"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
Spitting Against the Wind: A California couple has spent 3 million dollars on a house that supposedly keeps out germs:
The Landrys have built a home, for more than $3 million, whose architectural underpinning borrows from the school of germ warfare: its structure, largely of steel, has been treated with a substance to prevent the spread of bacteria, fungi, mold and other micro-organisms.
To mute the growth of germs, a silver-ion coating covers the door handles and faucets. The air-conditioning system contains elements that cleanse the circulating air. The doors have rubber jambs that keep unwanted pollen from seeping in, and the windows have double-laminated panes of UV-protected glass to prevent excessive sun exposure.
Think of the 11,000-square-foot estate as Chateau Disinfectant, or the Germinator.
Shades of the bubble man from Northern Exposure. Silver is known to have medicinal properties, especially antibacterial properties, although no one is quite certain how it works. There's speculation that it might interfere with bacterial cell membranes or some internal molecular pathways. For years, silver nitrate was used to prevent gonococcal eye infections in newborns. And there's an antibiotic cream called Silvadene, which is very useful for burns and abrasions. But how effective are silver ions at reducing exposure to ambient bacteria? The people who make it, say it's very effective (of course), but others say the evidence is shaky.
Certainly, it's not worth investing three million dollars to keep out bacteria. For one thing, given the ubiquitous nature of microbes, it's impossible to keep them all out. You'd have to hermetically seal yourself from the outside world to achieve that goal. For another thing, not all bacteria are bad. Our intestines rely on E. coli (in the appropriate numbers) to function properly. And there's pretty good evidence that everyday exposure to microbes helps keep our immune system bolstered against them and working properly.
And it looks as if eliminating all germs just may mess with your mind:
Mr. Landry had one health-related development, but it was imaginary: since moving into the house, he has experienced some hypochondria; it seems that living there has made him uncomfortably conscious of the lack of antimicrobial coatings elsewhere. "When I go to the bathroom in restaurants, I wash my hands, then use the towel to open the door," he said. "I never did that before. posted by Sydney on
10/11/2003 10:00:00 PM
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Overabundance: Interesting article in the New York Times on the root causes of our "obesity epidemic":
Cheap corn, the dubious legacy of Earl Butz, is truly the building block of the ''fast-food nation.'' Cheap corn, transformed into high-fructose corn syrup, is what allowed Coca-Cola to move from the svelte 8-ounce bottle of soda ubiquitous in the 70's to the chubby 20-ounce bottle of today. Cheap corn, transformed into cheap beef, is what allowed McDonald's to supersize its burgers and still sell many of them for no more than a dollar. Cheap corn gave us a whole raft of new highly processed foods, including the world-beating chicken nugget, which, if you study its ingredients, you discover is really a most ingenious transubstantiation of corn, from the cornfed chicken it contains to the bulking and binding agents that hold it together. posted by Sydney on
10/11/2003 09:51:00 PM
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Lotion Potions: Yesterday, the FDA approved an estrogen lotion to treat hot flashes:
Federal regulators found that the drug, called Estrasorb, effectively treates the nagging symptoms of menopause, which afflict an estimated 80 percent of women at some point. The lotion, which contains the female hormone estrogen, is applied daily to the legs, thighs or calves. It works by replacing the hormones lost during menopause.
The lotion uses nanoparticles to deliver the estrogen through the skin. They envelope the estrogen molecule in tiny bubbles that are smaller than a cell and that can
traverse the cell walls and enter the blood stream. But, with a lotion that can be applied as far and wide as the user wants, how do you control the dose?
UPDATE: A reader points out that the lotion could come in single-dose packets:
Well, the testosterone replacement gels out there (Androgel and Testim) come in single-dose containers -- a 1-month box of Androgel gives you 30 sachets that look like ketchup packets, and a box of Testim has 30 tiny little toothpaste-style tubes.
He's absolutely right. I had been imagining large bottles of lotion for some reason. But, there are plenty of medications that are topical that come in single-dose packets. Aldara, for genital warts, is another.
posted by Sydney on
10/11/2003 09:28:00 AM
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Thursday, October 09, 2003
Predicting Asthma: Recent research suggests that early childhood asthma translates into adult asthma:
The study followed 613 children who were part of a long-running study of the physical and mental health of all children born in the New Zealand town of Dunedin in one year, starting in 1972. Some participants never had asthma, but nearly three-quarters experienced wheezing asthma's hallmark symptom at some point.
....It found that the risk of an asthma relapse by age 26 rose steadily the earlier the wheezing began. Those whose asthma began 10 years earlier than others were 69 percent more likely to have a relapse by 26.
The study is unusual as studies go. Its subjects weren’t culled from the teaching clinic of a university hospital, but from a New Zealand town of 100,000. It followed all children born in that town from 1972 to 1973 for 26 years:
By the age of 26 years, 51.4 percent of 613 study members with complete respiratory data had reported wheezing at more than one assessment. Eighty-nine study members (14.5 percent) had wheezing that persisted from childhood to 26 years of age, whereas 168 (27.4 percent) had remission, but 76 (12.4 percent) subsequently relapsed by the age of 26. Sensitization to house dust mites predicted the persistence of wheezing (odds ratio, 2.41; P=0.001) and relapse (odds ratio, 2.18; P=0.01), as did airway hyperresponsiveness (odds ratio for persistence, 3.00; P<0.001; odds ratio for relapse, 3.03; P<0.001). Female sex predicted the persistence of wheezing (odds ratio, 1.71; P=0.03), as did smoking at the age of 21 years (odds ratio, 1.84; P=0.01). The earlier the age at onset, the greater the risk of relapse (odds ratio, 0.89 per year of increase in the age at onset; P<0.001). Pulmonary function was consistently lower in those with persistent wheezing than in those without persistent wheezing.
I’m not sure this adds much to our ability to predict who will have long-term asthma. Most of it we already know: allergies, persistent asthma symptoms, and smoking are all likely to indicate chronic asthma problems. But maybe it will make us less likely to label someone as asthmatic after one episode of wheezing caused by a respiratory infection. posted by Sydney on
10/09/2003 09:02:00 AM
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Making a Difference: Looks like CPR works, at least when it works:
A detailed quality-of-life analysis was conducted on 268 people who survived cardiac arrest because they got bystander help. The researchers measured vision, hearing, mental ability, speech and other characteristics, finding an average score of 0.80 on a 0-to-1 scale, barely below the 0.83 score for the general population, the report says.
'The perception is that trying to save people by bystander CPR is futile,' Stiell says. 'That is not at all true, according to what we found.'
The study also found that few people are trained to give CPR for cardiac arrest. Only 14.3 percent of the more than 8,000 persons who experienced cardiac arrest had CPR administered by trained bystanders.
However, if you’re unfortunate enough to need CPR, your chances of surviving at all are pretty low:
The 8091 cardiac arrest patients had overall survival rates of 5.2% to hospital discharge and 4.0% to 1 year. We successfully contacted and evaluated 268 of 316 (84.8%) of known 1-year survivors.
UPDATE: EMT, accountant, and blogger, Chuck Simmins has this to say about CPR:
The truly sad thing about CPR is pointed out in your blog post. As EMT's we go through all of the training, and all of the "hype", and almost never save anyone. If you're dead when we get there, you'll still be dead when we get you to the hospital. And, there is no dignity in our attempts to resuscitate.
In the five years that I have been with my current ambulance corps, we have had two saves. One guy dropped at an event that had several E/D docs and nurses, and several cardiac MD's in attendance, so got effective CPR immediately, and he responded to the AED. The other was effective drug box dumping on the part of the paramedic. In no other case that I am aware of did any patient in arrest recover, perhaps three dozen during that time.
In reality, the miracles of EMS that I see regularly are two, Lasix, and nebs (inhaled medication -ed.) for asthma. Both turn around a really sick patient on a consistent basis prior to our arrival at the E/D. Miracle reversals of patient condition. Paramedic skills, but I get to see them while I take blood pressures and such. I call Lasix the Lazarus drug, because of the way it reverses the patient's condition so effectively. posted by Sydney on
10/09/2003 08:40:00 AM
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Population Health II: To their surprise, researchers have found that minority children are over-represented in clinical trials:
To measure minority participation, Ross and Catherine Walsh, a medical student at the University of Chicago, combed through all the full-length articles in the three main pediatric research journals (Pediatrics, Journal of Pediatrics, and Archives of Pediatrics and Adolescent Medicine) from July 1999 through June 2000. They found 128 articles that included data on race and ethnicity. The number of subjects ranged from eight (their lower limit) to 6,982, for a total of 58,413 and a per-study average of 575. They compared the percentages of racial and ethnic groups in medical research to census data.
...They were surprised to find that African Americans were well represented, in fact overrepresented, in clinical research. Although they make up 15 percent of the U.S. population, 26 percent of children involved in medical research were African American, and 32 percent of those enrolled in clinical trials.
Although 69 percent of the U.S. population is white, only 54 percent of children in medical research were white and only 52 percent of those enrolled in clinical trials.
That isn’t so surprising, when you consider that most medical schools - which is where the majority of clinical trials occur - are in urban neighborhoods, where more minorities live. People tend to go to doctors that are geographically close. And while it may be difficult to get in for a routine appointment at a teaching hospital clinic, there’s no difficulty getting signed up for clinical trials. They even advertise for subjects around the neighborhood. But don’t worry, the researchers still manage to find racism lurking in their results:
Both black and Hispanic children were overrepresented in research on topics that were potentially stigmatizing, such as studies of child abuse, high-risk behaviors or HIV. Fifteen percent of the U.S. population is black but 30 percent of the children in potentially stigmatizing research studies were African American. While 17 percent of the U.S. population is Hispanic, only 10 percent of the children in medical research were Hispanic, and 17 percent of those involved in potentially stigmatizing studies.
Wait a minute. They already found that about 30% of research subjects in general were black, so blacks aren’t any more over-represented in “stigmatizing studies” than they are in any other study. There does appear to be a discrepancy for Hispanics. But then again, the researchers noted that classifying people as Hispanic or not-Hispanic was extremely difficult. There were just too many variations on "Hispanic", thanks to ethnic intermingling. Which could certainly influence the reliability of their findings.
And don't you think that someday, we'll reach a point where race is difficult to define across all ethnic categories? When I look at my young patients, I'd guess that day is only about a generation away. posted by Sydney on
10/09/2003 08:25:00 AM
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The world's population, currently 6.3 billion, is projected to rise to 8.9 billion by 2050. If Aids-related deaths in Africa, Asia and Latin America are not checked, that figure will be cut to about 7 billion.
...Launching the report, Thoraya Obaid, the executive director of UNFPA, said: "This report is a wake-up call for governments to increase funding and expand information and services to young people. If we do not provide the investment this will be a global catastrophe.
Medical Weblogs: I'm a little late to this, but Forbes.com has noticed medical weblogs, and compiled a list of "the best." Forbes has been compiling lists of weblogs for a while now. (And I must say, it's good to see speciality blogs getting some attention.) They have samplings of travel blogs, political blogs, war blogs, food blogs, etc. I'm not sure if any of them are necessarily "the best of" their categories. That's the wonderful thing about blogs. They're so varied that it's impossible to say one is better than another. Most are enjoyable and informative. (And I don't just say that because I'm the least favored medical blog, running behind "none of the above.") But, there are plenty of great war blogs that didn't make the list - Winds of Change, The Command Post, Sargeant Stryker. And there are plenty of great medical blogs that didn't: Med Rants, Cut to Cure, The Bloviator, RangelMD.....Oh, heck. It's impossible to list them all. Just go to my blog list to the left and start clicking. And check it for updates in the near future. There's been such an explosion in good medical blogs, I've had trouble keeping up. posted by Sydney on
10/09/2003 07:55:00 AM
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Small Things Considered: Sometimes in medicine, it’s the little things that’ll make or break you. Recently, one of my patients called and told my receptionist he wasn’t feeling so well and wanted to be seen. That’s a routine request from a patient, but not for this patient. Usually, when he wants to see me he tells the staff he needs to speak with me. When I call him back he asks, "Is it OK if I come by and see you?" Almost like one friend calling another and asking if it’s OK to drop by for a visit. And that’s what his office visits always turn out to be - social visits. When he arrived, the medical assistant took him back to the exam room and I could hear him making his usual jovial banter. Except for one small thing. He sounded a little short of breath as he walked down the hall. By the time I saw him, he was no longer short of breath, but sitting as usual in the chair in the corner and greeting me with his usual “How ya doin’, kiddo?” Except for one small thing. His blood pressure was about thirty points lower than it usually is. He gave me a history that sounded suspiciously like an intestinal virus. Nausea, vomiting, poor appetite, abdominal cramping. Except for one small thing. He went to bed shortly after the symptoms started the night before and woke up that morning feeling short of breath. To tell you the truth, he looked pretty good sitting there in my exam room. Except for those several small details, which made me uneasy enough to get an EKG. And sure enough, there was a full blown myocardial infarction in all of its electrophysiologic glory. Those small, seemingly inconsequential details, made all the difference in the diagnosis. Unfortunately, it didn’t make much difference for my patient. He died a few hours later.
Another patient not long ago. Her mom called for her appointment, as she usually does, even though my patient is in her sixties. She had been in the emergency room the night before for the flu and they noticed her blood pressure was high. She had been instructed to make an appointment to have her blood pressure medication adjusted. She had so many things to tell me at her visit - she needed referrals for her eye doctor, her foot doctor, her mammogram. Her diabetes was better, her struggle with her weight wasn’t. She wanted to see a surgeon to have gastric bypass surgery. She had diarrhea, she had nausea. Her bladder leaked when she coughed. Her joints ached. She had a headache. She had sinus congestion. She had a cough. She had indigestion. Her exam was normal except for mildly elevated blood pressure. So, I made the adjustments in her blood pressure medication and arranged for a follow-up within the next week to see if the changes worked. The next day, her mother called to say she was incoherent. Back to the ER. She had a subarachnoid hemorrhage. Her life’s still in the balance. Distracted by a myriad of small details, I missed the forest for the trees. Damn details. posted by Sydney on
10/09/2003 12:17:00 AM
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Wednesday, October 08, 2003
Life'll Kill Ya: Once again, medical errors are in the spotlight, thanks to a report in The Journal of the American Medical Association that “uncovered a number of medical injuries”:
• Potentially deadly infections of the bloodstream that can crop up after surgery, the No. 1 problem the researchers found. The team found that people who got such infections had a 22% higher risk of dying. Survivors had to stay an extra 11 days and had a hospital bill that was $58,000 higher than people who didn't get an infection.
• Reopening of a wound after surgery, often because of an infection. That injury means patients often spend 10 extra days in the hospital and have hospital charges that are $40,000 higher.
• Leaving a medical instrument or sponge in a patient's body, a mistake that rarely kills but often leads to two extra hospital days and $13,000 in additional charges.
Other “medical injuries” the paper documents are accidental puncture or laceration, birth trauma, complications of anesthesia, bed sores, collapsed lungs caused by a medical procedure, trauma to a mother after delivering a baby (lacerations caused by passing a baby, etc.), hemorrhage after surgery, falls that result in broken hips after surgery, metabolic derangements after surgery, transfusion reactions, and “selected infection due to medical care,” whatever that is.
With the exception of foreign bodies left behind after surgery and accidental punctures, these “injuries” aren’t so much a matter of neglect as they are known risks of the procedures involved.
Any time the skin is incised or broken, you’re at risk for infection. Surgeons try to minimize the risk by using antiseptic preps and sterile techniques, but they aren’t gods. They can’t elminate every microbe in the vicinity of the wound before, during, and after the procedure. Sometimes, despite their best efforts, a wound gets infected.
Babies enter this world through a narrow anatomical passage. They stretch the skin that makes up that passage in the process and sometimes they tear it badly. Obstetricians try to minimize the damage by making controlled tears instead. They’re called episiotomies. But sometimes, they have to use forceps or vacuum extractors to help a baby out, and sometimes that results in more damage to the mother. And sometimes it causes an injury to the baby. But given the choice between a torn labia or vagina and a dead baby, most people would chose the torn tissue.
Everyone in medicine knows that there’s no such thing as a risk-free procedure, and yet organized medicine does little to counter the exaggerated claims of papers like this. This particular paper passed peer review and editorial review to get published in the AMA’s own journal, thereby guaranteeing it national media play. And even then, the editors can’t bring themselves to point out the obvious - that these aren’t errors or injuries, but the risks of modern medicine.
That’s not to say that we shouldn’t minimize risk as much as possible. We should. But this sort of data doesn’t tell us how many of these complications were due to dirty hands or clumsy obstetricians and how many were simply unavoidable. The data comes entirely from discharge diagnoses with no assessment of the nuances behind those diagnoses. So one post-op wound infection is the same as another in the eyes of the paper. To their credit, the editors of JAMA point this out. (Unfortunately it’s only available online for a hefty fee.) They cite studies that have looked at the reliability of discharge diagnoses in determining quality of care:
The results of the CSP (Complications Screening Program) validation study...suggest that administrative data-based algorithms provide questionable insight into substandard hospital care. Briefly, the study failed to find objective clinical evidence in the medical record to support hospital-assigned discharge diagnosis codes used to identify complications for 19% of surgical and 30% of medical admissions. Discharge diagnoses used by the CSP to flag complications represented conditions that were present on admission for 13% of surgical and 58% of medical cases (ie, these conditions had not occurred during the hospitalization...). Although physician reviewers confirmed the presence of CSP-flagged complications among 68% of surgical and 27% of medical patients, they found quality problems in only 30% of surgical and 16% of medical cases. ...Indeed, an expert panel found it extraordinarily difficult to construct review instruments to identify specific process-of-care problems (ie actions by clinicians) that might contribute to the occurrence of many complications.
Unfortunately, it’s a very dry and uninteresting defense, so it hasn’t gotten the media’s attention. That’s unfortunate, because these things matter. Thanks to the media coverage that papers like this get, the average layperson - and that includes trial lawyers and juries - become ingrained with the idea that any complication from a medical procedure is a result of negligence. It sets an expectation for perfection that just isn’t attainable in the real world. posted by Sydney on
10/08/2003 08:35:00 AM
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Welcome Back: RangelMD is back after a long absence, with lots of good posts, including this one on managed care:
Two decades later the HMOs and insurance companies have found to their horror that the massive cash flow that they initially saw in this industry is not going to change course and flow into their coffers. To make matters worse, the massively expensive bureaucracies these businesses brought with them are simply adding to the expenses as they consume up to 30 cents of every health care dollar.
Lancet On-Line: The British medical journal, The Lancet, is now available online in its entirety - all 180 years of past issues. For a price, of course. Hopefully, this will catch on. posted by Sydney on
10/07/2003 08:22:00 AM
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Many people have asked me how I was able to do a successful daily three hour show while loaded up on pain meds,' Mr. Limbaugh said. 'I'm going to love telling them about the low incidence of side-effects I enjoy while gulping dozens of OxyContin each morning. When I say I do this show with half my brain tied behind my back, I'm not kidding.'
Sleep Safe: New research in the journal Pediatrics, suggests that babies who sleep in their parents' beds are at greater risk for sudden death:
The study drew on data collected by the federal Consumer Products Safety Commission about suffocation deaths in sleeping children 11 months old or younger and compared the figures for 1980 to 1983 with those from 1995 to 1998.
The number of deaths rose from 513 to 883. Deaths in beds, chairs or sofas rose from 152 to 391, and deaths in cribs fell from 192 to 107, the study found. Most deaths outside cribs occurred when children became trapped between mattresses and walls or headboards or when the children were covered by soft bedding that cut off their air supply.
The number of reported suffocation deaths in cribs fell from 192 to 107, the number of reported deaths in adult beds increased from 152 to 391, and the number of reported deaths on sofas or chairs increased from 33 to 110.
The findings are rather dramatic and should give a heads up to anyone who shares their bed with their children to use extra caution when doing so. It will, however, be sure to draw controversy, as in this online response:
Only breastfeeding infants are recommended to share the mother's bed as bottle feeding mothers have been found to treat the infant as another adult in the bed and turn their backs on them in their sleep (amongst other things).
Those mean old bottle-feeding mothers. The rest of the response, however, makes valid points about exercising appropriate precaution when sleeping with babies. But the caution should be heeded by both breast-feeding and bottle-feeding mothers. No one can control their movements in sleep, no matter how devoted a mother they are, or what feeding method they choose.
Power of Myth: A disconcertingly high number of patients believe that contact with air makes lung cancer worse. As a result, many refuse to have their lung cancers resected:
Thirty-eight percent of patients who responded to a survey in five urban clinics believed the myth that cancer spreads when exposed to air during surgery.
....Of the 38 percent who said they believed that cancer spreads when exposed to air, 24 percent said they would reject lung cancer surgery based on that belief. Nineteen percent said they would reject surgery even if their doctor told them the belief had no scientific basis.
Sense Breaks Out in the Senate: Unbelievable as it may seem, there's bipartisan support in the Senate for needs-testing Medicare:
With unexpected support from some Democrats, Republican negotiators from the House and the Senate say they are seriously considering a change in Medicare that would require elderly people with high incomes to pay higher premiums than other beneficiaries.
....In the past, Democrats have vehemently opposed the idea. But some of the social policy experts most respected by liberal Democrats now say they are receptive to it, as a way to avert cuts in Medicare and other domestic programs. Pressure for such cuts will increase, they say, as budget deficits grow and baby boomers cash in their claims to Medicare and Social Security.
Most of the 40 million Medicare beneficiaries now pay the same premium, $58.70 a month, or about $704 a year, for doctors' services and other outpatient care.
Under one proposal being discussed by House and Senate negotiators, premiums would rise gradually with a beneficiary's income. The change would affect only people with annual incomes above a certain level, perhaps $75,000 or $100,000. Individuals with incomes exceeding $200,000 could see their premiums triple, to about $2,100 a year.
And that's still a bargain compared to what working people with much lower incomes pay for health insurance. Still, there are those who object, predictably:
AARP, the lobbying group for older Americans; labor unions like the United Automobile Workers; and some liberal Democrats, including Senator Edward M. Kennedy of Massachusetts, say levying an extra charge on affluent beneficiaries would undermine the universal nature of Medicare. Such a change, they say, would be a dangerous first step in turning Medicare from a universal social insurance program into a welfare program.
Does that mean they think it's wrong for the government to help the needy without also helping the rich? posted by Sydney on
10/06/2003 07:42:00 AM
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Nobels: The Nobel Prize in medicine went to two researchers whose work led to MRI's. MRI has been a godsend to medicine. Before MRIs patients had to undergo painful, invasive procedures to determine if they had a herniated disc or a spinal tumor. And as functional MRI's evolve, they have even greater potential to revolutionize the diagnosis of disease. posted by Sydney on
10/06/2003 07:36:00 AM
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