Commentary on medical news by a practicing physician.

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    "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

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    Saturday, June 07, 2003

    Hiatus: I'll be away at a conference for the rest of the week. Blogging will resume June 16.

    posted by Sydney on 6/07/2003 11:21:00 AM 0 comments

    Calories, Calories: Michael Fumento looks at the latest on low fat diets.
    posted by Sydney on 6/07/2003 11:20:00 AM 0 comments

    Friday, June 06, 2003

    Truth: For once, a research study that frankly admits its limitations. But don’t worry, there’s a pony in there somewhere:

    In spite of the fruitless results, other researchers at Johns Hopkins expressed confidence that, in time, some positive results can be gleaned from the study. Ingels has relinquished all collected data to the university, but stressed that he will not offer any further assistance.

    posted by Sydney on 6/06/2003 08:30:00 AM 0 comments

    Domestic Goddesses: Housework is good for you, or so say some Australian and Chinese researchers:

    According to a new Australian-Chinese study, dusting and vacuuming could help prevent ovarian cancer.

    The study, published in the International Journal of Cancer this week, found moderate exercise such as housework decreased the risk of ovarian cancer with the benefits increasing the harder the work.

    Head researcher Colin Binns from Perth's Curtin University on Australia's west coast said the two-year study of 900 Chinese women found the risk of ovarian cancer declined with increasing physical activity. Housework was on the list.

    "If you are only doing the housework 20 minutes a week...it does not really count, but if you are doing three to four hours a day, this is fairly vigorous exercise and increases protection from ovarian cancer," Binns told Reuters.

    I’m not going to believe it until I see the numbers.
    posted by Sydney on 6/06/2003 07:35:00 AM 0 comments

    Failure to Communicate: Hong Kong may have been hit especially hard by SARS because no one warned the doctors to be on the lookout for it.
    posted by Sydney on 6/06/2003 07:21:00 AM 0 comments

    Fear Factor: Researchers say that whether or not someone makes eye contact with us when they're fearful or angry alters the way our brain deals with the threat:

    Eye contact is a paragon of polite conversation. Now the results of a new study suggest that it also plays an important role in how the brain perceives fear and anger. Findings published today in the journal Science indicate that the part of the brain that processes potential threats works differently depending on whether or not someone is looking at you.

    A team of researchers led by Reginald B. Adams Jr. of Dartmouth College and Harvard University used functional magnetic resonance imaging (fMRI) to study how the amygdala (a section of the brain that detects potential threats, regulates emotions and directs emotional behavior) reacts to faces displaying fear and anger. They showed subjects pictures of people with both angry and fearful facial expressions, some of which had been altered to change the direction of their gazes. The team found that pictures of angry faces with averted stares generated more amygdala activity than angry faces looking straight at the subject did. In contrast, an image of a fearful expression with a direct look elicited stronger signals than a picture of a fearful person looking aside did.

    But take a look at the faces they used. More funny than threatening.

    posted by Sydney on 6/06/2003 07:17:00 AM 0 comments

    Thursday, June 05, 2003

    One Consumer’s View: T. Crown emails these trenchant observations about popular drug advertising:

    ...I got a kick out of your post on drug companies' direct-to-consumer ads. I don't know how much attention you've paid to them, but they live in the same life-cycle as other ads: They start out long and detailed, explain what the drug is, why it, and not unleavened bread, should be the Host, explain what
    it's used for, then tell you to ask your doctor for it. After a while, message saturation sets in, and the cost to continue the full ad mounts, so they release a truncated version (that, of course, always includes the bit about telling your doctor). This, of course,is mind-numbingly stupid with prescription drugs, because unlike, say, a soda, all of that information is terribly important. Use Coke to bathe, rather than to drink, and you'll be a little less clean than you would be with water; use Thorazine to cure allergies and you'll have all sorts of issues.

    Why this is funny: My wife, brother, and I were talking about this just the other day. For example, a while back an ad came out for headache or sinus
    medicine, in which a nurse afflicted by whatever was so overwhelmed that she couldn't enjoy working in the maternity ward any more. It shows the before and after shots, and has a voice overlay while she gives the little bundle of joy to the new parents, a smile on her refreshed face the whole time. When the ad was cut, it basically just amounted to: "[Drug name]: Ask your doctor about it. It's the best thing you can do for yourself." The only scene is the nurse giving the baby to mom and dad. My wife came to the conclusion (on first seeing it) that it was a fertility treatment.

    Or the Dan Reeves http://www.zocor.com/simvastatin/zocor/consumer/dan_reeves/index.jsp commercials for whatever heart medicine that was. If you don't know who Dan Reeves is, or what his well-publicized medical condition is, then a commercial where he's walking up a set of bleachers, talking frankly to the camera with his legs Clinton-like spread wide, and saying, "Guys especially need to talk to their doctors; it helped me," you might be inclined to think that he's actually Bob Dole's odd younger brother.

    We had an odd laughing fit at the thought of folks demanding from their doctors -- on pain of losing their business -- these drugs for illnesses for which they're not intended. "I want my ZOLOFT NOW!! I have GOUT!!" and so on.

    Actually, that does sometimes happen - people asking for drugs that aren’t appropriate for them based on something they saw in a commercial. But, I can’t say that the phenomenon is entirely limited to drug advertising. Personal testimonials from friends and relations can have the same result. I once had a patient ask me for lithium because it worked wonders for her sister-in-law.

    posted by Sydney on 6/05/2003 08:44:00 AM 0 comments

    Health Police: The inclination to practice punitive medicine in England evidently extends beyond smoking and obesity:

    Dr Rachael Morris-Jones, a dermatologist at St Thomas's Hospital in London and consultant to Vichy Laboratoires, said: "I know we risk the dangers of the 'nanny state' . . . but it is neglect to allow a child to burn severely and in extreme cases, and where it was a recurrent thing, I think I would be in favour of prosecution."

    The article sites an American case in which this actually happened - an Ohio mother who was arrested after sheriff’s deputies spotted her with three sunburned children at the county fair. But, rather than support the dermatologist’s position, the case is actually one that shows just how dangerous it can be to use the club of the law to enforce good health habits (or parenting habits):

    Hibbits was arrested Aug. 14, after a sheriff's deputy noticed her 2-year-old daughter, Rose, and 10-month-old twin boys, Thomas and Timmy, had sunburned faces at the Jefferson County Fair the day before. Temperatures were in the 90s at the time.

    Hibbits was then charged with three counts of felony child endangerment, but the charges were reduced after authorities said the children were not as severely injured as they originally believed.

    Hibbits' attorney, Shawn Blake, said prosecutors charged his client too quickly.

    "There was nothing wrong with these kids in the past. There was nothing wrong with them from some sunburn. There was absolutely no evidence to substantiate a criminal complaint," he said.

    Overzealousness. A fault in anyone, whether they be prosecuting attorneys, sheriff’s deputies, or dermatologists.
    posted by Sydney on 6/05/2003 08:43:00 AM 0 comments

    Professional Blogs: The health reporter for the Spokesman-Review in Spokane, Washington has a blog, apparently supported by her newspaper. That puts them ahead of the curve compared to other papers with more national reputations.

    One of her posts is about this site, the Internet Medical Journal, whose mission is “to provide peer-reviewed, relevant medical information to isolated and busy medical professionals.” What’s not to like about a site that displays this quote?

    "Be careful about reading health books. You may die of a misprint."
    -Mark Twain (1835 - 1910)
    posted by Sydney on 6/05/2003 08:40:00 AM 0 comments

    Gulf War Birth Defects: A study published in April that claims an increase in birth defects among the children whose parents served in the first Gulf War is sprouting up in the media this week:

    The study by the Department of Defense Naval Health Research Center and Centers for Disease Control and Prevention examined birth defect data from 1989-93.

    In all, researchers identified 11,961 children born to Gulf War veterans and 33,052 children of veterans who had not been deployed in the Gulf. Of those, 450 had mothers who served in the Gulf and 3,966 had non-deployed mothers.

    They found four sons of female Gulf War veterans with a condition known as hypospadia, making children in that group about six times more likely to be born with the defect. Boys born with the condition have urethra openings located in the middle or the back of the penis.

    In postwar conceived infants of male Gulf War veterans, researchers found 10 children with tricuspid valve insufficiency, making children in that group 2.7 times more likely to have the defect, and five with aortic valve stenosis, a six-fold difference. Both are conditions in which heart valves do not function properly.

    Five postwar children of male Gulf War veterans had renal agenesis, a condition in which part of the kidney fails to grow and develop properly.
    (Emphasis mine.)

    Those are very small numbers, and the conditions are ones that occur rarely to begin with. Hypospadias has an incidence of 3 in 1000. Tricuspid insufficiency is usually an acquired defect, and not generally listed in textbooks as a congential cardiac anomaly in and of itself, but usually in conjunction with other cardiac anomalies. In fact, tricuspid insufficiency in a newborn can be the normal physiologic response to the shift in circulation patterns from those needed by the fetus to those needed by the air-breathing newborn. Aortic stenosis is also often associated with other congential heart disorders. It's interesting that they chose to break the findings down into the two separate lesions rather than report the overall incidence of congental heart disease (with which the two are usually associated) in the two groups. Could it be that there was no statistically significant difference? It’s hard to tell from the study’s abstract since it only reports the results in terms of relative risk and gives no data on the incidence in non-Gulf War veterans (also something the press report neglects to provide.)

    Renal agenesis also comes in different forms. It can be bilateral, which has an incidence rate of 1 to 3 per 10,000 births. It can also be unilateral, but according to my source, the incidence of that version isn’t known.

    But, the most critical point is that when you’re dealing with such small numbers, it really isn’t possible to say that there’s a clinically significant increase in incidence. Especially when the incidence itself can vary a factor of three per 10,000.
    posted by Sydney on 6/05/2003 08:36:00 AM 0 comments

    Median vs. Mean: A couple of days ago CalPundit looked at this report (warning: pdf file) mentioned in this Time magazine story as evidence that noneconomic caps have no influence on rates of increase of malpractice insurance premiums. Calpundit correctly points out that the report relies on median malpractice payouts and premiums rather than the mean. This is important because it ignores the effect that a few large payouts or increases in premiums can have. In fact, using the median, the report comes to the conclusion that, based on figures from the Medical Liability Monitor:

    * States with caps did have lower growth in malpractice payouts: a growth rate of 37% between 1991 and 2002 compared to 71% for states without caps.

    * However, exactly the opposite was true for malpractice premiums. States with caps saw premiums grow 48% between 1991 and 2002, while states without caps saw premiums grow only 35%. So in states with caps, payouts went up more slowly but premiums went up more quickly.

    Now, here’s what the folks at the Medical Liability Monitor came up with for the 2001-2002 period (admittedly a different period of time than that reported in the Weiss report which went from 1991-2002), using mean values:

    Most of the average premiums in the 19 states with noneconomic damage caps during the 2001-02 study period fell below the nationwide premium average. Caps ranged from $200,000 to $1 million.

    According to the report, in the states with caps:

    * Only internists in Michigan had a higher annual premium than the national average. Nationwide the annual premium was $12,177. In Michigan, internists on average paid $26,146. The other 18 state averages ranged from $4,023 to $10,098.

    * Only general surgeons in Michigan, Missouri and Utah paid more than the $36,354 national average. The Michigan average was $71,713; Missouri's was $38,326; Utah's was $37,290. The other 16 state averages ranged from $10,896 to $35,915.

    * Ob-gyns in Michigan, Massachusetts and Maryland paid more than the $56,546 nationwide average. The Michigan average was $88,945; the average in Massachusetts was $84,566; and Maryland's average was $64,385. The other 16 state averages ranged from $17,786 to $55,084.

    It’s all in how you spin the numbers. Which means that Calpundit is right. The Weiss Report appears not to be the impartial, nonpartisan look at the issue that it claims to be.

    UPDATE: Overlawyered has even more details on this.
    posted by Sydney on 6/05/2003 06:45:00 AM 0 comments

    Wednesday, June 04, 2003

    Powerful Medicine: The Chinese government says that refraining from spitting makes one invincible:

    SPITTING ON THE GROUND IS DANGEROUS TO YOUR HEALTH, AND SPIT CONTAINS INFECTIOUS DISEASES. BUT WITH ONE SMALL BAG IN YOUR HANDS, YOUR HEALTH WILL ALWAYS BE INVINCIBLE. - Printed on white spit bags handed out on the streets of China. The government's latest battle in the war against SARS is curbing the national habit of spitting.

    posted by Sydney on 6/04/2003 12:17:00 PM 0 comments

    Canadian Health: Here's a site that deals exclusively with all health matters Canadian.
    posted by Sydney on 6/04/2003 12:13:00 PM 0 comments

    Preparedness: Looks like all that emphasis on bioterror preparedness has gone unheeded by a lot of communities, according to a Congressional report (not yet available online):

    On May 7, 2003, before the House Oversight and Investigations Subcommittee, the General Accounting Office (GAO) identified a number of gaps in public health preparedness that could interfere in the nation’s response to a disease threat such as SARS. In site visits to seven cities and their respective state governments, GAO found that the level of preparedness varied and planning for regional coordination was lacking. The state and local officials identified communication problems, inadequacies in their surveillance systems and laboratory facilities, and workforce shortages due to state budget cuts and a shortage of people with the necessary skills. Most hospitals lacked the capacity to treat a large influx of infectious disease patients due to already overcrowded emergency departments, lack of adequate medical equipment, personal protective supplies, isolation facilities, and staff. While four out of five hospitals surveyed by GAO reported having developed an emergency response plan for large-scale infectious disease outbreaks, few have participated in drills or exercises.

    That’s depressing.

    UPDATE: The Bloviator points out that the original GAO testimony is available on the web here. (Although the report I quoted from was on SARS, and the quote is a paraphrased version of the GAO testimony.)
    posted by Sydney on 6/04/2003 12:09:00 PM 0 comments

    First Hand: A fellow blogger and West Nile survivor writes:

    I appreciate your comments. West Nile is here to stay. But rather than downplay the reportage of the terrors of this disease, I wish you would warn as well as (or instead of) dismissing them.

    You said:
    “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.”

    Dr. Michael Bunning and Dr. Catherine Chow at the CDC recently completed a study where I live (Slidell, Louisiana). They found, after sampling 1,226 individuals, a 1.8% infection rate, and incidences of inflammations of the brain and spinal column were about three times higher than expected. They estimate that at around one in 51 people infected, instead of the expected one in 150 to 200 people infected.

    Whether those numbers hold elsewhere remains to be seen.

    I don’t dismiss the potential complications of West Nile Virus infection, only the public health implications of them. Disabling and fatal complications of any illness are tragic on an individual basis. But, as a matter of public health concern, what matters is how frequently those complications occur. There are a lot of diseases carried by mosquitoes and other insects that can cause neurological damage and other complications, including death. (Lyme disease, Rocky Mountain Spotted Fever, Eastern Equine Encephalitis, to name a few.). But, like West Nile, they aren’t carried by the majority of insects and their incidence is very low compared to other diseases such as influenza. Their complication rates are also low. So, while it’s important to be aware of the disease, it isn’t nearly the public health problem that other, more established, diseases are.

    Granted, the study in Slidell, Louisiana found higher rates of infection and complications than those seen nationally:

    Based on a federal study of Slidell residents, the rate of severe complications from West Nile virus is at least three times higher than previously believed.

    "It's not what we expected," state epidemiologist Raoult Ratard said Friday. "We need to understand why, and nobody knows."

    Until they complete more studies, state and federal officials won't know whether the Slidell results are an aberration or whether they are the first hint that national estimates have been off by a factor of at least three.

    It’s important to remember that Slidell is in a region of the country that had higher rates of West Nile virus cases last summer than other regions - swampy Louisiana, where mosquitoes are more of a public health problem than they are in, say, Montana. It’s safe to say that if you live in a region teaming with mosquitoes you’re more likely to get bitten, and not only to get bitten, but to be bitten by an infected mosquito. It’s highly unlikely that national estimates are off by a factor of three, but instead that the findings in Slidell are an aberration of the climate and geography:

    The data came from a study the Centers for Disease Control and Prevention conducted last year by drawing blood from 1,226 randomly selected Slidell residents. They found a 1.8 percent infection rate, or about one in every 55 people.

    Given that Slidell has 25,695 residents, the survey results in an estimate of 463 people infected, Ratard said.

    Ratard couldn't say whether that number is out of line with expected infection rates because most people with healthy immune systems unknowingly fight off the disease. That makes reporting such rates difficult without the kind of wide-scale blood sampling done last year on the north shore

    ....In addition to the high number of reported West Nile infections last year in St. Tammany Parish, Slidell was picked for the survey because of its climate to determine whether that might make a difference, said Dr. Michael Bunning, the study's director.

    Of course, the fact that the higher rate is due to the climate doesn’t do much to comfort people who live near those swamps, and stories like these are heartbreaking:

    Two gentlemen to my knowledge have lost all or most of their vision, as has a co-worker I have never personally met. Another gentleman known to my family is severely, possibly permanently, impaired. All of us are, months after contracting WNV, far less able, physically and mentally, than we were.

    Most of the time, I feel as if the lights have gone dark inside my head. I have been under medical work restrictions, and have learned a disgustingly depressing new vocabulary that includes polite terms for abhorrent realities. For example, the genteel “viral encephalopathy,” for the more jarring “brain disease.”

    Prevention: I don’t argue that nothing should be done to protect against West Nile Virus, but only that public actions should be proportional to public risk. For example, dead birds don’t have to be collected and tested for the virus. We know the virus is in the mosquito population now from coast to coast, so testing birds won’t help control the virus. It probably isn’t necessary for every city to spray for mosquitoes, either. But it probably is necessary for especially swampy areas to invest in mosquito control and good drainage.

    It’s also a good idea to use insect repellent if you’re spending any amount of time in situations that put you at risk for mosquito or other insect bites - i.e. camping, hiking, etc. With that in mind, The Medical Letter has a good summary of insect repellents in this week’s issue. (Unfortunately only available by subscription, so I’ll summarize it.)

    The best repellents remain those that contain DEET. Not only does it repel mosquitoes, but it repels ticks, chiggers, fleas, and flies, too. Products with less than 20% DEET in them provide protection for 1 to 3 hours. (The less DEET, the less time.) Higher concentrations can provide protection for up to 12 hours, but concentrations over 50% probably don’t confer any longer protection.

    A commercial version of the insect repellent used by the Army is now available. Called Ultrathon, it can protect against mosquitoes for 6 to 12 hours, depending on the type and numbers of mosquitoes in the environment.

    Extra protection can be had by spraying your clothing, sleeping bags, and tents with permethrin, a chemical that’s most familiar as a lotion and shampoo to treat lice and scabies. It comes as a spray that doesn’t stain clothing and stays on for up to twenty washings. It’s poorly absorbed through the skin, and toxic side effects have not been reported, although skin irritation can occur if you’re sensitive to any of the ingredients.

    Many people are reluctant to use DEET-containing repellents because the risk of toxic reactions if over-applied, especially in young infants. For the chemically averse, there are some plant-based repllents out there, although they require more frequent application than DEET-based products. Citronella based products, such as Natrapel are popular, but my experience has been that they smell bad. There’s also a eucalyptus-based product that can provide up to four hours of protection. (I’m not sure how that smells.) And, although I’ve never tried it, I’ve got to wonder about the odor of a coconut-geranium-soybean repellent. (Their website claims that they’re as effective as DEET products, but click on the link to the data and you’ll find that DEET protected for 300 minutes compared to 95 minutes for the soybean oil.)

    And then, there’s always Avon’s Skin So Soft. Some say that its ability to repel mosquitoes is only an urban legend, but I found it very effective when my children were small and we lived near a mosquito-infested city pond. It comes in all sorts of incarnations now - lotions, sprays, bath oils, some with sunscreen added, some with insect repellents added - but I just used plain old Skin So Soft moisturizer. The disadvantage is that it needs to be re-applied after about an hour, and that you need to know an Avon salesperson to get it. It still doesn’t work as well as the DEET-containing products, which I now use on the kids since they’ve gotten older.

    For more information on mosquitoes and repellents, click here.
    posted by Sydney on 6/04/2003 11:42:00 AM 0 comments

    Tuesday, June 03, 2003

    Appalling: Britain’s Labour Party has plans to make demonization of the overweight and tobacco users a matter of national health policy:

    Overweight people and heavy smokers would have to sign contracts promising to diet or give up cigarettes in return for treatment, under radical new plans being drawn up by Labour.

    Written contracts would set out the patient's responsibilities while offering them help to cut down or quit smoking, lose weight, take more exercise or eat a more nutritious diet, The Times has learnt. Those who failed to keep their side of the bargain or kept missing appointments could be denied free care.

    The contracts would also bind doctors to certain standards of care and to providing a formal channel of redress if they fail to measure up.

    The Times provides a sample of what the contracts may look like:

    I, Margaret Smith, agree to co-operate with the following action plan to manage my emphysema, high blood pressure and irritable bowel syndrome:

    1: To reduce drastically and eventually cease smoking;

    2: To take moderate exercise daily;

    3: To reduce my intake of salt, eat more fresh fruit, vegetables and wholemeal bread and cut back fried, fatty and fast foods.

    In return, Dr George Kildare will treat me to the best of his ability for the above conditions, providing any medical assistance necessary, including nicotine-replacement therapy and blood pressure medication.

    Evidently the Labour Party hasn’t decided if the bit about denying care to those who fail to keep the pledge will be part of their plan. At least that’s what they’re saying now that angry voices have been raised:

    Dr John Chisholm, chairman of the BMA's General Practitioners Committee..."But we would deplore any suggestion that people would be denied free care because of their failure either to take medical advice or to respond to that advice.

    "At a time when we are working with the government to reduce bureaucracy in general practice, this idea amounts to a bureaucratic nightmare."

    ..Shadow Health Secretary Dr Liam Fox said: "This is yet further interference by the government in how health professionals should treat their patients.

    ....Claire Rayner, president of the Patients Association, called them a "nasty piece of political chicanery" ...Ms Rayner said the logical conclusion of the plan would be to deny somebody treatment if they were hit while crossing the road because they were looking the wrong way at the time....This is another piece of political manipulation of the nastiest kind.

    "I find it repellent, and no patient of any sense is going to fall for it.

    She’s got a point. Where does this sort of thing end? At the moment, the western world is more tolerant of sexual indiscretions than it is of dietary indiscretions. More tolerant of drug abuse than of tobacco abuse. But what happens when the pendulum swings and sexual indiscretions are no longer tolerated? Will the NHS deny publicly funded treatment for sexually transmitted diseases to people who have sex outside of marriage? Will they deny obstetrical care to single mothers? AIDS treatment to gay men who chose to have homosexual sex? Or to drug addicts who chose to use IV drugs? Taken to its logical conclusion, it’s a very rigid, inhumane policy. Surprising for a political party that’s supposed to be liberal.

    (Special thanks to all those who emailed with links to this story.)

    posted by Sydney on 6/03/2003 09:31:00 PM 0 comments

    Sleight of Hand: I haven’t paid much attention to the thimerosal controversy. Mostly because I think the issue of thimerosal causing autism is about as valid as the issue of cell phones causing brain tumors. Thimerosal was used as a preservative in immunizations for over thirty years without any observable adverse effects. It was removed from vaccines a couple of years ago at the suggestion of the FDA because newly adopted standards for mercury exposure (lower than before, largely due to the precautionary principle) and an increased number of recommended childhood vaccines meant that adding up environmental mercury exposure with vaccine exposure would give children more mercury exposure than the new standards recommended. It’s impossible to completely eliminate mercury from the environment (it’s a natural element), but it was possible to eliminate it from vaccines. So, thimerosal preservatives were discontinued.

    But, when trial lawyers heard of this, they automatically assumed some malfeasance on the part of vaccine manufacturers in collusion with the FDA. Rather than seeing the move to discard thimerosal for what it was - the attempt to avoid any hint of doing harm, no matter how remote - they saw it as an admission of guilt. It was, in some ways, the perfect case for trial lawyers anxious to make big bucks - products that were used in millions of children for years combined with a supposed injury (neurological damage) that because of its many causes, most of which are difficult to pin down in each individual case, can be also be found in millions of children. It’s a situation ripe for exploitation.

    It’s also one that lends itself easily to sleight of hand when manipulating data to try to prove a link. Recently, that’s just what two people who make their living testifying in vaccine cases did. The father and son team of Geier and Geier published a study (warning: pdf file) recently that purported to show a definite link between childhood vaccinations, thimerosal and autism. It got some media exposure, enough to catch the attention of the American Academy of Pediatrics which took the unusual step of publishing a detailed analysis and rebuttal of the study on its website. Among its most damning observations:

    The authors claim falsely that children in the United States in 2003 may be exposed to higher levels of mercury from thimerosal contained in childhood immunizations than any time in the past, when in fact, all routinely recommended infant vaccines currently sold in the United States are free of thimerosal as a preservative and have been for more than 2 years.

    That’s precisely right. No childhood vaccines sold in the United States contain thimerosal. There’s a lot of other stuff in the AAP’s analysis that shows the Geier’s paper for what it is - a sham. The elder Mr. Geier is a geneticist who has supplemented his income by testifying at trials against vaccine manufacturers and giving lectures about the dangers of vaccines. He’s also testified before Congress on the subject. His son and co-author runs a consulting firm that specializes in providing advice to trial lawyers on the vaccine issue. They may sincerely believe that vaccines are dangerous, but given their dependence on trial lawyers professionally, their impartiality has to be questioned.

    Then, there’s the matter of the reputation of the journal in which the study appeared. It’s the latest incarnation of the Medical Sentinel the mouth organ of the Association of American Physicians and Surgeons, a collection of professional loose cannon. As an example of its standards for publication, consider this article that blames Castro for West Nile Virus. The autism and vaccine study is no better. It just uses statistical sleight of hand to make it seem better.

    (Thanks to The Bloviator for pointing this out.)

    UPDATE: Reader observations on thimerosal and childhood immunizations:

    At one point I had high hopes that the thimerosal link would explain the uptick in the incidence of autism. That hypothesis seems to be suffering at the hands of the facts, LOL.

    However, as a moderately intelligent non-scientist, I more than anything else have come to have a lot of skepticism about the claims of the vaccine manufacturers. I looked at this chart (admittedly from an advocacy group), after I read your statement
    that there is no mercury in childhood vaccines now sold in the US. Maybe you are right, but the flu vaccine looks to me like it does. I wish somebody who has no axe to grind would really and seriously dig into where the science is OR at least assess the impact on public health compliance that the not unreasonable mistrust is generating.

    When I think about

    *the pressure to immunize the under 2 crowd for flu

    *the requirement that newborns get HepB vaccines, in part to make their parents more compliant with future vaccine requirements

    *the rapid development of the Chickenpox vaccine from a lifestyle choice for working moms who couldn't take off 10 days for itchy kids to a legal requirement before entering school

    *the rotavirus debacle

    I don't see a conspiracy, but I do see a lack of deference to
    parental choice, which is filling the arsenal of those who would
    attack vaccine makers.

    Excellent points all. The flu vaccine does contain thimerosal, but it isn’t considered a routine childhood immunization. (Although there are some who would like to see it become one.) In fact, I don’t know too many physicians who followed the recommendations this fall to immunize all children against influenza. The knowledge that there are thimerosal class-action lawsuits out there, weighted against the very marginal benefit a child gets from an influenza vaccine, just didn’t make it worth the while. (A list of routine childhood vaccines and their thimerosal content, compiled by the FDA, can be found here.)

    And the expansion of childhood immunizations to include diseases that are neither as widespread, as dangerous, nor as communicable as the traditional immunization-targeted childhood diseases is, at least in my patient population, a major reason that there is a growing number of parents who refuse to vaccinate their children. I ranted about this issue last fall, so I won’t go on at length here. But I do wish the public health experts who make the recommendations that become mandates would reconsider their approach to childhood immunizations. Just because we have a vaccine for something doesn’t mean we're required to use it.
    posted by Sydney on 6/03/2003 08:58:00 AM 0 comments

    Those Amazing Statins: The cholesterol-lowering drugs that are the darlings of cardiologists everywhere, the statins, are in the news again. Now they’re claiming to improve the health of kidney transplant patients:

    Experts say the study, published Tuesday on the Web site of The Lancet medical journal, provides important evidence that statin drugs can improve the health of kidney transplant patients, who are often vulnerable to heart trouble.

    A total of 1,788 kidney transplant patients completed the international study led by scientists at the National Hospital in Oslo, Norway. About half were given the statin drug fluvastatin, or Lescol, and the other half got a fake pill.

    After five years, there were 70 heart attacks in the statin group, compared with 104 among those taking the placebos.

    The risk of a fatal heart attack was 38 percent lower among those taking the drug, compared with those taking the dummy pill, while the risk of a non-lethal heart attack was 32 percent lower in the group taking the statin.

    But wait a minute. That’s not what the study (registration required) says:

    After a mean follow-up of 5.1 years, fluvastatin lowered LDL cholesterol concentrations by 32%. Risk reduction with fluvastatin for the primary endpoint [a heart attack, fatal or nonfatal -ss]...was not significant, although there were fewer cardiac deaths or non-fatal MI... in the fluvastatin group than in the placebo group. Coronary intervention procedures and other secondary endpoints did not differ significantly between groups.

    So, the difference between the two groups could have been due to chance and not to the drug. The authors even take pains to make this clear in their conclusion:

    Although cardiac deaths and non-fatal MI seemed to be reduced, fluvastatin did not generally reduce rates of coronary intervention procedures or mortality. Overall effects of fluvastatin were similar to those of statins in other populations.

    So, why are these “experts” quoted by the Associated Press making such a big deal about the findings? One expert is Dr. Jules Puschett, identified as a spokesperson for the American Heart Association. No surprise there. The AHA is a shameless booster for statins as miracle drugs. They’d put them in the water supply if they could get a way with it. The other expert is Sir Charles George, head of the AHA’s British cousin - the British Heart Foundation. Evidently, statin boosterism is just as rampant among British cardiologists. But you would think they would at least read the abstract of the paper in question before commenting about it to the press, wouldn’t you?
    posted by Sydney on 6/03/2003 07:14:00 AM 0 comments

    Flood the Zone: Is there an agenda at the New York Times against drug companies? Derek Lowe seems to think so. And so does
    Robert Goldberg writing at National Review Online:

    The Times article is part of a war the newspaper has been waging against pharmaceutical research and development for a number of years. The theme is always the same. Drug and biotech companies develop drugs of marginal value, and then corrupt the practice of medicine because they market their products and pay for research on the drugs by themselves. The solution is also always the same: Let the government determine what the best medicines are, and require doctors to follow the state's guidelines.

    I don’t always get those messages from the Times coverage of the pharmceutical industry. Maybe because there’s a kernal of truth to each accusation:

    Drug and biotech companies develop drugs of marginal value..

    For the past several years that’s what they’ve been doing, concentrating on developing copycat drugs rather than developing new drugs. Everyone’s got a proton pump inhibitor which they market as much for indigestion as they do for ulcers; everyone’s got a non-sedating antihistamine. And in the case of Schering-Plough now that Claritin is over the counter, they’ve got a copycat of their own drug, too. Ditto with Prilosec. Now that its patent has expired, AstraZeneca has got a copycat of it. (Nexium, the "other purple pill.") Defenders will say that there’s nothing wrong with this. That they use the profits from those fast and easy sure things to fund other research into new drugs, but sitting on the receiving end of all their advertising hype about those drugs makes them seem lazy and greedy. Of course, if we doctors didn’t fall for the hype, they wouldn’t have a market for the copycats.

    Which brings me to the next point:

    ...and then corrupt the practice of medicine because they market their products...

    It’s the way they market them that’s so objectionable. They ride piggy-back on the good will the public has toward science for one thing. Take direct to consumer advertising of drugs. Antihistamines claim in television and print commercials that they’re better because they’re “approved for indoor and outdoor allergies.” It may be true that they were clever enough to ask the FDA to give them that sort of label, but all antihistamines work the same way. There aren’t separate disease pathways for indoor and outdoor allergens. An antihistamine can’t distinguish between dust mites and flower pollen. Yet, patients routinely reject my offer of a prescription antihistamine because they want the one that works for indoor and outdoor allergies. (As seen on TV!) The most amazing thing is that these advertisement claims are so often accepted without any sort of scrutiny on the part of the consumer. In fact, it’s difficult to convince people sometimes that the commercial has shaded the truth. They assume too often that because it’s a medication the ad is being held to a higher standard of truth than a car commercial. It isn’t.

    ... and pay for research on the drugs by themselves...

    This one is a little trickier. It may be impossible to avoid bias in research, whether the grant is supplied by the government or by industry. Take, for example, the recent onslaught of obesity-related research papers. We have the government’s war on obesity (which has spawned numerous NIH grants on the subject) to thank for those. There’s always a temptation to put the most positive spin on results, no matter who funds them. Having the study support the original hypothesis not only feeds the ego, but it helps to get more grants in the future. And papers are more likely to be published if they show a positive result than if they show a negative result. But funding of legitimate research with legitimate grants isn’t really the issue here. The issue is the evidently common practice of drug companeis hiring people to write favorable review articles about their drugs and to do small “clinical trials” of dubious merit to promote the drug. And, in the case of one Canadian researcher, of quashing the results of a legitimate trial when it didn’t find in favor of the drug. Those are practices that deserve to have the media spotlight shone on them. And how.

    ..The solution is also always the same: Let the government determine what the best medicines are, and require doctors to follow the state's guidelines.

    Maybe I’m not reading those New York Times articles closely enough, but I’ve never come away with the impression that the paper advocates a statist approach to medicine. However, the FDA does play a critical role in checking the less altruistic motives of the businessmen who run the drug companies. Sure, drug companies take tremendous risks to develop new drugs and bring them to market. But they’re companies, run by men and women whose job it is to make a profit. Nothing wrong with that, but if allowed to run unchecked, the temptation to favor profit over safety and effectiveness would win out every time. It’s human nature. After all, the business people who run the companies have to answer to board members and shareholders every day (or at least quarterly.) They never have to face consumers. Or at least they wouldn’t if it weren’t for the FDA.

    But FDA approval isn’t the same as state-imposed guidelines. Doctors are currently given a lot of leeway to use drugs for uses that aren’t approved by the FDA. Where it becomes a problem is when the drug companies promote their drug for those uses. It may seem like splitting hairs, but there’s a world of difference between a physician deciding to try a drug on an individual basis for an unapproved treatment (say using a seizure medication for neuropathic pain) and flooding the market with claims of effectiveness for an unapproved treatment. In the first case, both patient and doctor know that the trial is an experiment. In the second case, it comes too close to being promoted as the standard of care - without proof of effectiveness.

    The New York Times may very well have an agenda against drug companies. They generally have an agenda against most companies - except of course The New York Times. But, in this case, the media attention is warranted. Someone has to keep the industry honest.
    posted by Sydney on 6/03/2003 06:50:00 AM 0 comments

    Monday, June 02, 2003

    Technology and Life's Dominion: Newsweek has an excellent article on fetal medicine, a subject also covered here. Added bonus: it opens with an update on a patient like this.

    posted by Sydney on 6/02/2003 08:22:00 AM 0 comments

    The Big CA: Cancer, that is. The new class of drugs that are supposed to selectively shut down the blood supply of cancer tumors appear to be working, at least a little bit:

    In the study of the Genentech drug, half of 800 patients with colorectal cancer that had already spread to other body organs were given Avastin, in combination with aggressive chemotherapy. Their median survival time, or the time that half of these patients survived, was 20.3 months. That's almost five months, or 30 percent longer, than the 15.6 months for patients receiving chemotherapy alone.

    A gain of almost five months is considered an important, if incremental advance, in a common cancer where long-term survival is poor once other organs are affected.

    Five more months isn’t exactly a cure, but it’s at least a little more time. Time enough to see a grandchild be born, or learn to walk, or graduate from high school or college, or to mend some broken fences.

    Derek Lowe, meanwhile, points to some evidence that the drugs might actually increase the blood supply to tumors. Since they’re used in conjunction with traditional chemotherapy agents, they might just be improving the delivery of the old drugs.
    posted by Sydney on 6/02/2003 08:00:00 AM 0 comments

    Bias Redux: My patients aren't the only ones who have experienced the prejudice against overweight people so prevalent in the medical profession:

    I cannot tell you how true it is what contempt many doctors hold for the overweight. I am 5'5" and 260lbs, and have been at least chubby all my life. I have coronary artery spasm/Prinzmetal's angina with no corresponding atherosclerosis or CAD (surprising everyone in the cath lab); amazingly I haven't experienced too much outright hostility on the weight front from the cardiology folks. (I have other problems with cardiology/ER folks, but from what I've heard, everyone does so oh well.)

    The worst was when I was referred by my family practitioner to a rheumatologist to confirm our suspicions that I have fibromyalgia. Basically he yelled at me for nearly a half hour, telling me that sure, I had fibromyalgia, but I got it because I was a good-for-nothing lazy fat slob who didn't sit up straight (darn near close to a quote). That's literally all he did. No referral to physical therapy, no nothing. I wonder what he does for thin people with fibromyalgia. Because they get it too. I left weeping I was so frustrated. I could barely walk from my car to the doctor's office, I was getting about one-two hours of sleep a night, and I was in constant, bonecrushing pain. But hey, I'm just a lazy fat slob who doesn't sit up straight; I don't really deserve help.

    posted by Sydney on 6/02/2003 07:40:00 AM 0 comments

    Quarantine: New York Times reporter Donald G. McNeil, Jr. on the difficulties of quarantine:

    But here's the thing: it's hard to stay in quarantine - especially if you feel fine. Taiwan has found it almost impossible to keep citizens in. It's a democracy, but the habits of 40 years of martial law are still vivid - every time the mayor of Taipei exhorted people to stay indoors, he mentioned the exact amounts of fines that would now be imposed. People skipped out anyway. A high school student went to his cram school - several public officials proudly pointed out to me how typical it was that a Chinese student got in trouble by sneaking into school. When he got sick, his school was shut down. A car thief slipped out to steal. A businessman drove across town to close a deal.

    The author wasn’t so strict with his own quarantine, either. Luckily, he didn’t have SARS.
    posted by Sydney on 6/02/2003 06:42:00 AM 0 comments

    Doctor Democrat: One thing that comes through in the New York Times profile of Howard Dean, doctor and Democratic presidential hopeful is - once a doctor, always a doctor:

    Howard Dean is a classic doctor: smart, abrupt and clinical. It's not hard to picture him in a white coat and loafers, backing toward the door as you try to ask one last question.

    It’s more than just the reporter’s impression of the man, however:

    ''I'm trying to figure out how to do this and not be arrogant,'' he confides. ''Sometimes I get impatient with people who don't agree with me.''

    Hmmm. Maybe the physician temperament isn’t the best fit for a national leader.
    posted by Sydney on 6/02/2003 06:37:00 AM 0 comments

    Sand Trap: A scary story about the hidden dangers of digging holes in the sand:

    It was a Tuesday afternoon last June, on the kind of day we'd come to Cape Cod for. My husband and I were lying on beach towels, reading in the sun. Our 8-year-old son, Brian, was digging a hole. If he'd been in the water, we would have been watching his every movement. But we never worried about the sand. At some point, our 11-year-old daughter, Rebecca, announced, ''Mom, look at Brian.'' She sounded more as if she were tattling than worried, so it took me a few seconds to respond. When I sat up, I saw my son's legs poking out of the sand. They were blue.

    I'm a doctor, so I knew that meant he was oxygen starved: four minutes and the brain begins to die. He was on his stomach. Sand seemed to have slid down from the sides of the hole and covered him. I remember screaming: ''Dig! Pull his legs out!'' Finally we got him free. He wasn't breathing.

    Not to be an alarmist or anything, but collapsing sand holes, though rare, are something to keep in mind when you're playing at the beach this summer. Just expecting the unexpected can make all the difference.

    posted by Sydney on 6/02/2003 06:34:00 AM 0 comments

    Sunday, June 01, 2003

    Weekend Fun: Didn't blog much this weekend because I was blowing bubbles and doing other fun stuff with my kids.

    posted by Sydney on 6/01/2003 10:22:00 PM 0 comments

    Hearing Hope: Researchers have succeeded in coaxing ear cells to regenerate, providing hope for the deaf:

    U-M scientists have now accomplished this goal by inserting a gene called Math1 into non-sensory epithelial cells lining the inner ear. Results from the study will be published in the June 1 issue of the Journal of Neuroscience.

    "We found that non-sensory epithelial cells in adult guinea pig cochlea can generate new sensory hair cells following the expression of Math1," says Yehoash Raphael, Ph.D., an associate professor of otolaryngology in the U-M Medical School, who directed the study. "We also found that some of these hair cells can attract the growth of new fibers from auditory neurons."

    ...Dr. Kohei Kawamoto, Ph.D., a former U-M research fellow who performed the laboratory experiments, used an adenovirus as a vector to deliver the Math1 gene to inner ear epithelial cells. Kawamoto injected the Math1 vector into inner ear fluid of 14 adult guinea pigs. The same procedure, but without the transfer of the Math1 gene, was performed on 12 matched control animals.

    Thirty to 60 days after inoculation, U-M scientists used scanning electron microscopes to examine inner ears from both sets of animals. In experimental guinea pigs that received the Math1 gene, scientists found new hair cells growing in areas where hair cells are typically absent. No new hair cells were found in the control animals.

    "The inner ear is an ideal target for gene therapy, because it is closed – not sealed, but nicely isolated," Raphael says. "As long as the amount you inoculate is small, the spread to other organs is minimal, and the risk of systemic toxicity is almost zero."

    The cells in question are the hair cells of the cochlea. The little hairs on the cells respond to the movement of fluid within the cochlea, which is set in motion by a series of events in response to sound waves hitting the ear drum. Hair cells can be damaged by loud noise, drugs, infection, and the ravages of age. This gene therapy definitely offers hope, although the researchers have yet to find out if the regenerated cells are functional.
    posted by Sydney on 6/01/2003 11:25:00 AM 0 comments

    Generosity: Maureen Dowd has a remarkably good column about organ donation today - a tribute to her niece.
    posted by Sydney on 6/01/2003 09:03:00 AM 0 comments

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