"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
Hazards of Outsourcing: You may not realize this, but a heck of a lot of medical transcription is outsourced to the Third World these days, usually to Pakistan and India. That raises concerns about the confidentiaility of records:
A woman in Pakistan doing cut-rate clerical work for UCSF Medical Center threatened to post patients' confidential files on the Internet unless she was paid more money.To show she was serious, the woman sent UCSF an e-mail earlier this month with actual patients' records attached.
....She wrote: "Your patient records are out in the open to be exposed, so you better track that person and make him pay my dues or otherwise I will expose all the voice files and patient records of UCSF Parnassus and Mt. Zion campuses on the Internet."
Actual files containing dictation from UCSF doctors were attached to the e- mail. The files reportedly involved two patients.
A doctor in my city runs a side business in international dictation. Rumor has it that his workers are his Indian relatives. A lot of my colleagues switched to his company a few years ago to save money. They were ecstatic with the turn-around time. Since the transcribers were half a world away, the transcriptions came back the next morning. The privacy aspect was always worrisome, though. Having patient records zipping around the Internet just didn't seem right. It's one reason my office didn't hop on the band wagon. Glad we didn't.
UPDATE: A reader emails to say that one California legislator is proposing a law that will forbid any California medical records from leaving the country, and wonders how this will affect people who move overseas to work. posted by Sydney on
11/01/2003 08:01:00 AM
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Better to Bleed : There's a moment in the movie My Dinner with Andre when one of the characters describes the plight of his ailing mother in the hospital. She lay dying, but each specialist who saw her only commented on how well their particular part of her body was doing. There's something like that going on at the current meeting of the American College of Chest Physicians, where news is coming out that it's dangerous to tell heart patients to stop taking their aspirin - even if they're at risk for bleeding if they continue to take it:
Coronary patients preparing for dental work or surgery are often advised to stop taking aspirin in order to avoid increased bleeding,' Ferrari said in a statement. 'Our study serves as a reminder for all medical professionals who treat coronary patients that aspirin withdrawal should not be advised, and that alternative recommendations should be considered.'
I wonder what "alternative recommendations" he has in mind? Live with your colon cancer so you can avoid another heart attack?
Here's his data:
Ferrari, from University Hospital Pasteur in Nice, France, and colleagues reviewed the cases of 1,236 patients with coronary artery disease who were hospitalized for an acute coronary syndrome, such as chest pain (unstable angina), clot formation in an implanted heart stent, or heart attack, between September 1999 and April 2002.
They discovered that 51 had stopped taking aspirin less than one week prior to the event. This accounted for 4.1 percent of all the hospitalizations for coronary events. Prior to hospitalization, all patients had been taking aspirin for at least three months.
That's a pretty small percentage. Probably much smaller than the percentage of people who bleed profusely during surgery if they continue to take their aspirin. So, Ferrari looked at his data this way:
However, if you consider only patients who had a recurrent coronary event, 10 percent of those patients had stopped aspirin on average seven days before the event,' Ferrari said. 'I think it is a very important percentage,' he added.
I don't. That means that 90% of heart patients had a recurrent event even when they took their aspirin every day. Still not worth the risk of bleeding during and after surgery. And consider this, patients on aspirin bleed and ooze a lot more into the field of surgery, making the surgeon's job all the more complicated, and increasing the risk of mistakes. I'd still recommend stopping aspirin before an invasive procedure. But then, I treat more than just the heart. posted by Sydney on
10/30/2003 10:09:00 AM
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Hope My Patients are Listening:Matthew Holt has a host of good posts this week, including why my elderly patients should be careful about switching from their current Medicare HMO to Kaiser. They're hoping to save twenty dollars a month in premiums, but they're going to end up paying more for drugs and lab fees. Unforunately, my patients don't read blogs. posted by Sydney on
10/30/2003 09:40:00 AM
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Rat Poison No More: Coumadin, an anticoagulant that's not only used to prevent blood clots in certain conditions, but is also used in De-Con to kill vermin, may be losing its place in the modern pharmacopeia:
A new, easier-to-use blood thinner pill offers the first potential alternative in 50 years to warfarin, the standard treatment given to millions of people to prevent blood clots.
The new drug has been tested in 17,000 patients for a number of uses and has been shown to work as well as -- or, in some cases, better than -- warfarin at preventing dangerous blood clots. It acts more quickly and does not require the frequent blood testing of warfarin, also known as Coumadin.
The new drug is called Exanta, and it's the subject of two papers in this week's New England Journal of Medicine. One paper compares its effectiveness to Coumadin in preventing blood clots after total knee replacement. This is a use of Coumadin not often seen here in the States. Most American orthopedists use injectable low molecular weight heparin instead. (It has fewer side effects and doesn't need monitoring the way Coumadin does.) They found that 20.3 percent of patients receiving the higher dose of Exanta ended up with blood clots after surgery compared to 27.6 percent of those receiving Coumadin. Unfortunately, it wasn't any safer than Coumadin:
Major bleeding occurred during treatment in six patients in each of the two ximelagatran [Exanta - ed.] groups and in five patients in the warfarin [Coumadin -ed] group. Additional major bleeding events occurred during follow-up in four patients in the lower-dose ximelagatran group and in one patient in the warfarin group. One bleeding complication was fatal; gastric-ulcer bleeding developed in a patient who had received two 36-mg doses of ximelagatran. The bleeding led to multiorgan-system failure and death on day 46. This patient had also received perioperative enoxaparin (as part of the anesthesia protocol) and diclofenac.
Looks like low molecular weight heparin will continue to be the standard of care after knee replacement on these shores.
The other study looked at Exanta's effectiveness in preventing recurrent blood clots in the legs. Normally, after someone has a blood clot in the leg for the first time, we put them on Coumadin for six months then stop it. The risk of bleeding from prolonged Coumadin use outweighs any benefits it confers in preventing future blood clots. In this study, people who had already completed their six month course of Coumadin were placed on Exanta for another eighteen months and compared to those who weren't:
Data from 612 patients in the ximelagatran group and 611 in the placebo group were analyzed. The occurrence of the primary end point, symptomatic recurrent venous thromboembolism, was confirmed in 12 patients assigned to ximelagatran and 71 patients assigned to placebo (hazard ratio, 0.16; 95 percent confidence interval, 0.09 to 0.30; P<0.001).
And side effects? They appear to be about the same as placebo:
Death from any cause occurred in 6 patients in the ximelagatran group and 7 patients in the placebo group, and bleeding occurred in 134 patients and 111 patients, respectively (hazard ratio, 1.19; 95 percent confidence interval, 0.93 to 1.53; P=0.17). The incidence of major hemorrhage was low (six events in the ximelagatran group and five in the placebo group), and none of these hemorrhages were fatal.
Although it looks like liver enzymes will have to be monitored:
The cumulative risk of a transient elevation of the alanine aminotransferase level to more than three times the upper limit of normal was 6.4 percent in the ximelagatran group, as compared with 1.2 percent in the placebo group (P<0.001).
So, at this point in the research, it doesn't look like the new drug will replace Coumadin to treat blood clots, but it may be a drug that can be used indefinitely to prevent a recurrence. That is, if it turns out to be safe in the long term. Unfortunately, only time and use will determine that. posted by Sydney on
10/30/2003 09:23:00 AM
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Mercury: This week's New England Journal of Medicine has a very good review article on mercury toxicology. ($$ required to read the full content. ) The review includes this synopsis of the thimerosal debate:
Thimerosal has been used as a preservative in many vaccines since the 1930s. At concentrations found in vaccines, thimerosal meets the requirements for a preservative set forth by the U.S. Pharmacopeia — that is, it kills the specified challenge organisms and can prevent the growth of the challenge fungi. It contains the ethyl mercury radical (CH3CH2Hg+) attached to the sulfur group of thiosalicylate and is believed to behave toxicologically like other ethyl mercury compounds. Early toxicity studies found no adverse health effects; recently, however, Ball et al. reevaluated thimerosal by applying the revised EPA guideline for methyl mercury to ethyl mercury. They calculated that infants undergoing the usual U.S. program of vaccines from birth to six months of age would receive more than 0.1 µg of mercury per kilogram per day. Steps were rapidly taken to remove thimerosal from vaccines by switching to single-dose vials that did not require any preservative. This process is now virtually complete in the United States. The decision itself is remarkable, and the speed of execution even more so; however, the EPA guideline is based on epidemiologic data on prenatal exposure to methyl mercury rather than postnatal exposure to ethyl mercury. Ethyl mercury has some similarities to methyl mercury. They are closely related chemically, have a similar initial distribution in the body, and cause similar types of damage to the brain in toxic doses.
They also have differences. Methyl mercury is more potent. Ethyl mercury is metabolized more rapidly to inorganic mercury; perhaps this is why ethyl mercury, unlike methyl mercury, causes kidney damage in humans. Of greater importance is the recent finding that the half-life of ethyl mercury in the body is much shorter . The half-life of methyl mercury in blood, which is assumed to indicate the total body burden, is usually assumed to be about 50 days. In contrast, in children receiving thimerosal in vaccines, the half-life of ethyl mercury in blood was 7 to 10 days, or 1/7 to 1/5 as long as that of methyl mercury. Therefore, in the two-month periods between vaccinations (at birth and at two, four, and six months), all of the mercury should have been excreted, so that there is no accumulation.
Given the short half-life of ethyl mercury, any risks of its damaging either the brain or kidneys would seem remote. A World Health Organization advisory committee recently concluded that it is safe to continue using thimerosal in vaccines. This is especially important in developing countries, where the use of a preservative is essential in multidose vials. The known risk of infectious diseases far exceeds that of the hypothetical risk of thimerosal. Claims have been made that thimerosal in vaccines may be a cause of autism and related disorders, but studies testing that theory have yet to be performed.
And the conclusion sums up the whole mercury brouhaha succinctly:
All forms of mercury have adverse effects on health at high doses. However, the evidence that exposure to very low doses of mercury from fish consumption, the receipt of dental amalgams, or thimerosal in vaccines has adverse effects is open to wide interpretation. Moreover, attempts to reduce such exposure may pose greater health risks than those hypothesized to occur from mercury posted by Sydney on
10/30/2003 08:37:00 AM
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One Butch Chick: That's what the Gender Genie says about me. So much for Andrew Sullivan's hunch that "gender is a far more profound determinant of human behavior than sexual orientation." All it means is that writing assertively gets you classified as male by the algorithm. And isn't the use of the passive voice considered poor form in writing?
I sampled a couple of blog entries and a couple of Tech Central Station columns. All were classified as male by a 2 to 1 ratio. I also sampled two letters I wrote recently. One was an explanation of the break down of a check I was sending my landlord. It was classified as female (by a narrow margin). The other letter was to the principal of my children's elementary school to let her know the school buses were posing a danger to children walking to school. That was 3 to 1 male. Maybe it just depends on how passionately the writer feels about his (or her) subject. posted by Sydney on
10/30/2003 08:28:00 AM
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Wednesday, October 29, 2003
Tea and Biscuits: Ginger and green tea might have some anti-cancer benefits. Emphasis on the "might." Ginger's effects were measured in immunologically challenged mice:
The first tumors appeared 15 days after the cells were injected. At that point, 13 tumors of measurable size were found in the control mice, while four appeared among the gingerol-treated mice. Mice consuming 6-gingerol lagged in both the number of measurable tumors and the average size of tumors.
Lucid Lancet: Medicinal chemist Derek Lowe caught a recent heated exchange between the British medical journal The Lancet and AstraZeneca over a new cholesterol-lowering drug called Crestor. They call the exchange, The Statin Wars. As Derek points out, the British medical journals spare no jibes in getting their point across. My favorite:
The sales strategy for rosuvastatin is based around the Galaxy programme. Galaxy is the contrived umbrella name for at least 16 clinical trials of wide-ranging quality designed to investigate the efficacy of rosuvastatin in various clinical settings.....But AstraZeneca has proceeded to push Galaxy into the realms of astrological rather than astronomical logic.
Why are the British so much more tart-tongued than we are? I suspect it's the accents. They always sound so genteel, no matter how vicious the words. Anyway, AstraZeneca's CEO replied just as tartly:
Regulators, doctors, and patients as well as AstraZeneca have been poorly served by your flawed and incorrect editorial. I deplore the fact that a respected scientific journal such as The Lancet should make such an outrageous critique of a serious, well studied, and important medicine.
Have we been poorly served by The Lancet's editorial? No. We have, in fact, been better served. If the editors of The Lancet hadn't spoken up, the newest statin would have been embraced unquestioningly as the next best thing to happen to preventive cardiology. It happened with Baycol. It's happening now with Zetia. It happens because physicians don't pay much attention to the details of the clinical trials. But most of all, it happens because of an unfortunately all too commono mix of intellectual hubris and naivete.
Here's what happens. Cardiologists (or other specialists) go to their national meeting put on by the American College of Cardiology where they hear things like this:
"Heart disease and stroke remain the leading causes of hospitalization and death for both men and women in Canada", says Dr. Lawrence Leiter, Head, Division of Endocrinology and Metabolism, St. Michael’s Hospital, Toronto, Ontario. "Too many Canadians continue to have unacceptably high levels of cholesterol, despite the fact that we know hypercholesterolemia is a major risk factor for cardiovascular disease. The aggressive LDL [low-density lipoprotein] reductions that can be achieved with drugs like Crestor should certainly help bring more patients’ cholesterol to optimal levels."
And this:
"Crestor will provide a tremendous additional weapon in the global fight against coronary heart disease," observes Philip Barter, Professor of Cardiology at the Royal Adelaide Hospital in Australia.
Being busy doctors, they don't bother looking up the actual results, but instead form their opinions of the drug based on presentations like this:
Data from two head-to-head comparative trials involving over 1,000 patients show a significantly better reduction in LDL cholesterol (a major marker for the development of cardiovascular disease) with Crestor, compared to other widely prescribed statins. In one study, LDL cholesterol was reduced by 49 percent with Crestor 10 mg compared to 37 percent with simvastatin 20 mg and 28 percent with pravastatin 20 mg. In another study, Crestor 10 mg reduced LDL cholesterol by 43 percent compared to a 35 percent reduction with atorvastatin 10mg.
In addition to LDL cholesterol lowering, Crestor 10 mg produced a significantly greater increase in HDL cholesterol compared with atorvastatin 10 mg (12 percent versus 8 percent, respectively) and a similar increase compared to simvastatin and pravastatin.Triglyceride levels were effectively reduced to the same extent by all the statins. All studies also show that Crestor is safe and well tolerated, similar to other statins.
These are busy doctors. They've got lectures to attend and continuing medical education credits to accrue. They don't stop to ask just what the starting numbers were for each agent, or how much of an absolute reduction in cholesterol each agent caused. They just hear the impressive sounding statistics coming from the experts in their field. And, anxious to be on the cutting edge of medicine, they buy it. Then, they go home and they tell others about the best new therapy, so much more effective than any other cholesterol medication, sure to reduce mortality, apparently as safe as any of the others on the market, blah, blah, blah. And the other doctors in the community, not wanting to appear backward, and not having the time or the resources to look up all the obscure research on the drug, adopt it as the new standard of care. After all, the experts, nationally and locally, say it's the right thing to do. And as for safety, well, it's FDA approved. Must be safe. And wasn't there an article in last Tuesday's newspaper quoting experts in the field on this marvelous drug? Sad to say, few bother to ask the difficult questions before adopting the new therapy. We're a lot like lemmings.
But, in this case, The Lancet editorial broke the circle. Here are legitimate questions being raised vociferously enough to be heard over the pharmaceutical company's hype. And the objections are being raised in a journal whose stature trumps the experts. Now doctors will be more likely to ask themselves the hard questions about Crestor. The profession could use more of this sort of critical thinking. And a lot less hype from "experts."
ASIDE: The safety of Crestor compared to other statins is yet to be established. But look here, the trial lawyers are on the case.
Ed. Note: Came back later and took out references to toothpaste and diseases, had misidentified the drug as "Crest" rather than "Crestor". My bad. posted by Sydney on
10/28/2003 08:06:00 PM
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Consider what would happen if employers paid for their workers' car insurance and if that insurance covered routine maintenance. No doubt, the cars would spend a good deal more time in the shop, and the price of repairs and the cost of auto insurance would skyrocket.
By the same token, some health policy experts say, Americans see doctors more often, have more procedures and take more medicine than they need because most, if not all, of the cost is covered by insurance.
'When consumers don't have to pay any regard to price, they overconsume,' said Kate Sullivan, director of health policy at the United States Chamber of Commerce. 'You get more value for what you buy when you have a stake in it.'
...There is no conclusive evidence that people's health would deteriorate if they were charged more for care. Mr. Gruber said he was convinced that "the health gains" from generous health insurance "are not large enough to justify the additional costs in aggregate."
But Mr. Reinhardt was skeptical and fell back on the auto insurance analogy. "When I was young and could not afford regular maintenance, my cars constantly broke down," he said. "Now my cars run forever."
Lessons: This isn't really an art history lesson, but I was feeling a little blue this weekend, so I image Googled "Norman Rockwell" to cheer myself up. He's often dismissed by the "serious" art world as too kitschy, too middle brow, but his talent for facial expressions and for telling a story with his art far surpasses what many of the greater artists of his day could achieve. For example, his paintings of two boys enjoying a smoke and suffering the consequences:
Not one of his most stirring works, but it's worth a thousand of those "This is your brain on drugs" public service announcements.
This was a deliberate, for-profit fad. The tort liability bar proved again that it knows how to exploit modern sensibilities to stoke fears of disease, raise hopes of a cash windfall and shape expectations of a national jury pool. In this it had the considerable assistance of the Ralph Nader empire; his "Public Citizen" sold information kits directly to breast-implant lawyers.
In 1988, Mr. Nader and Sidney Wolfe, head of his Public Citizen Health Research Group, started to lobby for regulation of the implants, which had been used by some two million women over 30 years. Soon trial lawyers convened a Breast Implant Litigation Group; one San Jose firm invested $3 million of its own capital in filing some 90 lawsuits. In December 1991, San Francisco lawyer Don Bolton won a $7.3 million jury verdict for a plaintiff who alleged that her implants had caused an autoimmune disease, despite testimony by her own doctors that she had symptoms before the implants. In January 1992, FDA commissioner David Kessler called for a moratorium on the implants, citing no scientific study but the Bolton verdict.
As early as June 1992, Dr. Marcia Angell, executive editor of the New England Journal of Medicine, published an editorial denouncing the ban. A survey of the matchless epidemiological records at the Mayo Clinic found no association between implants and autoimmune diseases. Both Dr. Angell and Mayo researcher Dr. Sherine E. Gabriel were rewarded with a barrage of subpoenas from tort lawyers. posted by Sydney on
10/27/2003 06:30:00 AM
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"Where'er that place be priests ca' hell,
Where a' the tones o' misery yell,
An' ranked plagues their numbers tell,
In dreadfu' raw,
Thou, Toothache, surely bear'st the bell,
Amang them a'!" posted by Sydney on
10/26/2003 05:37:00 PM
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Assumptions: The L.A. Timesexplains why healthcare costs are rising (requires annoying registration, but it's free):
These problems of cost and access are inextricably connected. It's easy to see how rising costs translate into reduced coverage. But the reverse is also true. The growing number of Americans without insurance means that doctors and hospitals have to provide more uncompensated care that must be subsidized by the premiums of those with insurance. As Bruce G. Bodaken, chairman and president of Blue Shield of California, put it in a speech last winter: 'In essence, we are charging the private health-care system a hidden tax, a tax that can't be sustained.
But that assumes that hospitals and doctors are able to dictate to health insurance companies, and Medicare, what they will accept as payment for their services. They can't. Prices are set by Medicare, which goes through complex financial formulas to set the prices they will pay. The insurance companies then use the Medicare formulas as their guides. Hospitals and doctors have very little influence in the negotiations, although once in a while they'll get exasperated and drop the plans all together. The only time this works to improve reimbursement rates is when the hospital or the doctor is the only one in a geographical area.
As an example, our city has a pediatric hospital, which is the only hospital in a sixty mile plus radius that can treat children. Every so often, an insurance company that doesn't realize this will refuse to negotiate prices with them. Every time it plays out the same way. The hospital announces that negotiations have failed and they will no longer accept that insurance plan. A public outcry follows. The insured write nasty letters to the insurance company, or pressure their employers to drop it for another one that covers the hospital. And before you know it, the insurance company has re-entered negotiations with the hospital. The hospital always wins. It's the most financially secure hospital in our city. Unfortunately, few hospitals have that much clout. Nor do many doctors.
In fact, the way our system works, it's the uninsured who are paying the higher prices to make up for the discounts given insurance companies. How fair is that? What we should do, is stop accepting insurance company payments, and bill all patients directly. Then, the patient could submit the bill to their insurance company for reimbursement. That way, every patient gets charged the same, and no one supplements the care of anyone else. Added bonus: the healthcare insurance consumer actually sees what his insurance premium dollars are getting him. It would correct so much that's wrong with our system. But will we ever have the courage to do it? posted by Sydney on
10/26/2003 03:50:00 PM
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Generous Medicare:The New York Times says that Medicare is paying doctors well, at least if they're cardiologists:
The hospitals here — hospitals across the United States, for that matter — covet patients like Robert E. Wilson. Mr. Wilson, 79, has had two open-heart operations, five angioplasties, three cardiac catheterizations and an implanted defibrillator. Just last month, he checked into the Heart Center of Indiana to get his first stent, a tiny bit of wire scaffolding that helps keep arteries open.
Mr. Wilson's primary health insurance is Medicare, and Medicare pays generously for cardiac care — so generously that hospitals and doctors scramble after the business.
The Heart Center, a 60-bed hospital that cost $60 million and boasts not just the most sophisticated new imaging technology but an executive chef and what it calls "room service," opened last December. Indeed, all four major hospital groups in Indianapolis are investing in new heart hospitals, collectively spending $215 million on multistory buildings with catheterization labs and bedside computers.
Most doctors gripe that Medicare doesn't pay well enough, and that's true for the less glamorous specialties - i.e. primary care, but this article is probably correct. My former employer ( a hospital) was busily recruiting cardiologists into their physician office network at the same time they were telling the rest of us good-bye. One of my patients has a friend who works in the administration of another hospital in town (which is also closing down many of their hospital-owned physician practices) who told her that the only specialty that was making money for the hospital was cardiology. Perhaps it's wrong of me to indulge in gossip like this, but short-shrifting other areas of medicine to concentrate only on the profitable seems to be a trend that goes well beyond my community:
Amid the building boom here in Indianapolis, some hospitals are laying off employees or scaling back programs, like psychiatric care, that are less generously reimbursed. Preventive care and case management, health experts add, get short shrift.
How much difference is there between the reimbursement for simple medical care and complex cardiac care? Plenty:
Hospitals will typically not disclose how much they profit from a particular procedure, like a coronary bypass or angioplasty. And Medicare — with little information about the cost of treatment — cannot say, either. But one full-service medical center that is leading the lobbying campaign against specialty hospitals, Sioux Valley Hospital in South Dakota, estimates that it makes nearly $1,500 for a typical coronary bypass under Medicare, while it loses almost $1,800 treating a case of simple pneumonia and $2,500 on a patient with kidney failure.
Now that the profitability of cardiac care has been brought to the media's attention, it will also be in the spotlight of lawmakers and Medicare administrators. Expect the reimbursement to go down, and the hospitals that have invested so much to suffer the consequences - which means more nursing lay-offs, residency program cut-backs, and overall poorer patient care.
UPDATE: A reader shares these thoughts:
This is what ALWAYS happens when we resort to central planning of large, complex areas of the economy by bureaucrats and accountants. It just doesn't work, it has never worked, and it WILL NEVER work. One reason for this is that, as soon as some some number-cruncher is appointed to oversee a program, he immediately believes that he is gifted with God-like powers of understanding in that field, and certainly knows more about it than the lowly peons who actually do the the work.
I think that Hillary Healthcare was the finest example of this to be found, at least outside the old Soviet Union. (I once walked out of a lunch presentation by the President of my professional association because she was going on in rapturous terms about the wonderfulness of HillaryCare. Unfortunately, I took the nearest exit, and wound up in the kitchens of a very large L.A. hotel- took a while to find a way out!)
Of course, "central planning" doesn't allow for adequate and timely feedback, and this is the ultimate reason it won't work. This problem is not fixable, even with the Internet and all sorts of technology- because the people in charge will not use the information they get if it jeopardizes their programs or their preconceptions. All of this should be blindingly obvious to Americans, but apparently it is not, and we are headed even further down this road with the "prescription drug program", which is going to be a real disaster for our economy.
I estimate that the country will be bankrupt not later than the year 2030.
Worth Mentioning: Here are two healthcare-related blogs worth pointing out: Magdalen News, by a hospital chaplain, and Medmusings by an urgent care physician, which I discovered through Magdalen News's comments section. posted by Sydney on
10/26/2003 06:50:00 AM
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