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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.''
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    Friday, April 16, 2004

    Menopause Relief: Hormone replacement therapy may not be as bad as some would have us believe:

    The benefits and risks of long-term estrogen therapy are about equal, says a study out Wednesday.

    "It's not a terribly harmful drug," says Fred Hutchison Cancer Research Center's Garnet Anderson, chair of the group that wrote up the findings. "It also doesn't do much work in terms of prevention."

    ...After seven years on average, estrogen raised stroke risk 39% and lowered hip fracture risk 39%. Estrogen didn't affect heart disease risk, the main question the study set out to answer. There were fewer heart disease cases in the estrogen group, but there weren't enough cases overall to prove that wasn't because of chance.

    Unexpectedly, women taking estrogen were 23% less likely to be diagnosed with invasive breast cancer. There weren't enough cases to rule out chance as the explanation, but the researchers say that a possible reduction in breast cancer risk needs to be investigated further. All other studies have found that taking estrogen raises breast cancer risk, Anderson says.

    That's the problem with result inflation. Another study is sure to come along and contradict it. In truth, all the other studies found very small differences (less than one percent) in the incidence of breast cancer among hormone users and non-users. And as far as stroke risk goes, the currrent study didn't find much of a difference between the two groups, either.

    There were 5,310 women in the study who took estrogen and 5,429 who took placebo. 158 of the estrogen users had strokes during the study, for an incidence of 3%. 118 of the placebo users had strokes, for an incidence of 2%. That isn't all that great a difference. Certainly not enough of a difference to force women to suffer hot flashes rather than seek relief by using estrogen.

    posted by Sydney on 4/16/2004 08:52:00 AM 0 comments

    Occupational Hazards: The porn industry has a crisis on its hands:

    Much of the San Fernando Valley's multibillion-dollar adult-movie business stopped production Thursday as it banned nearly four dozen actors and actresses from working after two tested positive for the AIDS virus, industry officials said.

    According to the story, the "industry" knows of 45 people who worked with just one of the infected actors. Porn makes big money, but do they make enough money to cover the disability costs that could result if many of their workers end up with AIDS?

    READER NOTE: The interesting thing about this outbreak is that the porn industry, all on its own, is using the traditional public health approach, contact identification and testing, an approach that gays stonewalled for years.
    posted by Sydney on 4/16/2004 08:27:00 AM 0 comments

    Thursday, April 15, 2004

    And the Greatest of These is Love: The advantages of love and friendship:

    A new study shows that if you had a heart attack and survived it, your chances of having another attack within a year are halved if you have close friends and/or relatives who love you (in comparison to patients who do not have close friends and loving relatives).

    You have to be a subscriber to get the full article, but the abstract only gives concrete numbers for depression and hedges on the value of loved ones by only expressing the hazard ratio:

    At 12 months’ follow up mortality and further cardiac events were assessed in 583 of 654 eligible patients (90% response); 140 of 589 for whom baseline data were collected (23.8%) were depressed before their MI. Patients who were depressed before their MI were not more likely to die (mortality 5.2% v 5.0% of non-depressed patients) or suffer further cardiac events (cardiac events rate 20.7% v 20.3% of non-depressed patients). After controlling for demographic factors and severity of MI, the absence of a close confidant predicted further cardiac events (hazard ratio 0.57, p = 0.022).

    Makes one wonder if the actual difference between beloved patients and crumudgeonly ones was as significant as the stories make it sound.

    posted by Sydney on 4/15/2004 09:36:00 AM 0 comments

    Not Ready for Prime Time: Looks like the advance praise for virtual colonoscopy was a little premature:

    The virtual method detected 55% of patients with at least one suspicious polyp at least 10 millimeters in diameter, compared with a 100% success rate for traditional colonoscopy. For smaller tumors, at least 6 millimeters in diameter, the results were worse: 39% for virtual colonoscopy versus 99% for the traditional method.

    Eight patients ultimately were diagnosed with cancer; virtual colonoscopy missed the disease in two of them.

    That's a good summation of the study. The difference between this study and the previous one that hailed the procedure as just as effective as regular colonoscopy, is that this one looked at the procedure as it was performed across several hospitals. Like any radiological procedure, the results are only as good as the person who interprets them.

    posted by Sydney on 4/15/2004 09:21:00 AM 0 comments

    Mini-Pumps: A company in Wales is working on tiny insulin pumps for diabetics:

    A diabetes “patch” that administers insulin through a plaster stuck to a person’s skin could end the need for the daily regime of injections endured by diabetics.

    .... The patch — which looks like a cross between a credit card and a first-aid plaster — is worn on the skin and lets patients carry and receive a three-day supply of insulin anywhere on their body.

    The BBC has a nice picture of the prototype. Compared to current insulin pumps, it looks like a vast improvement. The technology depends on something they call light-activated micro-actuators:

    At the heart of Starbridge's technology - and the cleverest and most innovative element of it - are the simple and inexpensive light-activated micro-actuators (LAMs) it uses to provide the energy and control for its range of miniaturised liquid handling devices (the company's products are typically 100 times smaller than those currently available and provide a high level of functionality).

    'The LAMs, activated by infrared radiation, comprise a thermomechanically active material that generates movement when heated,' explained Starbridge's chief executive officer, Dr Joseph Cefai, a recognised expert in microfluidic system development.

    Sounds like it will make Pump Boy's job a lot easier.

    UPDATE: A reader notes that there's a company in the U.S. working on this sort of thing, too:

    A startup called Therafuse in Carlsbad, CA has been working on something along the same line, and may well be farther along. Their system seems to call for an adhesive patch and a replaceable insulin cartridge has been in animal testing for some time.

    Tired as I am of the multiple daily insulin injections, I've had little interest in the current style of pump. However, given developments in MEMS technology, there seems to be little reason why the measurement and dose metering can not be combined in a much less obtrusive design...a direction that Therafuse seems to be moving toward.

    More about Therafuse here and here:

    The microneedle can also make standard skin injections less painful and more precise. Dr. Pisano cofounded the startup TheraFuse, which has developed a prototype insulin-delivery system about the size of a poker chip that attaches to the skin with adhesive. A preloaded, disposable capsule delivers insulin continuously through a 120-micron stainless steel microneedle. The device’s pressurized reservoir propels the fluid, while a snap-in, reusable, chip-driven component meters the dosage. TheraFuse expects to start testing the device on animals in May 2003 and to have a product out by late 2005.

    Still in the lab stage is the microneedle’s most promising application of all: with funding from darpa and Becton-Dickinson, UC Berkeley bioengineering professor Dorian Liepmann has developed a tiny all-in-one syringe that shoots freeze-dried drugs into the skin painlessly through an array of up to 100 microneedles. Patients self-administer the doses by pushing the 10-mm-by-10-mm device–nicknamed the chiclet for what it resembles–against their skin for a few seconds, which forces the dry drug out of the reservoir, through the microneedle channels, and into the skin.

    The chiclet's appeal for distributing vaccines and antibiotics in developing countries is enormous: the freeze-dried drugs don’t require mixing, can be stored indefinitely, and can be distributed safely to patients to self-administer. It could also be used to deliver drugs that are dangerous or ineffective when taken orally, as a time-saving device for paramedics, for bioterrorism attacks, and in space. And it doesn't even hurt.

    posted by Sydney on 4/15/2004 09:19:00 AM 0 comments

    Folk Tales: A few weeks ago on a bright, sunny and warm early April day, a patient of mine told me we could expect more snow. The female grackles hadn't yet returned to his yard. A few days later we had three inches of snow. I saw him again yesterday. The grackles still haven't returned.
    posted by Sydney on 4/15/2004 09:12:00 AM 0 comments

    Apologies: Sorry for the paucity of posts. I have more than the usual allotment of patients in the hospital, so morning rounds are taking up more of my time than usual.
    posted by Sydney on 4/15/2004 09:07:00 AM 0 comments

    Tuesday, April 13, 2004

    Bariatric Woes: Bard-Parker has a detailed post on the trials and travails of weight loss surgery. Health insurers are declining to pay, patients are finding out it isn't the piece of cake the media makes it seem, and malpractice insurers are paying out big awards for complications.

    posted by Sydney on 4/13/2004 06:31:00 PM 0 comments

    Beholder Eyes: Eyeball jewellery.
    posted by Sydney on 4/13/2004 08:05:00 AM 0 comments

    This Just In: Gifted students use their whole brain.
    posted by Sydney on 4/13/2004 07:49:00 AM 0 comments

    All the Rage: You know the average reporter is of boomer age when every newspaper and media outlet has a story about bifocal preventing eye surgery. (It's even advertised by its developers as designed for baby boomers. Bet that caught the media eye.) You can watch a promotional video for the procedure, conductive keratoplasty, here, which has good surgery footage even though it's an advertisement. And you can read about the complications of the procedure here.
    posted by Sydney on 4/13/2004 07:48:00 AM 0 comments

    Leaping Conclusions: Researchers say that women with a genetic predisposition to breast cancer should get very frequent mammograms:

    In their study of 13 women aged 32 to 59 with these genes, researchers at Columbia-Presbyterian found six had developed breast cancers detected in between their annual mammograms.

    The average time that had elapsed since their last annual screening was about five months, and four of the six had already developed relatively advanced cancers that had spread to their lymph nodes.

    "We feel that (every) 12 months definitely is not adequate screening for women with these genetic mutations," said Dr. Ian Komenaka, a breast surgeon and lead author of the study, published on Monday in the online edition of the American Cancer Society journal Cancer.

    "It looks like it needs to be every six months if not every four months," Komenaka said.

    The researchers assume that performing mammography more frequently will catch the cancer early enough to prevent it from spreading, thus saving lives. But that is an assumption that cannot be made from their data. Six of the thirteen patients in the study developed breast cancer within 2 to 9 months of having a normal mammogram. Four of them had invasive breast cancer, and three of these had cancer that had already spread to the lymph nodes. The lesson here is that these women had very aggressive cancers - so aggressive that they spread quickly, when the cancer was still very small. It doesn't necessarily follow that finding them earlier will prevent their spread. There's a good chance that they're so aggressive, they begin spreading before they're even detectable.

    We've been down this road before with chest x-rays and lung cancer:

    Various proposals to screen smokers for lung cancer were made throughout the 1950s, and by 1959 published reports documented a shift to earlier-stage disease and improved five-year survival rates in patients diagnosed by screening, compared with those diagnosed clinically. Screening smokers by annual chest roentgenograms was subsequently endorsed by the American Cancer Society (ACS), but eventually three large, randomized controlled trials documented no reduction in mortality in the screened population, and the ACS rescinded its recommendation in 1980

    The main lesson in this is that lead time bias and length biases are not just theoretical; they confound our ability to evaluate screening programs.

    We never learn.
    posted by Sydney on 4/13/2004 07:42:00 AM 0 comments

    Risky Business: A reader wonders about the rampant use of relative risk in medical research:

    When they are reporting the so-called relative risk at 15%, why is this type of misrepresentation accepted? I have been studying the rules of epidemiology for the last 4 months to try and get an understanding, but is seems the rules if risk factors are to be interpreted according to who benefits from the results and whether the subject matter is politically correct.

    I have examined many types of studies and have found relative risk factors of 1.60 or more that were dismissed as not significant. It may have been that the results would have affected large, essential corporations and thus would not have been in the best interests of the people doing the study.

    It would be nice if someone would produce a set of guidelines on interpreting studies that would provide some consistency.

    Amazingly, someone did produce guidelines for interpreting data. Even more amazingly, the guidelines have been endorsed by all the major medical journals. Here's what the guidelines say about relative risk (emphasis mine):

    The sample size per group (the denominator when reporting proportions) should be given for all summary information. This information is especially important for binary outcomes, because effect measures (such as risk ratio and risk difference) should be interpreted in relation to the event rate. Expressing results as fractions also aids the reader in assessing whether all randomly assigned participants were included in an analysis, and if not, how many were excluded. It follows that results should not be presented solely as summary measures, such as relative risks.

    Those guidelines were written in 1996 and revised in 1999. And yet, as of 2002, most of the endorsing medical journals were still ignoring them. Why?
    posted by Sydney on 4/13/2004 07:36:00 AM 0 comments

    Monday, April 12, 2004

    Don't Take Your Guns to Town: I had to put up a "no guns allowed" sign on my office door last week, when Ohio's new concealed carry law went into effect. It's not the criminals with concealed weapons I worry about. They'll have them no matter what the law. It's the law-abiding hotheads - the kind who pound the bejeezus out of my door when the office is closed for lunch. Now I'm just waiting for one of them to shoot it open instead.

    posted by Sydney on 4/12/2004 08:51:00 AM 0 comments

    Humor: The uses of research.
    posted by Sydney on 4/12/2004 08:41:00 AM 0 comments

    Antibiotic Choices: An article in the journal Pediatrics suggests that we should avoid penicillin for strep throats:

    They examined a number of previous studies, covering 7,000 children, to compare the effectiveness of the two drugs.

    Both penicillin and the cephalosporins are "narrow spectrum", which means they are targeted enough to tackle the bacteria but not so strong that they cause resistance.

    Resistance can lead to the creation of a superbug and is one of the reasons penicillin has traditionally been used.

    However, the researchers said the newer drugs both met this requirement and were more effective in attacking the bacteria that cause strep throat.

    Bacteria do develop resistance to penicillin and cephalosporins when those drugs are overused.

    Dr Janet Casey, a paediatrician and lead author of the study, said: "Children who have strep throat will have a superior outcome if they receive cephalosporin rather than penicillin.

    "Some penicillin proponents don't spend much time in the paediatrician's office. Many of these doctors aren't in the trenches anymore seeing sick children every day.

    "Those of us who are see how frustrating it is for families who need to come back for additional treatments who wonder why the antibiotic their child took didn't work."

    .....However, Dr George Rae, a GP and a member of the British Medical Association's prescribing committee, said the research "flies in the face" of what doctors have been taught and have found to work in practise.

    He said: "In my experience, I have found streptococcal sore throats have resolved using penicillin. Unless guidelines are produced by NICE or whoever, I am happy with the way I do it."

    He stressed that 90% of sore throats are viral and do not require antibiotics.

    I have to agree with the British doctor. Whether or not a strep throat will respond better to penicillin or a cephalosporin depends on where you live and the types of bacterial resistance that's going on in your community. The study didn't take this major factor into account. It just mixed together the results of a bunch of other papers of varying quality into a statistical equation to find a trend. Not the best basis for practice decisions
    posted by Sydney on 4/12/2004 08:38:00 AM 0 comments

    Comparison Shopping: Medicare is going to post drug prices on its website so people can shop for the best value:

    Through the federal Web site, consumers and government officials will have access to prices for more than 60,000 products sold at nearly 75,000 pharmacies around the country. 'That has never happened before,' said James L. Yocum, executive vice president of DestinationRx, a contractor that helped develop the site.

    The process of setting drug prices is notoriously secretive. Ten people buying the same drug at a retail pharmacy may pay 10 different prices, depending what insurance coverage they have, if any.

    Comparison shopping is difficult. 'This type of information is hard to get today,' said John C. Rother, policy director of AARP, the lobby for older Americans. 'Most consumers don't have access to it.'

    ...Elderly people who are not comfortable using the Internet will be able to call a toll-free telephone number, 1-800-MEDICARE (1-800-633-4227)

    It's amazing how much prices can vary between pharmacies - even when said pharmacies are just across the street from one another. Comparing prices between drug stores just isn't practical for most people. They have to call the pharmacist, who is usually busy filling prescriptions, to get the information. Not only will this help Medicare beneficiaries, it will help everyone who has to pay for their own drugs. And, as the article notes, it will increase competition among drug stores, helping to drive down the prices of prescription drugs. Hopefully.
    posted by Sydney on 4/12/2004 08:27:00 AM 0 comments

    Contaminated Candy: Watch out for lead-laced Mexican lollipops:

    At issue is candy that contains significant amounts of chili powder, including lollipops coated with chili, and powdery mixtures of salt, lemon flavoring and chili seasoning.

    Chili powder lollipops? Blech.
    posted by Sydney on 4/12/2004 08:25:00 AM 0 comments

    Book Review: My take on the historical novel Hadrian's Wall, over at BlogCritics.
    posted by Sydney on 4/12/2004 08:23:00 AM 0 comments

    Sunday, April 11, 2004

    Happy Easter

    posted by Sydney on 4/11/2004 11:09:00 AM 0 comments

    Resurrection: The resurrection plant, before and after.

    And a paper on its physiology.
    posted by Sydney on 4/11/2004 10:59:00 AM 0 comments

    Impressionism: From the "Lives" column of today's New York Times:

    His arms juddered as he placed a carton of eggs into a plastic sack. His bottom lip was slick with saliva. He wore a yellow plastic name tag upon which he had scrawled ''Jerry'' in kindergarten penmanship. He was middle-aged, like my brothers, David and Chris, and my sister, Diane. They have similar difficulties with motor skills and coordination, but they can't write their names. My siblings are affected by fragile X syndrome, a condition that causes their mental retardation and makes them hypersensitive to sounds and touch. I spent my childhood drawing them out of their shyness and helping them communicate with others. I couldn't guess Jerry's condition, but his mental age must have been about 12.

    The only evidence offered to support that estimate of mental age is the man's physical appearance. But physical appearance often belies what lies in the core of a man. I met a new patient last week who has a severe form of cerebral palsy. Her appearance could just as easily be described by that paragraph. She needed help filling out her insurance paperwork because her hand could not hold a pen steadily. Her speech was slow and garbled. I noticed that my staff spoke slowly and purposefully to her, as if talking to a child. But after a few minutes in the exam room, it became obvious that she was a smart and capable woman.

    She's also a writer, and she had samples of her writing to show me. She must carry her portfolio with her to new encounters like this to dispel the lie that her body conveys about her mind. First impressions are so hard to overcome. Sometimes we never overcome them.
    posted by Sydney on 4/11/2004 10:55:00 AM 0 comments

    Universal Coverage: One way to have universal healthcare coverage without the problems attendant with a national health service is to require everyone to have insurance, paid for by themselves, like auto insurance:

    The basic plan envisioned by the NAF is the mid-level Blue Cross plan offered to federal employees, which covers in-patient hospital visits, doctor visits in a preferred provider network and preventative care, but involves deductibles and co-pays. It costs about $7,000 a year.

    Scully proposes that employers be able to deduct only the cost of that plan from corporate taxes and that employees pay taxes on any insurance benefit they received that was more generous, thereby saving — after a phase-in period — $30 billion to $40 billion a year. He estimates government subsidies to hospitals to treat the uninsured in emergency rooms at $35 billion a year.

    He acknowledges political difficulties with such ideas — Republicans would oppose increased tax burdens on some corporations and unions would oppose taxes on members who enjoy so-called "Cadillac" health plans negotiated for them.

    Still, the fact is that, at the moment, employers facing double-digit health cost increases — and burdened by the duties of administering coverage — are cutting back or dropping coverage, causing insecurity among workers.

    Under present circumstances, most workers have no choice of health plans and have to accept what their employers give them. Under the NAF proposal, they'd have wide choice and could take their policies with them if they switched jobs.

    Average premium costs also would go down because everyone would be in the nation's insurance pool — including millions of healthy young people who pass up coverage because they don't think they need it.

    The idea of divorcing healthcare insurance from employment, often espoused on this blog, is being promoted by Ted Halstead as he promotes the book The Real State of the Union. An interview with him on C-Span should be available here soon.

    Widening the risk pool for healthcare insurance would make insurance more affordable for people like these, and avoid problems like this. It's an idea that should be given serious thought. And that should be getting much more media attention.

    posted by Sydney on 4/11/2004 10:16:00 AM 0 comments

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