"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
Gone Listening: I'll be away continuing my medical education for the next few days. Blogging will resume on Monday, Nov. 15. posted by Sydney on
11/10/2004 08:04:00 AM
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Under the plan outlined today, states and territories will be receiving 100 percent of any orders they had originally placed under federal, state, and multi-state contracts. Overall, this accounts for 3.1 million doses of vaccine. The distribution plan for the 7.2 million doses takes into account three things: 1) the number of high-priority individuals in the state, 2) the number of doses the state has already received and 3) the state’s unmet needs. In the coming weeks, another 1.2 million doses of pediatric will be allocated to states using the same approach.
Grand Rounds: Are here. A compendium of medical blog posts ranging from Elizabeth Edwards' breast cancer to mammograms in transgendered patients. posted by Sydney on
11/09/2004 08:23:00 AM
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Tennessee's Dragon: Tennessee spends a lot of money to insure the uninsured. So much, there Kerryesque program, TennCare, is known as the "dragon that eats everything." Like a dragon, it consumes a lot without giving much in return:
The three healthiest states are Minnesota, New Hampshire and Vermont. Among other things, their high rankings reflect low rates of poverty and premature death, safer-than-average drivers and generous spending on public health. Minnesota has ranked No. 1 for nine of the past 15 years and has never been out of the top two.
At the other end of the list are Tennessee, Mississippi and, as in 14 of the past 15 years, Louisiana in last place.
Their low rankings arise from high rates of poverty, infant mortality and cancer; large numbers of smokers; and, with the exception of Tennessee, many people without health insurance.
The North Country seems to be a healthier clime than the South, no? Actually, it's hard to tell. The survey measure health by giving different weights to various pre-selected health measures. Having a large population of smokers will cost a state dearly. Other measures, with less weight, are heart disease deaths, cancer deaths, infant mortality, the number of high school graduates, violent deaths, auto accident deaths, and the amount of money spent on public health. The more you spend, the healthier you are, right?
Strengths include ranking first for a low rate of deaths from cardiovascular disease at 259.2 deaths per 100,000 population, a low premature death rate with 5,595 years of potential life lost before age 75 per 100,000 population and a low rate of uninsured population at 8.7 percent. It is also in the top five states for high support for public health, a low percentage of children in poverty, a low total mortality rate, a low infant mortality rate, a low occupational fatalities rate and a high rate of high school graduation. Minnesota's biggest challenges are a high prevalence of obesity at 23.0 percent of the population and low access to adequate prenatal care with 76.0 percent of pregnant women receiving adequate prenatal care.
Go figure. They're fat but healthy. Kind of runs against the grain of common wisdom, doesn't it?
Tennessee is 48th this year; it was 46th in 2003. Its strengths are a low rate of uninsured population at 13.2 percent and moderate access to prenatal care with 77.1 percent of pregnant women receiving adequate prenatal care. Challenges include a high infant mortality rate at 9.2 deaths per 1,000 live births and a low high school graduation rate with 56.7 percent of incoming ninth graders who graduate within four years. The state also ranks in the bottom 10 states on seven of the other individual measures, including a high prevalence of smoking, a high prevalence of obesity, a high violent crime rate, a high rate of deaths from cardiovascular disease, a high rate of cancer deaths, a high total mortality rate and a high premature death rate.
Looks like TennCare isn't delivering much for its dollars.
Assuming, that is, that these weighted measures really mean anything. A more honest portrayal of health would leave out the violent deaths, auto accidents, money spent, insurance rates, and high school graduation and concentrate on real medical diseases. posted by Sydney on
11/09/2004 08:15:00 AM
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Elswhere, the battle goes on. Doctors in Virginia are planning a season-long protest in Richmond beginning in January:
Beginning in January, physicians said they plan to be in Richmond throughout the legislative session — as many as 100 strong on any given day, said Dr. Mitchell Miller, a family physician in Virginia Beach and outgoing president of the state medical society.
The "White Coats on Call" campaign, which kicked off during the medical society's annual meeting in Arlington this past weekend, will differ from previous attempts by doctors to draw attention to the rising cost of medical-malpractice insurance premiums.
The lawyers, of course, will be counter-demonstrating:
Mr. Harris said his lawyers group plans to call on former patients injured by medical malpractice to show up in Richmond to lobby lawmakers against the tort-reform proposal.
"We will have our members there, and we will have their clients who have been injured there, because they have got a very important story to tell, and that is that they have been injured by someone who is negligent," Mr. Harris said.
No Sanctuary: The coalition forces aren't messing around. They've even secured a hospital in Fallujah:
American officials also say the hospital has been a haven for insurgents in what has been a "no-go" zone for American forces for months. And they have made little secret of their irritation with what they contend are inflated civilian casualty figures that regularly flow from the hospital - propaganda, they believe, for the Falluja insurgents, whom they blame for much of the car bombings, beheadings and other acts of terror in Iraq.
In all, there were 160 Iraqis found at the hospital, according to the American Special Forces commander, and at least five people suspected of being foreign fighters, including one from Syria.
One they can be sure about: A man who identified himself as a fighter from Morocco was wheeled down the hallway, where he pointed out several others he said were also anti-American fighters from other countries.
American troops said they found four or five men at the hospital armed with Kalashnikov rifles, and at least one hand grenade. A poster hanging in an examination room on the first floor displayed scenes of carnage in Iraq and a row of flag-draped American coffins. The writing on the poster encouraged jihad, a translator said.
Perhaps the most intriguing discovery of the night - aside from the Moroccan - were two cellphones found on the roof of the hospital. The Americans said they were clear evidence that someone was monitoring the area in front of the hospital.
Dr. Rasheed al-Janabi, a general surgeon at the hospital, said many patients had left in the past few weeks in anticipation of an attack, though some, he said, including several wounded by American bombs, were in no shape to leave. "For many days we see on TV that an attack is coming," he said. Only about 30 percent of the Falluja population is left in the city, he said.
He denied that the hospital was a haven for insurgents. "Fighters?" he shrugged. "I don't know about fighters."
One of the Iraqi soldiers, sitting on a desk nearby, voiced skepticism.
"Doctors from around here are afraid of the terrorists," said the soldier, Hassan, who like many of the Iraqi troops was afraid to give his full name. "They're afraid they'll threaten them or shoot them."
Preparedness Watch:The Washington Post has a good summation of the sorry state of our bioterror preparedness:
According to former White House official Falkenrath, the U.S. government's reliance on state and local health agencies to speedily distribute vaccines and drugs is "the Achilles' heel" of U.S. biodefenses.
"The single biggest problem is the non-performance of state and local public health agencies" in drawing up plans that U.S. officials have requested on how they would respond rapidly to a biological attack, he said. The plans would detail how officials expect to deliver medicine to people after the drugs are flown to airports. "From tarmac to bloodstream, their time frames are way too lackadaisical," he said.
This season's flu vaccine shortage amply illustrates the problem with relying on the CDC and public health departments to distribute something nationwide. But what about all that federal money they got to prepare for just such situations?
Federal officials have given state health agencies and hospitals $4.4 billion in the past three years to develop such plans. But experts say that beyond buying computers or walkie-talkies and hiring some staff, the funds have hardly helped them prepare for large-scale bioterrorist strikes.
"This won't be solved by money alone," said Elin Gursky, a biodefense specialist at the private Anser Institute for Homeland Security.
Federal statistics show that among the 50 states, only Florida, Illinois and Louisiana are close to being ready to swiftly distribute vaccines or antidotes from the national stockpile, according to the nonprofit Trust for America's Health, which studies public health issues.
The article correctly identifies the greatest weakness in the system:
"The main priority of our biodefense program should be enlisting hospitals and private doctors to prepare [for bioattacks], but hospitals and private doctors are not now in the game," said a federal official with direct knowledge of the shortcomings. "This issue has completely fallen through the cracks. . . . No part of the federal government can deal with mass casualties."
I don't know what Ohio did with their bioterror money, but they've done nothing to enlist practicing physicians or even to educate them about bioterrorism preparedness. When I made inquiries to the state health department a couple of years ago, they referred me to my local health department, which had a fourth year medical student call me up to ask me some survey questions for a "study" they wanted her to do during her clerkship with them. She thought it was weird that they were giving the job to a student, who would only be with them for a few weeks. I did, too. We both concluded it just wasn't a priority for them.
Clearly, someone needs to take the bull by the horns:
"There's a lack of an overarching federal game plan in biodefense," said Shelley Hearne, executive director of the Trust for America's Health. "States aren't being told, 'Here are the things you need to do, and why.' . . . Nobody's in charge."
... Some believe that Bush should publicly declare the seriousness of the government's bioterrorism concerns, name a bioterrorism "czar" to focus public attention, and initiate vastly expanded research into new drugs. Administration officials said that such steps are unnecessary, and that the current arrangement works fine.(emphasis mine)
But the biosecurity center's O'Toole disagreed.
"The country cannot do what's needed to get prepared for bioattacks without very visible national leadership from the president," said O'Toole, who worked in the Clinton Energy Department. "We're not yet treating this like a national security emergency."
Looks like a job for a leader with a "mandate." We've grown far too complacent since 9/11 and the anthrax attacks about the very real threat of bioterrorism. It's time to take them seriously again. And with the abysmal performance of the CDC in the wake of the flu vaccine shortage (see the post below), it's time to re-examine that agency's role in the preparedness equation. Wouldn't plans for bioterrorism defense be better placed in the Defense Department or Homeland Security? (Certainly better placed than with a bunch of epidemiologists!)
UPDATE: As further evidence of a lack of preparedness on the local leve, in the wake of the flu vaccine shortage, the CDC found it necessary to distribute these instructions on operating a mass vaccination clinic. If the response to a bioterrorist attack with smallpox is to consist of local health departments having mass vaccinations, shouldn't they already have had plans like this in place?
UPDATE II: And the news that the WHO is considering allowing new research on a genetically altered smallpox virus to "investigate treatments" for the disease isn't too reassuring, either. Why would someone want to look for a treatment for a disease which no longer exists - unless they have reason to believe that the disease will be re-introduced. posted by Sydney on
11/08/2004 07:52:00 AM
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Flu Vaccine: Doctors and public health departments aren't the only ones in the dark about how to obtain the flu vaccines that the CDC is supposedly sending to high priority populations. Add nursing homes to the list (emphasis mine):
Nursing-home personnel have heard flu shots will be coming their way. They've heard their residents and workers are a priority.
But it's more than a month after grocery stores and pharmacies lured customers with in-store flu clinics, and Ohio's 800 nursing homes have yet to see any vaccine.
There's no word on when they will.
...Medical experts have known for decades that the flu virus preys on the elderly and infirm. While influenza typically kills five of every 1 million infected people between the ages of 5 and 49, it kills 1,000 out of every 1 million infected people 65 or older.
Put another way: 91 percent of last year's flu deaths were of those 65 or older.
...A few weeks ago, he saw a story on network TV news in which an 18-year-old college freshman got a flu shot. She told the network: ``I heard there was a shortage, so I thought I'd get one."
Summit Villa had ordered 110 doses from Chiron. It was to be delivered Oct. 25.
``There is none available, we're told. It's pending at this point,'' Pearson said. ``We have no date. We have no promise, other than if some comes available, we're a priority.''
But, he added: ``They say a lot of things, and we're trusting that's the case.''
It would be a whole lot easier to trust them if they'd communicate a little better.
Politicization Watch: I missed this, but a couple of weeks ago, the prestigious British Medical Journal descended to the level of The Lancet (perhaps a bit lower) with this diatribe against Israel and the U.S. - evidently the European version of an "axis of evil." One can only shake one's head in wonder that anyone thought this belonged in a medical journal:
Does the death of an Arab weigh the same as that of a US or Israeli citizen? The Israeli army, with utter impunity, has killed more unarmed Palestinian civilians since September 2000 than the number of people who died on September 11, 2001. In conducting 238 extrajudicial executions the army has also killed 186 bystanders (including 26 women and 39 children). Two thirds of the 621 children (two thirds under 15 years) killed at checkpoints, in the street, on the way to school, in their homes, died from small arms fire, directed in over half of cases to the head, neck and chest—the sniper's wound. Clearly, soldiers are routinely authorised to shoot to kill children in situations of minimal or no threat. These statistics attract far less publicity than suicide bombings, atrocious though these are too.
The article was appropriately savaged by the journal's readers. One pointed out that the author had published a similar piece at a Palestinian propaganda site. Another provided a link to video documentation from Reuters of Palestinian ambulance abuse. Others had scathing words for the journal:
Like all good cowards, Summerfield and to some extent the BMJ editorial team, prefer to attack the easy target. The hideous human rights abuses across the Arab world, the stonings, beheadings and amputations, the mistreatment of women and other minority groups are all swept under the carpet. Sudan, China, Iran and a large part of the Muslim world are all seemingly ignored while Israel is lambasted. Then to cap it all, Summerfield calls people who defend Israel ‘morally corrupt’. Well Derek, that’s what the Jews would call ‘chutzpah’.
I was one of the leaders of the "Supine" BMA [British Medical Association] who led it out of the WMA [World Medical Association] because of the readmission of the Apartheid- ridden Medical association of South Africa. Unlike Dr. Summerfield I am old enough to remember the root cause of the Israel-Arab conflict and why the refugee camps were established, and maintained. In 1948 the Arab League armies invaded Israel, and their radio urged Arabs -not Palastinians- to leave, and return behind their "victorious armies".
No one disputes many Palestinians suffer terribly, and their lives are miserable. Those languishing in camps could have been rehabilitated by the wealthy Arab states many years ago but they were political pawns in the long term aim of destroying Israel. Persistent attempts to destroy Israel militarily failed, but the dogma, formulated at Khartoum in 1967, of no recognition, and no negotiation - of and with Israel- is still the basis of their policy and actions.
I have sympathy for the Palestinian's plight. I have equal sympathy for those in Israel, and elsewhere, whose lives are blighted by the constant treat of suicide bombers and other terrorists. Much as I dislike the government of Ariel Sharon, sadly I accept that, at present, the "Wall" and its offensive presence is necessary.
When rational people on both sides decide to do it, the Palestinian "problem" will be solved.
.....I read Dr Summerfield's wholly political article in the BMJ with some sadness. The fact that it is totally biased and one-sided and fails to address a complex political situation leading to an ongoing urban war which is a tragedy for both sides is one issue. In my opinion the more important issue is that such political articles have no place in a respectable and respected medical journal which is demeaned by its publication.
....I have always enjoyed reading the BMJ. I have respected its principles of impartiality and fairness. I was horrified to read Summerfield's letter this week. It beggars belief that such an august publication as yours would print such a politically biased diatribe without evidence-based backup or even the opportunity for the other side of the argument to be aired.
Please distance yourself from such vitriol. If I wish to read propaganda like this, I can avail myself of the gutter press! If Israeli and Palestinian doctors are to work together, either in the Middle East or abroad, then letters such as Summerfield's will hardly pour oil over troubled waters.
In other words, stick to medical issues, not political ones!
And this was particularly interesting:
As a stamp collector, I found it interesting to collect certain themes. One was Israel and its relations with surrounding nations.
As late as 1970 most Arab states were still issuing stamps with a dagger or blood covering Israel, with words in Arabic (for which I cannot vouch personally, but have ascertained with the help of those who can read Arabic) inciting the destruction of the Jewish state.
The Israel Post Office on the other hand has more than recognised its Arab population, with stamps commemorating mosques, Moslem holidays and personalities.
And this was on the mark:
[I]t is inconceivable that something like this could be published if it were directed at anyone else than Israelis and Jews. Perhaps we can look forward to the appointment of a BMJ editor with something resembling integrity.
Levels of a naturally occurring cannabis-like compound rise sharply in a woman's body when she is about to go into labour, research has found.
Scientists from Leicester University believe the finding may help to identify women at risk of giving birth prematurely.
It may also help to explain why smoking cannabis is linked to a greater risk of premature labour. posted by Sydney on
11/08/2004 07:20:00 AM
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The hospital based, case-control study in Milan was based on 507 cases aged 25 to 79 with a first episode of non-fatal acute myocardial infarction and 478 controls admitted for conditions unrelated to heart attack. All those taking part were questioned about their lifestyle, including how much pizza they ate. Pizza eaters were classed as occasional (one to three 200 g portions a month), regular (more than one a week), and frequent (two or more a week).
The results show that the greater the consumption of pizza, the lower the risk of heart attack (odds ratio 0.78, occasional eaters; 0.62 regular; and 0.44 frequent)
Oh, well, it's one of those retrospective studies which are notoriously bad at predicting causes of illnesses. There could be any number of confounding circumstances besides pizza eating habits that also explain the differences between the groups. These kinds of studies are similar to exit polls - and equally unreliable. So don't give up your fruits and vegetables in favor of Pizza Hut. posted by Sydney on
11/08/2004 07:19:00 AM
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Arafat has been hospitalized outside of Paris for more than a week with blotchy skin, a low platelet count that is affecting his immune system, decreased mental capacity and a considerable loss of weight – all indicators of the presence of AIDS.
Both of these possibilities seem like far-fetched rumors. He's an elderly man with liver failure. There are many more likely causes of his symptoms than the sensational poisoning or AIDS explanations. Number one would be cancer, and despite his aides' denials, I still believe this to be the case. Number two would be alcoholic cirrhosis or cirrhosis from some other cause.
Hepatic failure is still the most likely explanation of his illness, especially when you consider images like this. His thin face and puffy belly is most consistent with liver failure. AIDS patients are emaciated all over.
In a related vein, several readers have asked why it is that people of importance from the Middle East always end up in hospitals in the West. Good question. Even here in the heartland of Ohio, we have a clinic that caters to the rich of the Middle East. There are very good hospitals in the Middle East - all of them in Israel. Perhaps it's just that science, and by extension medicine, just doesn't flourish under totalitarianism. It isn't conducive to the free flow of ideas. Not to mention that anyone with half a chance to flee does, including doctors. posted by Sydney on
11/08/2004 07:16:00 AM
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Sunday, November 07, 2004
It's All Relative: The Sunday paper here in my hometown is full of op-eds decrying the fact that exit polls showed people were motivated to vote by "moral values" - intimating that the less urban and academic areas that had a majority vote for Bush are hotbeds of homophobia, bigotry and scary religious people. The spin has been unspun elsewhere in the blogosphere. But here's something else to consider. Buried in thisNew England Journal of Medicine article is a table that ranks the most important issues for voters in previous presidential elections, from 1992 to 2000. Pollsters didn't ask about "moral values" in 1992, but they did in 1996 and 2000, and guess what? They were the most important issue in those elections, too - for 40% of voters in 1996, when President Clinton was re-elected, and for 35% in 2000, when Gore won the popular vote. Both of those are much higher percentages than the 22% of the electorate who named moral values the most important issue this election.
Does that mean Clinton and Gore relied on the homophobic, ignorant masses? Or does it mean that our moral values have changed dramatically in the past four years, from those that Democratic elites deem appropriate to ones that they deem abominable? Neither, of course. It means the phrase "moral values" is extremely nebulous and can be defined in any way one wants to suit whatever purpose one wants when intrepreting exit poll data, anyway. Chances are, when people rank "moral values" as their top reason for voting, they mean the moral values of the candidates, which basically boils down to which of the two they trust the most.
Sorry, pundocracy. The lesson of the election is that you have to convince the electorate to trust you to do a good job. Just like any other job interview. posted by Sydney on
11/07/2004 09:17:00 AM
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Superman Vision: Those X-ray glasses they used to sell in the back of comic books that promised little boys the ability to see through women's clothing are a reality:
AN X-RAY machine that sees through air passengers’ clothes has been deployed by security staff at London’s Heathrow airport for the first time.
The device at Terminal 4 produces a “naked” image of passengers by bouncing X-rays off their skin, enabling staff instantly to spot any hidden weapons or explosives.
But the graphic nature of the black and white images it generates — including revealing outlines of men and women — has raised concerns about privacy both among travellers and aviation authorities.
A British television channel is seeking a terminally ill volunteer to donate their body after death so it can be filmed as it decomposes.
Channel 4, which in 2002 broadcast Britain's first public autopsy for 170 years, said the programme was being made in association with London's Science Museum and would be a unique experiment.
"We hope the experts can learn more about the processes involved and that the data collected by the project can help forensic pathologists in murder investigations," said Simon Andreae, head of science and education at the publicly funded Channel 4.
