analysis. The Cox proportional hazard technique (which is what they used) works just fine even when the groups are unbalanced.
Except that in reality smaller samples make for greater errors. The human organism isn't a precise mechanism. There are so many tiny, uncontrollable variables that can skew results in small populations. If only 393 morbidly obese men died of cancer, extrapolating that number to death rates per 100,000 is going to magnify any error inherent in the small sample. Here's an example that's easy to reproduce. Try taking your pulse. Count it for five seconds and multiply by 12 to get your heart rate in beats per minute. Then, count it for a full sixty seconds. Chances are, they won't be the same. Missing just one beat or counting one additional beat in that five second count will throw your calculated heart rate off from your actual heart rate by 12 beats per minute. And that's with the heart - one of the most mechanically precise organs we have, when it's working right.
Blood Libel with a Modern Twist:Winds of Change has the details on a spurious charge that Israel is making a genetic weapon that can kill selectively by ethnic group. Too ridiculous for comment. Besides, Winds of Change says all that can be said on the subject. posted by Sydney on
4/24/2003 08:19:00 AM
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Weekly Art History Lesson: Still mourning the loss of linkage to JAMA’s weekly art history lesson. So, with yet more apologies to Dr. Southgate, here’s another Medpundit attempt at a substituion.
This week’s selection was inspired by a patient I recently had in the hospital who was hallucinating. Or, as she preferred to put it, having “vivid day dreams.” She told me one morning that Titian (1485-1576) had come into her room the night before and had dinner with her. I couldn’t resist asking her what he was like. “Egotistical, but interesting,” was her answer.
That is, in all likelihood, an apt description of the man. He was no starving artist, but one in great demand by the rich and powerful -noblemen, popes, and kings. One contemporary described him as the man who decorated “all of Venice, or rather all of Italy, and other parts of the world.” His career spanned over eighty years, beginning when he was apprenticed to an artist at the age of 10, and only ending at his death from plague at the age of 91.
Painted around 1515, The Madonna of the Cherries is one of his early, independent works, when he was no longer working as a member of someone else’s studio. It shows the Madonna in the usual loving pose with her Infant. At the lower right hand corner is a second child, John the Baptist. In the background are two, darker figures. To the left, her husband, Joseph. To the right, the Baptist’s father, Zacharias.
Mary holds in her left hand a bunch of cherries. With her right hand, she supports the Christ child as he thrusts yet more cherries upon her, in the typical exuberant fashion of a toddler. Cherries were once a common accompaniment to images of the Madonna and Child. They were considered the fruit of Paradise and a symbol of virtue. They play a prominent role in the Appalachian folk ballad, The Cherry Tree Carol, which portrays what might have happened when Mary told Joseph she was pregnant. As they walk through an orchard, she asks him if he would pick some cherries for her, because she’s hungry and she's going to have a baby. His reaction is all too human. In a rage, he tells her to have the father of her baby gather her cherries. The unborn Child intervenes and makes the cherry trees bow down to offer her their fruit. Seeing this, Joseph suddenly understands the mystery before him and asks for her forgiveness, and God’s.
In the Madonna of the Cherries everyone seems to be contemplating their own personal miracles. Zaccharias gazes intently on the miracle of his son, conceived in his old age, while Mary’s sole focus is on her Child. John the Baptist, like any child of two, is focused on those cherries. But it’s Joseph who is the most interesting. He looks not at his stepson, but at his wife, and not with anger or amazement, but with what can only be described as love and devotion. Of all the saints, Joseph is perhaps the most deserving of that title. It couldn’t have been easy going through life known by his neighbors and relations as a cuckold. Then, to have the child he supported so devotedly grow up to be an itinerant preacher spouting crazy, new religious ideas. Well, that would be more than most people could bear. Yet, at least as legend has it, he remained a constant and devoted husband and step-parent.
Titian’s success lay largely in his ability to portray the mythic in realistic fashion, to bring the legends of religion and mythology to life and make their lessons relevant to his viewers. In The Madonna of the Cherries he succeeds beautifully in bringing home the lessons of the story behind the Holy Family.
And my patient? Her equally realistic daydreams were caused by her medication. All it took was a little adjustment, and they were gone. No more dinners with Titian. Now she's complaining of boredom.
UPDATE: A reader makes this point about The Cherry Tree Carol:
Please note that The Cherry Tree Carol is of medieval origin. Appalachia, closer to its Anglo Saxon roots that the rest of us, inherited this lovely carol--with its understandably irritable Joseph--from its forbears.
Quite true. And if you'd like to learn more about the Anglo-Saxon roots of American folkways, I highly recommend Albion's Seed.
posted by Sydney on
4/24/2003 08:06:00 AM
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Universal Disaster: Richard Gephardt says he has a plan for universal health insurance - expand employee benefits. That might work if everyone could count on permanent employment. You know, like incumbent Congressmen. We need a new system of health insurance, one that's modelled on the rest of the insurance industry (auto, life, etc.) so that risk pools can be larger and costs more equally shared, and so people don't have to change insurance plans when they change jobs. (via The Bloviator) posted by Sydney on
4/23/2003 10:28:00 AM
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Psychology of Evil: One of Saddam's torturers explains his career choice:
"I went to the Fedayeen group because I didn't want to study anymore," he said. "I hated studying and I wanted to be in the army." But the army paid poorly and the prestige of working in a unit commanded by Uday was alluring. "The Fedayeen was special and I knew that Uday took care of them very well, not like the army."
By 1996, Ali said, he was chosen to join an elite 18-member squad within the Fedayeen called the Staff, which effectively served as special forces. At the end, he was being paid 150,000 Iraqi dinars a month, or roughly $70, a decent salary in Iraq, plus bonuses for assignments ranging from hundreds of thousands of dinars to 3 or 4 million, depending on the mission.
Life as a member of the Fedayeen made him a special man in Baghdad; his badge opened virtually any door. "They respected me so much," Ali said. "Everyplace I wanted to go into I could with my badge. Any place of Uday's or Saddam's I could go because I had my badge."
Could be any inner-city gang member or wise guy. Never underestimate the glamour of evil.
posted by Sydney on
4/23/2003 10:20:00 AM
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Meng Chunying says she felt the beginnings of a nasty head cold on March 18. But Ms. Meng, an Air China flight attendant who often flew the Hong Kong-Beijing route, said she never made the connection with an outbreak of atypical pneumonia that she thought was under control.
A few days later, Ms. Meng, feeling listless and feverish, flew to Hohhot, the wind-swept capital of the Chinese region of Inner Mongolia, to see her her family.
Though the atypical pneumonia, called severe acute respiratory syndrome or SARS, first appeared in southern China in November, local doctors did not figure out that Ms. Meng, 27, was Inner Mongolia's first case until early April. By then, Ms. Meng had infected her mother, stepfather, brother and doctor, who gave it to another patient. Ms. Meng also passed SARS to Li Ling, her husband of three months, who became one of the first people in Inner Mongolia to die of SARS
The rest of the article is one long, sad catalogue of how the Chinese government’s denial helped spread the disease throughout the country.Although, word has it that they've found a new health minister, which would explain this announcement:
China has developed a cheap and easy test to diagnose SARS within an hour, the country's state-run media reported yesterday. The method, lauded as an "absolutely certain indicator," uses a modified protein to detect the presence of an antibody the body produces in response to SARS infection.
"What we don't know yet are all the signs and dynamics of the virus and whether the test is sensitive enough to pick up the virus all the time," said Parker, deputy health officer for the South Fraser Health Authority.
The other worry is that severe acute respiratory syndrome may have an early stage when the virus isn't detected by the test.
Parker said victims could suffer from fever and cough, then stabilize for a few days before coming down with a more severe respiratory illness, at which point they would test positive.
...The test, which analyses stool samples and nasal swabs, was also performed on two probable B.C. cases: A woman who contracted SARS in Hong Kong, and a nurse who seems to have gotten the virus while treating her. Both came back positive, Parker said.
And at least one virologist has doubts about the guilty virus’s identity.
Meanwhile, Canadians have had some trouble getting “healthcare workers” to obey the quarantine. Judging from the description:
...this individual was obnoxious, was threatening. He was belligerent.
I’d be willing to bet the offender has a medical degree.
Air Canada, Sears Canada Inc. and Fairmont Hotels & Resorts Inc. are already saying the disease is hurting sales. Toronto tour bus operators are also facing troubles, with one coach company cancelling 52 trips and another losing a $77,000 contract when a convention was called off, according to a release issued yesterday by a trade association.
As well, the U.S. Centers for Disease Control and Prevention (CDC) yesterday urged travellers to Canada to pack a first-aid kit to reduce any need to visit hospitals or clinics where they might be exposed to SARS. And the U.S.-based cruise line Crystal Cruises is refusing to let Toronto-area and many Asian residents board its ships because of fears they could spread SARS to other passengers.
While in Hong Kong, doctors and nurses continue to be hit hardest by the infection:
Hong Kong will shut the emergency unit at one of its major hospitals after dozens of medical staff contracted the SARS virus, health officials said on Wednesday.
The outbreak at the Alice Ho Miu Ling Nethersole Hospital comes after scores of doctors and nurses fell ill in at least two other public hospitals in recent weeks, evidence that the territory is still far from being able to contain the epidemic.
Rodney Dangerfield Medicine:Family Medicine Notes, the oldest of the active medical blogs (And the second blog in medical blog history. The first one is dormant.) says family medicine don’t get no respect. I’ve experienced the same thing he describes. Even worse, I’ve seen specialists ignore the advice of the primary care physician to the detriment of the patient. Just last weekend I was covering for a colleague who explicitly told the cardiologist that a patient had a history of bad reactions to beta-blockers and that he should avoid them. He was brushed off, and sure enough, the patient tanked over the weekend, with no cardiologist in sight. I suspect all generalists have experienced this form of prejudice. But like all prejudice, it’s really just a form of egotism. I’ve noticed that the best specialists - those who are good at caring for patients - don’t seem to suffer from it.
Blog Alert: Even the Health Insurance Portability and Accountability Act (the notorious HIPAA) has its own blog. posted by Sydney on
4/22/2003 08:54:00 AM
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Proof in the Pudding: As predicted, now that Claritin is over-the-counter, many patients no longer want to use it. The over-the-counter version is cheaper for those who always had to pay for it out-of-pocket than the prescription version was, but those with drug benefits have seen the price increase from a $10 co-pay for thirty pills to $30, and they don't like it. The result?
Some patients find an antihistamine they haven't used for several years works again -- it's like the body recognizes it again, says Dr. Paul Ehrlich of New York University.
More Hyperbole: Officials are worried that the death rate from SARS is increasing:
The death rate from severe acute respiratory syndrome has more than doubled to 5.6 percent since the epidemic was first detected in mid-March, causing deep concern among health officials.
More than doubled? They've been saying for some time that the mortality rate is around 4%. Wouldn't it have to increase to over 8% to "more than double"? Well, it depends on how you define "double":
When WHO, the lead agency investigating SARS, first reported daily statistics on the disease, the death rate was about 2 percent. It was 2.4 percent on March 17 and 1.8 percent on March 18. At that time, the number of cases was less than 220.
The WHO first realized that there was something new going on in Asia around March 12. The data collected on March 17 were by no means complete. It's very disingenous to claim that this represents a real doubling in the death rate. The truth is, this illness hasn't been around long enough for anyone to have a good handle on its natural history. Until there's a reliable way to definitively diagnose it, we won't know for sure what the true mortality rate is. It could be lower if there are many milder cases of the disease that so far go unnoticed.
For a better perspective on the mortality of SARS, see the New England Journal of Medicine'sexcellent graphic (scroll down past the list of articles). Mortality still remains relatively flat compared to the number of cases.
posted by Sydney on
4/22/2003 08:14:00 AM
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Disagreement: The New York Times addresses the issue of what to think when two well-done studies reach different conclusions (requires free registration). This particular article deals with the still popular issue of hormone replacement therapy for menopause. In addition to last year’s much publicized study that found an increased risk of breast cancer and heart disease in estrogen users, it looks at an equally well-publicized study from several years ago that found a decrease in heart disease in estrogen users. The reporter quotes various researchers explaining how the studies may have had subtle differences that were responsible for the discrepancy, but no one mentions the most likely reason for the discrepancy - that both studies found such small differences in the incidence of heart disease among users and nonusers of estrogen that their findings have no true significance in the real world.
Unfortunately, I couldn’t find the raw data from the older Nurse’s Health Study this morning due to time constraints, but I remember that the actual differences were very small, and that there was initially some debate about whether or not the findings really meant that hormone replacement therapy protected against heart disease. That debate was quickly brushed aside, however, as media reports repeated again and again the researcher’s spin that heart disease was “decreased by 30%” in hormone users.
I do, however, have the data from last year’s Women's Health Initiative study which claims that women who take estrogen have “40% more heart attacks." (Unfortunately, the data isn’t linkable anymore. JAMA revamped its website and the link no longer works.) This is what that 40% increase represents in reality: 0.37% of estrogen users had heart attacks compared to 0.30% of placebo users. In the real world, that isn’t any difference at all.
The Times article quotes one expert as saying that when the Women's Health Initiative came out, he realized that “public health has a real problem.” He meant that doctors have been giving the wrong advice to women about estrogen replacement therapy, but the real problem is that our profession has completely forgotten the difference between statistical significance and clinical significance. And even more to our shame, we allow researchers to use statistics to exaggerate their findings without any criticism. Like sheep, we take their press releases at face value. That appears to be true whether we’re in private practice, editing medical journals, or doing research. Shame on us.
UPDATE: DB thinks we act on marginal results because our tendency is to want to do the best for patients. That's probably true, but it isn't necessarily for the greater good. It's one thing to mention marginal benefits when counseling a patient about preventive measures. It's quite another thing to base standards of care on marginal results. posted by Sydney on
4/22/2003 08:02:00 AM
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The mayor of Beijing was fired following the disclosure of a tenfold increase in SARS cases in China's capital and charges he mishandled the outbreak of the deadly illness, state-run media said Monday.
The dismissal of Mayor Meng Xuenong came shortly after he and China's health minister were removed from key Communist Party posts, and the Health Ministry announced that the number of cases of severe acute respiratory syndrome in Beijing had jumped from 37 to 339...
...Meanwhile, Hong Kong Chief Executive Tung Chee-hwa said efforts to contain the spread of SARS by quarantining households of victims and tracking down potential contacts are paying off.
An additional 150 suspected SARS cases have been identified through stepped-up measures to find people exposed to the disease. Those people have been able to get early treatment - which Hong Kong doctors fighting SARS say is crucial...
But elsewhere, things aren't going as well:
...Singapore announced that all 2,400 employees of a vegetable market are under quarantine after a coworker fell ill...
...Sunnybrook Hospital in Toronto, which has Canada's largest trauma unit, closed its critical care, cardiovascular intensive care and SARS units Saturday. Officials believe staff members were exposed to the virus a week ago while treating a patient.
The closing will place a "huge burden" on Toronto's health care system, said the hospital's president and chief executive, Leo Steven.
The mortality rate still appears to be around 4%, which is relatively low, but death can occur in all age groups regardless of health status. Far worse is the effect it has on the economies, and on the healthcare systems, of areas with the epidemic. You would think that this would cure us of our complacency when it comes to the dangers of bioterroism, and convince our public health community and healthcare workers of the wisdom of pre-attack vaccination against smallpox. But, so far there are no signs of that.
posted by Sydney on
4/21/2003 08:31:00 AM
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Wheezey Epidemic: The New York Times says that 25% of kids in Harlem have asthma, many unknowingly:
A study has found that one of every four children in central Harlem has asthma, which is double the rate researchers expected to find and, experts say, is one of the highest rates ever documented for an American neighborhood.
Researchers say the figures, from an effort based at Harlem Hospital Center to test every child in a 24-block area, could indicate that the incidence of asthma is even higher in poor, urban areas than was previously believed.
The Centers for Disease Control and Prevention has estimated that about 6 percent of all Americans have asthma; the rate is believed to have doubled since 1980, but no one knows why. New York City is thought to have a higher rate than other major cities, but that, too, is something of a mystery. The disease kills 5,000 people nationally each year...
....beginning last year, a team at the hospital set out to screen all of the roughly 2,200 children under 13 who live or attend school in the zone, asking about symptoms, listening to their lungs and measuring the rate at which they can exhale into a tube.
So far, the parents of 1,401 of the children have filled out questionnaires intended to detect possible signs of asthma, like nighttime coughing and wheezing, and 967 of the children have actually been examined. Nearly all of those tested so far are of school age, leaving out the younger children, in whom it can be hard to distinguish asthma from the respiratory ailments common to toddlers.
The project staff aims to screen all the children by this summer and then to publish its findings.
You have to wonder why they publicized it before publishing it. The high rate may be real, or it may not be. Not to be Clintonian about it, but everything depends on how you define asthma. Not everything a parent describes as wheezing is wheezing, sometimes it’s just noisy congestion that clears with a good hard cough. And not every night-time cough is asthma. The article points this out, but briefly, not very explicitly, and far into the story:
Herman Mitchell, an epidemiologist who is a leader in asthma research coordinated by the National Institutes of Health, cautioned that studies could differ simply because there were problems in defining asthma and in making an accurate diagnosis.
Of the Harlem findings, he said: "This is certainly one of the highest rates attributed in the United States, if not the highest. What they're doing is quite exceptional in scope and it sounds like it's good methodology, but until they publish and lay it out, it's hard to judge."
No matter. It will now be a widely held truth and matter of fact that kids in Harlem have higher rates of asthma than anywhere else. It’s been in the Times and just about every other newspaper in the land thanks to syndication. That’s one of the advantages of publishing your studies in newspapers instead of medical journals. You avoid scrutiny of your methodology, gain praise for your work, and insure more future research dollars. posted by Sydney on
4/21/2003 08:14:00 AM
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Doping: The US Olympic committee is being accused of covering up drug use by prominent athletes:
Documents purporting to show that a number of American athletes were allowed to compete in the Olympics after failing drug tests prove long-held suspicions of U.S. drug cover-ups, the head of the World Anti-Doping Agency said Wednesday.
Dr. Wade Exum, the former USOC director for drug control from 1991 to 2000, released more than 30,000 pages of documents to Sports Illustrated. He says they show that athletes such as Carl Lewis and Mary Joe Fernandez tested positive but were allowed by the U.S. Olympic Committee to compete anyway.
...WADA head Dick Pound said the documents reinforce what some critics believed all along.
"It's what many people suspected about the U.S. Olympic Committee, that it was being covered up," he said in a telephone interview from Montreal. "There were lots of rumors around."
Based on the evidence presented in the article, those rumors are still unfounded. Every case mentioned involves the detection of small amounts of pseudoephedrine, a common ingredient in cold and allergy medicines. It isn't a performance enhancer. In fact, a lot of people complain of drowsiness after taking it. It's a shame that Dr. Exum, who apparently has some unresolved issues with the Olympic committee, is making it seem like it's more than it is. He should know better. posted by Sydney on
4/21/2003 07:58:00 AM
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Prudent to a Fault: D.A. Henderson agrees that the link between smallpox vaccine and heart attacks is bogus. (free registration required) posted by Sydney on
4/21/2003 07:46:00 AM
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Falling: Could we prevent hip fractures in the elderly if we dressed them like football players? Evidently not:
In the intervention group, 18 hip fractures occurred vs 20 in the control group....In addition, the per protocol analysis in compliant participants did not show a statistically significant difference between the groups.
Just as well. It's hard enough to get people to use their canes or to wear unfashionable support stockings. Underwear that makes the hips look wider isn't likely to be popular, either. posted by Sydney on
4/21/2003 07:43:00 AM
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