"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
No Blogging Tonight: I wanted to blog tonight, but I'm on call, and just as I sat down to begin, this message came across my pager from a colleague's patient:
"Nerves bad. Trying to figure out what's wrong with children. Long story. Please call."
Homo soveticus: This story was making the rounds of the blogosphere yesterday. The effect of political persuasion on health:
It seems those who believe the state should take responsibility for most aspects of life also tend to eschew personal responsibility for taking care of themselves. As a result, they are more likely to engage in lifestyles hazardous to their health, including drinking to excess and not exercising.
...Psychologists identify a common person-type found in Russia and known as homo soveticus - defined as a person with a collectivist orientation who does not like to assume any individual responsibilities.
I'm skeptical. Homo soveticus might engage in unhealthy behaviors in Russia because he's depressed. According to the article, his health improved when he was living the socialist dream, and declined after the collapse of communism. And in the United States, Homo soveticus spends a great deal of time and energy trying to force his idea of healthy behavior on the rest of us. posted by Sydney on
7/17/2003 10:58:00 PM
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Sugar Sugar: A reader sent along this question about fructose vs. sucrose in the current obesity debate:
I've read that the higher fructose corn syrup used these days in lieu of sugar is fueling the obesity crisis, and that it isn't metabolized as easily. If it isn't metabolized as easily, shouldn't that make the calories less absorbtive, meaning the bloodstream has less sugar absorbed and less sugar to convert to fat?
Fructose, the simple sugar that’s derived not only from corn starch, but from fruits, dahliabulbs and Jerusalem artichokes, is often touted as a healthy sweetener, but it isn’t necessarily better for us than plain old glucose. (Conventional sugar is a combination of glucose and fructose).
While it’s true that fructose is probably absorbed a little less easily from the gut than glucose, once it’s in the body, it’s more likely to be converted to fat. The majority of glucose metabolism occurs in the liver, where it’s converted to energy and the building blocks of fat. The majority of fructose metabolism occurs in fat cells where it’s converted to energy and the building blocks to make two types of molecules that serve as energy stores - glycogen and fat. The liver at least has a metabolic function that requires energy to operate, so the glucose there isn’t entirely converted into stored energy. The fat production becomes a problem when the glucose intake exceeds the energy needs. But fat cells exist just to store energy as fat. (They can also mobilize that fat into fuel molecules for transport to other parts of the body when needed, but in our sedentary society, we rarely need the export.) The result is that fructose consumption is much more likely to lead to a surfeit of fat cells.
So, did the switch from conventional sugar to fructose as a commercial sweetener foster the obesity epidemic? Doubtful. It takes much less fructose to get the same amount of sweetness as conventional sugar, and conventional sugar has equal amounts of glucose and fructose in it. It's not so much the type of sugar we're eating, but the amount of it. posted by Sydney on
7/17/2003 10:32:00 PM
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Checkin' it Twice: The US government has put out a set of health maintenance checklists so you can make sure you're getting your money's worth from your doctor at your yearly check-up. There's one for women and another for men.
Can’t help but notice that when it comes to prostate cancer screening they recommend weighing the risks and benefits of screening before proceeding, but when it comes to breast cancer screening they unequivocally recommend mammograms every 1 to 2 years beginning at age 40. Unfortunately, the issue of mammography in forty-something women isn't so cut and dry. posted by Sydney on
7/17/2003 09:48:00 PM
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Stanford Antisocial Disorder: The author of Legally Blonde on Stanford Law School:
I was in my first week of law school, in 1993, and I saw this flyer for "The Women of Stanford Law," so I was like, "I'll go and meet some nice girls. Whatever."
I went to the meeting, and these were not women. These were really angry people. The woman who was leading it spent three years at Stanford trying to change the name "semester" to "ovester." I started laughing and I realized everyone in the room took it very seriously. So I didn't make any friends there.
The school wasn't hard at all. It was the people - the most loathsome dose of antisocial disorder. It was like an anthropological study of the law school species, and since nobody talked to me after my "ovester" moment where I started laughing, I had plenty of time to watch people and write letters. I was just writing letters to my friends to kind of amuse myself. By the end of my first semester, I had like 300 pages.
"Ovester"? What would that woman think if she found out that "semester" shares the same root word as "menses"? posted by Sydney on
7/17/2003 07:06:00 PM
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Viral Wit: There's some worrisom evidence in Europe that resistance rates of HIV to antiviral drugs are increasing:
The study involved 1,633 patients from 17 European countries who were recently diagnosed with the virus that causes AIDS and who had not yet been treated for it, according to the Times. About 9.6 percent of the patients were resistant to at least one of the three types of anti-retroviral drugs that suppress the virus that causes AIDS, the newspaper said.
I always wondered about that. Viruses are much better at changing their genome than bacteria, which we know are good at developing drug resistance. We were bound to see an increase in HIV resistance sooner or later, especially with the reliance on long-term use of antivirals to suppress the illness. Which raises the question of whether sending large amounts of HIV meds to Africa is a wise move. Perhaps it would be better to concentrate on improving nutrition and public hygeine - and to focus on prevention. posted by Sydney on
7/17/2003 10:55:00 AM
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Foolish Politics: The Washington Post on what's wrong with the current Medicare debate in Congress:
Yet behind the squabbles lurk deeper issues. Of these, perhaps the one that has received the most attention is Medicare's universality. Many Democrats and some Republicans consider this to be Medicare's central attraction. It is a program, they say, that gives the same benefits to everybody, rich or poor, and therefore receives universal political support. To preserve this universality, many are fighting against a provision in the House bill, for example, that calls for people with incomes above $60,000 to pay a larger share of their drug bills. They object on the grounds that nobody should be treated differently.
This kind of thinking helps to illustrate what has gone so deeply wrong with the bill, a piece of legislation that seems to be oblivious to its long-term consequences. In practice, the refusal to countenance any means-testing will set in motion a vast transfer of wealth, from the pockets of America's poorer children -- who will eventually be working adults -- to America's wealthier elderly. The desire to maintain political support for Medicare is understandable, but the zealous opposition to any reform that would provide fewer benefits for the rich is profoundly misplaced. It guarantees the swindling of a generation that cannot vote in order to benefit a wealthy constituency that can.
Class Action Logic: The problem with class action lawsuits:
Like many average IPO investors, Gallagher is hazy on exactly what iBeam or its investment bank was alleged to have done wrong. But he feels he deserves a cut of the settlement anyway.
``I feel I deserve it because, well, I'm not certain why,'' Gallagher said sheepishly. ``Nobody talked me into it, that's for sure. The opportunity was there, and I decided to go for it.''
Too Much Brain: Researchers say that autistic children grow too much brain in infancy:
"During this period of important learning and plasticity, when the brain is experiencing the world and deciding how to construct itself, it's growing too fast in the infant with autism," said senior author Eric Courchesne. He is a professor of neurosciences at the University of California-San Diego, and director of the Center for Autism Research at Children's Hospital and Health Center in that city.
"Without the guidance of experience and learning, the brain may be creating abnormal connections that make it very hard for autistic children to make sense of the world they live in," he added.
The accelerated brain growth occurs well before the first clinical signs of autism, and appears to predict the severity of the condition later in childhood, as well as the degree of brain abnormality at a later age.
The full study is here (available in its entirety - for free). It's an interesting hypothesis, but it remains just that - a hypothesis. The study only looked at head circumference measurements of autistic children, then compared the data to national averages. A better study would have been to compare the head circumference measurements between the autistic group and the same number of children without autism from the same geographical area. There very well could be a subset of normal children whose head circumference grows rapidly in infancy, too. But you can't tell that from this study.
And there's an even more fundamental problem with the study. The autistic children's head circumferences were within two standard deviations of the mean for normal head circumferences. Usually, two standard deviations from the mean are required to make a significant difference.
Virus of the Moment: Now that SARS has quieted down, everyone can turn their attention to West Nile again:
The West Nile virus is spreading much more quickly this year than last, raising fears the new infection may take an even bigger toll on people and wildlife, federal health officials said yesterday.
The virus has already been detected this summer in mosquitoes, birds, horses or other animals in at least 32 states, including Virginia, the federal Centers for Disease Control and Prevention in Atlanta reported. At this time last year, about 20 states had detected the virus.
But wait. Wasn't the virus new to most states last year, whereas this year it's alreay established in the continental United States? Yep:
The virus spread to 44 states last year, when more than 4,000 cases of human West Nile infection were reported, including 284 deaths. Health experts believe the virus is now permanently established in this country.
So of course more states are going to be reporting the virus this year. It doesn't have to be imported anywhere by birds and mosquitoes before it shows up. It already lives in states from coast to coast. posted by Sydney on
7/16/2003 07:13:00 AM
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SARS Update: Now that things have quieted down a little on the SARS front, those who were living and working in its midst have time to sit back and reflect on their experiences:
Infection with the SARS virus leads to critical illness in as many as one-quarter of patients. These people typically require prolonged treatment with respirators. Nearly half of those that do need mechanical breathing help die of the infection. In addition to serious lung damage, other deadly complications can include multiple organ failure, blood clots and shock resulting from blood infection.
The paper's over at JAMA's website, but you have to pay a pretty price to read the whole thing. The linked above is a good synopsis, though. posted by Sydney on
7/16/2003 07:04:00 AM
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Blame the Steak: Now fats are being blamed for breast cancer:
Researchers found that those women who ate the most red meat and high-fat dairy were 33% more likely to develop breast cancer than the women who ate the lowest amounts of those foods.
Of course, that's in relative risk, not absolute risk. The study is only available online to subscribers, but the abstract sheds no light on the issue. It, too, hides the results behind "relative risk" assesments. It does, however, provide a glimpse at how small and insignificant this finding is:
Dietary fat intake and breast cancer risk were assessed among 90,655 premenopausal women aged 26 to 46 years in 1991. Fat intake was assessed with a food-frequency questionnaire at baseline in 1991 and again in 1995. Breast cancers were self-reported and confirmed by review of pathology reports. Multivariable relative risks (RRs) and 95% confidence intervals (CIs) were calculated. All statistical tests were two-sided. Results: During 8 years of follow-up, 714 women developed incident invasive breast cancer.
To begin with, the estimate of fat intake was based on a survey - a notoriously unreliable method of gathering information. (scroll up for link). Then, out of 90,655 women, only 714 developed breast cancer. That's 0.007%. And the final kicker, the difference between the highest fat eaters and the lowest fat eaters, even in relative risk, was only 33%, an amount that's not usually considered statistically significant. "So, what?" say the researchers. They're not going to let the publicity gold mine of a study combining the media's two favorite health topics - fat and cancer - go unplumbed:
"What this study says is diet counts," said Len Lichtenfeld, deputy chief medical officer for the American Cancer Society.
The 33% increased risk means that about one in every 20 cases of breast cancer is caused by animal-fat intake in young adult women, said Patrick Remington, a professor of public health at the University of Wisconsin Medical School. That could be up to 10,000 women this year, based on the cancer society's estimate of breast cancer diagnoses in U.S. women.
Epidemiologists generally consider a relative risk factor of 33% to be small. But even a small risk could become an important public health concern, Remington said.
The recipe for modern medical research success: Take a handful of research subjects. Sprinkle with a pinch of differences in outcome. Combine with unreliable data. For leavening, multiply by the U.S. population. Mix liberally with experts who haven't read the study. And there you have it...... media significance.
Just a Reminder: Iain Murray's excellent weblog is here now. Do drop in and pay him a visit. posted by Sydney on
7/15/2003 10:19:00 PM
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The Importance of Tonsils: Tonsils aren't removed with anywhere near the frequency they once were. Here's a story about a doctor who put the brakes on tonsillectomies in the 1940's. Amazingly, he's 100 years old and just retired seven years ago. posted by Sydney on
7/15/2003 07:26:00 AM
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The Couric Effect: Regardless of how one may feel about her, there's no denying that Katie Couric has influenced America's healthcare:
In the weeks and months after Katie Couric underwent a colonoscopy on the morning news program three years ago, the number of people getting the colorectal cancer screening jumped by 20 percent, according to a study in this week's Archives of Internal Medicine. Researchers at the University of Michigan Health System and University of Iowa, who did the study, said the public response was so strong, they dubbed the increase ''the Katie Couric Effect.''
I still invoke her to get people to have colonoscopies, and to help explain what a colonoscopy is. When I get blank stares after my explanation, I just say "The thing Katie Couric had on the Today Show." and the eyes will light up in recognition. posted by Sydney on
7/15/2003 07:10:00 AM
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Judging Peers: There's an interesting discussion over at DB's Med Rants on who should sit in judgement in malpractice cases - a panel of doctors or a regular jury. It's tempting to prefer the panel of doctors. They're more likely to understand the intricacies of medical diagnosis. But, juries aren't necessarily the problem in the liability crisis. Most of the time, they return verdicts that favor the defendant. It's defending the frivolous cases and paying out the large punitive damages that are the problem.
Also, there's no reason to expect that doctors would be better at judging one another. Some physicians are so arrogant that they think their way is the only correct way ( remember yesterday's expert witness testimony - scroll up). And others have trouble criticizing a colleague at all. This is especially true in rural areas, where the supply of physicians is limited, and all of the doctors in an area rely on each other for referrals. No one is eager to offend in those situations.
Then, there's the whole issue of transparency. The public isn't likely to trust us if we are the only ones who sit in judgement of our errors. While it's true that this is the way lawyers discipline themselves, we don't want our profession to descend to the levels of public trust that the legal profession has. Do we?
Expertise or Arrogance? A reader forwarded these case reports of expert witnesses in the field of radiology:
Defense attorney (A): Doctor, what is the standard of care for a radiologist?
Plaintiff ’s expert witness (W): To make the correct diagnosis on an X ray.
A: Are you saying, Doctor, that every time a radiologist misses a diagnosis on an X ray, he or she is guilty of malpractice?
W: Yes.
A: Have you ever missed an abnormality on an X ray?
W: Not that I’m aware of.
But not all expert witnesses claim to be the height of perfection:
A: Doctor, in your experience, do you know if you have ever had occasion to miss a nodule on a chest X ray?
W: Yes.
A: On how many occasions?
W: I don’t know. Unfortunately, I see the ones other people miss, and they see the ones that I miss.
A: Do you have any estimate?
W: Very rarely.
A: What does that mean?
W: Maybe once or twice in my life.
Whenever someone claims they never make mistakes, it can mean only one thing. They're too arrogant to recognize their mistakes.
posted by Sydney on
7/14/2003 06:53:00 AM
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Pure, Sweet, Sugar: A BBC report says that sugar is as addicting as heroin:
Dr John Hoebel and colleagues at Princeton University in New Jersey based their theory on a study of rats.
They found that rats fed a diet containing 25% sugar are thrown into a state of anxiety when the sugar is removed.
Their symptoms included chattering teeth and the shakes - similar to those seen in people withdrawing from nicotine or morphine, according to researchers.
Dr Hoebel said he believed high-fat foods stimulate opioids or 'pleasure chemicals' in the brain.
"The implication is that some animals - and by extension some people - can become overly dependent on sweet food," he said.
Oh, but wait. That's just a theory, and a theory based on findings in this type of study on rats. It should be noted that the symptoms of rat anxiety occurred after they deprived the animals of food. Deprive any animal of food long enough and they'll get anxious.
The BBC does quote a researcher whose study is supposedly published, although not available yet online judging by their links:
Ann Kelley, a neuroscientist at the University of Wisconsin Medical School, the behaviour of rats after the were given sweet, salty and fatty foods.
She found a link between the brain's pleasure chemicals and a craving for this type of food.
She stimulated the rats' brains with a synthetic version of the natural opioid enkephalin. This caused rats to eat up to six times their normal intake of fat.
In addition, Dr Kelley identified long-lasting changes in rats' brain chemistry - similar to those caused by extended use of morphine or heroin.
Dr Kelley said: "This says that mere exposure to pleasurable tasty foods is enough to change gene expression and that suggests that you could be addicted to food."
Let's see, eating tasty food is a pleasure. Yes, we knew that. Getting high makes one eat more. Yes, we call that the "munchies." Getting high a lot alters your brain chemistry. Yes, we knew that. But does eating tasty food make you (or rats) high, and does it change the gene expression? No evidence of that based on the study synopsis provided by the BBC. Of course, that won't stop the trial lawyers from using it to turn a quick buck.
UPDATE: Another thought. Why are they doing this study in rats? The addicting properties of sugar or fast food could easily be tested in humans. Just feed people a diet high in sugar or fast foods and then take it away and see what happens. Of course, we all know why this isn't done. There would be no physical signs or symptoms of withdrawal comparable to heroin. Thus, no results to publish.
Unreliable Surveys: College students exaggerate their drinking exploits:
So far, the Kent State group's findings -- based on the 2002 research -- goes against conventional wisdom that drunkenness is a fairly regular state of being for many college students.
Graduate students working with Thombs gave breath tests to students on Wednesday though Saturday nights over 15 weeks. For Thursday through Saturday nights, students had an average blood-alcohol level in the moderate range -- from 0.048 to 0.051 percent. To be considered legally drunk in Ohio, the blood alcohol level must be 0.08 percent or above.
Yet under the definitions used in other studies, many of these students would be classified as ``binge drinkers,'' Thombs said. That's because many male students reported drinking five or more drinks and many female students reported drinking four or more. The so-called binge-drinking measure does not show if the alcohol was consumed over a number of hours, Thombs said.
New Weapon: Canadian researchers say that activated charcoal may help diminish the severity of peanut allergy reactions:
If taken early enough, the activated charcoal acts on the peanut protein in the stomach and prevents the allergen entering the bloodstream and causing the severe reaction.
"This provides us with another tool for treating the reaction. Even more than that, it is also a means of very effectively nipping in the bud the reactions when they are still at a very mild stage," said Dr. Vadas, director of the Division of Allergy and Clinical Immunology, where the discovery was made.
It has to be taken early, before the peanut proteins are absorbed into the blood stream, so it's important that the epi-pens still be kept on hand. Still, it's good news to know that there's something else to help in accidental ingestions.
It's also very messy, so it's still critical that people with peanut allergies avoid peanuts. Its mechanism of action is described here. posted by Sydney on
7/13/2003 08:20:00 AM
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Barriers to Treatment: A focus group of asthma patients has uncovered several barriers to treatment, including this one:
One of the barriers that was specific to this population was the belief that the patient's assessment of their disease control was superior to that of their provider.
I've noticed that, too, especially with my more recalcitrant asthma cases (and other diseases, too.) Not sure how to overcome that one. I even have a patient who was intubated last year for asthma, yet doesn't use his maintenance inhalers or monitor his peak flows because he "feels fine." If a near death experience won't change his ways, I don't know what will. posted by Sydney on
7/13/2003 07:38:00 AM
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Loose Standards: The FDA is loosening the standards for the claims food and supplement manufacturers make on their labels:
Health claims previously had to be supported by ''significant scientific agreement.'' One that has been OK: ''Calcium may reduce osteoporosis.''
Under the new procedures, which go into effect Sept. 1, health claims will be allowed based on different levels of agreement among scientists:
* A, significant scientific agreement for the claim.
* B, good scientific evidence but not conclusive.
* C, limited and inconclusive envidence.
* D, little scientific evidence supporting the claim.
They say that the change is in response to recent court rulings that indicate current standards may be an infringement of free speech. The food makers, I'm not so worried about, but the "supplements" include a wide range of herbal and other alternative medication which are more medication than food. They should be held to the same standard as every other drug. posted by Sydney on
7/13/2003 07:28:00 AM
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Hindsight: One of the neurosurgeons who tried to separate the conjoined Iranian twins shares the lessons learned.
posted by Sydney on
7/13/2003 06:53:00 AM
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