"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
Show Us the Money: One thing that's become clear in the past two years is that whenever America's public health departments are asked to do something, such as make contingency plans for potential bioterror attacks, they complain about it. There are only a handful of SARS cases in the United States, and here they are complaining about how much the disease is taxing them:
Seattle has yet to face its first confirmed case of severe acute respiratory syndrome, the stealthy, fast-moving illness that has caused panic and death from China to Canada.
But for Dr. Alonzo Plough, head of the Seattle-King County Public Health Department and for many of his colleagues around the country, the impact of SARS has arrived in full force, striking their agencies like a freak natural disaster.
"Very critical public health activities are not being done because of these very pressing demands of the moment," Plough said.
.....Plough calculates that SARS investigations and related work cost the department $160,000 in the first three weeks alone.
Goodness. How do they spend that money so fast? They say it’s spent tracking down contacts of possible cases, printing up multilingual patient-education signs for their public health clinics, and answering as many as six(!) phone calls an hour.
They claim to have had to investigate 60 possible cases of SARS in Seattle, but the CDC figures say that there have only been 44 in all of Washington. And six phone calls an hour? Staff at an average doctor’s office would think that a cakewalk.
But perhaps the most ridiculous of the arguments is this:
Dr. Laurene Mascola of the Los Angeles County Department of Health Services put the squeeze in blunt terms. "We have dealt with SARS to the detriment of other diseases," she said, pointing out that in California about 2,000 people die every month from unexplained pneumonia.
That figure seems high for just one state, especially since the entire nation, the death rate from pneumonia is around 64,000 annually. But, even if 2,000 people a month die of pneumonia in California, most of those deaths occur in people are at the ends of their lives (it isn’t called the “old man’s friend” for nothing). And the institutions that care for those people are hospitals and hospices, not public health departments.
But, of course, exaggeration is a critical tool when angling for more money. posted by Sydney on
5/03/2003 09:07:00 AM
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Trauma: Sally Satel notes that an army of psychologists may be about to be unleashed on the Iraqis, but will they really be needed?
A half-century of disaster research yields a largely sanguine picture of human response in the face of uncertainty, calamity and fear. The Center for Disaster Research at the University of Delaware has conducted hundreds of studies of natural disasters, chemical emergencies and building collapses. Over and over, researchers have found that people rarely panic or lapse into passivity.
Lee Clarke, a Rutgers University sociologist, has observed: "The rules of behavior in extreme situations are not much different from rules of ordinary life. . . . The most consistent pattern in disasters is that people connect in the aftermath and work to rebuild their physical and cultural environments." Most people are resilient and adapt well. They prefer to cope--and can cope--on their own. But the very idea that a potent stress could pose an ennobling challenge to the human spirit is the minority view among trauma professionals. posted by Sydney on
5/03/2003 08:33:00 AM
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PSA Screening:Dr. Jacob has an excellent post on the subtleties of prostate cancer screening. He's right, it's extremely difficult to discuss controversial screening tests like this without introducing your own bias. posted by Sydney on
5/02/2003 08:25:00 AM
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SARS Developments: Still trying to elucidate the natural history of the disease:
Researchers in Hong Kong reported that they had detected evidence of the virus in some people who have not gotten sick and in some who were thought to have recovered and, therefore, were no longer infectious.
"Some studies show people do continue to secrete the virus in feces and tears," said David L. Heymann of the World Health Organization, who was attending a scientific meeting on severe acute respiratory syndrome in Toronto. "Some cases actually recover and relapse. There are many more issues to be clarified."
But there have been no documented chains of transmission from SARS patients who have been released from hospitals, which indicates they may not be spreading the disease.
"We have to look at this," said Julie L. Gerberding, director of the Centers for Disease Control and Prevention in Atlanta. "The focus still needs to be on the people who are sick."
It isn’t uncommon for a virus to continue to be excreted in body fluids long after the illness is over. The virus that causes infectious mononucleosis is excreted for months, sometimes years, in body fluids, but only appears to be contagious during the early phase of the illness.
Guangzhou authorities divided the floor of People's Hospital No. 8 in half, putting SARS patients on one side of the elevator bank and AIDS patients on the other. Health care workers walked back and forth between the two sides, and some of those doctors and nurses contracted SARS.
Yet not one of the several dozen AIDS patients or their visitors, some of whom were also HIV positive, developed the disease. "I am wondering why there was no SARS virus co-infection in the AIDS cases," Dr. Zhang Fujie, director of AIDS treatment and care for China, said yesterday in an interview. "We are exchanging information with Hong Kong on this. We will continue to try to understand that."
Dr. Cheng Feng of the China/UK HIV/AIDS Project said he, too, was aware of the phenomenon. He wondered whether the drugs the AIDS patients were receiving for HIV control might be blocking a SARS infection. A similar notion was mentioned by Dr. Yuen Kowk-yung of the University of Hong Kong. With New York's Dr. David Ho, of the Aaron Diamond AIDS Research Laboratory, Yuen is exploring the AIDS apothecary for an effective SARS treatment.
It could be the drugs, or as Andrew Sullivan points out, it could be that the immune system’s response to the virus is the primary cause of the illness. That would help explain why so many of the victims are young and healthy, and why steroids, which suppress the immune system seem to help. posted by Sydney on
5/02/2003 08:18:00 AM
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Class Action: Efforts at tort reform are still quietly proceeding. According to this story about a bill in the Senate to reform class action lawsuits, some of those settlements are right out of a Seinfeld episode:
Class-action suits have also become an ATM for unscrupulous lawyers, who win millions of dollars for themselves but sometimes leave clients empty-handed. Last year, lawyers suing Blockbuster Video reached a settlement giving their clients coupons for free movie rentals. The lawyers pocketed $9.25 million - and Blockbuster was allowed to continue the late-fee practices that triggered the lawsuit. Plaintiffs suing Columbia House record club got nothing but a discount on future purchases. Their lawyers took home $5 million, plus expenses. Sometimes, plaintiffs lose money while lawyers get fat fees.
And, on the medical malpractice front, the Senate will soon be considering the issue, but whether or not they’ll get to vote will depend on the behavior of the Democrats:
The Senate will soon consider a medical liability reform bill, following last month's passage by the U.S. House of Representatives of the White House-sponsored Health Act, which would limit punitive damages in malpractice cases.
"We realize this is an uphill battle," Purdon said. "Some Democratic senators have threatened to filibuster
Dr Roy Kessels, from the University of Utrecht in the Netherlands found that between half and four-fifths all all medical information delivered during an average consultation was forgotten instantly by the patient.
In addition, half of the information that managed to gain a foothold in the memory of the patient was later recalled incorrectly.
The problem was particularly acute in older patients, he found, or in those who were anxious about bad news.
The elderly and the anxious are understandable, and there are some patients who need to have everything written down so they won't forget, but there are also a large number of people who just aren't capable of listening. You can see it in their eyes - they're thinking about the next thing to say as you explain your treatment plan, and they never let you finish a sentence. They say that doctors interrupt their patients frequently, (the implication being that we don't listen), but I'd like to see a study on how often patients interrupt their doctors. posted by Sydney on
5/01/2003 09:04:00 AM
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Misunderstanding: A reader sent along this Reuters account of a study published last month in JAMA:
The average weight loss among Weight Watchers participants "is not very much in comparison to what people hope they will lose, or what people need to lose in order to reach the desired, svelte self," study author Dr. Stanley Heshka told Reuters Health.
These findings suggest that people who need to lose a significant amount of weight fairly quickly for medical reasons may want to opt out of Weight Watchers and similarly structured programs, said Heshka, who is based at the New York Obesity Research Center, St. Luke's/Roosevelt Hospital in New York City. In the program, participants attend weekly meetings and receive guidelines for exercise and how to pick the healthy foods and portions.
To be fair, the article goes on to point out that Weight Watchers is just as successful as any other weight loss program, and in fact superior to doing it on your own, but the overall impression one gets from it is that Weight Watchers doesn’t work. The study in fact found that people on Weight Watchers lost more weight:
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.
The structured commercial weight loss program provided modest weight loss but more than self-help over a 2-year period.
The truth is that losing weight and keeping it off is extremely difficult. It requires a degree of obsession to detail (counting calories) that’s difficult to sustain. Quitting tobacco or alcohol is easy in comparison. It isn’t that difficult to avoid cigarettes or spirits, although you might have to give up social outlets to do so. It’s impossible to avoid food completely, so the temptation to overeat is always there. That’s not to say that it can’t be done; just that it is, in some ways, a Herculean task. posted by Sydney on
5/01/2003 08:47:00 AM
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SARS Shenanigans?Chuck Simmins says he's suspicious about the WHO's reasons for lifting the Toronto travel ban:
More good Canadian info. Illustrating the perils of recordkeeping, I suppose. WHO lifts its ban on Toronto because no new cases have been reported in 20 days, and the very same WHO reports four new cases in Canada during the period 4/28 to 4/29. The Canadian gov't site reports two more probable and eight more suspect in the same time frame, the two probable and four of the suspect are in Ontario.
I think it's fair to say the WHO really didn't lift its ban because there hadn't been any new cases... Just that they got so much flack about it.
When Toronto began fussing about the travel ban last week, one WHO official was quoted by the Times as believing any lifting of it would be due to political, not medical, realities. Chuck's data seems to support this:
The WHO accounting of Canadian cases as of April 30.
The figures speak for themselves.
And speaking of honesty as policy, Dissecting Leftism is attempting a one-man battle to bring transparency to that bastion of dishonesty, China:
The Chinese seem to have become really serious about internet censorship in recent months. They re-blocked Blogspot some time ago and lots of other sites are blocked too -- including at least some Lycos and some Yahoo. I have therefore decided to do my tiny bit towards keeping communications open by putting a mirror of my blog up on a site that China does NOT block. I keep all my blog entries as a file so once I have written my blog entries for the day, it takes me only a couple of minutes extra to put them up on a second site. So in future my blog will also be accessible at the following address: http://members.optusnet.com.au/~jonjayray/tripod.html. The site concerned is hosted by my local ISP so it may stay too insignificant to be blocked by China. With ISP hosting, the site is also advertising-free, which is a bit of a bonus. I will also be putting up my "China" postings several hours before I put them on Blogspot. Because Blogspot is so trouble-prone, I do not post there until just after midnight, California time, in the hope that the load and the errors will be minimal then. I would be much obliged if anyone with contacts in China would let them know of the new site. I even have some archives there so people can catch up with what was posted in the last 6 weeks or so. posted by Sydney on
5/01/2003 08:25:00 AM
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Nukes, Bugs & Poison:Winds of Change has a collection of news and reflections on all security threats biological, chemical, and nuclear. posted by Sydney on
5/01/2003 07:50:00 AM
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Weekly Art History Lesson: Claude Monet (1840-1926) saw the world as a fantastic mixture of color and light. How much of that world view was due to genius and how much to faulty eyesight, we’ll never know, but legend has it that when once fitted with eye-glasses to correct astigmatism, he threw them away, saying, “If the world really looks like that I will paint no more!”
What better subject for an artist of color and light than a field of tulips?
Tulip Fields in Holland,1886
Painted in the late 1880’s, when success finally left him well-off enough for a series of travels, the painting is a landscape unique to Holland - the quintessential Dutch windmill surrounded by a sea of tulips. It is a blurred panorama of light and color that leaves one wishing the focus could be adjusted ever so slightly.
How a flower from the high, rocky mountains of Pakistan ever came to be the agricultural mainstay of a marshy, low-lying northern European country is a story in itself. It is, in many ways, the story of beauty made possible by science and technology. It was the engineering feat of the windmill which made the marshy fields dry enough for successful bulb cultivation by pumping the excess water into canals that drain to the sea. And it was the science of pharmacology that brought the flower to the marshes.
It was a French pharmacologist, (back when pharmacologists were botanists, not chemists), who introduced the tulip to Holland. Charles De L'ecluse (aka Carolus Clusius), was forced to flee in succession not only his native France, but academic posts in Prague and Vienna because of his Protestant beliefs. He accepted the post of head botanist at the University of Leiden in 1593 with the intent of establishing a medicinal garden such as those in Vienna and Prague which had established his reputation. Among his collection of plants was the tulip, given to him by the Viennese ambassador to the Turkish court of Suleiman the Magnificent.
The tulip became one of the most popular flowers in the Leiden garden, although it had no medicinal value. Clusius was loathe to share his specimens, but contraband bulbs lifted surreptitiously from his garden made their way to private hands. Eventually, with time and hybridization, they gave birth to the brightly colored fields of modern Holland - and the Holland of Monet.
Monet, on seeing those fields, described them as “enough to drive a poor painter crazy - impossible to render with our poor colors,” but render them he did in his astigmatic but beautiful way.
Unfortunately for Monet, his vision continued to fail as he got older. Astigmatism gave way to cataracts, which not only robbed him of clarity, but of color perception. By the end of his life, he was quite blind; his view of the world unquestionably altered, but no less beautiful. posted by Sydney on
5/01/2003 07:24:00 AM
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Molehills: There seems to be a lot of angst out there about over-the-counter Clairitin:
Faced with higher co-pays or restrictions on prescription coverage, some patients might start self-diagnosing and self-medicating with over-the-counter antihistamines, said Dr. David Lang, head of allergy and immunology at the Cleveland Clinic Foundation.
``There's the issue of misdiagnosis,'' Lang said. ``In other words, not everyone who comes to us has hay fever.''
Patients might think their stuffiness is caused by seasonal allergies when, in fact, they're suffering from a chronic sinus infection or even hormonal changes caused by pregnancy or use of oral contraceptives.
Another major concern: Patients who self-treat their symptoms might miss other, more serious conditions, particularly asthma.
But anti-histamines have been available over-the-counter for years. Clairitin isn't any more effective at suppressing allergy symptoms than the previously available drugs - it just does it with fewer side effects. There's no reason to think that people will suddenly start to ignore their asthma in greater numbers (something which a lot of people unfortunately already do) because they have yet another anti-histamine to chose from.
Of course, the real issue here is that people are being asked to bear a greater burden of the cost of the drug:
Allergy sufferer Jody Yoxthimer, a 30-year-old Akron resident, used to pay an $11 co-pay each month to get a version of Claritin that included a decongestant.
When she recently called her pharmacist to see whether it would be covered, she discovered her insurer wouldn't pay for the drug anymore.
So rather than pay $30 each month for Claritin, plus more for a decongestant, Yoxthimer is switching to a drug that's still available only with a prescription.
She said ``The thing is, the idea of having the prescription drug go over-the-counter is so you can buy it without a prescription and it's not expensive. Claritin was really working well.'
She might have been paying only $11 for prescription Claritin, but it was much more expensive than the current over-the-counter price of $30 for others:
Before the switch, Akron's SummaCare Health Plan, for example, paid roughly $2.25 to $2.50 per tablet for Claritin -- or $67.50 to $75 for a 30-day supply.
The customers of that health plan, in turn, paid a $40 copay for the drug, plus whatever it took in higher premiums for the company to cover extra drug costs. But it's so much easier to complain about the insurance companies than to accept responsibility for our share of the cost burden:
In the meantime, some insurers are making people jump through new hoops to get their prescription; they have to prove they've tried an over-the-counter alternative without success.
``The insurance companies are essentially practicing medicine without a license by restricting access to medications that patients need,'' said William E. Berger, an allergist in Mission Viejo, Calif., and president of the American College of Allergy, Asthma and Immunology. ``Our position is, physicians should be the ones to make the decisions about what's appropriate for patients -- not insurance companies.''
Well, they're not really practicing medicine or restricting our practice. We can still recommend the antihistamine, but the patient is going to have to accept that those antihistamines are safe enough to be offered over-the-counter and paid for in cash rather than through the beneficence of their insurance company. And honestly, if your allergies are bad enough to require daily medication, is one dollar a day for the average consumer that much of a burden?
Genetic Revolution: A Cleveland company has had some initial success with a new cystic fibrosis therapy:
Researchers at University Hospitals and Case Western Reserve University began the clinical trial one year ago with 12 patients who received a corrected gene in a saline solution dripped into their nasal passages. Cystic fibrosis patients have a genetic defect that causes the buildup of thick mucus in the lungs and digestive system.
Scientists using a gene-transfer system developed by Cleveland-based Copernicus Therapeutics Inc. found that the patients suffered no ill effects and that the therapy appeared to normalize the nasal cells.
The experiment did not attempt to cure the 12 volunteers because the nasal passages were merely a test site.
Doctors don't know yet whether the gene transfer will take hold in the lungs or how frequently therapy would be necessary as mature cells die off and new, defective cells take their place.
But in eight of the 12 patients, the cells produced enough protein to improve the transport of salt and water, a critical balance that is upset in cystic fibrosis patients. The gene controls production of the protein responsible for maintaining the balance.
The technique uses something called PLASmin™ therapeutics to roll the DNA up into small enough sizes to infiltrate the cell's nuclear envelope:
The company licensed technology that compacts DNA - the structure that carries the genetic code - so the corrected gene would be small enough to enter the cell nucleus. The compacting technology is critical because viruses that are commonly used to introduce corrected genes into cells are fraught with problems for cystic fibrosis patients. Early gene therapy trials caused a devastating inflammatory response.
Sounds promising. The next step is to deliver it to the lungs and see if it works there, too. posted by Sydney on
4/30/2003 08:48:00 AM
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Overdoing It: Too much of a good thing is still too much:
No longer, the experts say, are they concerned about vitamin deficits. Those are almost unheard of today, even with the population eating less than ideal diets and skimping on fruits and vegetables. Instead, the concern is with the dangers of vitamin excess.
"There has been a transition from focusing on minimum needs to the reality that today our problem is excess - excess calories and, yes, excesses of vitamins and minerals as well," said Dr. Benjamin Caballero, a member of the Food and Nutrition Board at the National Academy of Sciences and the director of the Center for Human Nutrition at Johns Hopkins University.
This is nothing new. They’ve been teaching about vitamin toxicity in medical schools for years. The fat-soluble ones are particularly prone to having toxic effects, because they’re stored in the body fat for later use rather than excreted in the urine, like water soluble vitamins are. Their toxic effects are describe detail here: Vitamin A, Vitamin E, Vitamin D , and Vitamin K.
Even Vitamin B6 can cause a toxic neurological disorder.
Not only do large amounts of these vitamins cause toxic syndromes, they might actually make worse that which they’re promoted for improving:
...The most popular individual supplements are vitamins C and E, said Dr. Robert M. Russell, the director the Human Nutrition Research Center of Agriculture Department at Tufts University, who is head of the Food and Nutrition Board. Scientists once thought those vitamins could help prevent ailments like cancer and heart disease, but rigorous studies found no such effects.
Vitamin E supplements can increase the risk of heart attacks and strokes, and studies of vitamin C supplements consistently failed to show that it had any beneficial effects...
...Several recent large studies indicate that people with high levels of vitamin A in their blood have a greater risk for osteoporosis. People can easily reach a potentially dangerous level, about five times the recommended dose, by taking vitamins and supplements, nutrition researchers say...
....Two large randomized trials of vitamin A and beta carotene that researchers hoped would show a protective value against cancer found no benefit, and one found that participants who took the supplements had more cancer.
A large study of vitamin E and heart disease found that it did not prevent heart attacks and that people taking it had more strokes.
Another study, of women with heart disease, found that antioxidant vitamins might actually increase the rate of atherosclerosis...
....a European study, reported recently at a meeting of the American College of Cardiology, found that folic acid supplements actually made matters worse for heart disease patients. The study, the Folate After Coronary Intervention Trial, involved 626 patients who were having stents inserted into blocked arteries to keep them open. Half were randomly assigned to take folic acid, and the rest took a placebo. Six months later, the arteries of those taking folic acid were significantly narrower than the arteries of those taking a placebo, exactly the opposite of what the investigators had expected.
The article points out that other studies have shown the opposite effect. As one researcher puts it:
"Over all, the likely explanation is that there is a neutral effect, and these relatively small trials found opposite findings due to the play of chance.”
Blogospheric Applications:Business Word has some thoughts on applying blogs to business - both in terms of daily operations and public relations. posted by Sydney on
4/29/2003 08:18:00 AM
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Cancer Screening: The FDA has approved a screening test for bladder cancer:
The test is run on four drops of urine placed on the BladderChek cassette, which is designed to detect NMP22, a protein correlated with bladder cancer. If the protein is detected, the test displays a purple line. Results are available within 30 minutes during the office visit.
More than 1 million patients currently receive a diagnostic work-up for bladder cancer from urologists each year, according to Matritech. With the test now available for general screening, the company believes the market could expand to primary care physicians who would use the test in another 4million patients who present with blood in their urine.
Right now, when someone presents with blood in their urine, the only way to rule out bladder cancer is to do a cystoscopy. But, in at least one study, the NMP22 urine test predicted all the cancers subsequently found on cystoscopy. It had no false negatives, but it did have some false positives (caused by recent inflammation of the urinary tract, such as kidney stones, infection, foreign bodies, etc.) It certainly would be nice to be able to screen out those people who have just a few red blood cells in their urine and who don’t need to go on for such a costly and invasive procedure as cystoscopy. (And it's CLIA-waived, so your doctor can do it in the office without being subjected to oppressive government regulation.) posted by Sydney on
4/29/2003 08:15:00 AM
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Bioterror Update: Anthrax rears its ugly head again:
A crew member of an Egyptian merchant ship has died in northern Brazil, almost certainly from anthrax, after opening a suitcase suspected of containing the substance which he was taking to Canada.
A spokesman for Brazilian federal police in the Amazon state of Para said on Monday an autopsy of the Egyptian man, whom he named as Ibrahim Saved Soliman Ibrahim, showed that he had died after vomiting, internal bleeding and multiple organ failure.
"He was the victim of anthrax," said Fernando Sergio Castro, adding that police were 90 percent certain that Ibrahim had died of anthrax.
Ibrahim died in the hotel were he was staying on April 11. Several health workers who found his body were taken to a hospital after becoming ill but are now out of danger.
The Canadians, however, who have put the man’s ship in quarantine and are inspecting it for anthrax, tell a different story:
RCMP Insp. Dan Tanner dismissed media claims originating in Brazil that suggested the deceased was given a piece of luggage in Egypt before he travelled to the South American country, where he joined the crew of a ship now quarantined off Nova Scotia.
"I can assure you we've discovered no threat to Canada, criminally or terrorism-wise," Tanner said Monday in Halifax. ``Right now it's just a story."
...Ibrahim, chief officer of the vessel Wadi Al Arab, boarded the ship in a Brazilian port and became sick after opening the bag and exposing himself to anthrax spores, the Reuters report said. The man, said to be an Egyptian in his 50s, died in Brazilian waters after suffering from internal bleeding and multiple organ failure.
...Malcher said Ibrahim started feeling ill about seven hours after boarding the ship. "He was found dead early the next morning," he said. "Before boarding, Ibrahim was submitted to routine medical examinations and was found to be in perfect health, so it would seem that the infection occurred on board."
So where did he open the suitcase? The ship or the hotel? If at the hotel, wouldn’t the Brazilian authorities already have the suitcase and its contents? And where did he die? Sounds like this case needs a good investigative reporter.
Socialized SARS:Chuck Simmins sends along these thoughts on SARS and socialized medicine:
Someplace, in the last few days, and I wish I had the source at hand, I saw that several Canadian nurses were infected because they were intubating an infected patient and he vomited on them. Even a newbie paramedic knows you take universal precautions when intubating a patient.
Your points on the start of the Toronto situation are well taken, but I suspect that the above was only one of a few really, really stupid mistakes. And, yes, I would grant you that it could happen here. I would suggest that the U.S. has 41 plus cases and it doesn't appear to be happening here. Not necessarily the difference in medical systems, more like some half-assed medicine being practiced in Toronto.
My big concern is Communist China. I do not believe their numbers at all, and suggest adding a zero to the right side of all their numbers, for a start.
I don’t know about the Canadian nurses, but I still think the big difference between Canada and the U.S. when it comes to SARS was the timing. They had their first case long before it was recognized as a highly contagious, new disease. Our first cases were after the WHO alert. That makes all the difference in the world. The first Canadian patient wasn’t recognized as being potentially dangerous and highly infectious, through the fault of no one, and remained at large in the community until her death. In the U.S. we had the advantage of an advance warning from the WHO and could take precautions and quarantine patients before they infected people in their family or the community. We also may be classifying people as probable SARS who don’t really have it, but who have similar symptoms and a travel history that make them suspected cases. Until there’s a reliable diagnostic test, the true incidence will remain largely unkown.
And Communist China? Who could ever trust a totalitarian regime?
Canadian health officials, fighting a World Health Organization advisory warning people against traveling to Toronto, said today they will install advanced fever screening devices at airports in Vancouver and Toronto to try to halt the movement of people with SARS symptoms.
What do you suppose “advanced fever screening devices” are? Last I checked the only device available for detecting fever was a thermometer. And although the WHO has advised people to stay away from Toronto, the Canadians are hoping to lure all the SARS experts of the world there:
Canada also said today it will host a two-day international conference on SARS here starting Wednesday. Officials have invited representatives from WHO, the U.S. Centers for Disease Control and Prevention, the Pan American Health Organization, and officials from China, Britain and Mexico.
As long as they take anything China tells them with a grain of salt....
Evidently my fellow Ohioans aren’t letting some tiny old virus scare them away from one of their most popular weekend destinations:
No prevention measures were evident at the border crossing between Ontario and New York state, where thousands of cars transit each day. Over the weekend health officials did not stop motorists and did not hand out information cards for travelers entering or leaving the country. The government has said it would monitor border crossings and would alert travelers about SARS.
"We didn't get anything coming over," said Jolan Baranyai, who was riding with a busload of people from Cleveland. "We just blew right in. It was too easy."
Neither Baranyai nor her friend Geneen Petrowski were concerned about contracting severe acute respiratory syndrome. "It's common sense," said Petrowski. "Anywhere you go, you can catch anything. The basic thing is wash your hands. My boss gave us all masks as a joke. They have holes in them so we could drink a drink through them."
Ohioans like to go to Canada to gamble. Can you tell?
UPDATE: A reader says that this is what is meant by "advanced fever screening devices" :
Infrared thermography is a noninvasive diagnostic technique that provides a method to visualize and quantify changes in skin surface temperature. An infrared camera is used to convert infrared radiation emitted from the skin surface into electrical impulses that are presented in various colours on a monitor.
This visual image graphically maps the body temperature and is referred to as a thermogram. The spectrum of colours indicates an increase or decrease in the amount of infrared radiation being emitted from the body surface. Since there is a high degree of thermal symmetry in the normal body, subtle abnormal temperatures can be easily identified, even in a crowd. Once a person is identified with a higher than normal thermal pattern they can be isolated and further evaluated.
The portability of the Infrared Camera System makes it an ideal device for pre-screening, in-flight evaluation, and during disembarking.
Interesting.
UPDATE II: Chuck Simmins makes the point that Canada's death rate from SARS is higher than everyone else's:
If you check the SARS numbers at the WHO site, you find two curiosities. Canada has the highest death rate in the world, nearly 19%. The US data is four days old. The CDC SARS page is no more current. I'm calling the death rate: deaths / (deaths plus recoveries), which I believe to be the correct method.
Mammograms: A recent study in The Lancet suggests that mammograms might decrease mortality after all:
In the new study, researchers compared deaths from breast cancer diagnosed in the 20 years before mammogram screening was introduced in Sweden with those diagnosed in the 20 years afterward. The X-rays were introduced in 1978 and offered to all women older than 40.
During that time, 8,551 women developed breast cancer, and 2,143 of them died from it. The study found that, among women who received regular mammograms, the risk of dying from breast cancer was reduced by 44 percent compared with the early 1970s, when mammograms were not routinely done.
Although it isn’t clear if the credit should go to mammograms or to better treatment:
However, women who refused mammograms still had a 16 percent drop in the chance of dying from the disease. That means their improved survival must have been the result of factors other than mammography, such as better drugs.
Unfortunately, only the abstract is available for free online, so it's impossible to comment on the methodology, but the Washington Post story seems to have asked some of the right questions. posted by Sydney on
4/28/2003 07:55:00 AM
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SARS News: Beijing has essentially shut down thanks to SARS. Movie theaters are closed, schools are closed, churches are closed and weddings are forbidden. Seems draconian, but they're desperate to stop the spread:
Beijing's total number of cases has risen by 100 a day since the authorities reversed their previous attempts to cover up the true figure, and yesterday was no exception: 126 more cases, eight more deaths, making 48 in total.
Nationwide there were 161 more cases and nine deaths, a total of 2,914 and 131 respectively.
Hong Kong suffered 12 more deaths yesterday, bringing the total to 133.
Taiwan reported its first death, the brother of a sufferer who was infected in Hong Kong. There were also more deaths in Singapore - including a 37-year-old surgeon. A 79-year-old woman died in Canada, becoming the 21st victim of the epidemic in the country.
A Time magazine report calculating the epidemic's economic damage found China and South Korea could lose $US2 billion ($A3.26 billion) and Japan and Hong Kong $US1 billion ($A1.63 billion) each in tourism revenue, retail sales and productivity....
...The same magazine report found that Toronto was haemorrhaging $US30 million ($A48.83 million) a day. The Canadian city reported its 21st SARS death yesterday but received a boost when the United States gave the green light to travel there, contradicting advice from the World Health Organisation (WHO)
While in India, compromise (as well as some very obliging guests) prevents a wedding cancellation:
A wedding was in the making. Some relatives arriving for it via Hong Kong had brought the SARS virus with them. They had embraced the bride and immediate family members before authorities learned about it. Health officials wanted the wedding to be canceled. But no way would the family agree. There is a lengthy preparation behind traditional Indian weddings. The astrologer had chosen the most auspicious moment for tying the knot, and another equally auspicious date could be far away. In the end, the authorities gave in to tradition; the family yielded to make the wedding a simple ceremony attended only by the few who would all go into quarantine with the infected guests and the newly weds. posted by Sydney on
4/28/2003 07:48:00 AM
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Other Virus News: As if SARS weren't enough, now there's a new bird flu in Europe:
International health authorities are unnerved by the discovery that a bird flu circulating in Belgium and the Netherlands can infect humans and be passed from person to person.
The flu outbreak, which began in late February and is being caused by a strain named H7N7, has led to the slaughter of more than 20 million chickens in the two countries, according to the European Union.
And it was responsible for the death last week of a 57-year-old Dutch veterinarian, not named by health authorities, who developed severe pneumonia several days after visiting a farm where the disease had cropped up.
In addition, 83 Belgian and Dutch residents have developed mild symptoms indicating viral infection, either mild flulike illness or conjunctivitis, an eye infection.
But in a troubling development, the World Health Organization said Thursday that three family members of two poultry workers have developed respiratory symptoms without having direct contract with poultry, suggesting the flu strain has developed the ability to pass between people rather than jumping only from birds to humans.
It's too early to tell what kind of disease this virus will produce, although the death of that veterinarian is troubling. The SARS virus was orignally thought to be one of these "bird flu" cases, too. However, this one is pretty clearly from the birds since there have been documented illnesses among the poultry before the human illnesses began. Killing all of those birds will be bad for business, but it should stop the spread of the disease. posted by Sydney on
4/28/2003 07:38:00 AM
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Yet More Viral News: Another virus, against which there are very effective immunizations, had a surge in incidence last year:
Figures from the US Centers for Disease Control and Prevention showed there were 1,920 confirmed cases of polio reported by laboratories in 2002, up from 483 the previous year...
...The Indian outbreak centred on the states of Uttar Pradesh and Bihar. Cases there accounted for 71% of all those seen across the world in 2002.
It was the worst outbreak since 1988 when the World Health Organization began its bid to totally eradicate polio using mass vaccination campaigns.
Part of the problem in India was that parents were suspicious of the immunizations. We see that more and more here in the United States as well. It's easy to be fooled into thinking that those childhood diseases we immunize against have gone away forever, but the truth is that if enough people opted out of giving their children immunizations, resurgences could happen here, too. posted by Sydney on
4/28/2003 07:35:00 AM
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Welcome: To those of you arriving here from the dead tree version of The American Medical News, welcome. Think of this blog as a one-person op-ed page of medical news. My purpose in starting it was to give a physician’s-eye view of media coverage of medical developments - both political and scientific - and to critique some of the spin that researchers put on their work. It is but one person’s opinion. Hope you enjoy it, as well as the fine blogs listed in the column to the left. (And for the record, this man was the inspiration of the pseudonym.) posted by Sydney on
4/28/2003 07:29:00 AM
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Sunday, April 27, 2003
Just Looking:The Eyes Have It has a series of excellent posts lately, from the misuse of Power Point presentations (something all too common, I'm afraid) to the iconography of DNA, to an inner colon tour. Highly recommended. posted by Sydney on
4/27/2003 08:51:00 AM
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Smoking Motivation: A recent survey suggests that teenage girls smoke to stay thin:
A survey of 273 girls found those who most wanted to be thin were also most likely to smoke.
In contrast, those who were not worried about their weight were less likely to take up the habit.
...Of those who smoked, 93% felt it was important to be thin. This compared to just 7% of those who didn't smoke.
However, few girls said they believed smoking helped to keep weight off. This led researchers to conclude that other factors, such as peer pressure, may also play a role in determining which girls were most likely to start smoking.
Nevertheless, they suggested that changing girls' perceptions about being thin could help to stop others from taking up smoking.
But how are we going to change that perception when we're constantly inundated with messages about how dangerous it is to be fat . Reading last week's media reports, you could easily get the impression that being fat is responsible for as much cancer as smoking - which it isn't.
Doesn't this seem to you to be a classic instance of correlation being confused with causality?
From the story, it sounds as if there *isn't* evidence for a direct causal link, and I'd guess that both the smoking and the desire to be thin are common byproducts of a strong desire to be accepted (peer pressure being part of this, but by no means all).
That's true. However, on an anecdotal level, I have many women patients who tell me they don't want to quit smoking because they fear they'll gain weight. That's not the same as taking up smoking to lose weight, I know, but it suggests that weight control plays a role in the decision to smoke or not to smoke. I've even had patients who successfully quit only to take it up again because they were horrified by the ten or fifteen pound weight gain. On a personal level, sometimes the thought crosses my mind that my weight would be easier to control if I smoked. Usually it occurs to me after I've failed to exercise self-control. It would be so much easier to substitute one compulsion for another...... posted by Sydney on
4/27/2003 08:46:00 AM
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Mixing Politics and Medicine: An Israeli cardiologist who does ambulance duty in the West Bank responds to this editorial from a year (!) ago in The Lancet, which accused Israel of human rights violations:
A striking component of this process of dehumanisation has been the flood of examples of blatant disregard for medical neutrality, and other internationally agreed rules of conflict, notably by the IDF during its relentless attacks in the West Bank ordered by Ariel Sharon, and continued despite overwhelming international condemnation. There are numerous independent reports of Palestinian ambulance personnel being killed by IDF fire, even after the attacked ambulances had been cleared by the IDF for safe passage. The International Committee of the Red Cross was just one of several aid agencies obliged to limit activities in the West Bank as a result of threats to staff and attacks on vehicles and offices.
To which the cardiologist responds:
Unfortunately, Palestinian ambulances were repeatedly used to transport combatants and weapons, prompting the IDF to send an official protest to the International Red Cross on May 2, 2002. The communication included reports of terrorists who were disguised as being wounded and transported in ambulances of the Palestinian Red Crescent Society (the local form of the International Red Cross) in attempts to evade the IDF. Also, flagrant abuse of medical accreditation by Palestinian terrorists was reported on January 27, 2002, after a terrorist bombing in downtown Jerusalem. Both the female suicide terrorist (Wafa Idris), and the attack coordinators (Mohammed Hababa and Munzar Noor) worked for the Palestinian Red Crescent Society.
At the outset of the renewed violence, the IDF had received intelligence reports warning them that some terrorist organisations would use ambulances to smuggle bombs or as car bombs. Based on these reports, on March 27, 2002, IDF forces in the Ramah roadblock signalled an approaching Palestinian ambulance to stop. When the driver ignored the signals, IDF soldiers fired shots in the air and, fortunately, the ambulance stopped. Inside, the soldiers found a woman and three children, aged 4 years, 3 years, and 6 months. A sick child (reportedly with osteomyelitis) was lying on the stretcher. However, under the stretcher there was a 10-kg bomb-vest of the same type that suicide terrorists hide under their clothes (figure). The ambulance driver (Isalam Jibril, age 31 years) testified that he was moving the bomb to Ramallah, a 15-min drive from Jerusalem.
...Civilians are being killed on both sides. There is, however, a fundamental difference between the civilian losses suffered by Israel and Palestine. I do not pretend to have the absolute truth and I will not pretend to be unbiased. I can only give you the truth as I know it. This truth is so simple that it may be difficult for some to accept. Deaths among Palestinian unarmed civilians, caught in the crossfire between fighting forces, were unintentional. This is a tragic, yet unavoidable consequence of war, of all wars. Genuine, continuous efforts are being made by the IDF to keep Palestinian civilian losses to a minimum, at times at the cost of Israeli soldiers' lives. By contrast, civilian losses in Israel are nothing short of deliberate.
These accounts were widely available in news reports from the region at the time, but apparently ignored by The Lancet editorialists. The accounts didn't fit their particular bias. That's part of the problem of mixing politics within a medical journal - the biases and the prejudices of the editors cloud the issues. A medical journal is meant for a wide audience. Physicians are of all stripes - right, left, moderate. No matter what the political persuasion of the editorial staff, putting political editorials in a medical journal will offend someone. Imagine the uproar that would ensue if The Lancet suddenly began to publish anti-abortion editorials. posted by Sydney on
4/27/2003 08:19:00 AM
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SARS: The New York Times suggests that the coronavirus may have come from animals after all (earlier reports after its genome was sequenced suggested that it didn’t):
Indeed, preliminary studies of early SARS victims here in Guangdong have found that an unusually high percentage were in the catering profession — a tantalizing clue, perhaps, to how a germ that genetically most resembles chicken and rodent viruses has gained the ability to infect thousands of humans.
One of the earliest cases, last December, was a seller of snakes and birds here who died at Shunde's First People's Hospital of severe pneumonia. His wife and a several members of the hospital staff contracted it as well, setting off an outbreak that now sounds eerily familiar.
...Around the same time in December, Huang Xinchu, a chef, was admitted to the Heyuan People's Hospital, 100 miles to the north, ultimately infecting eight doctors there. On Jan. 2, another desperately ill chef was hospitalized in the city of Zhongshan, south of Shunde, setting off an outbreak.
The rest is an excellent detailed account of how the disease spread from there to around the world.
And the Times also has this description of a 37-year-old cardiologist's ordeal in Hong Kong:
His right lung and then his left would start to fill with fluid from pneumonia, his liver and kidneys would begin malfunctioning, and his blood would lose some of its ability to clot. He would have trouble speaking without falling into fits of coughing. Despite having been a physical fitness enthusiast before his illness and despite extensive physical rehabilitation since his discharge from the hospital, he still cannot run without breathing difficulties.
Yet he was one of the most functional cardiologists on a medical staff decimated by the disease:
..He was lying exhausted in bed after breakfast when a healthy physician came to him with an unusual request. The hospital staff suspected that an unconscious, SARS-infected doctor in the intensive care unit had suffered a small heart attack overnight. But there remained at the hospital only one senior cardiologist who had not been infected, and administrators were reluctant to expose him to the disease and risk being left without anyone to treat other patients.
Would Dr. Yu help? As he was already in a "dirty" ward with other SARS patients, he agreed to pitch in, conducting tests and prescribing a change in medication. He collapsed with exhaustion afterward.
Over the next few days, as he and a few colleagues began to recover in their hospital beds, they helped the overstretched hospital staff by drawing blood from each other, inserting intravenous tubes and performing other medical tasks. posted by Sydney on
4/27/2003 08:16:00 AM
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