"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
Note: I don't agree with the artist's message, but his use of clinical photographs to get his message across still made me laugh. posted by Sydney on
9/13/2003 06:38:00 PM
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School Hazards: School's been in session for two weeks now. Plenty of time for the children to share colds, sore throats, and head lice. One of the most frustrating things about treating head lice is reaching the nit-free state required by many public schools. (Nits are the egg cases the little creatures leave behind on the hair shafts.) Turns out that nit-free isn't necessary:
According to an article published in the May 7, 2001 issue of Pediatrics, more than 1,700 Atlanta-area schoolchildren were examined for head lice. Ninety-one were found with nits alone or lice. Of the 63 children with nits only, 50 completed the study. Of the 50 children with nits alone, only 9 or 18% became infested with lice during the 2-week follow-up. “This is good evidence that most nits do not develop into lice,” says Allen Hightower, statistician for the study. “There is some evidence that nits found within 1/4 inch of the scalp will develop into lice, but even in these cases, two-thirds did not.” In the study, seven of 22 children with five or more nits found within 1/4 inch of the scalp developed a lice infestation during the 2-week follow-up. The data suggest that health policy developers consider re-evaluating the usefulness of a "no-nit" policy that excludes children from school just because nits alone are found in the hair.
Treating SARS: It may be that the best treatment is no treatment:
Ninety percent of people suffering from Severe Acute Respiratory Syndrome (SARS) in China recovered naturally without using drugs, reports have cited a Chinese medical official as saying.
Director of Guangzhou Institute of Respiratory Diseases, Zhong Nanshan, was Advertisement
quoted by the Apple Daily as saying that these patients had only required "a good rest and good support" to recover, adding that no drug treatment had been needed.
Of course, these are the same people who said there was no SARS, so take it with a grain of salt. And yet, the consensus seems to be that supportive care (mechanical ventilation, IV fluids, etc.) is the only treatment we have that's effective:
His comments seemed to provide support for those medical experts who criticised the Hong Kong health authorities for continuing to use a mixture of the anti-viral drug Ribavirin and steroids to treat SARS patients.
US experts have stated Ribavirin is not effective in tackling SARS while a recent study by Hong Kong's Chinese University also concluded the anti-viral drug was largely ineffective in treating the pneumonia-like disease. posted by Sydney on
9/13/2003 03:21:00 PM
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Mercury Update: A few days ago, I cynically accused a school of over-reacting to a teaspoon of mercury in classroom carpet. A reader pointed out to me that mercury can disperse across a wide area when it's in ground into carpet (see the update here, if my archives are working.) And sure enough, there have been case reports of children getting mercury poisoning from small spills in carpet:
A 9 year old boy presented to his local hospital with a three week history of abdominal pain, constipation, lethargy, limb pain, and unsteadiness. Physical examination showed mild facial weakness, areflexia, ataxia, and impaired sensation and led to a provisional diagnosis of Guillaine-Barré syndrome. The boy's constant restlessness was considered strange, but his mother described him as hyperactive and regarded this behaviour as normal. It was noted, however, that his handwriting and schoolwork had deteriorated over the preceding month.
...Three months before presentation, our patient had dismantled the sphygmomanometer in his bedroomspilling mercury on his bed and carpet and had played with it for a day or two before informing his mother. Attempts had been made to dispose of the mercury by vacuuming, and then by flushing it down the toilet.
The suspected diagnosis of mercury poisoning was confirmed by the finding of a serum mercury concentration of 1000 nmol/l (normal reference value <30 nmol/l).
Thy Saving Health: A nearby nursing home has recently finished a pilot study on the power of prayer:
Cameron was among the 10 staff members who volunteered to participate in the study by praying two or three times a day for 15 long-term residents. The residents selected for prayer did not know they were being prayed for, and the staff members didn't know their identities.
Each staff member was instructed to pray for two residents -- identified by a letter in the alphabet -- in five specific areas: mood/behavior, pain, infection, falls and weight. Richison, the only staff person who knows the names of the residents, prayed for each resident by name and by needs two or three times each day.
Although the project ended Aug. 31, staff members still find themselves praying for their assigned letters.
``I'll be praying for `I' and `J' forever. It will never really end,'' said Darlene Seaver, director of activities at Traditions. ``I'll just keep praying and believing the prayers are working.''
A preliminary look at the data related to falls indicates that the group being prayed for had fewer falls, and that when falls did occur, they resulted in less injury. Complete results from the study are expected to be compiled within two months.
The results haven't been published yet, but even if you don't believe in the power of prayer, there's a good possibility that the approach helped improve the care of the residents. Even though the participants didn't know the names of the people for whom they were praying, the prayer meetings did help focus their attention on their patients and brought the staff members some inner peace as well:
Staff members are confident the results will show prayer works and affects the well-being of long-term-care residents. They are already reporting a positive impact on their personal spiritual lives.
``I've been more peaceful and happy,'' said Laurie Winkleman, nurse case manager. ``It strengthened my prayer life and just gave me a sense of peace.''
Staff members also said weekly meetings that brought them together for prayer served to bring them closer together.
Happy workers are better workers, and there's a good chance that the time spent thinking about the well-being of their elderly charges made them more conscientious about their care.
posted by Sydney on
9/13/2003 09:44:00 AM
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Hippocrates' Descendants: Greek doctors have been conning British tourists. Does the sting of imperialism last this long? Or is it just tourist fatigue?
One of my colleagues once practiced in Maine. I asked him once why he left, and he said he got tired of having to "bend over and kiss the butts" of all the wealthy summer residents. (Wanted house calls, demanded more than their fair share of time, etc.) And he's someone who is usually over-accomodating to his patients. Can't imagine things are much different in Corfu. posted by Sydney on
9/12/2003 08:37:00 AM
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Looking for a Cure: Two clinical trials of West Nile treatments have started this week. One uses Israeli blood to try to fight an already existing infection:
A study sponsored by the National Institute of Allergy and Infectious Diseases is now enrolling patients already infected with West Nile to see if intravenous infusions of antibodies, substances produced by the immune system to fight infection, will prevent death or brain damage. The clinical trial will enroll about 100 patients who are hospitalized and have West Nile encephalitis or are at risk of developing it.
The antibodies were taken from the blood of Israeli blood donors, says microbiologist Bracha Rager.
... Because West Nile is common in Israel, she says, most adults there have developed antibodies to it that protect them. Based on this research, Omrix, an Israeli company, developed the treatment that will be used in the study.
The other tries to block viral replication:
In another study, scientists at AVI Biopharma of Portland, Ore., expect to begin treating patients this week with a drug based on a technology called "antisense," which reproduces pieces of the DNA of the virus or gene the drug is trying to attack. When given to a patient, the drug binds to the part of the DNA it mirrors, making it impossible for the West Nile virus to replicate.
Meanwhile, in other viral news, Bill Gates is putting his money behind the search for a cure of another mosquito-borne infection that's a much more serious threat worldwide:
The Seattle philanthropy is contributing $55 million to a consortium called the Pediatric Dengue Vaccine Initiative that includes research institutions, public health organizations and industrial firms. The Gates grant will be managed by the International Vaccine Institute, a Seoul-based organization that specializes in Third World vaccine development.
Dengue, and its more serious manifestation known as dengue hemorrhagic fever, is spread like West Nile by certain species of mosquitoes. Tens of millions of people, mostly in tropical regions, come down with dengue fever every year and thousands die from it.
And some people think the smallpox vaccine will protect against HIV. The evidence is shaky:
To test the theory, Alibek and Weinstein studied blood samples from 10 people who received the smallpox vaccination and 10 who did not.
When the HIV virus was introduced to the blood samples of those who had been vaccinated, the virus either failed to grow or had its growth slowed considerably. The study results were statistically significant despite the small sample size, Alibek said.
Bet that if it pans out, suddenly there won't be so many objections to its safety, or to offering it to young people. posted by Sydney on
9/12/2003 08:34:00 AM
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Motivation: The benefits of exercise are extolled in this week’s research round-up over at JAMA. For one thing, it can reduce the risk of breast cancer:
The researchers analyzed data on 74,171 women ages 50 to 79 who participated in the government's Women's Health Initiative study from 1993 to 1998.
Women who said they engaged in about 1.25 to 2.50 hours of moderate exercise weekly had an 18 percent lower risk of breast cancer than inactive women.
But, as is their wont, the Women’s Health Initiative is exaggerating the implication of their findings by publicizing the relative risk rather than the actual risk. According to their data the annualized incidence rates between the physically active and couch potatoes only differ by a few percentage points, except for 35 year olds where the difference is ten percentage points.
But, on a more encouraging note, a little bit of exercise is just as likely to help you lose weight and keep your heart healthy as strenuous exercise:
A separate study in JAMA found that moderate exercise combined with dieting is about as effective as intense exercise in helping younger women lose weight and improve cardiovascular fitness.
Interestingly, with diet and exercise, the women lost an average of 6 to 8 kg (13 to 17 pounds), not much different than the amount of weight loss claimed by diet pills like Meridia and Xenical. posted by Sydney on
9/12/2003 08:21:00 AM
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People want quick fixes, but that's not what works, he says. ''We are a hedonistic society, and people want what they want right now. They want fast results. But if you are going to get the weight off and kept it off, my experience has told me and the research shows that this is about really changing your lifestyle.''
In July 2003, a cluster of hepatitis A cases was identified among young adults who had attended outdoor concert and camping events featuring various "jam bands." As of September 2, a total of 25 cases have been reported among residents of nine states (Arizona, California, Colorado, Indiana, Michigan, New York, Oregon, Tennessee, and Wisconsin). The majority of cases were among young adults who attended concerts during the spring and summer. The median age of infected persons was 23 years (range: 17--44 years); 14 (56%) were male.
Twenty-five cases does not a major epidemic make, but evidently they were concentrated among fans of three particular bands. The notice from the CDC doesn't identify the bands whose fans were hardest hit, but they worry that there will be more spread of disease this fall :
The three bands that infected persons most commonly followed completed their summer concert tours in early August. However, fall tours are scheduled to begin in September. Concert attendees are advised to wash their hands frequently with soap and water, particularly after using the bathroom and before eating; to cook their food and drink only potable water; and to avoid food or drugs that could have been prepared under unsanitary conditions or handled by an infected person.
Who would have ever thought that the CDC would be giving out advice on how to prepare recreational drugs. The sixties generation really is the establishment now.
At least 17 of 23 people who fell ill in the past few months of a particular strain of salmonella ate at the restaurant, said epidemiologist Susan Lance-Parker of the Division of Public Health.
"We feel pretty certain there's a connection with the restaurant," Lance-Parker said.
One person who ate at the restaurant died, but whether the infection caused it wasn't clear because the person had other health problems.
Salmonella is a bad bug. It's found in chickens, beef, and fish, and passed on to us most often in undercooked meat these days, although it can also be passed person to person through sewage. It's the reason you shouldn't put a stuffed turkey in the refrigerator overnight.
Overkill: A school in our area has been closed for two days because of a mercury spill:
The contamination appeared to be mostly contained in a first-floor science classroom, where the silvery metal leaked from a manometer, a U-shaped glass device used to measure air pressure, Dieringer said.
About a tablespoon of mercury was found on the classroom's carpet, he said. Mercury vapor also was detected in the connected drains of two nearby restrooms, and two school mops and vacuum cleaners were contaminated.
Hmm. I seem to remember playing with mercury in science class. The teacher would put it in a pie pan and pass it around so we could watch the little coherent droplets scatter around the pan. I don't remember anyone getting brain damage from the exposure. But, in this day and age of overprotection, the small amount of mercury was a very big deal:
The Akron Health Department was notified Wednesday morning. Then the Akron Fire Department's hazardous materials team was called.
The Ohio Environmental Protection Agency also was notified, though the spill did not have to be reported to the EPA because it was under 1 pound, or about a fifth of a cup, said agency spokeswoman Kara Allison.
At least the EPA recognizes that it takes a certain amount of mercury to be toxic. To be fair to the school officials and the health department, though, they were probably following the prudent course to avoid running into any trouble with the Occupational Safety and Health Administration.
UPDATE: A reader says:
Mercury actually is rather dangerous. Its vapor pressure is 50 times the acceptable exposure limit, and it readily disperses into microscopic droplets that have a large aggregate surface area. It's a fairly common occurrence for kids to develop clinical signs of mercury poisoning after finding a small vial.
In large enough concentrations mercury is dangerous. However, it isn't necessarily true that it's common for kids to develop clinical signs of mercury poisoning after finding a small vial, unless they intentionally inhale it repeatedly, or they spill it and ground it into the carpet. The reader provides a link to this site, which
has this to say about mercury spills:
The element mercury is a liquid metal with a vapor pressure of 0.00185 mm at 25 degrees C. This corresponds to a saturation concentration in air of 20 milligrams of mercury per cubic meter of air or 2.4 ppm . The American Conference of Governmental Industrial Hygienists has established a threshold limit for mercury vapor of 0.05 milligrams of Hg per cubic meter of air for continuous 40 hour per week exposure. Long term chronic exposure to mercury vapor in excess of 0.05 mg Hg per cubic meter of air may result in cumulative poisoning. The use of mercury in laboratory amounts in well-ventilated areas is fairly safe; however, mercury can present a health hazard under the following circumstances:
1. When a mercury spill is not cleaned up promptly it may be ground into the floor, fracturing into extremely small particles with a large total surface area (6.4 ft for 1 ml as 10 micron spheres). From such large areas mercury may vaporize at a rate faster than the room's ventilation can safely dilute it.
There actually have been case reports of children who developed mercury poisoning after such a spill, as in this case:
Features of encephalopathy accompanied by peripheral neuropathy led to a suspicion of heavy metal poisoning. No history of likely exposure to lead could be found; there was no lead piping or paint at home. Further inquiry revealed that the patient's sibling had undergone renal transplantation as a result of nephrotic syndrome, and the family had been provided with a mercury sphygmomanometer for home blood pressure monitoring. Three months before presentation, our patient had dismantled the sphygmomanometer in his bedroomspilling mercury on his bed and carpetand had played with it for a day or two before informing his mother. Attempts had been made to dispose of the mercury by vacuuming, and then by flushing it down the toilet.
The suspected diagnosis of mercury poisoning was confirmed by the finding of a serum mercury concentration of 1000 nmol/l (normal reference value <30 nmol/l).
And so I stand corrected. The manometer spill on a carpet in the classroom wasn't an over-reaction. posted by Sydney on
9/11/2003 08:44:00 AM
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Wednesday, September 10, 2003
Premium Pay: The cost of health insurance just keeps going up:
As wages stayed stagnant, health care premiums skyrocketed by almost 14 percent in 2003, the largest such increase since 1990 and the third consecutive year of double-digit increases, according to a study released yesterday. And there are few signs that such increases would let up anytime soon.
Employees are paying 50 percent more for family medical coverage than they did just three years ago, according to the report released by the Kaiser Family Foundation and the Health Research and Educational Trust in Washington, D.C. That employee portion has now reached $2,412 - 27 percent of the total average premium cost.
And the rise in insurance costs is a prime explanation for why companies aren't creating new jobs - or giving their current employees raises, experts said.
Sadly, one of the reasons health insurance keeps going up is that we doctors keep giving patients expensive medication with marginal benefits. Just recently one of my patients told me his rheumatologist had put him on a new drug for osteoporosis, Forteo. He has to give himself daily injections for two years. He's never had a fracture. He just had signs of early osteoporosis on his bone densitometry. I asked him what he thought of it. He didn't like giving himself injections, but, if it would make his bones stronger it would be worth it. The trouble is, it might not be any better than less expensive oral medications. It's only been compared to placebo in clinical trials. And even then, the results weren't that dramatic:
The data also showed that Forteo reduced the relative risk of spinal fractures by 65 percent (9.3 % absolute risk reduction), compared with placebo, and lowered the relative risk of nonspinal fractures overall (sites such as the wrist, ribs, hip, ankle/foot, etc.) by 53% (2.9% absolute risk reduction), compared with placebo. (emphasis mine)
And the cost for that 9% and 2% reduction in the chance of a fracture? $600 a month. As my patient said, "Thank God I don't have to pay for it." Unfortunately, everyone else is paying for it.
If my patient did have to pay for the drug, no doubt he'd look at those numbers, factor in the inconvenience of giving himself a daily shot and say "No thanks, I'll take my chances." But absolutely no one in the loop has to make any of the choices or look at any of those numbers. Not the doctor, who no doubt wants to give every possible advantage to the patient. Not the patient, who wants to comply with his doctor's recommendation. Only the insurance company has any responsibility. But, if they refuse to cover the medication, they only stand to be accused of pinching pennies at the expense of quality care.
We need to come to our senses and accept more accountability for the decisions we make. But that isn't going to happen as long as there's no financial responsibility.
UPDATE: A reader points out:
I noticed that you left out side effects. Were there any. If there were, were they worse than the possible effects of osteoporosis?
In addition, there is an interesting thing to think about. Few insurers pay for alternative medicine. In general, you have to decide on alternative medicine without the rationalization that someone else is paying. If it does you good, you keep it up. If it doesn’t work you give it up. My wife who is a very small time practitioner of alternative medicine has a very rude rule with respect to alternative practitioners: If you see a practitioner three times and you aren’t feeling any better, then you should try something else. Imagine if such a harsh rule was applied to conventional medicine.
Like all lists of side effects, it's a very broad list. The drug is a synthetic version of parathyroid hormone, a hormone that regulates the metabolism of calicum. Theoretically, the side effects could be very similar to the symptoms of hyperparathyroidism. My patient's only complaint was that he would sometimes bruise himself while injecting the drug. But then again, he'd only been taking it for about a month.
And yes, conventional medicine often would fail the "three strikes and your out" test. The human body is so unpredictable.
UPDATE II: Another reader observes:
I wanted to say that weight lifting has been shown to increase bone mass too. For $600, you can easily buy a set of dumbbells from 1 lb to 45 lb plus a rack to hold them. For around $1800, or 3 months of that overhyped drug, you can buy a very nice home gym with weights going up to 200 lb. It takes longer to use than a shot of drugs, but the side effects are almost all highly beneficial (unless you drop a dumbbell on your foot). Even a gym membership doesn't cost $600/mo. posted by Sydney on
9/10/2003 08:20:00 AM
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Tuesday, September 09, 2003
The Future is Now at.... Is the day when our medical records include a profile of our DNA around the corner? (Or at least the 0.1 percent of our DNA that distinguishes us from other people) There's a lot of work to be done yet to identify the relevant 0.1 percent and what it does, but there are a lot of labs working on it - and press-releasing their findings, which makes it difficult to gage their progress. It's hard sometimes to separate the hype from the reality:
One skeptic, Elaine Mardis, a genetics expert at Washington University in St. Louis, worries that too many labs are releasing 'data by press release' rather than subjecting the information to scientific review. She isn't convinced that scientists are solving problems such as how to read longer DNA snippets or in developing precise instruments to perceive fluorescent light.
'Honestly, it's going to take us 10 or 15 years to get there,' she said of the $1,000 genome. 'The non-scientific public is hearing this and saying that sounds really great, and people must be at that goal because they're talking about it. That's totally not the case. This is the plan for the future, and the future is not now.' posted by Sydney on
9/09/2003 08:17:00 AM
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SARS Update: Investigators still haven't been able to pin down the origin of SARS, although they have found "Son of SARS," or maybe "Parent of SARS":
Count the mutations, geneticists say, and you can figure out how far removed this new virus is from its ancestor.
'The common link between those two is about a year ago,' when separation likely occurred between the virus in animals from the one infecting humans, said Earl Brown, a virologist at the University of Ottawa.
And it's highly possible that the virus has passed back and forth many times among animals and humans in the market that sells these exotic animals, he says.
'If it was bumping back and forth between people and animals a year ago then it probably wasn't making people that sick. But that's all part of the natural history of SARS, which we don't have together.
Requiescat in Pace: Warron Zevon died last night, of lung cancer. His philosophy was admirable:
Zevon said he 'chose a certain path and lived like Jim Morrison and lived 30 more years. You make choices and you have to live with the consequences.
By all accounts his last CD, finished when he was homebound by his illness, is excellent. More about his life and career can be found here.
The chorus of his song "Don't Let us Get Sick" from Life'll Kill Ya is a fitting tribute:
Don't let us get sick
Don't let us get old
Don't let us get stupid, all right?
Just make us be brave
And make us play nice
And let us be together tonight
The Slippery Slope: This is just so wrong - a woman becomes severely disabled and her husband, after denying her standard rehab care for ten years, now wants to deny her food and water. And the court agrees. According to her family's website, money is the root of it all:
In a malpractice lawsuit, Terri’s husband personally received over $300,000 for his loss of consortium. Terri was awarded $750,000 from this suit and an additional $250,000 from a separate malpractice lawsuit. The money was awarded to Terri for her care and rehabilitation and to be placed in a Medical Trust Fund. Terri’s husband received his personal award money and Terri’s medical fund money in early 1993. From the date he received the award money in 1993, Michael Schiavo has denied Terri any rehabilitation treatment. Michael Schiavo has confined Terri to a nursing home (currently, Terri is in a Hospice facility) where she is 'maintained.'
Her husband has directed that Terri only be sustained in a nursing home which is contrary to the intent of the award money. Michael Schiavo has on two occasions unsuccessfully attempted to end Terri’s life by instructing her caretakers not to medicate Terri for potentially fatal infections. The first occasion occurred less than nine months after her husband received the malpractice award money.
Of course, we're only getting one side of the story. Both sides could be equally motivated by the money. Who's to say her family won't be just as negligent if they get control of her funds? (Sadly, I've seen it happen with elderly people)
Still, it's unbelievalbe that a judge is going along with the husband's request to deny her food and hydration, and that her doctors are classifying her as being in a permanent vegetative state. So unbelievable that it's tempting to think that both the NRO article and the family are exaggerating. But, then, go to the video. She's severely disabled, yes. But vegetative, no. She's clearly responsive.
This is a situation in which the judge should exercise some, er, judgement. The court could give her parents the power to make healthcare decisions for her and appoint a trustee to manage the healthcare money. The court could solve her husband's problem by dissolving the marriage leaving him free to marry the mother of his children - and free from all obligations to his first wife. Such an arrangement would make everyone happy. At least it would in a world without greed.
Universal Suffering: According to a new survey, the majority of Americans are hurting most of the time:
New poll results show that more than half of all Americans (57 percent) have suffered chronic or recurrent pain in the past year. Surprisingly, younger people (18-34) were only slightly less likely than older Americans to be in pain. The impact of pain is experienced by three out of every four surveyed (76 percent), who are either suffering from pain themselves or have a close family member or friend who suffers.
The survey doesn't mention how the "chronic pain" or "recurrent pain" was defined, but it would be surprising if that many people actually had unremitting daily pain for months at a time, which is what "chronic pain" really is. The article says that the survey was sponsored by an unbiased advocacy group:
Research!America, a not-for-profit, public education and advocacy alliance, sponsored the nationwide survey timed to be released during September, which is National Pain Awareness Month.
Why would they time a survey to coincide with National Pain Awareness Month unless it was as a promotional gimmick? Which, in turn, calls into question the reliability of the survey. In fact, Research!America is a lobbying group for the healthcare research industry. Now, there's nothing wrong with pooling resources to advocate for more research dollars, but there is something wrong with using hyperbole and vague surveys to get those dollars.
The most likely force behind the survey is the chronic pain industry :
This survey should serve as a wake-up call to all Americans -- including our elected leaders -- that chronic pain is a problem of epidemic proportions in our country," said Mary Woolley, president of Research!America.
James Campbell, MD, chair of the American Pain Foundation, agrees that the survey reveals a widespread misunderstanding of both the prevalence and the debilitating effects of pain in our society. "These poll results show that pain is a pandemic health problem," Campbell said. "In a society where we can do heart transplants and treat AIDS, severe pain should no longer be acceptable. Perhaps most importantly, the poll demonstrates that pain research needs more emphasis and funding so that we can improve the quality of life for countless Americans."
Campbell is also professor of neurosurgery and director of the Blauststein Pain Treatment Center at Johns Hopkins University Medical Center.
Which means, of course, that he makes his living from pain research and management. Take it all with a grain of salt - and a grain of aspirin.
