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Saturday, August 09, 2003The Lancet report was based on the ''Million Woman Study'' which surveyed 1,084,110 women in the United Kingdom aged 50 to 64. They were recruited between 1996 and 2001, and followed up for cancer incidence and death. Professor Valerie Beral, director of the Cancer Research UK Epidemiology Unit and lead author of the study, said there was ''overwhelming evidence'' that the combination therapy was associated with a greater cancer risk. Among 1,000 postmenopausal women who do not use HRT, there will be around 20 breast cancer cases between the ages of 50 and 60, Beral said. In every 1,000 women who begin 10 years of HRT at the age of 50, there will be five extra cases among estrogen-only users and 19 among estrogen-progestin combination users, she said. Dr. JoAnn Manson of the Harvard University Medical School commented that ''the evidence is now compelling that estrogen plus progestin is more deleterious to the breast than estrogen alone.'' Unfortunately, the full article isn't available without a subscription, but the abstract is: 1,084,110 UK women aged 50-64 years were recruited into the Million Women Study between 1996 and 2001, provided information about their use of HRT and other personal details, and were followed up for cancer incidence and death. ...Half the women had used HRT; 9364 incident invasive breast cancers and 637 breast cancer deaths were registered after an average of 2·6 and 4·1 years of follow-up, respectively. The abstract doesn't make clear whether that was 9,364 total breast cancers out of the more than 1,000,000 women in the study or if that figure is just for the women who used hormones. Either way, it's an awfully small proportion. The rest of the abstract expresses the results only in terms of relative risk - which is meaningless in the face of such small numbers. Meanwhile, here in the United States, the Women's Health Initiative people now say that hormone replacement therapy doubles the risk of heart disease: "For American women who have been told that hormones are still safe if taken short-term, there was more bad news Thursday. In a study published in the New England Journal of Medicine, researchers report that women taking a leading combination hormone therapy for menopause face nearly double the risk of a heart attack in the first year of use." Here’s what the study actually found: 188 out of 8506 HRT users had coronary heart disease (defined as a heart attack, fatal or nonfatal). That’s just 2.2% of estrogen users. For non-users the incidence was 147 out of 8102, or 1.8%. Not much of a difference. They then expanded the definition to include women who had symptoms of heart disease. But expanding the definition narrowed the gap even further. 369 out of 8506 users, or 4.3% had evidence of coronary artery disease, compared to 356 out of 8102 nonusers, or 4.4%. That's hardly a doubling of risk, now, is it? Interestingly, another study in the same issue that involved measuring the degree of coronary artery stenosis over time, confirms that there's no difference in the progression of coronary artery disease between estrogen users and nonusers. But that study hasn't gotten nearly the press that the first one has. The only thing that we can conclude from the studies done to date on hormone replacement therapy and the heart is that hormones don't prevent heart disease. And they don't appear to cause it, either. posted by Sydney on 8/09/2003 10:47:00 PM 0 comments
Friday, August 08, 2003Warnings by drug regulators about the safety of Paxil, one of the world's most prescribed antidepressants, are reopening seemingly settled questions about a whole class of drugs that also includes Prozac and Zoloft. ...And the findings have unsettled some of the very experts who absolved S.S.R.I.'s of a link to suicide a dozen years ago. Of the 10 American specialists who, as members of an ad hoc F.D.A. panel, formally cleared the drugs of a link to suicide in 1991, seven now say that the new information would prompt them to reconsider that decision, if they were asked. "In 1991, we said there wasn't sufficient evidence to support a link between these drugs and suicide," said Dr. Jeffrey A. Lieberman, a professor of psychiatry and pharmacology at the University of North Carolina and a member of the panel. "Now there is evidence, at least in children, and I wouldn't rule out that it's in adults, too." The furor has been set off by an analysis of unpublished studies by the British version of the FDA: The British regulators said that their analysis of the nine studies of Paxil found 3.2 times the likelihood of suicidal thoughts or suicide attempts among teens and children given the drug as among patients given a placebo. They also said that Paxil has not proved effective against depression in children and teenagers. The British regulator’s announcement is here, but it doesn’t shed any more light on the subject than the Times article. The evidence that these drugs increase the risk of suicide is sparse. In fact, it’s more than sparse. It’s unpublished and unavailable except to the regulators. The Medical Letter, an excellent, unbiased source of drug information, reviewed the subject last month and found the evidence wanting. According to The Letter, the FDC Reports cited a study that found among 1,134 children, “emotional lability” occurred in 3.2% of users compared to 1.5% of nonusers. “Emotional lability” was defined as “crying, mood fluctuations, thoughts of suicide and attempted suicide.” There were no completed suicides in the group. That's an important distinction. It isn't uncommon for depressed people, especially teenagers, to make a consciously feeble attempt at suicide - such as taking a drug they think is harmless, like Tylenol. Their goal isn't to kill themselves, but to gain attention. On the face of it, the current recommendation to avoid these drugs seems overly cautious. For one thing, compared to older anti-depressants, they are more effective and they are safer. In the old days, before SSRI’s, doctors always excercised caution with anti-depressants because the drugs themselves could be instruments of suicide. Patients would only be given a small amount of the drugs at a time, say a week or two, to avoid intentional overdoses. With the SSRI’s, that’s not a problem. The other suspicious aspect of the findings is that the suicide risk is highest in the first few weeks of the drug’s use. Paxil takes three or four weeks to work. Might it not be the case that the suicide risk is highest in those first few weeks not because of the drug but because the depression isn't yet fully treated? And Another Thing: Have you ever noticed that the New York Times has a bias against primary care physicians, especially family physicians? This is the second time in as many months that they’ve insinuated that primary care physicians - specifically family physicians - don’t know how to treat depression. The last time, their interview subject had to make a public apology, although The Times never did. UPDATE: Or maybe the suicide rate in the first few weeks of treatment is due to the success of the treatment, as this reader points out: There's an interesting theory about why SSRIs may actually lead to suicide in some cases that I, as a depression sufferer myself (treatable, thank god) find quite rational. When you are really depressed, you can barely get out of bed. Sometimes you just curl up in a ball. The very idea of leaving the house fills you with dread. In that state, you don't want to be alive but going through the motions of committing suicide is far beyond your capabilities. However, let's say you start an anti-depressant and START to feel better but insofar as recovery is slow you're far from feeling the full effect of the drug. During that short window of generally a few weeks you may get just enough recovery to kill yourself. That is, you're recovering but you don't realize it yet. You just realize that at last you have the ability to realize your fantasy of being dead. I'm sure the day will come when we have pills or some other therapy that will knock out depression in a day. But until then, I think the possibility of the occasional suicide as opposed to a lifetime of depression is a highly acceptable trade-off. Deep depression is death anyway. Good point. posted by Sydney on 8/08/2003 08:44:00 AM 0 comments
Thursday, August 07, 2003In Vermont, where I served as governor for the last 11 years, nearly 92% of adults now have coverage. Most importantly, 99% of all Vermont children are eligible for health insurance and 96% have it. But that's not it. We coupled our success in insuring kids with a new early childhood initiative that we call "Success by Six." As a result, nine out of 10 parents with a newborn baby -- regardless of income -- get a home visit from a community outreach worker who's there to help them with parenting skills and to put those parents in touch with the services they may need or want. Thanks to Success by Six, we've cut our state's child abuse rate nearly in half, and child sexual abuse of kids under 6 is down by 70%. If Vermont -- a small, rural state that ranks 26th in income in the United States -- can achieve this, surely the country that ranks No. 1 in the history of the world can do so as well. I'm not so certain that lower child abuse and sexual abuse rates can be completely credited to the Success by Six program. There could also be tougher reporting laws that account for it, or stiffer penalties for abusers. And as Miller points out, Vermont actually lags behind other New England states with lower taxes in indicators of children's health such as infant mortality and vaccination rates. Vermonters just must not be using the services they've been handed. But here's Dean's plan for the nation: 1. He'll expand Medicaid to cover everyone, rich and poor, under 25 years of age: First, and most important, in order to extend health coverage to every uninsured child and young adult up to age 25, we'll redefine and expand two essential federal and state programs -- Medicaid and the State Children's Health Insurance Program. Right now, they only offer coverage to children from lower-income families. Under my plan, we cover all kids and young adults up to age 25 -- middle income as well as lower income. This aspect of my plan will give 11.5 million more kids and young adults access to the healthcare they need. 2. He'll also expand it to cover everyone making up to 185% of the federal poverty level: Second, we'll give a leg up to working families struggling to afford health insurance. Adults earning up to 185% of the poverty level -- $16,613 -- will be eligible for coverage through the already existing Children Health Insurance Program. By doing this, an additional 11.8 million people will have access to the care they need. 3. He'll also establish another federal health insurance program: Many working families have incomes that put them beyond the help offered by government programs. But this doesn't mean they have viable options for healthcare. We'll establish an affordable health insurance plan people can buy into, providing coverage nearly identical to what members of Congress and federal employees receive. And subsidize the premiums with a tax credit: To cushion the costs, we'll also offer a significant tax credit to those with high premium costs. By offering this help, another 5.5 million adults will have access to care. 4. The government insurance program will be offered to employers at a discounted rate, and it will cover COBRA premiums for the recently unemployed: With the plan I've put forth to the American people, we'll organize a system nearly identical to the one federal workers and members of Congress enjoy. And we'll enable all employers with less than 50 workers to join it at rates lower than are currently available to these companies -- provided they insure their work force. I'll also offer employers a deal: The federal government will pick up 70% of COBRA premiums for employees transitioning out of their jobs, but we'll expect employers to pay the cost of extending coverage for an additional two months. 5. And finally, he'd require all employers to provide health insurance to their employees: The final element of this plan is a clear, strong message to corporate America that providing health coverage is fundamental to being a good corporate citizen. I look at business tax deductions as part of a compact between American taxpayers and corporate America. We give businesses certain benefits, and expect them to live up to certain responsibilities. Those are, in many ways, laudable goals, but they're also very expensive ones. At a time when national defense is of utmost importance, it's hard to justify spending so much on so many who don't really need the help. Then, too, how do you make all of that new federal health insurance program "affordable"? You could ration care, and only pay for a limited number of services. But everyone cries foul whenever an insurance company - be it private or Medicare - takes that approach. The only alternative is then also an inevitable one - pay for everything but control the prices. Which means that doctors and hospitals, already pinched by inadequate reimbursement, would be driven into further economic losses. But the biggest drawback to his healthcare plan is that it insists on maintaining the status quo of having a third party bear the brunt of healthcare costs. The actual consumer and his provider continues to be divorced from the financial reality of their healthcare decisions - which aren't always matters of life and death. In this day and age of expensive cosmetic pharmacology and minimally beneficial, but expensive preventive drugs and procedures, that's just asking for trouble. posted by Sydney on 8/07/2003 01:21:00 PM 0 comments
Wednesday, August 06, 2003posted by Sydney on 8/06/2003 09:50:00 AM 0 comments
Tuesday, August 05, 2003"The federal government should require all health insurance policies to pay for vaccines, should reimburse insurers for the costs and should subsidize vaccines for uninsured people, an expert panel from the the National Academy of Sciences said Monday." Of course, doing that would drive up the cost of health insurance. But, as things stand now, doctors are the ones subsidizing vaccines. You'd be surprised at how expensive some of those childhood vaccines can be. Ten doses of the chickenpox vaccine (the smallest amount I was able to find from suppliers) cost $600. The Comvax, which combines Hib and HepB is $360 for ten doses. And those are only three of the seven recommended immunizations for childhood. Yet, reimbursement from insurance companies is often so poor, it doesn't cover the cost. A friend of mine who opened her own practice recently doesn't offer immunizations because she can't afford them. Myself, I'm struggling with the decision. I believe I have an obligation to provide the immunizations to my patients. But frankly, I, too, am having trouble finding the funds to buy them. The cost of buying the smallest supply of childhood immunizations possible is more than all the rest of my medical supplies for the start-up of my practice. I'll probably compromise and only offer those that are required for school. Since most of the vaccines are required for public school attendance, and since they're given for the greater good of the general public, it actually makes sense to have the federal government subsidize them for everyone. Right now, they do that only for the poor, those without insurance, and those whose insurance plans don't cover immunizations. (Evidently the National Academy's panel never heard of the Vaccines for Children Program.) The only ones left to subsidize are the insurance companies. A better solution would be to leave the insurance companies out of it altogether and just have the same government-subsidized immunization program for all citizens. posted by Sydney on 8/05/2003 07:22:00 AM 0 comments
Monday, August 04, 2003posted by Sydney on 8/04/2003 08:41:00 AM 0 comments
Sunday, August 03, 2003John at Number Watch would love this type of digit twiddling. 1) Although the number of 70 and older killed increased by 27% the number of drivers 70 and older increased by 32% 2) The average daily mileage of 70 and older drivers also increased by 20%. By my calculation: 1) The accident RATE per driver changed by 1.27/1.32 or 0.96, DOWN 4%. 2) The accident rate per mile changed by 1.27/(1.32*1.20) or 0.80, DOWN 20%. Figures don't lie, but liars figure. posted by Sydney on 8/03/2003 11:42:00 AM 0 comments
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