"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
Riding the Rolls: A British researcher says that when it comes to preventing heart disease, we've been buying Rolls Royces when bicycles would do:
THE ANALYSIS found that low-dose aspirin was as effective as and much cheaper than statins, which lower cholesterol, or the blood thinning drug clopidogrel, which is sold under the brand name Plavix by the French drug firm Sanofi-Synthelabo.
“This analysis confirms the poor cost effectiveness of statins and clopidogrel compared with aspirin and antihypertensive treatments,” Tom Marshall, of the University of Birmingham in England, said in the British Medical Journal.
The most cost effective preventive treatments are aspirin, initial antihypertensive treatment (bendrofluazide and atenolol), and intensive antihypertensive treatment (bendrofluazide, atenolol and enalapril), whereas simvastatin and clopidogrel are the least cost effective (cost per coronary event prevented in a patient at 10% coronary risk over five years is £3500 for aspirin, £12,500 for initial antihypertensives, £18,300 for intensive antihypertensives, £60,000 for clopidogrel, and £61,400 for simvastatin). Aspirin in a patient at 5% five year coronary risk costs less than a fifth as much per event prevented (£7900) as simvastatin in a patient at 30% five year risk (£40, 800).
Grass is Greener: The British National Health Service thinks it should act more like Kaiser Permanente, but Kaiser Permanente is already acting like the NHS.
Come on Sydney, Kaiser's not like the NHS--you know they don't have Greyhound buses in England!
He also begs me to caution you to avoid HMO's who spurn the only hospital in your town. Trouble is, you never know when they're going to turn from friendly to hostile, and most people can only change insurance companies during periods of "open enrollment" at work - usually once or twice a year. posted by Sydney on
11/29/2003 07:21:00 PM
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Preparedness: The United States is unprepared for a serious influenza epidemic, so says a researcher whose work is devoted to a vaccine-producing technique that he'd like to see used more:
Moreover, the long time now required to develop and mass produce a vaccine in enough quantity to protect large populations would be a serious vulnerability in any strategy for responding to such an outbreak.
The customary way to make a vaccine against a specific influenza virus is to let viral genes mix inside chicken eggs that include genes from a virus known to be safe to use in humans. Viruses arising from this mixing that are both safe to use in humans and carry hemagglutinin (H) and neuraminidase (N) proteins that trigger immune system responses in humans are used to make vaccines.
"In the event of a pandemic, the process of initially developing a "seed" virus suitable for mass production as a vaccine would be too slow and too dependent on a steady supply of eggs," said Richard Webby, Ph.D., assistant member of the St. Jude Division of Virology and co-author of the Science article. Particularly worrisome is the fact that the highly pathogenic H5 and H7 subtypes of the flu virus kill embryonated chickens eggs.
However, Webster's laboratory demonstrated earlier this year that it is possible to dramatically reduce the overall vaccine development time by using a new technique to develop the seed virus.
Led by Webby, the St. Jude team successfully modified a technique called reverse genetics to develop a seed vaccine against H5Nl. The researchers mixed two genes from H5Nl with six genes from a second virus (A/PR8/34)[HINI]) to produce a seed vaccine virus that was safe in humans but that carried the H and N proteins that stimulated the immune system.
"Although the viruses still have to be grown up in eggs to make vaccines, the initial process of making the seed vaccine is much quicker using reverse genetics," Webby said.
But reverse genetics requires specific populations of animal cells in which to grow the viruses, and there are only a few lines of cells suitable for this process. Most of those cell lines are owned by large pharmaceutical companies rather than academic research laboratories such as St. Jude.
Federal and provincial health officials are finalizing a new pandemic influenza plan that could call for the stockpiling of huge amounts of anti-viral drugs and the establishment of old-fashioned 'fever hospitals,' last seen during the Spanish Flu of 1918.
The plan would stop short of ordering mass flu vaccinations, sources say.
'If a killer strain hits us, there won't be time to get a workable vaccine ready,' said a senior Ontario health official. 'SARS gave us a taste of what to expect.'"
And just how serious is the influenza disease outbreak so far? Here's the latest data from the CDC (for the week of November 15):
The proportion of patient visits to sentinel providers for influenza-like illness...overall was 3.3%, which is above the national baseline of 2.5%. The proportion of deaths attributed to pneumonia and influenza was 6.1%, which is below the epidemic threshold for the week.
In contrast, this is where things stood last year at the same time:
The proportion of patient visits to sentinel providers for influenza-like illness...overall was 1.1%, which is less than the national baseline of 1.9%. The proportion of deaths attributed to pneumonia and influenza was 6.8%.
The overall proportion of patient visits to sentinel physicians for influenza-like illness... was 1.2%, which is less than the national baseline of 1.9%. The proportion of deaths attributed to pneumonia and influenza was 6.6%
So, it looks like it's just a little more prevalent than usual, and about as deadly as usual. Hardly cause for alarm. posted by Sydney on
11/29/2003 07:02:00 PM
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Friday, November 28, 2003
Money, Money: Looks like money may be the motivating factor on both sides of the Schiavo debate:
Pinellas-Pasco Judge George Greer concluded in a 2000 ruling ordering Terri Schiavo's feeding tube removed that the argument was about money.
"It is clear to this court that (the argument) was predicated upon money and the fact that Mr. Schiavo was unwilling to equally divide his . . . award with Mr. and Mrs. Schindler," Greer wrote. "Regretably, money overshadows this entire case and creates potential of conflict of interest for both sides.
Researchers at Canada's McGill University installed UVGI or ultraviolet germicidal irradiation ventilation systems in three office buildings in Montreal.
Like many modern offices, these were sealed buildings.
Windows were fully sealed and the only air getting into each of the buildings came through air conditioning units and ventilation vents.
The researchers tested the UVGI system over the course of almost a year.
UVGI was initially off for 12 weeks before being turned on for four weeks. This pattern was repeated for the duration of the study.
The researchers questioned a total of 771 people who worked in these offices.
They found strong evidence to suggest that UVGI can reduce the symptoms of sick building syndrome.
They reported that workers who suffered from unexplained headaches, irritation around the eyes, the nose and in the throat and respiratory problems had reduced symptoms.
The number of people reporting irritation around the eyes, nose and throat fell by 30%.
The number reporting fewer respiratory problems dropped by 40%.
The original article is only available with an expensive Lancet subscription, the abstract doesn't shed much light. It only gives reduction rates. Hard to tell if the findings justify the cost:
"To install UVGI in the ventilation systems of an 11,148 square-metre office building with 1,000 occupants would cost US$52,000 and $14,000 per year for energy, maintenance and bulb replacement.
"For every worker, the estimated $52 for initial and $14 for yearly operating costs compare favourably with the estimated yearly losses from absence caused by building-related sickness."
I've always been a little skeptical of the diagnosis of sick building syndrome. Certainly, there are some environments that are unhealthy for everyone - say working around volatile, toxic chemicals without protection. And there are people who are more sensitive to certain conditions than others - asthmatics who are forced to work with heavily perfumed co-workers or who are allergic to something else in the office - like mold spores. But is there really an epidemic of sickness in workers in modern office buildings? Not in my practice. And many of my patients share the same work places - their insurance and the network of doctors they can choose from is, after all, dependent on their employment.
Which makes me even more skeptical of the cost savings that would be had by adopting the ultaviolet lights in the ventilation system. It's been my impression that frequency of absenteeism due to illness, at least among my patient population, is directly related to job satisfaction. Those who complain most bitterly about their jobs are also those most likely to ask for work excuses - even for minor illnesses. posted by Sydney on
11/28/2003 09:13:00 AM
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Housekeeping: Finally got around to some maintenance on the site last night. The blog lists to the left have been updated. My apologies to those whose URL's changed months ago - Iain Murray, Tim Blair. I've also added a few more medical blogs - Medmusings, SOAP Notes, Obels (a 99% non-Dutch medical blog), and last but certainly not least, A Chance to Cut is a Chance to Cure.
In other areas....my husband kindly tweaked the site so that the permalinks work and the garish red background that used to appear to the left on some internet browsers is now the plain white that it was originally meant to be. posted by Sydney on
11/28/2003 08:08:00 AM
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Marketing Obstacles: Sometimes even the best-laid plans of pharmaceutical marketers can't overcome the shortcomings of their products:
The influenza vaccine has always been a shot-in-the-arm proposition -- until this year, when a quick, painless spritz up the nose was offered as an alternative.
But as the peak flu season draws nearer, consumers are ignoring the nasal vaccine known as FluMist.
Not even a nine-week, $25 million advertising campaign has overcome the vaccine's obstacles: storage difficulties, a different target audience, the use of a live virus, problems training pharmacists to administer the drug and, most obviously, cost.
``We had a lot of phone calls (asking about FluMist),'' said Tom Nameth, Discount Drug Mart's director of pharmacy operations, ``but once they found out the price, that was the big turnoff.''
Most doctors aren't surprised.
``None of us expected it to catch on,'' said Dr. Ellen Kempf, medical director of Children's Hospital Physician Associates. ``The company kept telling us what a great influx this would be and we said, `Huh? We don't think so.'
``It's, what, five times the cost? As soon as you tell a family this... they say, `Forget that.'
It also has to be stored in a non-defrosting freezer. Who's going to go out and purchase a freezer just to store an expensive vaccine that few people want, especially when there's a cheaper alternative? posted by Sydney on
11/27/2003 08:49:00 AM
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Wednesday, November 26, 2003
SARS Update: No, it's not back, but those who had it last year are now developing bone problems:
China is reporting a high incidence of a bone disorder among patients who suffered Severe Acute Respiratory Syndrome. Previously Hong Kong researchers found that SARS patients are at risk of developing avascular necrosis. The new data could signal the problem is more common than first thought.
...KY Yeun, a microbiology professor at Hong Kong University, recently said that roughly 10 percent of recovered SARS patients in the city developed avascular necrosis.
He said this figure was almost double the incidence of the disorder in other patients treated with similar steroid doses.
The Beijing research, however, indicates that SARS patients are three to four times more likely to develop avascular bone necrosis than other patients taking steroids.
Professor Yeun in Hong Kong speculates this is because SARS patients' bones were weakened by a lack of oxygen and the steroids only added to the damage.
Avascular necrosis is a condition caused by a loss of blood supply to a bone. The oxygen and steroid therapy makes sense, but it's also possible that the virus itself plays some role in the pathology. Only time will tell. posted by Sydney on
11/26/2003 08:32:00 AM
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Reverse Schiavo: Another unresponsive patient whose treatment decision has been sent to the court, even though his wishes to be kept alive were documented:
Ernest Carpenter of Perrysville is seeking a court order to suspend life-sustaining efforts on his comatose, 82-year-old father, Gerald.
Opposing him is Ashland attorney Josiah Mason, who was appointed Gerald Carpenter's guardian two months ago when Akron City Hospital officials could not locate family members.
Mason, who has never talked to Gerald Carpenter, said he is abiding by the last known words his client made on the issue of life support: ``Don't let me die; do everything you can.''
Ernest Carpenter told the judge his father saw life support differently: ``He'd say he'd never wanted to live that way. That's not living.''
Problem is, the son hasn't exactly "been in touch" with his father's feelings:
Walker contends Ernest Carpenter rarely visited his father's Mifflin home and had not talked to him since April-- two months before his dad entered the nursing home and five months before he entered Akron City Hospital.
....A store owner who talked to Gerald Carpenter daily for 17 years testified he never knew that the man he called ``Grandpa'' had a son named Ernest. He said another son, Gary, who died in 1998, visited regularly and left a phone number for him to call in case of an emergency.
Ernest Carpenter explained his absence from his father, saying the two had a ``spat'' in April. He could not remember what the disagreement was about.
He said he talked to his father about life support 15 years ago.
The son stands to inherit $300,000 if his father dies.
When the elder Mr. Carpenter entered a nursing home, he made it clear to the staff that he wanted everything done to keep him alive if he should become critically ill. That may not have been a wise decision at the age of 82, but it was his decision to make and it has to be respected.
The judge ruled that doctors at Akron City Hospital should keep the 82-year-old man ``comfortable with no surgical procedures to prolong the dying process.''
Ashland lawyer Josiah Mason, appointed Carpenter's guardian by another judge, had wanted doctors to do all they could to keep the Ashland County man alive.
Mason, who has never talked to Carpenter, was relying on a medical form the man signed when he was admitted to an Ashland nursing home in June. Carpenter told a nurse he wanted medical staffers to do all they could to prevent his death.
Spicer ruled that the form is invalid because it addressed only life-saving measures to be taken in the event Carpenter suffered a heart attack -- and not the prolonged state of unconsciousness the man is currently in.
The moral of the story is: Make your wills - both the conventional type and the medical type - as detailed and as clear as possible to keep avaricious relatives at bay.
If it's the onions, why aren't people dying here? Everybody here eats them. There should be a ton of people sick here. They're the same onions,' he said.
They aren't getting sick there because they're immune to the diseases that their water carries. We aren't:
Dr. Mike Doyle, a microbiologist and director of the Center for Safety at the University of Georgia, agrees. 'There is a greater potential for contamination to occur in some developing countries where growing standards differ from U.S. standards,' Dr. Doyle said. 'One of the biggest problems is in the quality of the water used.'
Dr. Tauxe of the Centers for Disease Control said: 'As far as I know there is not a mandatory requirement that water used to rinse or ice or wash vegetables be potable. There are guidelines recommending this, but in terms of fairness we don't require other countries to meet standards that aren't required in this country.
Now that so much of our fresh fruit and vegetables are imported, we face the same risks at home that we usually only risk when travelling. So, what to do? Wash your fruits and vegetables carefully before eating them raw. Remember, the solution to pollution is dilution. The CDC has more prevention tips. posted by Sydney on
11/24/2003 07:47:00 AM
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Changing the Face of Medicine: A reader alerted me to this exhibit from the National Institutes of Health, about women in medicine. For my generation, choosing a career in medicine wasn't that big a deal. Medical schools welcomed women by then. So much so that fifty percent of medical school classes were women (this was the mid-1980's), and there were women on the faculty in just about every department. I don't remember ever encountering any overt prejudice from either my professors or my classmates.
The first women in medicine, however, are nothing short of an inspiration. They went into the field at a time when women were considered little more than children. Women like Elizabeth Blackwell, who graduated from Geneva Medical College in 1849. (Although it isn't true, as the bio states, that she was the first woman since the Renaissance to become a doctor. There were others before her, but she may have been the first to do it without resorting to an elaborate ruse). Her entry was serendipitous:
The faculty, assuming that the all-male student body would never agree to a woman joining their ranks, allowed them to vote on her admission. As a joke, they voted 'yes,' and she gained admittance, despite the reluctance of most students and faculty.
On Blackwell's first day of school, Smith remembered, "the Dean came into the classroom, evidently in a state of unusual agitation. The class took alarm, fearing that some great calamity was about to befall the College. … He stated, with a trembling voice, that … the female student … had arrived. … With this introduction he opened the door to the reception room and a lady … entered, whom the Dean formally introduced as Miss Blackwell. She was plainly but neatly dressed in Quaker style, and carried the usual notebook of the medical student. A hush fell on the class as if each member had been stricken with paralysis. A death-like stillness prevailed during the lecture, and only the newly arrived student took notes."
A few paper darts flew her way, but Blackwell ignored them. She later wrote that she hoped her "quiet manner would soon stop any nonsense."
In fact, she had difficulty getting the people of the town to take her seriously. The women shunned her. And after graduation she couldn't find a hospital in which to get her clinical training. She overcame it all and founded her own hospital - not only to treat women, but to train them as doctors. (You can read more about her here.)
She paved the way for other women, like her younger sister, and this Civil War surgeon, and this physicist, and this figure skater. All of whom, in their turn, have made it easier for all those who followed. And all because of a little joke by several dozen medical students in rural New York.
ADDENDUM: Although it's much easier to be both a woman and a doctor these days, here's a little etiquette tip for dealing with women physicians. Be very careful how you use your terms of endearment. If you're over a certain age, say 75, and you have a sweet grandmotherly voice, you may be able to call them "dear" and "honey" with impugnity. If you use the term in an obviously affectionate way, such as "Thank you, dear," then you're not likely to cause offense. But, if you use it in sentences like this, "Look, honey, I know my own body and I know when I need antibiotics," you're not likely to win over the doctor. Just think to yourself- could I/would I use this word of endearment if I were talking to a man? posted by Sydney on
11/23/2003 08:57:00 AM
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