Over the past 20 years I have treated thousands of patients with cancer and lost some dear friends and relatives to this dreaded disease.
The power of my authority comes with knowledge built on 40 years of study and 25 years of active involvement in cancer research. Your power and authority rest on an accident of birth. I don't begrudge you that authority but I do beg you to exercise your power with extreme caution when advising patients with life-threatening diseases to embrace unproven therapies.
It is in the nature of your world to be surrounded by sycophants who reinforce what they assume are your prejudices. Sir, they patronise you. Allow me this chastisement.
Amazingly deferential. Even though royalty no longer holds the power of life and death, they still hold the power of patronage. posted by Sydney on
7/10/2004 08:04:00 PM
Medical Imperialism: What's wrong with the UN's HIV program, UNAIDS, according to Dr Jean-Louis Lamboray, one of its founders:
Although he praised some of UNAIDS work, Dr Lamboray, who has been the principal coordinator of the competence programme of UNAIDS and UNITAR (United Nations Institute for Training and Research), said that it was not doing all it should and he felt the need to leave so that he could "tell the truth." Dr Lamboray also questioned the authority and accountability of the organisation.
.... "What I learned was that [while] you do need the distribution of condoms and drugs and tests, nothing substitutes for what people decide to do by themselves for themselves. They have to have a feeling of `ownership,' that they are in charge of the response from the bottom up. Being told from the top what to do and what not to do is not good enough," he said.
Sounds like imperialism. Then there's this, from a Botswanan:
I always ask about the millions or is it billions of dollars that are always talked about that the local people never see. The UNAIDS officials, consultants and experts do definitely see them in terms of salaries, stipends, per diems, international flights, hotel accommodations, never ending meetings and conferences....! A lot of us are living off HIV/AIDS Programmes while the people living with HIV/ AIDS are living in misery and as 'volunteers'. I even know of some colleagues who were looking after the environment, but are now HIV/AIDS Consultants in Africa as that is where the money is.
Quote of the Day: Alack for him that depends upon the aid of physic. I do not deny that medicine is a gift of God, nor do I refuse to acknowledge science in the skill of many physicians;but, take the best of them, how far are they from perfection?…. I have no objection to the doctors acting upon certain theories, but, at the same time, they must not expect us to be the slaves of their fancies. -Martin Luther, c.1566, Of Sickness and of the Causes Thereof posted by Sydney on
7/10/2004 04:48:00 PM
For years, her condition was a mystery — both to her and her doctors.
"I said, 'Wow, my hands are really sweaty, my feet are really sweaty, is there a name for this condition?' And the doctor laughed me off," Burke said. They said, 'Oh, you're just clammy.' Everybody blew me off."
Finally, while being treated for an unrelated condition, she found a doctor who didn't dismiss her complaints.
"It wasn't until recently, when I had foot surgery, that my podiatrist said, 'You have a condition called hyperhidrosis,' " she said. "And I was just so relieved that there's an actual name behind the condition."
This patient also says she got relief with Botox injections, which is why she was on Good Morning America. But hyperhidrosis is difficult to treat, which is probably why most of her physicians seemed dismissive. They probably knew what she had but had nothing to offer of any use. There are topical treatments, such as the prescription anti-perspirant Drysol, and there are more extreme treatments such as Botox injections or
surgical amputation of the nerve supply to the sweat glands. They all have their drawbacks. Drysol doesn't work well for everyone. Botox requires frequent injections (every four to six months in some cases), is expensive, and may cease to be effective after a while. And surgery sometimes either doesn't work at all or causes a condition called compensatory hyperhidrosis, which means that the excessive sweating is directed away from the armpits, hands and feet and toward the rest of the body. An even more difficult problem. posted by Sydney on
7/09/2004 07:36:00 AM
Searching the Deepest Pocket: When a Kentucky man had a reaction to one of his drugs, he sued not his doctor, but the drug company:
Robert I. Larkin and his wife, Barbara A. Larkin, sued Pfizer Inc. and G.D. Searle & Co. after he suffered from toxic epidermal necrolysis and Stevens-Johnson syndrome. His physician believed either the Daypro or Zithromax, or both, that he prescribed for Larkin caused the problems. Larkin sued the companies, claiming that they didn't warn consumers about potential risks. He did not sue his physician.
The court said it wasn't the drug makers fault. They warned the doctor that such a reaction could occur. In fact, Stevens-Johnson syndrome is a severe allergic reaction that could happen with any drug. (It can also be caused by a viral or bacterial infection.) It's unpredictable and thus unavoidable - and no one's fault unless the patient had a previous reaction to one of those drugs. Doesn't sound like he did. posted by Sydney on
7/09/2004 07:26:00 AM
Drug Cocktails:CombinatoRx - mixing and matching drugs in search of a cure, by robot:
Why hasn't anyone tried this before? It's only recently that the technologies have been available to do such data-intensive screening. Of course, all major pharmaceutical firms already use robotics for high-speed scouting of potential drug treatments. It's a relatively straightforward process to analyze the interactions of a single chemical and a single protein. By contrast, searching out unexpected interactions among 2,000 disparate compounds yields nearly 2 million possibilities for any one disease. Three- and four-part combinations, which Borisy hopes to try, will produce between 1 billion and 600 billion possible combinations. posted by Sydney on
7/09/2004 07:06:00 AM
It's a guerrilla war in which soldiers frequently die without warning from remotely detonated explosive devices. In Vietnam, our troops often complained that the enemy couldn't be seen. But in Iraq, it may well be that the enemy isn't even there.
When there is face-to-face combat, attacks are usually instigated by the enemy; 92 percent of respondents reported being attacked or ambushed, the study found. Soldiers see the suffering of innocent civilians everywhere because they are the enemy's main target; three-fourths of respondents said they observed ill or injured women or children they couldn't help.
Pop Screening: How much enthusiasm does the public have for cancer screening? Lots:
Americans are enormously committed to cancer screening. In a national survey recently published by Dr. Lisa Schwartz and co-authors in the Journal of the American Medical Association, 87 percent of respondents agreed that "routine cancer screening is almost always a good idea," and 74 percent felt that early detection saves lives "most or all of the time." In fact, so enthusiastic were the survey participants that 73 percent of them said they would rather receive a free full-body CT scan than $1,000 in cash.
Why We Need Reform: A medical malpractice review panel says "no malpractice," but a jury penalizes the doctor to the tune of $3 million anyways. (Hey, what the heck. It's not his money, it's the insurance company's!) posted by Sydney on
7/08/2004 03:26:00 PM
The GOP’s criticisms will perhaps be tinged with envy, though, because Mr. Edwards is now certain to place at Kerry’s disposal one of the most fabulous political fund-raising machines in all history. That lawyer-driven machine did extremely well for Mr. Edwards in the primaries; the only reason it didn’t do even better is that it ran into the ceilings imposed by federal election finance law, which limit donations from individual donors to $2,000. In fact, Mr. Edwards raised a bigger proportion of his campaign war chest in $2,000 donations than any of his Democratic rivals.The list of donors who maxed out included not only the expected plaintiff’s attorneys and their spouses, but also a roster of low-paid paralegals, receptionists, and other support staffers of law firms along with their spouses — even though (as an investigation for the Hill revealed) some of the staffers had recently suffered bankruptcies and other personal financial reverses and some were not recorded as having voted in years.
“In many instances, all the checks from a given firm arrived on the same day — from partners, attorneys, and other support staff,” reported The Hill. The law-firm employees duly denied that their employers had signaled any willingness to reimburse the donations — that would constitute a violation of federal law, after all. But pursuing the money trail was not easy, since Mr. Edwards, alone among major candidates, refused to disclose the identities of the big financiers who bundled checks for him, a stance that drew fire from places like the editorial page of the Washington Post.
Impressively, throughout all this, Mr. Edwards managed to make a personal selling point of his proclaimed freedom from entanglement with those dreadful special interests. It’s in the field of rhetoric that the senator’s career skill in jury persuasion really comes through for him. As journalist Stuart Taylor Jr. puts it, Mr. Edwards sounds as if he really, truly believes “that behind every misfortune there must be a wealthy villain” — at the grand level of national policy just as in the particulars of an individual client’s calamity. It’s as if Michael Moore checked into a spa and finishing school and emerged with good looks and polished manners: No wonder party activists swoon.
And here's more on the presumptive Democratic vice-presidential candidate, over at EdwardsWatch. (via PointofLaw.)
UPDATE: And he's uncommonly crafty when it comes to investing, too:
During the buildup and aftermath of the Iraq war, Edwards bought and sold stock in several defense contractors, including Lockheed Martin, United Technologies, General Electric, British Petroleum, and General Dynamics.
Product Placement: Did the New England Journal run an infomercial for a tissue bank that provides cadaver cartilage for joint surgery last month? It might seem that way if you were "Tissue Bank A" in this study. Especially when one of the authors is the medical director of a competing tissue bank, and another one has been an expert witness in a class action lawsuit against you. And especially when the study's conclusions praise said competing tissue bank:
One tissue bank has developed and implemented a low-temperature chemical-sterilization approach (BioCleanse) that kills spores but preserves the biomechanical integrity and function of some allografts. The efficacy of this sterilization method is supported by the absence of reports of bacterial or viral allograft-associated infections in tissue processed by this method (CDC: unpublished data). In contrast, tissues processed with all other disinfection and sterilization methods, including gamma irradiation, have been associated with reports of allograft-associated infections (CDC: unpublished data). Currently, BioCleanse and other sterilization methods cannot be used to process fresh femoral condyles, since it is thought that chondrocytes must be viable to maintain articular cartilage function. (emphasis mine)
Nice to see all those assertions from unpublished data thrown about after such a recent uproar over the importance of research transparency.
The authors say someone at the Journal told them they didn't have to disclose their ties to the company, and anyways, the paper was submitted before Dr. Archibald joined the maker of BioCleanse:
After clearance by the director of the Division of Healthcare Quality Promotion, the manuscript was submitted to the Journal for publication in December 2002...On January 20, 2003, Dr. Archibald became an employee of Regeneration Technologies, the manufacturer of BioCleanse. Stock options were granted to Dr. Archibald subsequent to his employment at Regeneration Technologies, subject to a vesting program over a period of five years. The article was accepted for publication, pending revision, by the
Journal in March 2004. Dr. Archibald signed a financial-disclosure form on August 1, 2003, attesting in good faith that the investigation had been conducted and completed
while he was employed by the CDC. Dr. Archibald did not indicate on that financial-disclosure form that he was now employed by Regeneration Technologies. In March 2004, Dr. Archibald orally discussed his new affiliation with staff at the Journal. It was his understanding that no further revision of his financial disclosure was required.
What are the chances that Dr. Archibald had not a clue in December that he might be joining Regeneration Technologies the next month? And although a two year lag time between submission and publication is fairly standard, he surely must have known in August 2003 that disclosing his ties with the company was the right thing to do.
The editors say they were duped:
When we publish a research report, our policy is to disclose to readers any relevant financial ties of the authors. To accomplish that, we rely on disclosure forms that all authors complete and sign. It is essential that we receive this information in writing; we cannot rely on telephone communication. In this case, Dr. Archibald’s disclosure form, completed on August 1, 2003, stated that he had no relevant financial associations. Specifically, his form did not indicate that after the research was completed, he became an employee of Regeneration Technologies, an association that is relevant because Regeneration Technologies makes BioCleanse, a product that is mentioned in the article. It is our policy that disclosure forms must reflect the most current information. If this author’s new affiliation had been indicated on the disclosure form, it would have been printed in the article according to our policy. The above letter with the financial disclosure has been linked permanently to the article as a correction, both on the Journal Web site and in the Medline database.
Except that the financial disclosure is very hard to find on the web version of the article (it's just a "correction" link in the upper right hand corner underneath a lot of other links), and it isn't attached to the medline citation at all.
The wonderful thing about the internet is that corrections and addenda can be added to articles and posts easily, unlike the printed page. And that's what the NEJM should do with this. Add an addendum to the online version that is easily seen and doesn't require opening another link. It's the right thing to do.
UPDATE: You may wonder why on earth the editor of a premier scientific journal would allow such prominent product placement in a scientific paper. Normally, drugs and such are identified only by their generic or chemical names in studies. Don't medical editors edit? Well, in this case, it could be because the editor doesn't think it's a problem. posted by Sydney on
7/07/2004 11:22:00 PM
Tending Our Gardens: I love going to our community garden. Usually, I go after work with a couple of the kids in tow. After being cooped up in the office all day, it feels so good to stand in an open field exposed to sun and wind. And because I go after work, I often find myself musing on the analogies between the community garden and modern American medicine.
On its face, the community garden seems a system that would be ripe for flirtation with communism, as its origins during a more socialist stage of our history would suggest. The state (or in most cases, a city) owns a plot of land that its citizens can use to grow food. But, of course, the community garden is anything but communist. It is quintessentially American. Each gardener or family pays the city a nominal fee for a plot of land. And each gardener or family can do what they want , how they want. They can devote their plot of land to one crop or a variety. They can plant as far apart or as close together as they want. They can have an organically maintained garden, or a chemically maintained garden, or one that is hardly maintained at all. Walk around the average community garden and you'll see as many types of gardens as there are gardeners. And everyone's happy, because they can garden in a way that suits them best .
Imagine, however, if the community garden were a communal garden instead, and all of its harvest shared among the gardeners. There would be a lot of resentment among the more productive gardeners towards the less productive. Rules about what to grow and how to grow it; how often to weed and how to weed, would soon be instituted. No one would be allowed to risk new varieties of vegetables or new gardening techniques for fear it would diminish the harvest. It would sap all the fun out of gardening.
Alas, practicing medicine these days is too often like tending a communal garden. We may not have a socialist healthcare system, but we have one that is pretty darned close. Because third party payers pay most of the healthcare bills in this country (in contrast to the patient), they decide what constitutes good medical care. And because they aren't the patients, they base their quality standards on what's considered best for populations rather than individuals. They analyze patients' bills to see if their doctors are ordering recommended labs and screening tests, or to see if patients are visiting the doctor with necessary frequency. And in some cases, they've set up "disease management" programs that track a patient's lab results and symptoms to make sure they meet the standards.
At first glance, this may seem like a good thing. Standardized care means everyone gets quality care. But, the problem is that in medicine, one size does not fit all. Take, for example, diabetes. There are well-established standards for good diabetic care. A diabetic patient will, in most cases, do better if his blood sugar is consistently less than 120, if his blood pressure is less than 130/80, and if his cholesterol levels are kept at very low levels. However, for some diabetics, meeting those goals comes at too high a price. There are diabetics who can not maintain ideal blood sugar levels without sending their sugars spiralling to intolerably low levels, those who cannot maintain ideal blood pressure levels without getting hypotensive when they stand up, and those who cannot achieve ideal cholesterol levels because of side effects of cholesterol medications. In each of these cases, it would be better medical practice to ignore the standard and treat the patient.
But, in our third party quality control system, there's no room for individuality. An insurance company auditor doesn't care about the details (or isn't trained to notice them.) His only concern is whether or not the numbers are where they're supposed to be. If they're not, the doctor gets chastised. The chastisement may be in the form of an "educational letter" reminding him of the standard of care. Or it may be more punitive. Either way, the net result is a tendency among doctors to treat the numbers, not the patient.
Running Mates: Tort reform won't be on the front-burner for the Kerry/Edwards team. For John Kerry, it seems to be a non-issue. And as a trial lawyer, John Edwards isn't likely to be a friend of tort reform, although he has made pretty speeches about it in the past.
Of course, tort reform isn't the main issue in the election, even for someone like me, whose livelihood depends on it. If I thought that the Kerry/Edwards team would be stronger on the war on terrorism than Bush/Cheney, I'd vote for them in a heart beat. But, fortunately, I don't have to make that choice. They're weaker in that respect, too. posted by Sydney on
7/06/2004 11:29:00 PM
Kathy Rasmussen and her husband, Philip, provided free health insurance to their full-time workers when they bought the Lakewoods Resort near Cable 33 years ago. As costs rose, they asked staff members to pay half.
Now, the Rasmussens are wrestling with whether they can continue providing insurance at all, as premiums rose steadily in recent years and then jumped suddenly from about $1,200 to about $2,000 for each employee.
'It is sad,' Rasmussen said from the lodge on Lake Namekagon in Wisconsin's North Woods. 'I don't think businesses can afford it anymore.'
As a new federal report showed last week, the Rasmussens would not be the first business owners to cancel policies after being confounded by rising costs. Companies continue offering the insurance plans, but some employees don't sign up because they cannot afford the rising share of premiums they are asked to pay.
And, at least in Ohio, if 50% or more of a company's full-time employees don't sign up, the insurance company won't cover the business. It's a lose-lose situation for small business owners.
I've broached this subject before, and in more depth (not to mention more seriousness.) But, the other interesting observation from the study is that the undervaccinated - that is kids who have just some of their shots, tend to be from
the opposite end of the economic spectrum. What's more, they're missing their shots even though their parents feel immunizations are important. My patients in this situation tell me that they have trouble getting off work to bring the kids in for their well child checks (and shots.) That doesn't really fly in my practice since I have evening hours, but that's the excuse I hear. (And yes, I know that I could be giving them their shots at sick visits, but a lot of them either haven't been sick or their parents refuse the vaccinations when the kids are ill.) posted by Sydney on
7/06/2004 06:02:00 PM
Avoidance Therapy: One of my patients told me about a product she's been using to avoid poison ivy - Ivy Block. I'm not sure if it works, but it's FDA-approved. The active ingredient is bentoquatam, the chemistry of which I haven't been able to track down, except that it "acts as a physical barrier between the skin and the irritant." According to my patient it makes your skin white. According to the FDA, it's like mud:
Available without a prescription, the drug, bentoquatam 5%, is enveloped in a clay-like medium and is contained in a lotion applied to skin at least 15 minutes before exposure to poison ivy, oak or sumac to provide a barrier that protects against or reduces the severity of rash caused by these plants. The lotion dries to form a visible, clay-like coating that indicates where the skin is protected.
You can probably get the same protection by wearing long sleeves and long pants. And you can get even better protection by avoiding poison ivy all together, as well as its cousins poison sumac and poison oak.
Following, as a Medpundit public service announcement, are visual aids for recognizing the various "poisons":
The findings were based on 100 children aged 2 to 18 with upper respiratory infections. Their parents were quizzed about the severity of the children's cough and how well both parents and children slept the previous night.
In the evening of the day the parents were questioned the children were given either one of the commercial preparations or an inert placebo -- in this case simple syrup.
'There was a significant improvement for all symptoms over the previous night, which should reassure clinicians and parents that, regardless of treatment, the natural history of an upper respiratory infection favors resolution of symptoms with time,' Paul said.
...He said the sleep of both parents and children improved but the improvement was the same in the group given sugar syrup as for the children given the drugs.
Asked what parents should do, Paul said 'my advice has been to do things that are harmless but could help -- saline nose drops, good hydration and humidified air.
It would be interesting to know if the results would be the same if the children were asked how well they slept after getting placebo. The placebo effect would be expected to be strong in this study, since it's the parents' perceptions that are being evaluated, and when a parent has a sick child, their perceptions are twisted by anxiety. They feel an intense need to do something - anything - so their child won't suffer. Cough medicine fills that need nicely, whether or not it's real medicine or sugar water. Of course they would sleep better after giving it. But were their children's coughs any better? posted by Sydney on
7/06/2004 07:04:00 AM
When Food Fights Back: A panel of gastroenterology experts has told the NIH that celiac disease goes unrecognized and untreated in this country:
Celiac disease isn't nearly as rare as once thought: Roughly 3 million Americans may have the severe digestive disorder, most undiagnosed and thus suffering unnecessarily, an expert panel told the National Institutes of Health.
On average, patients suffer symptoms for 11 years before they're diagnosed, because the disease, triggered by the gluten protein found in certain grains, is so little understood even by physicians, the panel found.
Simple new blood tests can help diagnose celiac more easily today than just a few years ago, but only if doctors know to order them -- and many patients complain of symptoms very different than those long taught in medical school.
To determine the prevalence of celiac disease in the United States, 2,000 healthy blood donors were screened for IgA and IgG antigliadin antibodies. Those with elevated levels were tested for antiendomysial antibodies. The prevalence of elevated antiendomysial antibody levels in healthy blood donors in the United States was found to be 1:250. This rate is similar to the prevalence in Europe, where subsequent small intestine biopsies have confirmed celiac disease in all patients testing positive for antiendomysial antibody (positive predictive value: 99 percent). The authors of the U.S. study conclude that data suggest that celiac disease may be greatly underdiagnosed and is relatively common in this country.
The antibodies mentioned, of which IgA is the most sensitive screening test for the disease, are antibodies to proteins found in wheat, rye, and barley. In celiac disease (also known as celiac sprue), the presence of these grain proteins in the gut activates the immune system in the lining of the gut. Unfortunately, the immune system then not only attacks the grain proteins, it also attacks the gut itself. It's like a contact dermatitis of the intestines. The resulting inflammation is the source of the symptoms - gas, bloating, diarrhea, and malabsorption. But, like contact dermatitis of the skin, there are varying degrees of severity of inflammation, so not everyone has the symptoms or intensity of symptoms.
Treatment doesn't require medication, just a gluten-free diet, which is actually somewhat difficult to follow. Treatment doesn't necessarily prolong life (except in severe cases accompanied by malabsorption), but it does make one feel better.
So why don't we diagnose it more often? The tests aren't too expensive, around $135 for a series of antibody tests. We probably could do a better job of diagnosing it in symptomatic patients, especially those who have been given the diagnosis of irritable bowel syndrome. However, screening the general population probably isn't warranted. If the disease is so mild that it doesn't cause symptoms, then it really doesn't need treatment. posted by Sydney on
7/06/2004 06:08:00 AM
Give Us Liberty: In keeping with the holiday, DB at MedRants links to this article on the meaning of Independence Day from National Review Online:
It was not for nothing that Jefferson put liberty first, limited government second, as a means to liberty. What the Founders envisioned was a world in which individuals pursued happiness as individuals or as members of private, voluntary associations — families, businesses, churches, charities, and the like. That world of private individuals and associations — the civil society that Tocqueville spoke of — was where most of life was meant to be lived, with government limited primarily to securing the rights we have or we create in that world.
The idea that we pursue happiness "as individuals or as members of private, voluntary associations — families, businesses, churches, charities, and the like," is not just the bedrock of American society, it's the key to our success. posted by Sydney on
7/05/2004 10:55:00 PM
Insights: A commentor at the Business Word Blog makes a good point that is too often overlooked in the healthcare debate:
This leads to a fourth useful insight - that it is necessary to keep health care and health insurance analytically separate. Policy makers and the public are forever mixing these up, and it makes identifying the problems much harder than it needs to be. Health insurance is costly because health care is costly, and not the other way around. If the cost of health care were moderate, the cost of health insurance would be moderate.
Fifth of July: Yesterday was the real holiday, of course, but this being America, if it falls on a Sunday we celebrate it on a Monday so we can get a real holiday out of it. So, today our town shut down Main Street and had a parade:
It was the typical Fourth of July Parade. Firetrucks, Shriners in silly cars, politicians throwing candy at the crowd (the practice is supposedly banned since a child was hit by a float a couple of years ago, but somehow the politicians and judges in the parade always ignore that rule), marching bands, and Elvis impersonators.
Some would say it's pure corn and kitsch. But there's something moving about seeing an entire town come out to watch and cheer as other of its members march down a street. It really is a sincere expression of our happiness at and gratitude for our liberties and freedoms.
Housekeeping: I took down the "Logorrhea" posts. They were all over two years old. It's obviously time to retire that feature.
I also made some long-overdue changes to the blog list in the left-hand column. Finally corrected Nurse Alwin's blog address (sorry it took so long, Alwin), and added a few more very good medical and medical policy blogs: Black Triangle,HealthLawBlog, and The Business Word Inc.. There are a lot more out there that I should be linking to, but our town's Fourth of July parade is starting soon, and I've got to get going if I'm to stay in my family's good graces. posted by Sydney on
7/05/2004 09:19:00 AM