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    Friday, November 07, 2003

    Between an Oil Change and a Brake Job: Another doctor breaks free of the insurance company hegemony:

    In order to keep costs down for the uninsured and the increasing number of patients who have high co-pays and deductibles, we cannot assume the massive overhead involved in billing third party payers. This has the added benefit of eliminating bureaucratic hassles and intrusions into the doctor-patient relationship as well insuring strict confidentiality of patient information. Besides, our typical charges are usually between the cost of an oil change and a brake job.

    He was profiled in the Wall Street Journal yesterday, but it isn't available on line. Making less money, but a lot happier than he used to be.

    UPDATE: You can read more about his approach here.
     

    posted by sydney on 11/07/2003 08:31:00 AM 0 comments

    Thursday, November 06, 2003

    Jack-of-All: Kentucky's new governor - fighter pilot, pastor, Congressman, family physician.
     

    posted by sydney on 11/06/2003 09:55:00 AM 0 comments

    Soft Science: Cats have a master plan for taking over the world. They're infecting us with a bacteria that makes us behave like them.
     
    posted by sydney on 11/06/2003 09:53:00 AM 0 comments

    DEA on the Rampage? Is the DEA conducting a war on pain doctors and pain clinics? I don't think so. There are legitimate concerns about "pill mills" that hand out narcotic pain meds in high volumes. And the DEA's methods are nothing new. They have a long history of tracking prescriptions of controlled substances (that's why they're called "controlled") and investigating suspicious prescribing patterns. What's changed in the past several years is that narcotic activists have sprung up. They're kind of like the medical marijuana activists, but with more legitimacy since their drug of choice actually serves a medical purpose. Their common refrain is that pain is undertreated and that narcotics should be more widely and freely used. But, their credibility is undermined by statements like this:

    Opioids when taken under clinical supervision are not that dangerous,' says the American Pain Institute's Myers. 'The data tells us that only 3 percent of people who take opioids become addicts. The latest research conclusively shows that the best medicines for the treatment of chronic pain are narcotics. They have less side effects and more benefits than any other type of drug.'

    More dangerous, contends Myers, are the everyday drugs that pain sufferers turn to when they can't get narcotics. He talks about something called 'suicide by Tylenol': 'When chronic pain patients can't get opioids, they go out and use tremendous amounts of drugs like Tylenol and Motrin, which can cause serious liver and kidney damage. Pain patients are dying from kidney and liver disease because of this.'


    Nothing in that statement is true. Chronic pain sufferers aren't dying in record numbers from Tylenol overdoses. (Most Tyelonol deaths are intentional overdoses in suicides.) Narcotics don't have less side effects than other pain medication. They're highly addictive and they foster a physical dependence that's difficult to overcome. Just ask Rush Limbaugh. And, they can cause respiratory depression and death.

    Since the rise of the narcotic advocacy groups several years ago, and the acceptance of the idea that all pain is created equally and that narcotics are "safe", I've had three patients overdose on narcotics in the hospital, two of them under the auspices of "pain management specialists". They kept complaining about pain and kept getting more and more narcotics in response to their complaints until they were comatose from the drugs. (Luckily, they responded to drugs that reverse the side effects of narcotics.) You never see that sort of thing with non-narcotic analgesics. They're prescribed with explicit instructions not to exceed a certain dose.

    What all those patients had in common was a significant psychosocial component to their pain which went ignored. And that's what's happening in the case of the pain management clinics and doctors under fire. They're ignoring the nuances of pain, and the reality of the medications they promote.
     
    posted by sydney on 11/06/2003 09:48:00 AM 0 comments

    Misplaced Sympathy: One recent Nobel laureate and a few others are calling the trial of the Texas professor who mishandled vials of plague McCarthyism:

    In a statement released Monday night (November 3), Peter Agre, Sidney Altman, Robert Curl, and Torston Wiesel wrote that the Justice Department's determination to send Butler to jail sends a strong message to the scientific community 'that those scientists most involved in bioterrorism-related research are most likely to be victims of punitive attacks at the hands of federal authorities.'

    The group predicted that this message will intimidate 'precisely the scientists we need most in this effort of high national priority,' and they urged the prosecution and defense to agree to a plea bargain that does not include prison time.

    'I think the four of us all feel just adamantly that this is turning out to be a gross miscarriage of justice,' Peter Agre, a Johns Hopkins University professor who won half of this year's Nobel Prize in Chemistry, told The Scientist. 'This is outrageous,' he said. 'It smacks of McCarthyism.'


    Dr. Butler, you may recall, lied to his university, and to law enforcement officials, about
    missing vials of plague bacteria. He reported them as missing or stolen, even though he knew otherwise. His university has rules about the handling of potentially hazardous biological materials, such as vials of highly infectious and deadly bacteria, to protect their workers and their students. Likewise the government. He felt himself above the rules of his university and above the law. So he handled his plague vials in any way he saw fit. Damn the rules, damn the laws. And then he lied to avoid the consequences of his actions.

    Happening as it did a year after 9/11 and the anthrax mailings, his lie touched off an investigation - a very serious and expensive investigation. After all, plague is one of the diseases that can be weaponized. Think this is McCarthyism? Try reporting false crimes to your local police department and see what happens. What he did was against the law, and for good reason.

    The details of his indictment give little cause for sympathy:

    ....between September 9 and 12, 2002, Butler is alleged to have illegally exported 30 vials of Yersinia pestis via Federal Express to Dar Es Salaam, Tanzania, utilizing Federal Express without obtaining an export.

    ...Two additional false statement violations are charged predicated upon Butler's alleged statement to the TTUHSC Responsible Reporting Officer for Select Agents which caused the submission of a false national inventory document to the CDC indicating that the TTUHSC facility
    [Texas Tech University Health Sciences Center -ed.] did not possess any Yersinia pestis in response to a Congressional mandate of the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, and Butler's false statement on the Federal Express International Air Waybill that a package, which in fact contained Yersinia pestis being exported to Tanzania, was "laboratory materials.

    Maybe he had legitmate reasons for sending plague vials to Dar es Salaam. But why be so sneaky about it? Were the rules all that odious? And if so, were they so odious that circumventing them was worth imperilling the lives of Federal Express workers? Surely Nobel laureates could find better fights to fight.

     
    posted by sydney on 11/06/2003 09:19:00 AM 0 comments

    Knight-Ridder Crusade: The Knight-Ridder newspaper empire is on a crusade against off label use of medication. The series makes some valid points - drug companies do devote a lot of money and energy promoting off-label uses for their drugs, and many doctors don't fully evaluate drug rep claims about drugs before putting them to use. Doctors don't do this out of stupidity, as the article claims, but out of laziness or lack of time. Unfortunately, in true Knight-Ridder journalistic fashion, the series also contains distortions and over-the-top, accusations:

    Doctors are giving their patients epilepsy drugs for depression and hot flashes and to help them lose weight. They use antidepressants to treat premature ejaculation and pain, and powerful antipsychotics for insomnia and attention deficit disorder. High blood-pressure pills are prescribed for headaches and anxiety; antibiotics are used to treat viruses.

    The use of antibiotics "to treat viruses" isn't an off-label use, it's an inappropriate use, often born of the difficulty of distinguishing a viral respiratory infection from a bacterial one, and succumbing to patient demand. High blood pressure pills to treat migraine headeaches refers to the use of beta blockers and calcium channel blockers to treat chronic migraine sufferers. It's true that the FDA hasn't approved the drugs for that specific indication, but they've been used that way for years, and they work. And, why would taking a pill every day for headaches be any more dangerous than taking it every day for high blood pressure? In fact, one could argue that the migraine sufferer sees a much more tangible benefit for his drug risk than the hypertension patient, since hypertension is asymptomatic.

    "Powerful antipsychotics for insomnia" refers to the use of antipsychotics for the elderly demented who often wander at night and have hallucinations. It cuts down on their hallucinations and gives their caregivers some peace. I haven't seen antipsychotics used for attention deficit disorder, so I can't comment on that one.

    Yes, anti-depressants are used for chronic pain and they're effective in helping to alleviate it because: 1) they work at the level of the pain receptors to decrease the transmission of pain and 2) chronic pain induces depression which in turn increases sensitivity to pain. Anti-depressants break the cycle. They also help treat premature ejaculation (especially the SSRI's) because one of their side effects is delayed orgasm. Again, there's no reason to think that taking a pill like Zoloft or Prozac once a day to delay orgasm or to dull chronic pain is any more dangerous than taking it once a day to treat depression.

    The Knight-Ridder series blames the problem on "tepid regulators" and "cavalier doctors" but they forget to mention the role of the press in the widespread use of medication for off-label purposes. They often aid and abet the pharmaceutical industry by publishing glowing reports of the latest research on the latest drug without ever taking the trouble to critique the data. They help create a demand for drugs that would not otherwise be there. But don't look for that admission anywhere in the series. It would require too much introspection, a quality which seems to be congenitally absent from journalists.

    Not that they would be any good at critiquing data, judging by this description of the methodology used in their series:

    To estimate how often patients are harmed by this practice, Knight Ridder reviewed the FDA's database of adverse drug reactions. The FDA estimates that only 1 to 10 percent of reactions are reported. Knight Ridder identified more than 800 reports filed during 2002 of serious reactions involving off-label prescriptions for its sample of 45 drugs. Experts say that means anywhere from 8,000 to 80,000 people probably were affected.

    That's quite a spread. But, in the world of Knight-Ridder, that bit of journalistic conjecture passes as scientific truth.

    Then there are the unexamined case histories. The first article opens with the story of a woman who developed a heart problem after having twins. She took terbutaline, an asthma drug, to stop premature labor for the last three months of her pregnancy. She blames the drug, even though pregnancy and delivery in themselves run a small risk of heart damage. In fact, she says she hates the drug, and she has a lot of animosity toward her obstetrician, too. However, at the end of the article, we learn that she wanted her babies so badly she went to the time and expense of in vitro fertilization to get pregnant. Can she honestly say that given the choice again, she would forego the medical treatment and elect to expose her babies to the risk of death by having them three months prematurely?

    The second article opens with a suicide tale. The doctor, a cardiologist, blames Prozac. So does the patient's family. They all say he wasn't depressed. But all too often in depression, the family is the last to know (or admit it.) And why would the cardiologist put the patient on Prozac if he didn't think he had at least a modicum of depression? Far more likely that the man committed suicide because he was depressed rather than because he took Prozac.

    The final article details the case of a young woman who died of Stevens-Johnson syndrome after taking the antibiotic Avelox for a respiratory infection. Stevens-Johnson syndrome is a severe auto-immune reaction that can be fatal. It can be associated with any drug, not just Avelox. It's one of the risks we take each time we take an antibiotic. What's more, it can be caused by a virus or a bacteria, too, so foregoing antibiotics for an infection doesn't protect you from getting it. To give you an idea of how many agents have been implicated in the syndrome, here's a partial list of drugs:

    * Fansidar-R
    * Sulfadiazine
    * Sulfadoxine
    * Sulfasalazine
    * Trimethoprim-sulfamethoxazole
    * Carbamazepine
    * Phenobarbital
    * Phenytoin
    * Acetaminophen (Tylenol -ed.)
    * Allopurinol
    * Aminopenicillins
    * Amithiozone
    * Amoxapine
    * Barbiturates
    * Cephalosporins
    * Chlormezanone
    * Clobazam
    * Diclofenac
    * Fluvoxamine
    * Hydantoins
    * Imidazole antifungals
    * Indapamide
    * Lamotrigine
    * Macrolides
    * Mianserin
    * Oxicam nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, piroxicam, tenoxicam)
    * Propionic NSAIDs
    * Propranolol
    * Pyrazolone derivatives (eg, dipyrone)
    * Quinolones
    * Salicylates (aspirin - ed.)
    * Sertraline
    * Tetracycline
    * Tiapride
    * Trazodone
    * Valproic acid

    Note that the list includes old stand-by antibiotics like the penicillins and sulfas, and that it includes aspirin and Tylenol.

    And here's the list of infectious agents that have been associated with it:

    * Adenoviruses
    * Calmette-Guérin virus
    * Deep fungal infections
    * Enterobacter
    * Enteroviruses
    * HSV
    * Influenza
    * Measles
    * Mumps
    * Mycobacterium tuberculosis
    * M pneumoniae
    * Streptococcus pneumoniae
    * Syphilis
    * Typhoid fever

    Five of those agents - adenoviruses,enteroviruses,influenza, M pneumoniae, and Streptococcus - cause respiratory illnesses. The reporter may accept unequivocally that the young woman's death was the caused by her anitbioitic, but in truth there's just no way of telling.

    But then, they don't really care about the truth. They just want to prop up their themes that drug companies are bad, the FDA is useless, and doctors are "cavalier."
     
    posted by sydney on 11/06/2003 08:16:00 AM 0 comments

    Tuesday, November 04, 2003

    Occupational Medicine: The health hazards of artificial nails.
     

    posted by sydney on 11/04/2003 08:52:00 AM 0 comments

    We Suffer More: Yet another report that women experience illnesses differently than men:

    Lack of significant chest pain may be a major reason why women have more unrecognized heart attacks than men or are mistakenly diagnosed and discharged from emergency departments.

    'Many clinicians still consider chest pain as the primary symptom of a heart attack.'

    Belinda Linden, of the British Heart Foundation said the study 'exposes the need for women to be aware of the wide range of possible symptoms of a heart attack such as chest and throat discomfort, breathlessness, sweatiness, weakness or dizziness.

    'Tiredness, as a symptom, is important when it is severe or unusual.


    The study was a retrospective one that asked women what their symptoms were months after the fact:

    Researchers recruited 515 women diagnosed with a heart attack and discharged from five different medical sites in Arkansas, North Carolina and Ohio within the previous four to six months. The women were age 66 on average, and 93 percent were Caucasian, 6.2 percent black and 0.4 percent Native American. Data collection occurred over three years.

    ..... About 95 percent of women reported having new or different symptoms more than a month before their heart attacks that resolved after their heart attacks. This led them, in retrospect, to believe that these symptoms were related to the subsequent heart attack. The most common early symptoms were: unusual fatigue -- 70 percent; sleep disturbance -- 48 percent; shortness of breath -- 42 percent; indigestion -- 39 percent and anxiety -- 35 percent.

    Only 30 percent reported chest discomfort before their heart attack. They described the discomfort in terms like aching, tightness and pressure – not pain, McSweeney said.
    [emphasis mine]


    It isn't uncommon for people to look back in retrospect and attribute earlier symptoms to their current disease, even when those symptoms have nothing to do with their illness. Here's how the abstract breaks down the results:

    The most frequent prodromal symptoms experienced more than 1 month before AMI were unusual fatigue (70.7%), sleep disturbance (47.8%), and shortness of breath (42.1%). Only 29.7% reported chest discomfort, a hallmark symptom in men.

    Notice that those are "prodromal symptoms," that is, symptoms experienced in the month prior to the discovery of their heart problems. And actually, there's no evidence,other than the author's belief, that chest pain is the "hallmark" of impending heart disease in men. (see here.) In fact, men who present with new onset fatigue, weakness, or shortness of breath should also be evaluated for the possibility of coronary artery disease.

    But, when you talk about presenting with an acute onset of heart disease - that is, the day of the heart attack - those other vague symptoms take a back seat to chest pain/discomfort:

    The most frequent acute symptoms were shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%). Acute chest pain was absent in 43%. Women had more acute (mean, 7.3±4.8; range, 0 to 29) than prodromal (mean, 5.71±4.36; range, 0 to 25) symptoms.

    Clever way to bury that information. A full 57% of women presented with chest pain, just like men do when they're having heart attacks. And more of the women had the acute symptoms than the vaguely recalled prodromal symptoms. Things aren't as different between the sexes as sex-biased researchers would like us to believe.
     
    posted by sydney on 11/04/2003 08:42:00 AM 0 comments

    The Envy of Ponce de Leon: Apparently, some senior citizens have found the fountain of youth:

    Thousands of seniors believe they've found the fountain of youth. They say it makes them leaner and more muscular, gives them more energy and improves their sex lives.

    What is this elixir?


    Pepsi? Coke? No, it's human growth hormone:

    But there's growing concern among health experts about older Americans, as many as 50,000 of them a year, who are getting daily injections of the hormone. Some researchers say this practice, for which the users pay between $5,000 and $10,000 a year, can have serious and potentially deadly side effects.

    Those side effects include diabetes, liver problems, and increased growth of other tissues, resulting in a coarsening of facial features, head enlargement and growth of the arms, legs, hands, and feet. Every choice has its consequences.
     
    posted by sydney on 11/04/2003 08:13:00 AM 0 comments

    Pro-Choice? The American College of Obstetrics and Gynecology says that it's OK to let a woman choose a Cesarean delivery over a vaginal one, although they stop short of promoting it:

    Where medical evidence is still limited, ACOG says there is no one answer on the right ethical response by a physician considering a patient request for surgery. Thus the decision on whether to perform an elective cesarean delivery (also known as 'patient choice cesarean' or 'cesarean on demand') will come down to a number of ethical factors including the patient's concerns and the physician's understanding of the procedure's risks and benefits.

    In the case of an elective cesarean delivery, if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth, then he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery. In this case, a referral to another health care provider would be appropriate if physician and patient cannot agree on a method of delivery.


    This is a sticky situation for obstetricians. Having a baby is one of the few medical conditions in which the patient has the leisure to shop around for the kind of care she wants (unless she lives in a remote rural area.) The conventional wisdom holds that Cesarean deliveries are fraught with more complications and dangers both for the baby and for the mother. That surgical delivery should only be resorted to when the risks of a vaginal delivery are greater than the risks of surgery. But there's little data to back the conventional wisdom:

    ....ACOG cautions that "both sides to this debate" must recognize that evidence to support the benefit of elective cesarean is still incomplete and that there are not yet extensive morbidity and mortality data to compare elective cesarean delivery with vaginal birth in healthy women. With better data, there may be a shift in clinical practice.

    Sometimes, though, the conventional wisdom is right even though it hasn't been extensively studied. When things go right, vaginal delivery is less invasive and has a quicker recovery time. That means less chance for infections and other complications. And when things don't go right, well, that's the place for Cesareans.
     
    posted by sydney on 11/04/2003 08:00:00 AM 0 comments

    Monday, November 03, 2003

    Hogwarts Headache: The correlation between headaches and the length and heft of the Harry Potter books.
     

    posted by sydney on 11/03/2003 09:41:00 PM 0 comments

    Golden Food: Michael Fumento on fortified crops.
     
    posted by sydney on 11/03/2003 08:15:00 PM 0 comments

    Burdens: I've always suspected this:

    A new study finds grandparents who care for a grandchild just a few hours a week have an increased risk of heart disease.

    The study of 54,000 women found those who cared for a grandchild just nine hours a week had a 55 percent higher risk of problems like heart attack compared to women who didn't care for a grandchild.


    Hard to tell how significant that "55 percent increase" is without the raw data. The study is supposedly somewhere in this journal, although I couldn't find it.
     
    posted by sydney on 11/03/2003 08:36:00 AM 0 comments

    Nature's Influence: Is there a gene that determines how much we eat?

    The Imperial study, of more than 1,200 people, identified two forms of the GAD2 gene. One protected against obesity, the other made it more likely by stimulating the appetite.

    Thinner volunteers were found to be more likely to carry the protective form of the gene, while the other version was more common in obese people.

    It seems to stimulate overeating by speeding up production of a chemical messenger in the brain called GABA, or gamma-amino butyric acid. When combined with another molecule GABA stimulates us to eat.


    There's no doubt some of us are more prone to gaining weight than others, all other factors being equal, but the discovery of genes that influence our metabolisms shouldn't become an excuse for our failure to control our appetites. Just remember, no one ever walked out of a concentration camp overweight. (Although entering one overweight could arguably bestow a survival advantage.)
     
    posted by sydney on 11/03/2003 08:19:00 AM 0 comments

    Saturday, November 01, 2003

    Heal Thyself: American family physicians are told to put their money where their mouths are. (Or at least to take the food out of their mouths.)
     

    posted by sydney on 11/01/2003 08:25:00 AM 0 comments

    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 1 comments

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