"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
On a recent afternoon, Kerry was in his Russell Building office, sitting on a wing chair with his legs crossed next to a fireplace. The office is decorated with a watercolor painted by Ted Kennedy and framed $5 and $1 bills that Eugene McCarthy contributed to his first campaign. Kerry's computer screen is filled with a smiling photo of ... John Kerry.
1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) (See the Swiftvets charges, the Cambodia story, and his general defensiveness re: war hero status.)
5. Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations (See Do you know who I am? )
6. Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends (See wives, own and POW's)
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others (See Sampan incident.)
8. Is often envious of others or believes that others are envious of him or her. No examples come to mind.
9. Shows arrogant, haughty behaviors or attitudes SSpeaks for itself.
You only need five of those to qualify for a personality disorder. Kerry's a winner! (And this handwriting analysis agrees, for what it's worth.)
Playing spot-the-personality-disorder is an admittedly easy game to play with people one dislikes, but Kerry's public persona comes too close for comfort to those diagnosis categories. That's rather worrisome, since the fatal flaw of the narcissist is the inability to admit when he's wrong.
Mad Doctor Watch: Greek fertility specialist and cloning maverick Panayiotis Zavos says he's cloned the dead. Meanwhile, the world's still waiting for the birth of his cloned baby. posted by Sydney on
9/04/2004 07:48:00 PM
0 comments
Slaughter of the Innocents: And then there was this. Can anyone doubt the importance of the war against terrorism after reading of such brutal barbarism?
And the sense of hope that accompanied the sight of each survivor was tempered by the horrors among even the lucky. One speeding ambulance contained a girl who appeared to be about 5, blood rolling down her short and matted black hair. She stood in the back of the crowded ambulance, palms pressed against the glass, wild-eyed and screaming in a black floral print dress.
Because of the sirens and the gunfire and the roar of the overworked engine, her screams seemed soundless, drowned out by everything else. Then she was gone from sight.
....The morgue had reached capacity. Children and dead Russian fighters were arranged in rows on the grass.
One row contained 13 dead and bloodied children, aged roughly 4 to 16. The youngest, a boy, shirtless and with his hands folded neatly on his stomach, was unclaimed. A few were covered with sheets or towels, which mothers passing by lifted, to see if they hid the faces of their missing children. One girl, a young teenager in a dress, appeared to have been executed, having been shot through the eye.
The covered remains of one woman, carried out of the hospital and set in the hospital yard, told of a terrible end. Her bare feet protruded, showing soles of feet that were covered with fresh nicks and cuts, as if before she died, she had run and run and run.
My oldest son turned thirteen two days ago. I have no doubt that when he's eighteen we will still be waging this war; that it will be bloodier and more widespread; and that there's a good chance he'll be among those fighting it. But I wouldn't begrudge the nation, or the world, his service. Not with enemies like this. posted by Sydney on
9/04/2004 03:41:00 PM
0 comments
Distracted by Life: I've been distracted from blogging these past couple of weeks by the non-medical news. I've been voting in Presidential elections for twenty-four years now, and I've got to say, those Republicans put together a good convention this year. I'm not normally a political junky. In the past, I might have caught a few speeches here and there on television, but this year the networks (we don't have cable in the Medpundit household) ran the convention so late at night that I would only hear snippets on awakening to NPR's Morning Edition. But what snippets they were - Giuliani, McCain, Schwarzenegger, Zell Miller, and even Dick Cheney. Those morning NPR snippets were so tantalizing, I ended up listening to the speeches in full during lunch while finishing the morning's paperwork. It's the first time that I've felt compelled to look up political speeches that I only read about in the paper or heard in brief on the radio.
The Democratic convention speeches didn't have the same effect, even though they were also the first things I heard in the morning during their convention. Nothing new there (with the exception Barak Obama.) "Two Americas," "Hope is on the Way," Teddy Kennedy, Jimmy Carter - the message hasn't changed in the twenty-four years I've been listening. The American people are downtrodden and only the Democrats can save them. As far as I could tell, there were only passing references to the War on Terrorism, certainly nothing that would make it into those morning snippets on NPR.
And that's the problem right there, with the Democratic Party this time around. Three years ago this month, our country got a wake up call from the Islamic world. The Republicans heard it. The Democrats didn't.
Full Disclosure: I'm listed as a registered Republican, but only because I had to declare myself in the 2000 election to vote for John McCain in the primaries. This may come as a surprise to some people, but there have been only two Presidential elections in which I've voted Republican - in 1988 for George H.W. Bush, and in 2000 for George W. Bush. This will most certainly be my third. posted by Sydney on
9/04/2004 02:04:00 PM
0 comments
Senator Clinton said her husband first experienced mild chest pains and a shortness of breath on Thursday at home in Chappaqua, and went with his Secret Service escort to Northern Westchester Hospital in nearby Mount Kisco, where initial tests showed nothing extraordinary.
Mr. Clinton returned home for the night and told his wife, who had begun a three-day trip upstate on Thursday, that he "felt fine and not to worry," she recalled.
....Rising before dawn, Mr. Clinton went to the Westchester County Medical Center in Valhalla, arriving about 6 a.m. A nurse, Donna Florio-Bronen, said he walked in under his own power and was "very pleasant, very upbeat" and "looked great."
Three cardiologists were present - Dr. Ronald Wallach, Dr. Carmine A. Sorbera and Dr. Anthony L. Pucillo - and Dr. Pucillo performed an angiogram, an X-ray in which an opaque dye is injected into the blood to outline the contours of the coronary arteries. The X-rays, Dr. Pucillo said, revealed "multivessel coronary artery disease, normal heart function and no heart attack."
Mr. Clinton was taken by ambulance to Milstein Hospital, the main treatment facility at New York Presbyterian's Columbia campus, at West 168th Street and Broadway in Washington Heights. The center is a renowned medical teaching institution whose cardiovascular treatment facility is widely regarded as being among the best in the nation.
His initial tests must have shown something out of the ordinary or they wouldn't have gone right to an angiogram the next morning. And he has multi-vessel disease - also very serious. The operation he'll be having is explained in detail here. Say a prayer to St. John of God for him.
It's a Small World: A man in New Jersey has died of lassa fever, a virus that's common in West Africa, where he had recently travelled. He was asymptomatic on his flight home to New Jersey, however, so his fellow passengers should be safe:
We are comfortable that this case will remain an isolated case,'' Karabulut said.
Authorities said they were still trying to identify the flight the man was on, which landed in Newark, and that the CDC would attempt to contact those who were on the plane.
The man's family said he did not have symptoms of the disease, such as diarrhea, vomiting or coughing while on the flight, so there is little chance any other passengers were exposed, Bresnitz said.
Stem Cells and Diabetes: One of the more vocal advocacy groups on behalf of embryonic stem cell research has been Juvenile Diabetes Research Foundation. They've been very effective advocates. (It was they who introduced Nancy Reagan to the issue.) Who could be so heartless as to deny young children a cure? Today's New England Journal of Medicine has a review of recent pancreatic rejuvination research that suggests pancreatic cells replenish themselves without the help of stem cells:
Their first experiment confirmed the widely held view that normal turnover of beta cells occurs through the replication of preexisting beta cells. The second and much more intriguing result was that after partial pancreatectomy, newly formed beta cells also arose from preexisting beta cells. Does this mean that there is no such thing as a pancreatic endocrine stem cell? The answer is 'probably,'
But the authors can't resist putting in a plug for embryonic stem cell research, and a slam against adult stem cell research:
The new study places increased emphasis on promoting the replication of adult beta cells4 and the differentiation of beta cells from embryonic stem cells at the expense of pursuing research into the use of adult stem cells for beta-cell replacement.
But didn't the authors just say that it's the beta cells (the cells that produce insulin) that create new beta cells? Wouldn't it make more sense to find ways to coax the existing beta cells in diabetics to produce more of themselves, rather than try to start all over with foreign embryonic cells?
And this story from the BBC says that Canadian researchers have isolated those immature adult pancreatic cells (in mice). Amazingly, they can also be coaxed into becoming nerve cells. Their findings seem solid.
Looks like the money should definitely go toward adult pancreatic cell work. That won't be good news for the equity in PanCell, Inc. held by one of the authors of the New England Journal of Medicine article, though. It's probably not good news for their department's researchfunding, either. posted by Sydney on
9/02/2004 09:40:00 AM
0 comments
Prejudging: There's a movement in academic medicine called cultural competency that's beginning to take root. The idea is that we need to be trained to be sensitive to people from other cultures. Here's an example:
Being competent in cross–cultural functioning means learning new patterns of behavior and effectively applying them in the appropriate settings. For example, a teacher with a class of African–American children may find that a certain look sufficiently quiets most of the class. Often African–American adults use eye contact and facial expression to discipline their children. However, this is not effective with all African–Americans. Intra–group differences, such as geographic location or socioeconomic background, require practitioners to avoid overgeneralizing. With other students, one might have to use loud demanding tones, quiet non–threatening language, or whatever is appropriate for those students. The unknowing teacher might offend some students and upset others by using the wrong words, tone, or body language. Being culturally competent means having the capacity to function effectively in other cultural contexts.
This week's New England Journal of Medicineprovides more examples (subscription required):
Consider the case of a Hispanic woman with hypertension whose blood pressure had been difficult to control for more than two years. A workup had ruled out secondary causes, and she had received various antihypertensive medications. Finally, an exploration of her perception of hypertension revealed that although she said she took her medication every day, she believed she knew when her blood pressure was high and therefore took it at different times of the day and sometimes not at all. Asking this patient about her understanding of the cause of hypertension clarified her perspective. This discussion provided an opportunity for reeducation and negotiation about medication.
And then there are the Italians:
Or consider the case of an elderly Italian woman whose son asked her surgeon not to inform her that she had metastatic colon cancer. A culturally competent clinician discovered that the son thought it would "kill" his mother to know the truth. This scenario is common in many cultures, but decision-making and truth-telling processes vary from family to family. Exploring the reasons for and consequences of this preference for secrecy leads to negotiation and an ethically appropriate compromise whereby the patient may be informed of her condition in a way that is agreed on by the family.
Or the Chinese:
In response to the proper inquiry, a Chinese man with limited English proficiency who was treating his asthmatic daughter with herbal remedies (in addition to her prescribed inhalers) explained that this tradition had been passed down for generations. Once the herbal treatment was revealed, the appropriate use of inhalers could be reviewed and reemphasized.
You don't have to be "culturally competent" to tease out these kinds of details from patients' lives. You just have to be humanly competent. Each of those examples could have occurred in any ethnic group. It's a mistake to train young doctors to think of each ethnic group as a cultural stereotype. There are as many different types of families among Chinese, Italians, Hispanics, etc. as there are among Boston brahmins. It's much better to approach every patient with an open mind, and to make as few assumptions as possible about them.
Poet Laureate Greeting Cards: Did you know that Maya Angelou is doing greeting cards now? I ran across them while shopping for a sympathy card. They are less than inspiring. I ended up going with some lesser, unknown, greeting card writer who managed to express sympathy without descending to the maudlin or trite. That must be the height of frustration - to produce better work than a celebrated poet and yet remain an unknown among the rank and file of greeting card poets.
UPDATE: Blogborygmi says we bloggers could find ourselves in the same position:
I have a friend who edits children's books, and the same thing is going on in that industry. She secretly despises the recent mediocre forays into children's lit by Billy Crystal and Madonna, and wishes she could promote some stellar work by newcomers.
But the public wants brand names uber alles, it seems. And we could be in the same boat, too -- say, if Sanjay Gupta started a blog... posted by Sydney on
9/01/2004 09:43:00 PM
0 comments
The Frist Speech: Although Guiliani, McCain, and Arnold gave the most moving (and entertaining) speeches of the Republican Convention so far, Senator Bill Frist had some points worth hearing:
Our opponents have a way of confusing compassion with dependency. We believe true compassion encourages and empowers Americans to be responsible and take control of their own lives.
That's what President Bush and the Republican Congress did when we made Health Savings Accounts, HSAs, the law of the land. With an HSA you can invest tax-free in a personal savings account. You can roll it over year to year or withdraw funds if you get sick without paying a penny of tax.
You own it. You invest it. You grow it. You control it. It is yours.
So here's the choice: Do we grow the bureaucracy and gouge you with higher taxes, as Mr. Kerry will do, or do we let the American people grow their own HSAs and own their health care, as George Bush wants to do?
We've made our choice.
But I'll tell you what Senator Kerry's prescription will be: Take a handful of tax increases and don't call me in the morning.
....We have a choice. John Kerry's trillion dollar government-run plan will place your health care in the hands of others far away. President Bush's plan is patient-centered, which is the only sure prescription for superior care. Mr. Kerry will empower those who tax you. President Bush will empower those who cure you.
Batty Belfries: All you need to know about bats and rabies. Most important take home point:
People usually know when they have been bitten by a bat. However, because bats have small teeth which may leave marks that are not easily seen, there are situations in which you should seek medical advice even in the absence of an obvious bite wound. For example, if you awaken and find a bat in your room, see a bat in the room of an unattended child, or see a bat near a mentally impaired or intoxicated person, seek medical advice and have the bat tested. posted by Sydney on
9/01/2004 09:08:00 PM
0 comments
Have you taken your pet to the vet lately? Remember writing that check for $50 or $135 without flinching because you wanted the right shots and the best possible care for Fluffy?
It's probably been a long time since you wrote a check for $35 for an office visit in an MD's office.- You probably wrote only a check for a $10-15 copay. Then your insurance program (after a lot of paperwork for the doctor) reimbursed him an additional $18-25, making his total payment for your visit $28-35.
Strange, isn't it, that we think nothing of writing those big checks to the vet because we haven't been 'educated' that we're 'entitled' to veterinary care for our pets. We pay his price because we know it's the right thing to do for our pets, and we're willing to pay even a little extra for a vet with a good reputation or a helpful office staff.
Obviously we don't value our pet's health more than we do our own; so why have we been taught to balk at paying for our routine health care ourselves?
Amen, brother. And there's loads more at his home page.
German Stem Cells: While US researchers whine about limited funding for embryonic stem cell research, their German colleagues face much more serious obstacles:
Germany's 1991 Embryo Protection Law bans the production of human embryonic stem cells. Under a hotly debated law that took effect in 2002, scientists now can apply for licenses to import embryonic stem cells, but only from cell lines that date before January 1, 2002.
Those found to have been working on newer lines, or creating stem cell lines, are liable to prosecution. If convicted, scientists could face fines or up to 3 to 5 years in prison. posted by Sydney on
8/31/2004 10:32:00 PM
0 comments
Tort Reform Renegades: There's a tort reform revolt in southern Illinois, where the cities are daring to do what the state won't. (Thanks to the family practice management email listserve for the tip.)
UPDATE: And over at PointofLaw, evidence that tort reform is lowering malpractice insurance premiums in Texas:
Insurance rates for hospitals have declined 8% and 17% for fiscal 2004 and 2005; the Texas Medical Liability Trust, the state's largest medical malpractice insurer for individual doctors, reduced premiums by 12%. Christus Health, which self-insured, has saved $21 million, and will use that money to build a community clinic for the indigent in Corpus Christi. A trial lawyers' front group representative churlishly complains that 'We should not be measuring the success of this on whether hospitals are making more money.'
It's worth noting that in many communities, free clinics have had to shut down because their volunteer staff couldn't afford the malpractice premiums. Nice to see doctors in Texas putting the reforms to good use.
UPDATE II: And over at Point of Law's sister site, Overlawyered, we find out what happens when doctors try to police their own. (The same thing happened at our hospital a few years ago when the surgical staff tried to oust a bad surgeon. They got sued, and lost, to the tune of a couple million.)
Oh, Those Statins: New research suggests that giving high doses of those beloved cholesterol lowering drugs, the statins, after a heart attack, will dramatically reduce the incidence of further heart attacks and strokes and chest pain:
An aggressive, high-dose regimen of cholesterol-lowering drugs within days after a heart attack may reduce further heart problems, says a new large-scale study.
Doctors from Boston's Brigham and Women's Hospital joined a team of national researchers to track nearly 4,500 patients in 41 countries for up to two years.
They found those who were given a 40 milligram daily dose of cholesterol-lowering statins for a month, followed by an 80 milligram daily dose for up to two years suffered fewer heart problems compared to those given a placebo the first month followed by a 20 milligram daily dose.
"There was a 25 percent lower rate of death or major cardiac event after four months in the 80 milligram group,'' said Dr. James de Lemos, a cardiologist at the University of Texas and lead author of the study in the Journal of the American Medical Association.
Here's their data. They placed 2232 heart attack patients on a placebo for four months, then on 20mg of simvastatin thereafter and followed them for two years. They placed 2265 heart attack patients on 40mg of simvastatin for one month followed by 80mg for the next two years. Then, they counted the number of those patients who had heart attacks or strokes or who had to be admitted for chest pain during those two years.
Of those taking actual drugs from the beginning, 14% had a cardiovascular illness during the follow-up period. Of those who started out with placebo, 17% had a cardiovascular event. Death from a heart attack or stroke occurred in 5.4% of the patients initially given placebo and in 4.1% of those getting high dose statins - the other events (non-fatal stroke, heart attack, and chest pain) occurred at the same rates in the two groups.
That's not a great change in individual risk. And when you consider that one month of 80mg of simvastatin (Zocor) is $124, you have to wonder if it's worth it.
Of course, there's the rub. If someone else, say an insurance company or Medicare, is paying the bill, then it's worth it for most people. But if they have to pay, then it's not.
As the Boston Herald story noted, this is the third study advocating the use of high dose (and high price) statins for prevention of heart disease. It will be a very big deal if their conclusions become widely adopted, considering the billions of dollars involved. We would do well to ask ourselves if its really worth it.
UPDATE: Reader email on the economics of statins:
I think your economic comment is incorrect.
One month of 80mg costs $124 or about $1500/year
Outcomes are better by 1%.
If this improvement occurs over one year, then the cost saving one life is $150,000/life-saved.
As a general rule, cardiac patients successfully treated live on average about 10 years. Therefore the cost is $15,000/life-year-saved. If it's 1% over two years, it's about $30k/life-year-saved.
Cost-effectiveness is currently about $50-80k/life-year-saved. Based on this back of the envelope calc, high-dose statins are cost-effective. This does not account for costs of avoided ICU stay, other complications (stroke et al), and so on.
That's assuming that the advantage for high dose statins continues beyond two years. We don't know that it does.
There has been one study that looked at the overall mortality for ten years, using traditional doses of simvastatin (40mg instead of the 80mg used in the most recent study). In that study, 21% died in the placebo group after ten years compared to 19% in the simvastatin group. (That was of all causes, not just cardiovascular disease.) But again, we don't know if the same holds for high dose statins. The studies simply haven't been done yet. Keeping in mind that the higher the dose the greater the chance of side effects, the prudent move would be to proceed with caution.
Whole Body Scams: Another reason to avoid those whole body CT scans - radiation exposure:
"The radiation dose from a full-body CT scan is comparable to the doses received by some of the atomic-bomb survivors from Hiroshima and Nagasaki, where there is clear evidence of increased cancer risk,'' said David Brenner, professor of radiation oncology at Columbia University in New York City...
...Brenner found that a 45-year-old who had one of the high-tech X-rays - which deliver much larger radiation doses than normal scans - would increase his cancer risk by .08 percent. That translates to about one more cancer case for every 1,200 people.
But for a 45-year-old who gets a scan every year for 30 years, the risk would rise to 1.9 percent, or almost one in 50, Brenner said.
That's still a small individual risk, but probably not worth taking for the limited value of these whole body scans. Despite the advertising hype, there are few conditions that they can detect early enough to save lives. And they have far too many false positive results.
posted by Sydney on
8/31/2004 06:40:00 AM
0 comments
A California man who once tested positive for the virus that causes AIDS has learned the diagnosis made eight years ago was mistaken and he was never infected.
...The error may have occurred because Malone arrived at the clinic in 1996 with lab results from a testing firm showing he had HIV, said Karen Pridmore, spokeswoman for the VA's Northern California Health Care System.
The clinic performed its own HIV test on Malone to confirm the first set of results and it came back negative, but that information was never shared with the patient, Pridmore said.
Always confirm those outside tests. And always follow-up on the test results. posted by Sydney on
8/30/2004 08:24:00 AM
0 comments
Wonderful Chocolate: Good news for chocolate lovers. A little bit of chocolate appears to improve arterial blood flow:
The scientists, who presented their work Sunday at Europe's most important cardiology conference, gave 3.5 ounces of either dark, bittersweet, chocolate or fake chocolate to 17 healthy volunteers.
On another day, the volunteers were switched. They had no chocolate outside of the study, and investigators did not know what each volunteer ate during the study.
An ultrasound was taken of each volunteer's upper arm to see the functioning of the endothelial cells in the main artery. The cells accomplish their goal of controlling the stiffness of the blood vessel by secreting several active substances that regulate the flexibility of the vessel and influence clot formation.
'During the chocolate session, endothelial function was improved, whereas during the placebo day there were no such changes,' the study concluded. 'The favorable effects of dark chocolate lasted for three hours at least.'
The fact that it improves blood flow for a few hours in an arm doesn't necessarily mean that eating chocolate prevents heart attacks, but those of who like chocolate can feel a little less guilty about eating it. posted by Sydney on
8/30/2004 08:16:00 AM
0 comments
Vioxx and Hearts: What to make of the news last week that Vioxx causes heart attacks? Hard to say. The study was released in France, at a conference. The only figures available are those from press releases, so it's impossible to evaluate the claims that Vioxx users had three times the risk of heart disease as Celebrex users. (Three times what? 0.1 or 10?)
It's also impossible to inspect the data for confounding variables. Was there something about the Vioxx users that was different than the Celebrex users? Were they heavier, more likely to smoke, older? The fact that they were all on twice the normal dose of Vioxx suggests that perhaps they had arthritis pain that was not responding to traditional doses or therapies. With all of the recent evidence pointing to the role of inflammation in coronary artery disease, might the inflammation from their arthrititis be playing a role?
Too early to tell. But full disclosure of the data would be extremely helpful. posted by Sydney on
8/30/2004 08:07:00 AM
0 comments
