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    "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.

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    Saturday, March 13, 2004

    Birth Trauma: Interesting finding reported in The Lancet this weekend. Bleeding in the brain might be a common consequence of being born, irrespective of the type of birth. The babies in the study were all asymptomatic, and never would have been found to have the bleed if they hadn't been part of the study.

    Makes one wonder how many shaken baby convictions might be unjust.

    posted by Sydney on 3/13/2004 08:07:00 PM 0 comments

    Cost Cutters: Medicare is reducing reimbursement for cancer drugs, forcing some oncologists to cut their services. Notes one oncologist:

    'We provided a Nordstrom level of care that was funded by these outrageous drug markups,' Dr. Eisenberg said. 'Now, reimbursements are going down to Kmart levels, and we can't provide the level of service our patients have become accustomed to.'

    The problem is, the patients keep expecting Nordstrom service at Kmart prices.
    posted by Sydney on 3/13/2004 07:54:00 PM 0 comments

    Granny Dealer: Did you hear about the 96 year old woman who was arrested for having crack cocaine in her wheelchair? It's not the first time she's hid it:

    But according to the search warrant affidavit, it's the third time Cleveland County deputies have seized crack cocaine at Roberts' home, which she shared with a son. An informant told deputies that Julia Roberts hid crack in her prosthetic leg during a previous search, according to the affidavit.
    posted by Sydney on 3/13/2004 07:45:00 PM 0 comments

    Friday, March 12, 2004

    The Skinny on Obesity: Now here's someone with a brilliant idea. Instead of trying to find out why we gain weight so easily (which most of us do), find out why skinny people don't:

    In the past, when I studied obesity, the thin rats were just a control group. But what I realized was that regaining energy balance following a period of overfeeding is a very dynamic process. Obesity is the more passive process. An animal or person overfeeding -- if they don't respond to that overfeeding, if nothing changes -- then they just keep gaining weight.

    posted by Sydney on 3/12/2004 08:48:00 AM 0 comments

    Activist Science: Michael Fumento looks at MMR and autism.
    posted by Sydney on 3/12/2004 08:43:00 AM 0 comments

    Thursday, March 11, 2004

    Plague Penalty: The Texas plague researcher who had some careless and shady plague-handling policies was sentenced today - to two years in prison, $15,000 in fines and $38,675 in restitution. He also lost his job, has to pay the university $250,000, and lost his medical license. A ruinous penalty. But then, he did illegally ship plague to Tanzania for some reason.

    posted by Sydney on 3/11/2004 09:54:00 PM 0 comments

    Canadians Take Action: Class action, that is, in law suits against Canadian hospitals for overlong waiting lists. And here's how one of the plaintiffs finally got her radiation therapy for breast cancer:

    Ms. Cilinger, three months after her operation, finally called her daughter in her native Turkey for help. Within 24 hours, she had secured a radiation appointment at an Istanbul hospital. She returned to Canada $15,000 poorer and decided to take action.
    posted by Sydney on 3/11/2004 09:47:00 PM 0 comments

    Preparedness Watch: Some progress in the search for a safer smallpox vaccine.
    posted by Sydney on 3/11/2004 09:39:00 PM 0 comments

    Policing Food II: First, they came for our french fries, then they came for our popcorn.
    posted by Sydney on 3/11/2004 09:34:00 PM 0 comments

    Wednesday, March 10, 2004

    Crisis Mounts: People weren't kidding when they said that fast food would become the next tobacco:

    Eating too much and exercising too little are poised to pass smoking as America's leading cause of preventable death, researchers from the Centers for Disease Control and Prevention said Tuesday.

    The finding, announced Tuesday at a Washington news conference and published today in the Journal of the American Medical Association, elevates to a crisis the continuing trend of obesity, the researchers said.

    Haven't the public health scolds been calling it a "crisis" for some time now? Well, yes, but now they see it as more of a crisis. It's a crisis crisis!

    "We knew there was an epidemic of obesity, and that it would have important effects on disability and mortality," said Dr. James Marks, a study co-author and director of the CDC's chronic disease center. "But this is the worst we could have thought of."

    The study that's brought on all the furor is this one written by, among others, Julie L. Gerberding, the head of the CDC. (Who once famously remarked that obesity is more of a threat than terrorism.) Their objective was to link lifestyle choices to mortality. Of course, when the coroner lists the cause of death on death certificate, you can bet he never writes - "smoking" or "obesity." He documents the disease he found - "heart attack," or "cancer." So how do they know that obesity is gaining on smoking as the number one cause of death? For that matter, how do they know that smoking as opposed to say, aging, is the number one cause of death? They don't. They are, in large part, assuming it.

    Here's what they did. They got the leading causes of death for the year 2000 from CDC data. That is, the disease that actually killed people in 2000:

    1. Heart Disease 710,760
    2. Cancer 563,091
    3. Strokes 167,661
    4. Chronic Lung Disease 122,009
    5. Accidents 97,900
    6. Diabetes 69,301
    7. Influenza/pneumonia 65,313
    8. Alzheimer's 49,558
    9. Kidney disease 37,251
    10. Overwhelming infection 31,224

    Then, they did a literature search of all articles published between 1980 and 2002 on the risk factors that interested them - smoking, physical activity, diet, obesity, alcohol, sexual behavior, illicit drug use, etc. They took the data from these articles and determined the relative risk of getting a disease for each chosen risk factor, and the relative risk of death for each risk factor. With this, they derived an estimate of how many deaths from each disease were caused by any given risk factor. Then, they had the audacity to call their estimate the "actual cause of death." (You will notice that they did not do a search for "aging," perhaps the greatest risk factor of all for the top three leading causes of death.)

    It is, all things considered, a very weak study. Certainly too weak to be the foundation of sweeping public policy:

    In addition, the National Institutes of Health has proposed an anti-obesity research agenda, and a special task force is expected Thursday to give formal recommendations to the Food and Drug Administration on what the agency can to do to help reverse the cresting public health crisis.

    What will the FDA do about it? Condemn our food? Make it illegal to sell cookies? Or just illegal to buy them unless your BMI is less than 25?

    UPDATE: Steve Milloy calls the CDC study statistical malpractice. Heh.

    posted by Sydney on 3/10/2004 08:26:00 AM 0 comments

    Tuesday, March 09, 2004

    Getting Along: I confess, I was prepared to dislike Dr. David Servan-Schreiber's new book, The Instinct to Heal. Curing Stress, Anxiety, and Depression without Drugs and Without Talk Therapy. Especially after reading the desciption of him on the cover as "co-founder of the Center for Complementary Medicine at the University of Pittsburgh." And especially after a glance at the table of contents listing chapters such as "The Power of Qi," "The Energy of Light," and "Eye Movement Desensitization and Reprocessing (EMDR): The Mind's Own Healing Mechanism." My knee-jerk reaction was to dismiss it as yet another paen to alternative medicine at the expense of traditional, proven, medical therapies.

    But Dr. Servan-Schreiber is not your typical alternative medicine guru. He has no product to sell, no "newly discovered" technique (with video tie-in) to hype. He's just a psychiatrist who has seen way too many people placed on Prozac simply because they wept in a doctor's office. And he wants to do something about it.

    Too often, traditional medicine assumes we can counsel away any trauma, medicate away any pain. It's this sort of thinking that gave rise to one of the most ridiculous sites in the aftermath of September 11 - the flight of mental health professionals to lower Manhattan to provide "emergency counseling" for the victims, as if their training had given them some god-like inner wisdom that would allay the suffering of mere mortal laypeople. But pills, and even talk therapy, can't obliterate the horror of facing your mortality, the pain of a lover's rejection, or the loneliness of old age, let alone erase the emotional scars inflicted by man's general inhumanity to man.

    Dr. Servan-Schreiber knows this all too well. He has spent a lot of his time doing psychiatric liaison work. That is, he helps other doctors deal with the repercussions of their illnesses. It's these sorts of patients who modern psychopharmacology fails the most. And it's these sorts of patients Dr. Servan-Schreiber has in mind when he talks about the instinct to heal.

    Take the example of the lonely old person. Many's the time Dr. Servan-Schreiber was consulted by other doctors to recommend therapy for them. He knew from experience that no amount of psychotherapy, no potent anti-depressant, was going to cure their loneliness. So, he often made sensible recommendations instead. Recommendations like "get a pet." The response of his colleagues was not kind. "We asked you to recommend an anti-depressant, not a zoo," they would tell him, as they ignored his recommendation and made their own choice of anti-depressant. And one could easily imagine them scoffing at most of the ideas in this book.

    The central premise of Servan-Schreiber's approach is that our emotional brain is much more closely related to the parts of our brain that control our bodies than it is to our rational brain. (That's why we get "sinking feelings" when we're apprehensive, and "heartaches" when we're sad.) We have a hard time reasoning ourselves out of our emotions. In fact, too often, we let our emotional brains overrun our rational brains. But, as hard as it may be to reason ourselves out of emotional turmoil, we can gain some control over them by controlling the parts of our bodies that are closely tied to our emotional brains. That's what we do when we take a few deep, calming, breaths before stepping up to make that big speech, or when we count slowly to ten to avoid an angry confrontation. Those are the simple, instinctive, steps we take. According to Servan-Schreiber, we could do more. Much more, or at least seven more things of varying complexity to help control our depressions, rages, and anxieties.

    The first is a method he calls "heart coherence." By consciously controlling the variability of our heart rates, we can induce a sort of negative feedback loop to fool our emotional brain into becalming itself. It's the same theory that has been promulgated by the dubious HeartMath Institute, but it's also the same principle that lies behind yoga and meditation. And although there's never been a large clinical trial to prove its efficacy, it probably works for some people - at least for those who are able to learn the technique (usually done with the assistance of computer software that monitors and displays the heart rate in real time).

    The second is the awkardly labeled, and much more controversial, Eye Movement Desensitization and Reprocessing, or EMDR for short, a technique that's often promoted for the treatment of post-traumatic stress disorder. The theory is that by invoking the sorts of eye movements we have when dreaming, or watching a movie, while thinking of a particularly traumatic event, we are able to establish new connections in the brain that override the old ones associated with the bad memory. Some studies have found the technique wanting, although there have been some that suggest it might be effective. And the case studies that Servan-Schreiber details in his book certainly seem compelling, especially those involving Kosovar children traumatized by the brutality of war.

    Methods three through five are even less compelling. One is the use of light to treat depression, specifically a dawn simulator, which is a light switch that gradually brightens the room lights to mimic the rising of the sun. Instead of a jarring alarm, you wake up slowly and peacefully to the rising light. Another is the use of acupuncture, not just to treat physical pain, but to treat depression. And perhaps his weakest claim is that omega-3 fatty acids, the kind you get from taking fish oil supplements can effectively treat depression, and even in one case, schizophrenia.

    The best one can say about any of these methods is that although they haven't been proven, they're also not likely to be harmful, at least not for the run of the mill depressions and anxieties that most of us suffer at some time or another. I wouldn't recommend them for the suicidal or the severely schizophrenic, but for the chronically sad or anxious, they could be worth a try. Especially when conventional medicine has failed. And to Dr. Servan-Schreiber's credit, he provides ample reference to back up his support of each method. And he never claims miracles for them or touts them to the exclusion of other treatment modalities.

    The best recommendations, however, are at the end of the book. Not just the chapter that covers the importance of regular exercise to mental well-being, but the final five chapters devoted to the importance of emotional communication. That doesn't mean just telling everyone baldly what you think of them and their ideas, but of developing the emotional maturity to speak honestly without giving offense, and to respond to the emotional rants of others without taking offense. In stark contrast to the beginning of the book, which emphasizes the disconnect between the rational and emotional brains, this emphasizes the supremacy of the rational mind over the emotional mind. (The author recommends carrying around index cards with acronyms that stand for each step in both the process of effective emotional communication -both in the giving and the receiving - to help you get through it at first.) And as dorky as it may seem to take out a cheat sheet in the middle of a hot exchange, I find myself tempted to make up a set of cards to carry around in my pocket. Lord knows there are plenty of times I could use them. Couldn't we all?

    (Double-posted at Blogcritics, where there's been a lot of ineffective emotional communication lately. Just click on any of the Passion posts and read the comments.)

    UPDATE: You can learn more about Dr. Servan-Schreiber's theories at his website Instinct to Heal, which, amazingly, doesn't try to sell anything other than his book.


    posted by Sydney on 3/09/2004 10:02:00 PM 0 comments

    The Love Affair Continues: Between cardiologists and statins, that is. This week sees a "ground-breaking", "sea-changing" study that proves that everyone should be put on the highest dose of one of the most expensive statins to achieve ultra-low cholesterol levels and striking benefits:

    The findings should prompt doctors to give much higher doses of drugs known as statins to hundreds of thousands of patients who already have severe heart problems, experts said. In addition, it will probably encourage physicians to start giving the medications to millions of healthy people who are not yet on them, and to boost dosages for some of those already taking them to lower their cholesterol even more, they said.

    ...."This is a sea change, and I don't use that term lightly," Topol repeated in a telephone interview. "This is big. This will mean a major change in the daily practice of medicine."

    Maybe Dr. Topol should take a closer look at that study. (Available for free, in in its entirety here, albeit in pdf form.) The study looked at 4162 patients from around the world who were hospitalized within ten days of enrollment for an acute coronary syndrome - that is they were admitted with chest pain that ended up being caused by heart disease. Half were put on 40 mg of Pravachol (whose maker sponsored the study) and half were placed on 80 mg of Lipitor. The Pravachol dose is a commonly used dose, the Lipitor dose is much higher than routinely used. They followed the patients for 18 to 36 months, looking to see how many would die (of any cause), have a heart attack, a stroke, or have to be admitted again for unstable angina.

    The results are more notable for what they don't tell us than what they tell us. Rather than following patients over a given period of time and tallying the number of events each group had, they stopped the study when they had 925 events, then relied on statistics to estimate the rates. As a result, the paper deals not with actual event rates but with Kaplan-Meier event rates. A far better study would have been to look at the actual rates. But then, the significance of the findings might not have been as impressive. That is, it would have been harder to present their statistically significant findings as equally clinically significant.

    But even using the statistical mill, the difference between the Pravachol group and the Lipitor group wasn't that impressive. Twenty-six percent in the Pravachol group had bad outcomes compared to and twenty-two percent in the Lipitor group. (Keep in mind that those aren't acutal outcomes, just "estimated" outcomes), for a whopping 4 percent difference.

    Now, consider the risks of achieving that four percent estimated improvement in outcome. The authors were kind enough to present the adverse events in terms of real rates, so they're worth noting. Twenty-one percent of the patient's on Pravachol discontinued the drug during the study compared to 23 percent of those taking Lipitor. Even more worrisome, three percent of the high dose Lipitor group had to stop it because their liver enzymes were elevated above three times the normal level, compared to one percent of those in the Pravachol group. There's no mention of how many patients in each group had mildly elevated or moderately elevated liver enzymes.

    It's common among cardiologists to insist that patients remain on statins even if their liver enzymes are elevated, unless they're elevated above three times normal. Their world revolves around the heart, all other organs be damned. But elevated liver enzymes are a sign of liver inflammation. And chronic liver inflammation, even if mild, increases the risk of liver cancer and cirrhosis. That's why we worry about alcoholics and chronic hepatitis victims. And although there's no evidence - yet - that statins are associated with higher rates of liver cancer, we need to remember that they've only been in widespread use for the past ten years or so. There just hasn't been time to find out yet what the long term consequences of taking statins might be. Those consequences could just end up outweighing the marginal benefits that pushing the cholesterol to ever lower limits conveys.
    posted by Sydney on 3/09/2004 08:46:00 AM 0 comments

    Apologies: Sorry for the lack of posting. For some reason, I've had a sudden deluge of paperwork at the office - both from patients and from insurance company recredentially, and hospital privilege updates. Then, too, I'm shopping around for a new malpractice insurance carrier, and filling out the applications is taking more time than I thought.
    posted by Sydney on 3/09/2004 08:42:00 AM 0 comments

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