"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
Mosquito Menace: Another sure sign that summer’s here - the newspapers are brimming with West Nile virus stories. Listen up. West Nile is here to stay. Forever and ever it will be a disease carried by a few mosquitoes from coast to coast, as are many other diseases. Birds will die from it. Unvaccinated horses will, too. Some people will also die, but not in large numbers. Most people who get bitten by an infected mosquito won’t even know they have an illness (less than one percent who are infected develop serious complications). It is not a public health threat on a par with SARS, or even influenza.
Where it does have public health implications is its possible transmission to the blood supply, which has now been well-documented. An infected person could easily donate blood without knowing he has the virus, which puts the recipients - who are much more likely to be in frail health and more susceptible to the virus - at risk. Which means we need to find a good way to screen for it (link requires subscription):
Since most persons infected with West Nile virus have mild symptoms or none, and since meningitis or encephalitis develops in only 1 of 150 infected persons, screening donors on the basis of a clinical history alone will have limited effectiveness. Antibody tests are available, but such screening does not identify recently infected donors with viremia who are not yet seropositive. These are the blood donors who are most likely to transmit the virus.
Since most infectious agents cause a transient bacteremic or viremic stage before antibody production, screening with the use of nucleic acid amplification can have an important role in reducing the risk of transplant- or transfusion-associated infectious diseases. In the past three years, more than 30 million blood donations were screened for HIV and hepatitis C virus with the use of nucleic acid amplification, resulting in the identification of more than 100 infected donors who would otherwise have gone unrecognized. If West Nile virus continues to infect large numbers of people, nucleic acid amplification screening of blood donors for the virus will be required to prevent transfusion-associated illnesses. This type of screening could also be used for organ donors, as is currently being done on a case-by-case basis at the New York State Department of Health's Wadsworth Center.
Not sure what that will do to the cost of processing blood, but it seems like a necessary step. posted by Sydney on
5/30/2003 08:57:00 AM
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Clever Clap: English gonorrhea is becoming resistant to the antibiotic Cipro, the drug of choice:
Unlike viral sexually transmitted infections such as HIV or herpes, doctors can prescribe antibiotics which should clear it up quickly.
But experts are becoming increasingly worried about the effectiveness of the best-known of these, ciprofloxacin, since strains of gonorrhoea resistant to it started to emerge in Asia.
An initiative set up to measure the prevalence of resistant strains found that in 2000, only one in 50 strains had this ability.
In 2001, this had increased to 3.1% - but the latest figures, published in the Lancet medical journal, show that the figure has risen to 9.8%.
In some areas things were worse - in the Yorkshire and Humberside area, more than 18% of strains isolated had resistant qualities.
The situation is not as bad as in China and Hong Kong - where 98% of strains have resistance to common antibiotics - but the researchers are alarmed by the finding.
They wrote: "It is a general principle with gonorrhoea that the chosen treatment should eliminate infection in at least 95% of patients, and ciprofloxacin no longer meets this criterion.
All is not completely lost, though. In the Cleveland, Ohio, area, the bug’s resistance to Cipro has fluctuated from year to year, so with some restraint in antibiotic choice, the resistance may be able to be overcome. (To find out what sort of gonorrhea is incubating in your state, click here.)
Although gonorrhea is still with is, thankfully it isn’t as wide spread as it once was. Although we still routinely put antibiotic drops in newborn’s eyes to prevent blindness from congenital gonococcal conjunctivitis, and we still screen all pregnant women for it, we at least no longer have mailboxes on our street corners like this. posted by Sydney on
5/30/2003 08:31:00 AM
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Pharm Aid: Here’s better drug company news. Pharmaceutical companies are offering discount programs to financially strapped senior citizens:
About 350,000 American senior citizens, including 18,000 in Ohio, have enrolled in Pfizer's program since it launched last year.
``Our most difficult challenge is certainly reaching the seniors,'' Harper said. ``They just don't believe that there's hope out there.''
The discount plans from various drug companies have financial requirements. Most target Medicare recipients who can't afford an insurance plan that has drug coverage but whose income is too high for them to qualify for state-run Medicaid programs.
Pfizer's card, for example, sets a maximum annual income of $18,000 per individual or $24,000 per couple. Assets are not included in the eligibility review.
Some discount programs, such as Pfizer's, let qualified low-income seniors buy their drugs for a flat fee.
Others, including one called Together RX from a consortium of drug makers, give people a percentage discount off the price of their prescriptions at participating pharmacies.
The average saving from a free Together RX card ranges from 20 percent to 40 percent on medicines for common conditions such as diabetes, high blood pressure, high cholesterol, cancer, allergies, asthma, arthritis and depression.
The woman profiled in the article dropped her monthly drug bill from $300 to $15. Hard to beat that. Cynics say that it’s just a bait and switch con, but so far no one’s complained of a switch.
If you or someone you know could benefit from such a program, here’s a list. And here are some more:
Warner-Lambert paid dozens of doctors tens of thousands of dollars each to speak to other physicians about how Neurontin, an epilepsy drug, could be prescribed for more than a dozen other medical uses that had not been approved by the Food and Drug Administration. The top speaker for Neurontin, Dr. B. J. Wilder, a former professor of neurology at the University of Florida, received more than $300,000 for speeches given from 1994 to 1997, according to a court filing. Six other doctors, including some from top medical schools, received more than $100,000 each.
And that, in a nut shell, is why I don’t go to lectures sponsored solely by drug companies. Who can trust someone who’s making the equivalent of a general practioner’s salary just by shilling for the pharmaceutical industry?
But wait a minute, one guy’s wife says he was free to say whatever he wanted to say:
Dr. Wilder, who received the most money for speaking about Neurontin, could not be reached yesterday. His wife, Eve Wilder, said that Warner-Lambert had never told her husband what to say. "He had total freedom on all the education programs he put on," Mrs. Wilder said.
Well, up to a point. It’s probably true that no one sat down with Dr. Wilder and gave him a lecture outline, but you can bet if he failed to mention Neurontin or mentioned it in an ambivalent or uncomplimentary way, he wouldn’t be invited to give any more lectures. I know a lecturer in geriatrics who was invited to speak on Alzheimer’s by a drug company for a handsome fee. He, too, was told he had complete freedom of content. In his lecture, he called Alzheimer’s drugs “fancy bug spray” (they’re cholinesterase inhibitors) and said they don’t really make that much of a difference in outcome or quality of life. The drug reps at the talk were livid and he was never asked to speak again.
But this is probably the most shameful practice of all:
Other doctors were paid to write reports on how Neurontin worked for a handful of their patients, the court papers said. Still others were paid to prescribe Neurontin in doses far exceeding the approved levels as part of a clinical trial that Warner-Lambert created to market the medicine, according to the court papers, which are new documents filed in the lawsuit by the whistle-blower.
At least in a lecture you know who’s paying the guy's salary. Disguising sales promotion as research destroys the credibility of all industry-funded research. posted by Sydney on
5/30/2003 08:20:00 AM
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Compassion: This whole public health campaign against obesity is getting out of hand. Yes, it’s bad to be fat. Being fat makes you more prone to diabetes and to joint pain from arthritis. It makes you prone to sleep apnea and congestive heart failure. It makes it hard to walk up a flight of stairs without getting winded. But one of the consequences of constantly harping on the subject is that the fat are being demonized.
For an example, just check out the comments section of my TechCentral column. There’s many a reference to laziness and the idea that fat people should be taxed. I’ve also been more aware recently of an overt prejudice against the obese among my professional colleagues. I’ve had overweight and obese patients tell me stories that make me ashamed of my profession. One woman went to an orthopedist for painful degenerative arthritis in her knee. He didn’t do anything for her but tell her she had a problem because she was fat. As she put it, “Duh!” But here’s the shameful thing - he would have given anyone else a steroid injection to reduce the inflammation and allow them more mobility. He just told her to lose weight. And she paid him over $200 for the insult. Now, she’s going to find it all the harder to initiate that exercise program she wants to do because her knee still hurts.
Then, there was my patient who was hospitalized for chest pain. Before finding out the cause of her chest pain, the cardiologist told her walking around with her body would be the equivalent of his walking around with his wife and child strapped to him all day. She already knows that. Here’s what he doesn’t know - she’s living an unhappy life in a miserable marriage which she can’t leave for a myriad of reasons. Her eating disorder and lack of exercise is a lot more complex than he was willing to consider. And his comment only served to add to her unhappiness. Far from being a motivation, it was just one more blow to her will to help herself.
Underlying all this anger is the assumption that fat people are a greater drain on the healthcare system’s resources than skinny people. There isn’t any concrete evidence that this is true. There are many obese people who have no health problems at all. There are also many skinny people who have diabetes, arthritis, and heart problems. There’s absolutely no evidence that fat people go to the doctor more often than skinny people. In fact, they may go to the doctor less often. Who wants to sit naked in front of someone who in the end will just harangue you about your weight?
Obesity and weight gain are a complex issue. Some of us have high resting metabolic rates and can eat more and exercise less without gaining weight than others with lower resting metabolic rates. And substantial weight gain can come from the slightest alteration in our energy balance. It can be from a slowing of our resting metabolic rates due to drugs or aging or disease. Or it can be from just a very small increased caloric intake over a period of years. Or it can be from declining physical activity due to age and disease. Is it really reasonable to harangue a 70 year old with arthiritis and hypothyroidism into starving herself and exercising everyday for an hour so she can attain a “normal” BMI? Is it reasonable to expect the 38 year old father of four to give up 45 minutes of the few hours he has in the evening to spend with his children for the treadmill or gym? I’m beginning to wonder. Maybe we should all lighten up. And I don’t mean physically.
UPDATE: A reader emails:
You are incorrect. There is a small but growing body of research that shows (consistently) that obese people incur larger health care costs, on average, than non-obese people. A couple of weeks ago a study by economist Eric Finkelstein, published in the respected journal Health Affairs showed this (see here for the press release and here for the study and here for a sample of news coverage). Moreover, Finkelstein found that much of the cost is borne by Medicare, Medicaid, and other government programs (i.e., the taxpayer). Earlier research by Roland Sturm of RAND and several other researchers have come to essentially the same conclusion. Obviously, not all obese people have high health care costs, but referring to the population as a whole, obesity clearly is associated with increased health care use and costs. The magnitude of the cost is similar to that of smoking, according to Finkelstein.
I think you should retract your erroneous claim.
Whenever the word “respected” is used to strengthen an argument, proceed with caution. The New York Times is a “respected” newspaper, yet only a fool would believe everything it prints. The New England Journal of Medicine is a respected medical journal, yet it often publishes studies in which authors make dubious claims based on their data. So it is with this study, which can be summed up in three words: estimate, estimate, estimate:
In this study we use a regression framework and nationally representative data for adults, including those over age sixty-five, to compute per capita and total medical spending attributable to overweight (body mass index [BMI] = 25.0– 29.9) and obesity (BMI ? 30). This approach allows us to assess the impact of overweight and obesity on select payers, including individuals, private insurers, Medicare, and Medicaid.
....The 1998 Medical Expenditure Panel Survey (MEPS ) and the 1996 and 1997 National Health Interview Surveys (NHIS) are the primary data sets used to develop spending estimates. MEPS is a nationally representative survey of the civilian noninstitutionalized population that quantifies people’s total annual medical spending (including insurance spending) and annual out-of-pocket spending....The data also include information about each person’s health insurance status and sociodemographic characteristics (such as race/ethnicity, sex, and education).
The MEPS sampling frame is drawn from the 1996 and 1997 NHIS. Although MEPS does not capture height and weight (the determinants of BMI), these self-reported variables are available for a subset of adult NHIS participants and can be merged with the MEPS data
For good measure, and because the spending reported by their first selection, MEPS, was considered too low by the authors, they introduced yet another set of data into the equation:
For a variety of reasons, including the lack of data on institutionalized populations, MEPS spending estimates are much lower than comparable estimates from the National Health Accounts (NHA), which are generally considered the gold standard for annual health spending data in the United States. Therefore, we report overweight- and obesity-attributable spending estimates based on the 1998 NHA in addition to the MEPS estimates. To compute the NHA estimates, we multiply the percentage of total expenditures attributable to overweight and obesity estimated via MEPS by total expenditures for the corresponding insurance category reported in the 1998 NHA.
Admittedly, I’m no statisitician, but there seems to be a lot wrong with this study. Mixing data from different years is one. Taking information from one set of people and applying it to a different set is another. Then, too, the authors don’t include the results of their analysis. They only present their conclusions from that analysis in table form. They would have a much stronger argument for the association of obesity and healthcare spending if they showed us their data, especially given the limitations of their methods:
Multiple regression is a seductive technique: "plug in" as many predictor variables as you can think of and usually at least a few of them will come out significant. This is because one is capitalizing on chance when simply including as many variables as one can think of as predictors of some other variable of interest.
They’ve left out a key component in their argument; one that’s necessary to know if their conclusions are to be taken seriously. Which only leaves one wondering what they’re hiding. Could it be that their numbers aren’t as supportive of their conclusions as the press release would have us believe? I stand by my original assertion. posted by Sydney on
5/30/2003 08:05:00 AM
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Thursday, May 29, 2003
SARS Images: Here's a Hong Kong-based website with SARS xrays and details on how suspected cases are handled there. posted by Sydney on
5/29/2003 07:53:00 PM
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SARS Testing: The Koch Institute in Germany has come up with a new SARS blood test that detects antibodies to the virus. It isn't clear if it will be better at diagnosing the disease than the current tests, since according to the CDC, SARS can be present before antibodies show up in the blood stream. Others have already introduced tests for the virus, but they must not be very accurate since health officials still classify people as "suspect" or "probable" cases rather than making definitive diagnoses, and the final diagnosis seems to pivot on ruling out everything else.
A good diagnostic test would help eliminate Canada’s definition dilemma:
Canadian health officials found themselves grappling Wednesday with concerns that they only define more severe SARS cases as "probable," thus making their outbreak seem smaller than it is.
The guidelines doctors use to define each SARS case are critical, because lab tests for severe acute respiratory syndrome have drawbacks and aren't widely available.
The World Health Organization advised Canadian officials Wednesday to adopt the same definition used globally, so that Canadian doctors would be less likely to overlook cases like the one that spawned the current outbreak. posted by Sydney on
5/29/2003 07:46:00 PM
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My focus was on exercise, but I mentioned in passing that calories are calories, no matter where they come from. That elicited a comment from a reader that suggested I’m an old fogey and that there are other, better doctors out there who know the truth. Phooey. just ask RangelMD:
The simple truth is that input in calories = weight. There may be a lot of details underneath this equation but all anyone needs to know is this simple concept. The more you eat . . the more you weigh. Period! Notice that I don't make a distinction between the source of the calories being fat vs carbohydrates because . . guess what? Your body doesn't make the distinction either! The idea that is popularly held is that fat in the diet is taken directly by the body and stored as "fat" in those areas that people complain about; the abdomen, hips, butt, etc. How sweet and simple a concept this is but it is complete hogwash. Physiologically the body absorbs all caloric dietary sources whether they are carbohydrates or fats and breaks them down into more manageable components (glucose from carbohydrates and glycerols from fat sources). These two different energy sources are actually interchangeable depending on energy needs because they occupy the same metabolic pathways. The body utilizes glucose directly as an energy source for tissues and can convert glycerol into glucose. Conversely glucose can be converted into glycerols to store as "fat".
What this means is that the body does not care what form its nutrition comes in whether it is carbohydrates or fats but that it takes these molecules and converts them into whatever form is needed for its current energy requirements. The body can take fats and ultimately convert them into glucose to use as energy while at the same time it can take carbohydrates and convert them into fats in order to store them. How much fat or carbohydrates are ultimately used as energy or stored as fat (as a future energy source) depends ultimately upon the energy requirements of the person and upon the overall caloric intake. If a person is taking in more calories in the form of carbohydrates or fat than they need then these "excess" calories are stored in the form of fat (in those unsightly areas). It does not matter if these calories are in the form of carbohydrates or fat because as I stated above, it will all ultimately be converted into what ever form that the body needs. This means that a high caloric diet whether it is in the form of carbohydrates or fat in excess of the energy requirements of the person will ultimately result in obesity.
Back Later: Blogspot was down this morning so I'm not able to post everything I wanted. Tune in later tonight (after six or seven) for the rest of Medpundit. Got to get to work. posted by Sydney on
5/29/2003 09:10:00 AM
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SARS Update:Chuck Simmins has gathered up all the latest SARS cases statistics by nation, and he has some further observations about Canadian SARS. posted by Sydney on
5/29/2003 09:06:00 AM
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Lost Leader: In reading the coverage of mismanagement at the New York Times, this comment from a Times reporter stood out:
“In the last couple of years, especially, I’ve bitched about being pushed into corner-cutting jams. Some of us were seen as slugs compared to the high-stepping Blair. But there is a line we don’t cross however strident the new institutional demands for speedy production and instant datelines from everywhere.
Been there, done that. As someone who’s coming to the end of twelve years of employed physician status, I can tell you that this is a common tactic among management types. I’ve sat in countless staff meetings where doctors who see fifty patients a day are held up as examples to the rest of us sluggards who see twenty-five to thirty. And when management is asked, “Well, just how do they squeeze in so many patients?” they offer answers like, “They work smarter, not harder,” or “They work as if they’re poetry in motion.” But I’ve been around long enough now to know that the truth is they cut corners. They either refer all of their chronically ill patients to other doctors (diabetics, emphysema, etc.) or they ask only the briefest of questions and perform only perfunctory exams on them. And they don’t do much in the way of documentation. Or worse, they just refill all of their medicines by phone without seeing them.
Anyone in a mangement position in any field would do well to remember that there are lines that shouldn’t be crossed. That quality should never be sacrificed to quantity and speed. posted by Sydney on
5/29/2003 09:02:00 AM
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More Hormone Hysteria: The Women's Health Initiative Study is at it again. The latest spin on the data to come out of the study on hormone replacement therapy is that hormone replacement therapy causes dementia:
Hormone replacement therapy for post-menopausal women took a hit on Tuesday -- the second one in 10 months.
Women who begin taking combined estrogen-progestin compounds after the age of 65 double their risk of developing dementia, according to the just-released results of a large federal study. Most of the dementia was classified as Alzheimer's disease.
While the number of women who developed symptoms of dementia while on hormones was twice the number of those on a placebo, the numbers were small -- 45 women in 10,000 on the hormones compared to 22 out of the 10,000 on a placebo.
So, the incidence of Alzheimer’s in hormone replacement users was 0.0045%. The incidence in non-users, 0.0022%. Hardly a dramatic difference. Yet, the authors framed the difference in much more dramatic terms in their abstract:
Overall, 61 women were diagnosed with probable dementia, 40 (66%) in the estrogen plus progestin group compared with 21 (34%) in the placebo group.
Perspective is everything. Too bad the researchers responsible for the WHIMS have such a tendency to hysteria.
They indulge in even more hysteria in two other studies in this week’s JAMA. In one, they compared hormone replacement users’ with non-users’ performance on a mental status examination, called the Modified Mini-Mental State Exam:
The Modified Mini-Mental State Examination mean total scores in both groups increased slightly over time (mean follow-up of 4.2 years). Women in the estrogen plus progestin group had smaller average increases in total scores compared with women receiving placebo (P = .03), but these differences were not clinically important. Removing women by censoring them after adjudicated dementia, mild cognitive impairment, or stroke, and nonadherence to study protocol, did not alter the findings. Prior hormone therapy use and duration of prior use did not affect the interpretation of the results, nor did timing of prior hormone therapy initiation with respect to the final menstrual period. More women in the estrogen plus progestin group had a substantial and clinically important decline (2 SDs) in Modified Mini-Mental State Examination total score (6.7%) compared with the placebo group (4.8%) (P = .008).
In other words, the actual scores weren’t all that different between the two groups. And, in fact, their raw data show that mean scores were essentially the same. But, they managed to find a difference by converting the scores to “mean rates of change,” thus exaggerating a very small, clinically insignificant difference into a more ominous sounding, but equally clinically insignificant, difference. Their conclusion that there is a “small increased risk of clinically meaningful cognitive decline” in hormone replacement users is disingenous at best.
The other study claims an increased risk of stroke in hormone replacement users (also found in last years attention-grabbing study.) The researchers begin the comment section of the paper with this obesrvation:
In this clinical trial involving 16,608 postmenopausal women, those taking estrogen plus progestin had an approximate 31% increase in total stroke risk compared with those taking placebo.
But here’s the actual data:
One hundred fifty-one patients (1.8%) in the estrogen plus progestin and 107 (1.3%) in the placebo groups had strokes.
I think the media is catching on, however. Here’s the Wichita Eagles’take on the study:
In the journal articles today, the researchers said women taking the hormone combination had twice the risk of developing dementia as women taking the placebo. They also said the women on hormones had an increased risk of cognitive decline.
And, they said, the women had a 31 percent increased risk of stroke, confirming study results from a year ago.
Those numbers are scary, Grainger said, but they should be looked at in terms of "relative risk" and "absolute risk."
For example, 1.8 percent of the women taking the hormones had strokes, compared with 1.3 percent of those taking the placebo. That means those taking the hormones were 31 percent more likely to have a stroke, he said. That's the relative risk.
But the absolute risk of stroke in both groups was low -- 151 patients among 8,506 in the hormone group and 107 among the 8,102 in the placebo group had strokes.
Now, all we have to do is get them to stop reporting the hyped up “relative risks” and “relative rate of increase” numbers and just give the public the straight dope. posted by Sydney on
5/28/2003 09:10:00 AM
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SARS in Toronto: Chuck Simmins blasts the Canadians for allowing a second SARS outbreak to occur. He’s very harsh in his judgement, but I’ve got to think they just let their guard down too early:
Public health officials are still trying to determine the origins of the latest SARS outbreak. They still do not know where the index patient - the first patient during this second outbreak - contracted SARS. That was a 96-year-old man who was in North York General for a pelvic operation.
He started showing symptoms of SARS on April 19, but his case went diagnosed as post-operative pneumonia, said Low. The man died on May 1.
Health officials became aware of this secondary outbreak after a patient with a compromised immune system was transferred to the Toronto General Hospital from St. John's.
That patient arrived at St. John's on April 28 with no SARS symptoms and became sick after the transfer.
Officials knew they had another potential SARS outbreak when health care workers started coming down with symptoms.
There would have been no reason to suspect SARS in a 96 year old man who had a pelvic operation. It doesn’t say what sort of pelvic operation it was - it could have been a hip fracture repair or a prostate surgery - but surgery in a 96 year old is inherently risky. It isn’t uncommon for someone that age to develop acute respiratory distress syndrome in response to the stress of surgery, which is very similar to SARS clinically except that it isn’t infectious, or to develop pneumonia afterwards. No one would have suspected SARS under those circumstances.
But Simmins makes a good point - strict use of respiratory precautions are essential to stopping the disease’s spread. Which makes me wonder if perhaps we shouldn’t be more aggressive with these than we currently are. A patient admitted with community aquired pneumonia wouldn’t be placed in respiratory isolation in most U.S. hospitals. But maybe they should be given the sneakiness of SARS.
Then again, there’s the report of healthcare workers who got SARS even though they protected themselves, which reminds us that even careful precautions aren’t perfect. Still, quite a few of them came down with the illness, while in the U.S. there have been no cases of healthcare workers falling ill. It could be that the equipment we use is better. Or, it could be that the Canadian healthcare workers in the report weren’t being entirely truthful about their use of masks, goggles, and gloves for fear of repercussions. Quite honestly, sometimes doctors and nurses forget to protect themselves, especially in unexpected emergency situations (say, a person found suddenly unresponsive or in severe respiratory distress). But in the age of SARS, it's probably better to treat every hospitalized respiratory infection as potentially highly contagious until proven otherwise. posted by Sydney on
5/28/2003 08:23:00 AM
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New Look:Blogcritics has a new design. Much easier to read than the most recent incarnation. And lots of good stuff over there, too. Check it out. posted by Sydney on
5/28/2003 07:09:00 AM
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The White Plague: There’s a new book out about Gary Trudeau’s great-grandfather’s tuberculosis sanatarium in the Adirondacks, Portrait of Healing: Curing in the Woods. From the review in the New York Times it sounds as if Dr. Trudeau’s sanitariam was a blissful haven of happiness:
Accounts of Dr. Trudeau's nurses and patients, teased from diaries and interviews with survivors, are gathered in a large photo-filled book, "Portrait of Healing: Curing in the Woods" (North Country Books, 2002), by Dr. Victoria E. Rinehart, a nurse in Burlington, Vt. Unlike some of the other accounts dwelling on the suffering of the patients, this book, with a foreword by Garry Trudeau, the creator of "Doonesbury" and great-grandson of the founder, paints a remarkably happy picture of the sanitarium.
....These were the days before there were drugs to treat tuberculosis, a leading killer in the United States. Most patients back home were left to wither and die. At the sanitarium, many patients died or were sent home to die. But they were not allowed to wither. They were commanded to maintain a positive attitude in an effort to ward off the illness.
... Dr. Trudeau told his patients when to rest, what to eat and how to socialize. Mandatory arts and crafts classes were considered an adjunct to treatment. (Dr. Trudeau was usually too sick to go to dances and formal dinners that he insisted his patients attend.)
...Alcohol and intimate liaisons were strictly forbidden, though prohibitions may have fostered frequent boozing and romance. Historians of the Trudeau cure have found a trove of love letters revealing clandestine affairs, often adulterous. It was all very adolescent, with patients referring to their secret lovers as cousins and their favorite spot for courtship on the compound as the Cousinola, Dr. Rinehart writes.
Despite Dr. Trudeau's insistence on a rigid life, patients sought the cure. Perhaps, as Dr. Rinehart said, patients were seeking hope and companionship more than remedies.
"I looked for some negatives and couldn't find them," Dr. Rinehart said. The oldest patient she interviewed, she said, was 95 and had been there as a patient and then as a nurse supervisor. "Obviously when one looks backward, the memory could be distorted," Dr. Rinehart said. "But I couldn't find anyone alive today that didn't have anything but glowing things to say."
The review points out that historians are skeptical. Back in the days before antibiotics, tuberculosis patients went through all manner of horrible “cures.” They had their lungs collapsed intentionally, sometimes just by puncturing the chest wall, sometimes by adding foreign material to the chest cavity to keep them collapsed. (I remember once reading about a case in which lucite balls were packed in the chest.) But most of the time, they went to these santariums for the “rest cure,” where they lived by strict rules until their tuberculosis either killed them or went into its natural dormancy stage.
A good, first hand account of living in a tuberculosis sanitarium is The Plague and I, by Betty MacDonald, creator of Mrs. Piggle-Wiggle and Ma and Pa Kettle. (The latter a spin-off of the movie version of her hilarious book about life in the rural Pacific Northwest, The Egg and I.) This is MacDonald’s description of leaving home for the asylum:
As we drove off I turned and waved and waved to the children. They stood on the sidewalk, squinting against the sun. Young, long-legged, and defenseless. I loved them so much that I felt my heart draining and wondered if I was leaving a trail behind me like the shiny mark of a snail.
Once at the sanitarium, she would only be allowed to see them once a month for no more than ten minutes. Children were too disturbing to patients. And then there were the rigidly applied rules:
”Patients must not read. Patients must not write. Patients must not talk. Patients must not laugh. Patients must not sing. Patients must lie still. Patients must not reach. Patients must relax. Patients must...” I was ready for the bath so I interrupted to ask if I might put a little cold water into the steaming tub or if there was a rule that patients must be boiled.
She describes a life of enforced bedrest, twenty-four hours a day, under the watchful eye of doctors and nurses. (And I do mean strict. They weren’t even allowed bathroom privileges but had to use the bedpan.) A bedrest that was enforced by constant reminders that any failure of the cure was solely the fault of the patient for failing to adhere to the rules.
She also describes a kind of slave-labor system, in which patients who were further along in their cures were allowed to indulge in gradually increasing levels of activity - most of which consisted of performing menial labor for the sanatariam. It isn’t a pretty tale, but it’s told with a biting wit, which makes it an enteraining read despite its depressing subject matter.
Not to mention a sobering reminder of just how paternalistic medicine can be. posted by Sydney on
5/28/2003 06:40:00 AM
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Tuesday, May 27, 2003
O, Canada: Canadian doctors say that their public health infrastructure is dismal at responding to infectious disease threats:
In the interview, Dr. Hoey argued Canada is suffering from a "real lack of sophisticated health leadership nationally." Senior bureaucrats in the federal health department are "not particularly strong in dealing with critical issues of public health" and few have any formal training in medicine, he said.
..Two weeks after the first case of SARS was diagnosed in Canada, some SARS patients were still not being treated in isolation, the editorial notes. That lapse may have contributed "to the widespread outbreak in Toronto, particularly among health care professionals."
While health is a provincial responsibility, Dr. Hoey said it makes far more sense to have one national strategy to combat new viral and bacterial infections and other "environmental threats" to human health rather than rely on a hodgepodge of "10 or 12" different provincial and territorial strategies.
Surprisingly, the land of socialized medicine doesn't have a central public health agency, but they want one.
UPDATE: A Canadian reader notes that Canada’s health system is province based rather than nationally based:
In Canada health is a provincial responsibility. Thus there are 10 different jurisdictions across the country. The federal government tries to control provincial governments on health care by giving, or taking away, money.
Moving an elderly family member from one province to another, as I have just done, is like moving them to another country.
Conflicting Data: While doing some research for a Tech Central Station column, I came across this from the USDA:
*A greater percentage of white Americans (59%) eat out compared to black Americans (51%).
*More high-income Americans (65%) eat out than low-income (45%).
*The most popular foods eaten outside of the home were beverages, followed by lettuce salads, sandwiches, and french fries.
So, if the restaurant industry is responsible for the obesity epidemic, then why is it that obesity occurs disproportionately in black Americans and the poor (at least among women) and not rich white people ? And if hamburgers are the problem, why aren’t they consumed with more frequency than salads? posted by Sydney on
5/27/2003 07:36:00 AM
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Strange Bedfellows: The war on obesity has made some strange partners:
When Hershey Foods Corp. launched its line of sugar-free chocolate in March, packages were adorned with a logo of the American Diabetes Association. Hershey sponsors the ADA's Walk for Diabetes, one of its largest fund-raisers, with both cash and products.
"We were obviously extremely pleased that they accepted our sponsorship and thought well enough of the product to do so," Hershey spokeswoman Christine Dugan said.
The American Diabetes Association said there are a number of companies interested in working for the association, which conducts public education, outreach and research.
....Jerry Franz, an ADA spokesman, said Hershey pays between $100,000 and $300,000, a typical amount for a sponsorship. Hershey declined to discuss the financial terms.
These alliances are common. ConAgra's Healthy Choice line and PepsiCo's Quaker Oats both collaborate with the American Dietetic Association.
The American Heart Association invites food makers to join its certification program; General Mills's Cocoa Puffs and the Yoo-hoo Chocolate Beverage Corp.'s lite drink are among the products listed.
Yoo Hoo and Cocoa Puffs? Is there any money the American Heart Association won't accept? posted by Sydney on
5/27/2003 07:20:00 AM
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Crying Wolf: GruntDoc says that the new “prehypertension” label is goofy. I tend to agree. More on that later, if I ever get a chance to look over the studies on which it’s based. posted by Sydney on
5/27/2003 07:16:00 AM
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Blow out, you bugles, over the rich Dead!
There's none of these so lonely and poor of old,
But, dying, has made us rarer gifts than gold.
These laid the world away; poured out the red
Sweet wine of youth; gave up the years to be
Of work and joy, and that unhoped serene,
That men call age; and those who would have been,
Their sons, they gave, their immortality.
Ordinarily, human eyesight becomes blurry under water because the eye is structured to see through air. But the Moken nomads, who tie stones to their waists so they submerge long enough to forage for seafood, can constrict their pupils to pin-prick size and spot pearls measuring only 1.5mm in diameter. They also squint in order to squeeze the lenses of their eyes, which temporarily thickens them and improves focus under water.
"They use the optics of the eye to the limits of what is humanly possible," said Anna Gislen, a Swedish biologist who led the study. At best, the sharpest-eyed children could distinguish objects that measured 3mm across.
Young snorkellers volunteered to toss aside their masks and be tested at the tourist islands of Ko Samui, Ko Phi Phi and Ko Poda. None of them could constrict their pupils at will, as the Moken did routinely on every dive.
The Swedes speculated that the Moken sea gypsies must learn these skills, although after generations of scavenging the sea floor, "the ability to see well underwater could have become a genetic trait."
Into the Fat, Again: Last week saw a vindication of sorts for the low-carbohydrate approach to dieting. Two studies in the New England Journal of Medicine suggest that people on low-carbohydrate diets lose more weight than those on low-fat diets:
In the study, 132 men and women were randomly put on either a low-fat or low-carbohydrate diet for six months. The low-carbohydrate group was told to limit carbohydrate intake to 30 grams per day. They received counseling on healthy types of fat, such as omega-3 fatty acids, but had no limit on total fat intake. The low-fat group was put on a calorie-restricted diet, with no more than 30 percent of total caloric intake from fat.
Overall, volunteers assigned to a low-carbohydrate diet lost an average of about 13 pounds, compared to 4 pounds for the low-fat group. The low-carbohydrate dieters reduced their levels of triglycerides--blood fats that, like cholesterol, may contribute to clogged arteries--by an average of 20 percent, versus 4 percent for the low-fat group. There were no significant changes in cholesterol or blood pressure levels in either group.
Sounds like low-carbohydrate diets are the answer. But wait, there’s something missing from the media report. In the study, the two groups consumed different amounts of calories. At the beginning of the study the people in the low-fat diet group were consuming an average of 1848 calories a day (Give or take 1338 calories. Talk about a spread!). At the end of the study, the low-fat group were eating 1,576 calories a day (give or take 760 calories). During the course of the study they were eating on average 272 fewer calories a day than they usually consumed. The low-carbohydrate group began with a base-line daily calorie intake of 2090 calories (give or take 1055 calories.) By the end of the study they were eating an average of 1630 calories a day (give or take 894 calories), or 460 fewer calories a day than they normally ate. Of course they lost more weight. They had a greater calorie deficit from baseline than the low-fat diet group.
There may be some truth to high-carbohydrate diets contributing to insulin resistance, but there’s no escaping the fact that when it comes to weight loss, it’s still calories that count the most. To the authors' credit they admit that the problem is not necessarily what you eat, but how much you eat:
The authors said the study results underscore the paradox of America's fascination with low-fat eating: Americans are taking in less fat, but not losing weight or improving their cardiovascular health as a result.
"People have gotten the message loud and clear--they're restricting their fat," said Samaha. "But they're still overeating. And when they overeat carbohydrates, they remain overweight and perhaps even exacerbate the development and management of diabetes, unfavorable lipids and heart disease.
But at least they recognize that there are other factors involved in weight loss:
Stern pointed out that even the best diet must be combined with other lifestyle changes, such as increased physical activity, to combat obesity. "Half the equation is to get people to be aware of what they're eating, and to eat less," she said. "The other half is to get them to move. Any weight loss program, at the VA or elsewhere, must include a formal exercise program."
The other study also showed more weight loss in low-carbohydrate dieters, but it didn't include baseline calorie intake in the data. What it did show, was equally high rates of recidivism in both groups, suggesting what we all know - diets are hard to stick to forever. What it takes to maintain weight loss is a fundamental change in behavior - as fundamental as any change made by an alcoholic or a smoker when they quit their vices - and a commitment to that change forever.
Medicaid Denial: The state governors are resisting federal attempts to slow down the growth of Medicaid spending:
The negotiations are immensely important. Medicaid, the nation's largest health insurance program, pays for one-third of all births, covers one-fourth of all children and finances care for two-thirds of nursing home residents. It is also the fastest growing item in most state budgets, rising 13 percent last year, even though state revenues were virtually flat.....
...The basic concern, set forth in documents from the National Governors Association, is that the president's proposal does not protect states against unforeseen costs that might result from changes in the economy, natural disasters, outbreaks of disease or the development of drugs and treatments....
....The governors readily embraced Bush's proposal to give states power to alter Medicaid benefits, modify eligibility rules and charge higher co- payments.
But the governors said they had reached no consensus, among themselves or with the administration, on the financing of the program, which provides health insurance to 50 million low-income people.
Medicaid is expected to cost $277 billion this year, of which $158 billion is the federal share and $119 billion comes from the states. ....
...Medicaid benefits are now generally all or nothing. Eligibility standards vary widely from state to state, but states have to cover children under the age of 6 whose families have incomes up to 133 percent of the poverty level. People who qualify for Medicaid usually have access to a package of benefits more extensive than those available in commercial health insurance.
.... Medicaid provides more extensive benefits than Medicare, a program financed entirely with federal money.
People who qualify for both programs account for 12 percent of Medicaid recipients, but more than 30 percent of state Medicaid spending, including $7 billion a year for prescription drugs and $24 billion a year for nursing homes and other long-term care.
That's a lot of money. And here's the worst part - those numbers are nowhere near the actual cost of the healthcare Medicaid consumes. Throughout the country, Medicaid programs have notoriously poor reimbursement rates. Depending on the state, a $60 office visit might be reimbursed for $10 or $15. (My own practice gave $4,000 worth of immunizations to Medicaid patients last year and got paid $821) Few doctors are willing to accept Medicaid patients for this very reason.
So, where does all that money go? It would be interesting to know how much of it goes to adminstering the state programs and how much of it goes to actually paying for care.
posted by Sydney on
5/25/2003 02:02:00 PM
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SARS Origins: Not from outerspace, but maybe from civet cats:
WHO expert Francois Meslin, responding to new evidence that found the Sars virus in three small mammals,including a civet cat that is eaten as a delicacy by some, said: 'It's certainly too early to draw final conclusions on those findings but they are clearly quite exciting.'
Researchers from the University of Hong Kong examined 25 animals representing eight species in a live animal market in southern China that supplies restaurants in Guangdong province, where the Sars outbreak is said to have started.
Six of the animals tested were masked palm civets, which look like long-nosed cats but are related to the mongoose. All the civets, which came from several different owners at the market and appeared healthy, tested positive for a Sars-like virus, said WHO's chief Sars virologist Klaus Stohr.
A racoon dog (not to be confused with a coon dog) tested positive, too, and according to the WHO investigators it isn't clear whether the animals were the source of the virus or whether they caught it from infected humans. The puzzle continues.
posted by Sydney on
5/25/2003 01:19:00 PM
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Where I've Been: Sorry for the light posting. I've got the call duty this weekend and it's been busier than I expected. Between phone calls and hospital rounds I haven't had time to blog. Stay tuned. Posting will resume when things slow down. (And by the way, when calling a doctor in the middle of the night for advice on a minor health concern, it's not a good idea to address her as "honey.") posted by Sydney on
5/25/2003 09:37:00 AM
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A Little Too Little: David at Cronaca says that the French have lower rates of heart disease and obesity because they believe in giving their children a little too little rather than a little too much. posted by Sydney on
5/25/2003 08:45:00 AM
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