"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
@%&!: My email isn’t working properly, so I apologize if I haven’t answered any this week. Our DSL server has teamed with Yahoo for email services, supposedly to make things better. But, for people like me with email subaccounts, it’s only made things worse. The Yahoo system blocks my outgoing messages because it thinks they’re spam. (Everyone’s a critic.) Of course, plenty of spam still finds its way into my inbox. Such an imperfect world. posted by Sydney on
6/20/2003 09:33:00 PM
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The Mouse that Roared: That's Michael Fumento's post-mortem assessment of the SARS outbreak. I still think that the CDC and the WHO were right to act quickly to isolate cases as much as possible. When that wasn't done, the results were devastating to health systems - even though the devastation was confined to a few hospitals. It could have been worse, but it wasn't thanks to the efforts of the WHO.
UPDATE: Michael Fumento replies:
A system by definition is not a few hospitals, a few hospitals is just that. When CNN.com warned that SARS could overwhelm the US health care system, everybody who read that understood that it meant essentially the entire nation, not a hospital here and there. As to WHO's efforts, if this disease were anywhere near as transmissible as WHO would have wanted us to think, quarantines would have done no more good than they do with flu. Moreover, WHO didn't get in on the act until March when the first SARS cases go back at least to mid-November. The epidemic peaked because contagious disease epidemics always do. It's called Farr's law. In my AIDS book I wrote that when the epidemic failed to do what PHS had promised, PHS would say it was only because of its own actions. I also pointed out the first PHS AIDS campaign didn't begin until 1987about two years after infections had peaked, so that couldn't possibly be the reason. Sure enough, it later became common to hear that but for the PHS quick and decisive action on hetero AIDS .... Some things never change. posted by Sydney on
6/20/2003 08:58:00 AM
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Depressing: Three weeks ago, I visited my malpractice insurance carrier's website to get an online quote on my premium. It was $8,000 a year. I did it again last night, just to be sure. Now it's $14,000 a year. posted by Sydney on
6/20/2003 07:35:00 AM
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Reckless Endangerment: A woman from Pittsburgh was charged with child endangerment for breast feeding while driving on the Ohio Turnpike (speed limit 65 miles an hour). Her excuse:
Donkers has said she understood there was a risk in breast-feeding while driving, but she said using a cell phone behind the wheel was riskier.
Except it isn't as tragic if the cell phone dies when it's thrown from the car in an accident. posted by Sydney on
6/20/2003 07:29:00 AM
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Between a Man and a Woman: A detailed analysis of one Buffalo, New York, man’s Y chromosome has turned up many intriguing differences between men and women, including this:
But researchers have recently found that several hundred genes on the X escape inactivation. Taking those genes into account along with the new tally of Y genes gives this result: Men and women differ by 1 to 2 percent of their genomes, Dr. Page said, which is the same as the difference between a man and a male chimpanzee or between a woman and a female chimpanzee.
On Prostates: A reader had this to say about the study suggesting that prostate cancer screening may do more tharm than good:
The European medical community looks for thousand excuses not to treat prostate cancer. Why don’t they just admit that they do not have the money for life saving operations on men over 65? If they stopped doing all these "Don't treat prostate cancer" studies, they might have some money left to treat the disease.
The fact is that the PSA will find all cases of prostate cancer. The only way to prove that a high PSA is wrong is to do nothing. Then you have a 50% chance of dieing of cancer.
I refuse to die of prostate cancer. I don’t care what those Europeans say.
It isn’t just the Europeans who question the value of prostate cancer screening.The problem is, although about 4,000 men in the U.S. die each year from prostate cancer, most men with prostate cancer don’t die from it:
Although data from autopsies indicate that approximately 70 percent of 80-year-old men have prostate cancer, this malignancy is the cause of death in only 3 percent of all men. Prostate cancer is often an incidental finding in elderly patients. The tumor grows so slowly that no symptoms appear; in essence, patients often die of other causes before the cancer causes serious problems.
And the cost of that screening?
Although an individual PSA test is relatively inexpensive ($20 to $40), expenses multiply when a patient with an abnormal PSA test must be evaluated. Transrectal ultrasound examination costs approximately $100 per patient, and random biopsies cost another $150. Pathologic evaluation of the biopsy specimens costs approximately $300 per patient. When compounded by the fact that three patients without cancer must be evaluated for each cancer that is detected, the estimated overall cost of initiating a nationwide prostate cancer screening and treatment program for all eligible men ranges from $8.5 to $25.7 billion per year.
So, if the Europeans are squeamish about spending money on a screening program that doesn’t actually save lives, that’s understandable. Those billions of dollars spent on prostate screening - especially in Europe where healthcare is paid for by the government (i.e. by the people through taxes) - means billions of dollars unavailable for other things. In the United States, it translates into higher health insurance premiums, as well as higher Medicare spending. You could argue that it’s a significant contribution to the deficit as well as to our healthcare insurance woes.
And the European study isn't the first to suggest that the end result of widespread prostate cancer screening is to find lots of asymptomatic cancers that never would have caused harm. There are many others. posted by Sydney on
6/20/2003 06:57:00 AM
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Thursday, June 19, 2003
Pittance: Think doctors are exaggerating when they bemoan the state of Medicaid reimbursement? Take a look at this check. posted by Sydney on
6/19/2003 08:30:00 AM
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Dental Hygiene: Who knew that brushing the teeth is such a precise science? Apparently not the British:
Prof Heasman, whose school of dental science reported three years ago that two out of three Britons could not use a toothbrush properly, called for clearer advice from dentists. posted by Sydney on
6/19/2003 08:27:00 AM
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Use It or Lose It: Why the New York Times crossword puzzle is important.
Population Explosion Solution: The proverbial "contraceptives in the drinking water" solution may already be happening:
Three chemicals widely used on corn and soybean crops have been implicated in low fertility among central Missouri men, according to a University of Missouri-Columbia study released this week.
The study's author, Shanna Swan, reported earlier that the study group had lower sperm counts and impaired sperm quality, compared with men from several major cities. She then set out to determine why.
Her conclusion: The herbicides alachlor and atrazine and the pesticide diazinon may be to blame.
Problem is, those same men evidently have no problem conceiving children:
Swan's findings are based on urine samples provided by men whose pregnant partners sought prenatal care at university clinics in Columbia.
Which raises an obvious question: If the men were able to impregnate a partner, where's the problem?
The researcher says it isn't fertility that's the issue, it's the fact that the sperm have been damaged in some way, indicating that the pesticides may be causing other sorts of cell damage. But, if they were causing significant cell damage, wouldn't there be an increase in cancer or other illnesses in those areas? Absent any clinical disease, it's hard to argue that the pesticides are causing significant harm.
Another problem, according to the abstract (pdf file), is that the link between sperm quality and pesticide levels only held for Missouri residents, and not for residents of Minnesota. Makes one wonder if there's not some other factor accounting for the sperm damage in Missouri. posted by Sydney on
6/19/2003 08:18:00 AM
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Half of all prostate cancers picked up by a popular blood test are "irrelevant" and will never become life-threatening, a major new study suggests.
The report estimates that 50 per cent of men aged 55 to 67 who are diagnosed with prostate cancer after a yearly PSA blood-screening test would not have shown symptoms of the disease during their lifetime. The PSA, or prostate-specific antigen test, measures a protein produced by the prostate gland; rising levels can mean cancer.
The findings suggest thousands of men could be undergoing treatments that can leave them impotent and incontinent for a cancer that might never have killed them.
Learn As You Go: The puzzle of the natural history of SARS continues. Looks like there are cases that are asymptomatic:
Scientists are puzzled by a group of 120 people, mostly from the Toronto area, who tested positive for the SARS coronavirus but were not classified as probable or suspect cases.
.....Dr. Frank Plummer, scientific director of the Winnipeg-based lab, yesterday said they are now working with local public health officials to track down and question this "very interesting group of people" about how they could have been exposed.
The samples were taken from 2,100 patients since the first SARS outbreak in March at hospitals around the country, but mostly from the GTA. The samples were tested at the laboratory for the presence of the coronavirus.
"Some of them probably are SARS, but no epidemiological link was made for some reason," said Plummer.
A few of the patients were asymptomatic and some "clearly had illnesses not like SARS," he added.
Plummer said he can't draw conclusions from the results because there's not enough information yet on the patients.
But this may just be "the spectrum of the disease caused by the Toronto virus," he added, saying a similar phenomenon occurred in Hong Kong where a number of SARS patients didn't show the familiar symptoms like a fever and a cough.
The article also reveals the case of a Texas man who returned from Toronto with SARS symptoms:
A patient who claimed to have travelled to Toronto also appeared at a North Texas hospital last Thursday evening with SARS symptoms.
The patient, who was ordered into quarantine and is in isolation under police guard in Dallas County, faces a hearing today, which will determine whether the individual's stay in the hospital will be extended.
The individual is being called unco-operative by Dallas County officials, who say the patient has provided a name, residence, recent contacts and travel history they can't verify.
There's more about the case here. But this may be why the U.S. has avoided the spread of the disease that occurred in Canada and Asia. Any suspected cases are kept quarantined. Even if it requires force. posted by Sydney on
6/19/2003 08:03:00 AM
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Wednesday, June 18, 2003
SARS Dead? That's what the WHO says, even though there are still suspected cases being investigated in Canada. But, judging by the New England Journal of Medicine's SARS graph, the incidence does appear to be leveling off. (scroll down to bottom of page.) posted by Sydney on
6/18/2003 06:13:00 AM
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Approximately 20 genes involved in the spread -- or metastasis -- of prostate cancer have already been identified. The new one -- designated RKIP, which produces the RKIP protein -- is important because it serves as a kind of traffic cop. It acts early to stop cancer cells from leaving the prostate and entering the bloodstream and wreaking havoc, says a report in the June 18 issue of the Journal of the National Cancer Institute.
"There is a metastatic cascade, in which the cells enter the blood vessels, then go into a target organ, then grow there," says study author Evan T. Keller, an assistant professor of comparative medicine and pathology at the University of Michigan Medical School.
"This gene [RKIP] works at an early stage in the cascade. If you can block that stage, you could prevent the cascade," he explains.
...The researchers spent three and a half years studying the workings of the gene, starting in a laboratory with two lines of human cancer cells -- one non-metastatic, one metastatic. The scientists first found the RKIP gene was relatively inactive in the metastatic cells.
Then they began more specific measurements. One critical test used cancer cells taken from prostate cancer patients within hours of their death, when the fragile molecules involved in RKIP activity were still present. RKIP levels in 12 samples of non-metastatic cancers were close to those of healthy cells. But no RKIP protein was found in any of the 22 samples of metastatic prostate cancer.
The hope is that they can introduce the gene into cancer cells to help halt their spread through the body. Someday. posted by Sydney on
6/18/2003 06:10:00 AM
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"Alcohol intoxication brings out people's natural tendencies in the expression of anger," said Dominic Parrott, the graduate student who conducted the study. "Our findings strengthen the notion that alcohol increases the likelihood that certain drinkers, particularly those with the tendency to be angry and to express their anger outwardly, become aggressive when provoked.
Haven’t we always known that alcohol is a disinhibitor? Isn’t that why people have cocktail parties? So they can unleash their inner chatterbox? posted by Sydney on
6/17/2003 08:49:00 AM
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Press Embargoes: Meant to post on this before I went away, but it got sidelined. A reader pointed out that the recent controversy over Robert Goldberg’s article at National Review Online (no longer available online) on the New York Time’s anti-drug company crusade brings up the issue of JAMA’s famous press embargo. Supposedly, the press is not supposed to get information about articles in the journal before physicians. That’s to give us half a chance to look over the studies before our patients start calling with questions. What happens, though, when a paper reports a study before it’s even been accepted for publication? That’s what the New York Times did with a study presented at a meeting of psychiatrists last month:
Yesterday, researchers at the psychiatric meetings presented a study of the cost effectiveness of Zyprexa in treating patients at 17 Veterans Affairs medical centers. The study, led by Dr. Robert Rosenheck, a professor of psychiatry and public health at Yale and the director of the Department of Veterans Affairs Northeast Program Evaluation Center, found that Zyprexa cost the V.A. $3,000 to $9,000 more per patient, with no benefit to symptoms, Parkinson's-like side effects or overall quality of life.
Zyprexa was less likely to produce the physical restlessness called akisthesia, the study found, and was associated with slightly better memory and motor skills. The study was financed by Eli Lilly.
And here’s what the author of that study said in its defense after Goldberg accused the Times of mischaracterizing it as a study since it was only presented at a meeting:
This is erroneous information. The study was submitted to JAMA on May 5 in full paper form that had been reviewed in depth by both VA researchers and members of the Eli Lilly Corporation — the corporation that indeed did finance the study.
....I made it clear at the beginning of the presentation both verbally and through a written slide that the study had been submitted for publication and that the presentation of results could change somewhat after it is revised for final publication... [But the New York Times didn't make it clear that the results could change -ed.]
And the response of the New York Times:
The research was submitted to the Journal of the American Medical Association on May 5. This was fifteen days before Ms. Goode's article appeared. You may verify this fact independently by contacting JAMA directly.
So, the media can report the results of a study before it’s been peer-reviewed. That certainly is a violation of the spirit of the JAMA embargo. For all we know, the study could have been badly done, or the data exaggerated. Who can possibly judge? And has JAMA slapped the wrist of the Times reporter like they did the Detroit Free Pressreporter? Somehow, I doubt it. posted by Sydney on
6/17/2003 08:39:00 AM
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Comfort and Care: A reader sent along this account of one of her patients. It’s a sobering reminder of how our current system often encourages us to overlook the human side of medicine. Whether it’s trying to fit a patient’s symptoms into a certain diagnosis code so the insurance company or Medicare will recognize the visit as justified, or to make a hospital visit reimbursable, too often these days, the patient ends up being just a number:
Last week, one of our patients came in. He is a rancher. About six months ago, his kidneys started to fail--we're not quite sure why, perhaps from diabetes. Six months ago we had him seen by a Nephrologist who advised us to arrange a Cardiac evaluation, to see if he was a candidate for transplant, and then send him back.
Well, we had his heart checked, and it was fine, but the gentleman didn't follow up. After three months, we traced him down, and got him in. Since my partner was on vacation, I was the one to see him. His Creatinine was 8, and his hemoglobin was 6. His electrolytes were good, and except for problems breathing at night and when he walked out to the pasture, he was fine. It took awhile to convince him he needed to be seen NOW. Can it wait til I get my sick horse checked? NO. You could go six months like this, or drop dead tonite. I want you to get to the hospital now. (I once had to convince a farmer that his appendicitis surgery wouldn't wait til he finished the harvest. We rural doctors are used to this type of discussion).
So he went, got a peritoneal dialysis catheter and six pints of blood, and came home. ("I'm too busy to spend three days a week at dialysis).But of course, caring for horses isn't the cleanest job in town, so after a few weeks, the peritoneal catheter got infected. So back to the hospital, some antibiotics and home. Then the abdominal incision dehissed: didn't heal right, and opened up, with blood and dialysis fluid all over. The ambulance crew rushed him down to the hospital, where the wound was closed...and a shoulder catheter placed to temporarily dialyze him...
So here's our rancher, in the hospital, with dried blood and fluid down his clothing, scared to death, and ...But there's no beds. Go home. We'll bring you back to arrange a shunt in a few days.
Medically this makes sense. The wound is closed. The dialysis will keep him going for a week. The antibiotics aren't going anywhere. His vital signs are stable. No big deal. We'll place the catheter in a day or two when an elective bed opens.
So our rancher goes home, very frightened, for two days, comes back for the surgery and dies on the table.Electrolyte imbalance? Too many catecholamines from being frightened causing an arrhythmia? Septic shock from the peritonitis? Or just a very week body that just ran out of strength?
I remember a phrase from a historian about people in a famine: There was nothing those in charge could have done, "but if only they had been kind"....
How many people are sent home early from surgery for their families to care for them: families who may be non existant, too busy working, or too naive to figtht the medical system? How can we convince people that medicine is simply not about effieciency and science, but comfort and care?
I have no answer, but all I know is that a man died in fear and alone in a callous medical system that has forgotten the importance of caring is part of the healing process. posted by Sydney on
6/17/2003 08:38:00 AM
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Apologies: Sorry for the late return. Delayed flight, lost luggage, swamped at work, and this Blogger has gone to a new format that's driving me a little bonkers. Expect slow blogging until I get used to it. posted by Sydney on
6/17/2003 12:41:00 AM
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A Pox on Small Mammals: Who would have thought that the pox visited on us would turn out to be not from terrorists, but from small mammals? The monkey pox outbreak seems to have knocked SARS out of the media radar, at least in the newspaers I was reading last week in the Tidewater region of Virginia. As of today, the CDC was investigating 82 possible cases in five states, but no word yet on how many of those have been confirmed. (At least a google search doesn’t come up with any concrete number, and the CDC website doesn’t distinguish between suspected and confirmed cases)
The rash looks like this. Other symptoms include a , fever, swollen lymph nodes (aka “glands”), fever, muscle aches, headache, sorethroat, and/or cough. And, of course, exposure to a prairie dog or other little mammal from that Texas distributor, but not exposure to monkeys as simian lovers are quick to point out:
Monkey owners say monkeypox ought to be called "ratpox." The virus was discovered in laboratory monkeys in 1958 in Africa. But scientists say the disease-causing virus' natural host may be the African squirrel and that it is typically transmitted by rodents.
It can be transmitted from person to person, as happened in the Congo, but we aren’t very good hosts so it burns itself out quickly:
After smallpox eradication, surveillance for human monkeypox from 1981 to 1986 in the DRC identified 338 cases (67% confirmed by virus culture). The case-fatality rate was 9.8% for persons not vaccinated with vaccinia (smallpox) vaccine, which was about 85% efficacious in preventing human monkeypox. The secondary attack rate in unvaccinated household members was 9.3%, and 28% of case-patients reported an exposure to another case-patient during the incubation period. Transmission chains beyond secondary were rare. A mathematical model to assess the potential for monkeypox to spread in susceptible populations after cessation of vaccinia vaccination indicated that person-to-person transmission would not sustain monkeypox in humans without repeated reintroduction of the virus from the wild.
And the latest news says that so far no human-to-human transmission has occurred here. Not yet a public health problem on the scale of SARS. Just stay away from those little rodents.
