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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Friday, December 17, 2004

    Another Healthcare Policy Blog: Managed Care Matters. Or maybe it's better described as a healthcare insurance industry blog.

    posted by Sydney on 12/17/2004 07:43:00 PM 0 comments

    Next! Pfizer has been hit by the revelation that it's Vioxx-like arthritis drug, Celebrex, doubles the risk of heart attacks:

    Pfizer said the Celebrex trial involved patients taking 400-milligram and 800-milligram daily doses of the drug to prevent tumors that grow from glandular tissue, known as adenomas. The anti-inflammatory drug was being tested on the theory that inflammation is a cause of cancer.

    Vioxx and Celebrex both work by selectively blocking a protein called COX-2 that has been linked to inflammation. They were both launched in 1999 and quickly became top-selling drugs, helped by massive television and print advertising.

    Pfizer also said on Friday that Celebrex was not shown to increase heart risk in a second long-term trial designed to see if the drug could prevent colon polyps. Negative findings in a similar trial led to the withdrawal of Vioxx.

    New York-based Pfizer said National Cancer Institute officials decided to halt the Celebrex trial on adenomas after confirming "an approximately 2.5-fold increase" in the risk of fatal or non-fatal heart attack in patients taking the drug, compared with patients taking a placebo.

    The full details aren't available, so it's impossible to say how significant that 2.5 fold increase is. Is it from 10% to 25% or from 1% to 2.5%, but given the recent events with Vioxx, it does make one hesitant to prescribe these sorts of drugs in these litiginous times.
    posted by Sydney on 12/17/2004 03:07:00 PM 0 comments

    Trauma as a Chronic Disease: Surgeon Bard-Parker is on a roll this week with posts about specialty hospitals, doctors as crime victims, and one doctor's zealous crusade against the death penalty
    posted by Sydney on 12/17/2004 11:26:00 AM 0 comments

    It's All Relative: Find out if you're better off dead. As Tony and Tacky says, they need to watch It's a Wonderful Life a few more times.
    posted by Sydney on 12/17/2004 08:42:00 AM 0 comments

    Can't Hold Your Liquor? Maybe it's genetic.
    posted by Sydney on 12/17/2004 07:35:00 AM 0 comments

    I Only Said it For the Lawyers: One doctor tries to take back his expert testimony.
    posted by Sydney on 12/17/2004 07:34:00 AM 0 comments

    Screening Intervals: How necessary are annual mammograms? Maybe not so necessary.
    posted by Sydney on 12/17/2004 07:30:00 AM 0 comments

    Dysfunctional Family Picnic: Welcome to new healthcare policy blog hcrenewal, "dedicated to the open discussion of health care's current dysfunction with the hopes of generating its cures."
    posted by Sydney on 12/17/2004 07:22:00 AM 0 comments

    Flu Vaccine Update: The CDC is having a Grand Rounds devoted to Vaccine Shortages: Protecting the Public's Health amid Strategic and Ethical Concerns, in which they will educate public health departments in distributing vaccines in short supply. Their model will be Arkansas, a state that apparently has its act together. This is what the Arkansas state department of health did in October when the flu vaccine shortage hit:

    The Arkansas Department of Health (ADH) has identified the site of each flu vaccination clinic in the state on November 3, 2004, for high-risk groups. It has started a statewide distribution of the 107,500 doses received this season.

    Of the 107,500 total doses, approximately 58,860 are being divided among the counties based on population base and taking into consideration 10 counties with a greater number of persons 65 or older. The remaining doses were distributed to nursing homes.

    Here's what the Ohio State Health Department did:


    I called the Ohio Department of Health this week to see if I could get some of that flu vaccine the CDC is supposedly sending to states. When I asked the woman who answered the phone if I could order flu vaccine, the answer was "Sort of." I could email my information to them, but they might not get it because it was snowing (?!), and they couldn't tell me when or if I would ever see any flu vaccine.

    Which state do you think will be better prepared for a bioterror attack?

    Since the nation's public health authorities decided the best way to respond to a bioterrist attack with, say, smallpox, would be to respond after the attack with targeted immunization, you would think that vaccine distribution plans would have been a high priority for local and state public health departments. Apparently not. There's an opportunity here for a good investigative reporter to delve into where the money for bioterrorism preparedness went in each state. It certainly didn't go into preparing. Except in Arkansas.

    UPDATE: Meanwhile, Michigan has so much flu vaccine, they're giving it to low risk people. I know there's a long-standing feud between Ohio and Michigan, but can't we get some of that flu vaccine down here?
    posted by Sydney on 12/17/2004 07:18:00 AM 0 comments

    Agenda: Michael Fumento writes about the American Public Health Association's recent conference. These are the men and women who run our local and state health departments. No wonder they haven't been able to get a good flu vaccine distribution plan up and running. They've got other things on their minds.
    posted by Sydney on 12/17/2004 07:02:00 AM 0 comments

    Reader Mail: The battle between McDonald's and the crusading Cleveland Clinic cardiologists brought this email about the consequences of having a fast food restaurant in a hospital:

    We had the same problem in the cath lab at the WLA VA Medical Center. It was as if they vented the Burger King hood directly into the cath lab. Every morning at 10 AM the odor of greasy hamburgers was piped directly into the lab.

    The irony was that a couple of the cardiologists thought that the Burger King food was the most edible/safe in the cafeteria - since the grill got the meat up to a high enough temperature to kill any potential E. coli, and the steam table food was always suspect.

    On a more serious note, a reader had this to say about end-of-life issues:

    I needed to make a point about the letter sent to you by a reader about her relative with end-stage alzheimers and the decision to continue feeding/hydrating. It is very clear to me that the nursing administrator had a agenda and sold her point. I quote, "Then an interesting thing happened, she thanked me on behalf of the staff. They are the ones that must carry out these orders. They are the ones that hear the dying person's moans and watch as they starve to death and suffer from not having fluids." Most hospice data would indicate that in a demented patient dehydration is an "easy" death, not associated with suffering. Moaning and crying is common in demented patients unrelated to their nutritional status. Most have no anatomic difficulty swallowing but become anorexic, exhibiting no appetite or thirst. Unlike stroke patients that have difficulty swallowing though usuallyl feeling hunger and thirst, Alzheimer's patients just stop eating and drinking. Based on only what is in the letter (and of course I realize that there may be more to it) the nursing administrator essentially lied to this patient's family because she had her own opinion about the ethics of initiation and withdrawal of enteral nutrition in this situation.

    What it comes down to is a choice — which should be based on the patient's known (in the best case) or inferred wishes. Whether to "suffer" (debatable) starvation and dehydration or to undergo a painful invasive procedure at least once ( feeding tubes whether nasal or percutaneous clog, become displaced, and fracture on a regular basis) for the benefit of extended life which for most end-stage Alzheimer's patients consists of incontinence, inability to perceive pleasure (or pain perhaps), a bedridden state, pressure ulcers, skin tears and a lingering death from recurrent infection. Yes as a surgeon I can too "sell" a patient on my own opinion when I'm asked to place a surgical feeding tube in a patient such as this one. I take pride in not doing so and alowing the family to make an informed decision based on the best information I can offer.

    Yes of course the nurses take "point" on the carrying out of most orders. They also have to take care of the withering patient, losing all elements of personality, laying in stool, with recurrent episodes of pneumonia and UTI. I don't think for a minute that that is any easier.

    posted by Sydney on 12/17/2004 06:54:00 AM 0 comments

    Paging Carnival of the Recipes: The BMJ is having a Polymeal recipe contest. Sounds like a job for Dr. B.
    posted by Sydney on 12/17/2004 06:51:00 AM 1 comments

    Eat, Drink, and Live Long: First we had the polypill, now the polymeal:

    Scientists claim it is possible to extend your life and avoid heart disease by regularly eating a simple set of ingredients hailed as the 'Polymeal'.

    Researchers gathered evidence on the beneficial effects of different types of food, including fish, dark chocolate, wine and garlic, in reducing heart disease, blood pressure and cholesterol levels.

    From this they worked out the combined effect of the ingredients and calculated their potential effect on an adult population.

    The team suggested that dining on the Polymeal on a daily basis could cut the risk of heart disease by 76 per cent.

    They said the effect was most dramatic in men, meaning they would live on average 6.6 years longer than those not eating the meal.

    They would also live for nine years longer without suffering from heart disease, while those who did succumb would suffer for less of their lives.

    In women the Polymeal increased life expectancy by nearly five years, the researchers suggested.

    They said it would also delay the onset of heart disease for eight years longer.

    (Note to the irony impaired: It's a joke. But then, so is the polypill.)
    posted by Sydney on 12/17/2004 06:47:00 AM 0 comments

    Many Good Things: At Shrinkette's this week, including an ongoing discussion of the confluence of anti-depressants, depression, and doctors.
    posted by Sydney on 12/17/2004 06:40:00 AM 0 comments

    Claire de Lune: The FDA has just approved a new sleeping pill, called Lunesta:

    'This novel non-benzodiazepine[non-valium-like -ed] sleep aid provides a new option for the millions of Americans with chronic insomnia. Unlike all other available prescription sleep aids, which are generally indicated for short-term use, eszopiclone has been studied and approved for use when longer-term treatment is needed,' said Andrew Krystal, M.D., Director of the Sleep Disorder Research Laboratory and Insomnia Program at Duke University Medical Center, Durham, NC. 'The six-month, double-blind, placebo-controlled study of eszopiclone provides unprecedented evidence of sustained efficacy. There were statistically significant improvements in patient-reported measures of sleep onset and sleep maintenance versus placebo for the entire duration of the study with no evidence of tolerance.' [Translation: People could take it for six months without "getting used to it" as my patients would say.]

    LUNESTA is indicated for the treatment of patients who experience difficulty falling asleep as well as for the treatment of patients who are unable to sleep through the night (sleep maintenance difficulty).

    'The approval of LUNESTA makes an important treatment option available for patients who have trouble sleeping. Insomnia can include difficulty falling asleep and/or staying asleep. LUNESTA is an important advance for doctors and patients alike, as it can provide sleep efficacy, even over the long term,' said Thomas Roth, Ph.D., Director of the Sleep Disorders and Research Center at Henry Ford Hospital, Detroit"

    The data the FDA considered:

    The LUNESTA NDA contained a total of 24 clinical trials, which included more than 2,700 adult and older adult (ages 65 and older) subjects, and more than 60 preclinical studies. Sepracor conducted six randomized, placebo- controlled Phase III studies for the treatment of chronic or transient insomnia in both adult and older adult patients and included these studies as part of the NDA package, which served as the basis for the FDA's approval of LUNESTA.

    The drug, eszopiclone, is the mirror image (as Nexium is to Prilosec) of a drug already in use in Europe, called zopiclone. The Air Force once did a compairson of zopiclone to other sleeping aids and found it the most effective:

    The sleep-inducing power of the medications before psychomotor testing was zopiclone > zaleplon > melatonin > temazepam. The corresponding effect after psychomotor testing was zopiclone > melatonin > zaleplon > temazepam.

    Suppposedly, the new drug, eszopiclone, had fewer side effects and isn't addicting. Although we won't know how true that is until it's been on the market and used by many people. Detailed, unhyped information about the drug can be found here. The most common side effect : bitter taste.

    It's nice to have a non-addicting, well-tolerated drug to treat insomnia, but the trouble is that insomnia is most often a symptom of some deeper lying problem - usually anxiety or depression. Treating the insomnia without addressing the underlying cause doesn't solve anything. In fact, it only makes it easier to ignore the underlying problems longer, potentially making things worse. But, the company plans to launch a direct to consumer ad campaign (of course!) so expect this to be the next "miracle pill" along with that long-acting enhancement pill and the little purple indigestion pill.

    UPDATE: I stand corrected:

    You write:

    The drug, eszopiclone, is the mirror image (as Nexium is to Prilosec) of a drug already in use in Europe, called zopiclone. The Air Force once did a compairson of zopiclone to other sleeping aid and found it the most effective:

    Nexium actually isn't the mirror image of Prilosec. It's the pure S-isomer, whereas Prilosec is a racemic mixture. Based on the name, I'd guess that that's the relationship between eszopiclone and zopiclone as well.

    That is correct.

    UPDATE II: Some experience from Canada:

    It is also available in Canada (trade name Imovane). I use it in my ICU patients a fair bit to try and improve their sleep. And on a personal note; it is the easiest way to readjust your circadian rhythm after flying - zopiclone for 3 nights post flight, and you are golden.
    posted by Sydney on 12/17/2004 06:34:00 AM 0 comments

    Best Intentions: Yesterday, I had big plans. During lunch I was going to run Christmas errands - to the post office to mail packages, to the specialty deli/catering service to order next week's office Christmas luncheon, to the cleaners to have least year's mud from someone's (coughyoungestkidcough) boots removed from my good winter coat so I won't have to wear a parka with a dress. Instead, I ran twenty minutes late in the morning and spent the remaining forty minutes of lunch answering phone messages and documenting my morning encounters. After work, I planned to go to the hairdresser. Instead, I ran thirty minutes late and spent an hour and half more answering phone messages, sorting through lab results, and documenting the afternoon. My list of undone errands hadn't a chance against all the office paperwork. Now, I'll have to wear my parka with dresses a little while longer, and it won't be until after Christmas that I'll be able to get my hair cut. That dumpy looking woman at the mall doing her Christmas shopping will be me. Thanks Door knob issues!
    posted by Sydney on 12/17/2004 05:46:00 AM 0 comments

    Wednesday, December 15, 2004

    Ukrainian Medical Mystery Update: Fox News has a detailed update on Yushchenko's poisoning, which includes information on dioxin poisoning from toxicology experts. Interestingly, there have been other people have been intentionally poisoned with dioxin before:

    Brouwer said the highest dose recorded so far was in a woman in Vienna, who was intentionally poisoned with dioxin in the mid-1990s. Tests showed her blood had 144,000 units per gram of fat, and she survived.

    'We don't actually know what the lethal dose is. The only thing we do know is there's a woman who had an even higher dose, who didn't die, so it must be higher than that,' Brouwer said.

    The woman, who was among five people deliberately poisoned at a textile institute in 1997, was sick for two years and was in and out of hospital with various symptoms, said Schecter, who was involved in tracking the case. A second woman fell ill from the poisoning, but the other three people had no symptoms at all.

    It would not be difficult to deliver the dose Yushchenko received, experts say. If the dioxin he ingested is the most hazardous type, tetrachlorodibenzoparadioxin, or TCDD, it would take only a drop or two, or a tiny amount of powder mixed in food, to poison him.

    Maybe it was the soup.

    posted by Sydney on 12/15/2004 08:13:00 PM 0 comments

    Public Service: The Top 10 Unfounded Healthscares of 2004.
    posted by Sydney on 12/15/2004 08:00:00 PM 0 comments

    Consequences of Aging: More and more employers are finding it difficult to bear the financial burden of an increasing retired worker population:

    For today's workers hoping for medical benefits when they retire, the future is looking increasingly grim.

    Eight percent of employers interviewed said they had eliminated subsidized health benefits for future retirees this year and an additional 11 percent said they are likely to do so next year, according to a survey of 333 large firms by the Henry J. Kaiser Family Foundation and the consulting firm Hewitt Associates released Tuesday.

    Last year, 10 percent of firms surveyed said they dropped coverage for future retirees.

    The latest survey, the groups' third annual study of health benefits for former employees, also found that companies are passing on to their retirees an increasing share of medical costs, just as they are doing with benefits for active workers.

    ... Retiree benefits are a significant part of employers' total health costs, accounting for nearly 30 percent of their medical benefit expenditures. An aging population is increasing the pressure.

    The problem's only going to get worse as the boomers reach retirement age. Although it should be noted that those who are 65 or older do have Medicare coverage, so they aren't going without. And soon, that will include drug coverage. Nevertheless, we're fast approaching the time when the boomer elderly will have to be supported by generations who were less fecund than the boomers' parents.
    posted by Sydney on 12/15/2004 07:45:00 AM 0 comments

    Dire Warnings: A new study says that taking calcium channel blockers with diuretics may increase your risk of dying:

    The new study indicates calcium channel blockers may indeed double the risk of dying of heart disease, especially when paired with diuretics, which reduce the amount of fluid in the blood. Although the study involved women, the authors believe the findings also apply to men.

    The new study in today's Journal of the American Medical Association involved almost 20,000 women being treated for high blood pressure in the long-term study of postmenopausal women called the Women's Health Initiative.

    It found that women who took diuretics plus calcium blockers had twice the risk of death as women who took diuretics with beta blockers, drugs that reduce the heart's workload. Women took a calcium blocker alone had a 55 percent higher risk of death than women who took a diuretic alone.

    The authors cautioned that the study's design, in which patients are followed for a number of years, doesn't yield the same 'gold-standard' evidence that comes from randomly dividing patients into treatment and control groups.

    And yet, despite that caution, the author's still can't restrain themselves from making comments like this:

    'This raises serious questions about using calcium channel blockers in patients with uncomplicated high blood pressure,' says lead author Sylvia Wassertheil-Smoller of Albert Einstein College of Medicine, New York. 'If I were on that combination, I would want to know, 'Why this one?'

    These are the same authors and the same study that gave us hormone hysteria a few years ago.

    Their abstract only presents their results in terms of hazard ratios, which can be very distorting. But the morning paper had the details, and they aren't nearly as impressive:

    Still, the number of heart-related deaths was relatively small: 31 out of 1,223 women taking the calcium channel blocker combination versus 18 out of 1,380 on the beta blocker combination and 17 out of 1,413 on the ACE inhibitor duo.

    That's 2.5% vs. 1.3% vs. 1.2%. We already know that beta blockers and ACE inhibitors can play important roles in treating heart disease. We would expect that patients on those drugs would do better from a cardiac standpoint. What's more, some people with hypertension are also placed on calcium channel blockers to treat arrhythmias, which could also increase their cardiac mortality. Although the abstract says the authors controlled for "multiple covariates" it doesn't tell us what those covariates were. I'll have to wait until my complementary issue of JAMA arrives in the mail to find out. (Unable to access online.)

    posted by Sydney on 12/15/2004 07:28:00 AM 0 comments

    Clinic Tzar: The CEO of the Cleveland Clinic, a cardiologist by training, wants to oust McDonald's from the hospital food court. The restaurant has ten more years left on its lease, and it argues that its food is no more harmful than other restaurants in the hospital - such as Subway and Au Bon Pain. Hospital employees aren't too crazy about the ouster, either:

    But Cosgrove's crusade has been met with resistance from not just McDonald's executives, who say they are being singled out for a problem that goes beyond the occasional Happy Meal, but also from staff and visitors who resent what they consider to be a paternalistic attitude from bosses who can afford pricier, more healthful food.

    'What they have in the cafeteria is not a lot better, and it's certainly not affordable,' said Donna Wilkison, a post-operative nurse waiting in line for her McDonald's salad with chicken. The cafeteria salad bar, priced at $4.64 a pound, 'gets very expensive. They need to bring in something else that's more affordable.'

    She's got a point there. Hospital cafeteria food isn't exactly full of healthy choices, either.

    Dr. Eric Topol, the anti-arthritis drug crusader is behind this crusade, too:

    "I can't tell you how many patients found this repulsive," said cardiology chairman Eric Topol. "How can the Cleveland Clinic, which prides itself on promoting health, have the audacity to have a McDonald's in the main lobby?"

    Some days, the scent of cooking grease wafts up the one flight to Topol's domain, a heart center that has been ranked first in the nation by U.S. News & World Report for 10 straight years. He has heard all the wisecracks and not-so-amused comments about serving up a side of fries with that angioplasty.

    "If this was a strip mall or a food court in a public place, that would be a different matter," he said in an interview. "We're supposed to be the icons for promoting good health."

    Sometimes, you get the feeling that those Cleveland Clinic cardiologists watched too much Quincy when they were growing up. Everything's a crusade.

    They may have met their match, however, in targeting this particular McDonald's:

    Phillip Wilkins, a representative of the National Black McDonald's Operators Association, warned Cosgrove: "We vigorously support one another and will not hesitate to do so with every resource available to us."

    Does that mean they'll be calling in Jesse Jackson?

    posted by Sydney on 12/15/2004 07:08:00 AM 0 comments

    The Nose Knows II: Again with the nose. A Portuguese researcher is using olfactory stem cells for spinal cord injuries:

    The technique involves extracting olfactory ensheathing cells from the upper nasal cavity. This area contains the body's only surface neurons and is a source of nerve stem cells.
    posted by Sydney on 12/15/2004 06:44:00 AM 0 comments

    Tuesday, December 14, 2004

    Flu of a Different Feather: Gilbert Ross on the bird flu.

    posted by Sydney on 12/14/2004 03:29:00 PM 0 comments

    Euthanasia Rebellion: In the UK, legislation on living wills sparked parlaimentary chaos.
    posted by Sydney on 12/14/2004 02:45:00 PM 0 comments

    Dissecting Uwe, GM, and the NY Times: Business Word Blogger Donald Johnson takes apart a recent healthcare forecast that appeared in The New York Times. Johnson asks, "How does such a piece get in to the N.Y. Times? They don’t know health care and they don’t care."
    posted by Sydney on 12/14/2004 08:36:00 AM 0 comments

    Grand Rounds: Travel to the Phillipines for this week's Grand rounds. All the healthcare blogging you could want, and in a nice, easy-to-pick-your-interest format.
    posted by Sydney on 12/14/2004 08:26:00 AM 0 comments

    Flu Vaccines: Finally, comes some solid information on how to obtain the flu vaccine for my patients. Where did I get this information? Not from the CDC's twice weekly email alerts. The instructions came in the mail, from medical supply distributor Henry Schein, Inc. The letter was dated December 2, but just arrived in the mail yesterday. According to the company, in mid-November they gave the CDC the names and addresses of everyone who had ordered flu vaccine from them, and the amount ordered. The CDC then used that information to decide how much flu vaccine to distribute to each state. The distribution of the vaccine will then be up to each state's health department. Notably, there's been no communication from the Ohio State Health Department. Nor from the local health department, aside from their newspaper announcement of a flu vaccine clinic early in November.

    Henry Schein must be wondering what's up. Their letter urged me to contact the person in charge of the vaccine for my state and request my flu vaccine doses. (And of course, to ask that Henry Schein, Inc. be the distributor.) Evidently, the information will be sent to the CDC and then to Henry Schein, and sometime, maybe, I can get some flu vaccine. But, if it took a month to get the information for ordering to me, how much longer will it take to actually get an order filled? Will I get the vaccine before Spring, let alone before flu season begins in 2 to 4 weeks?

    Information for each state is here. For doctors out there looking for vaccine, call the person listed as "IZ."

    posted by Sydney on 12/14/2004 07:06:00 AM 0 comments

    Art History Lessons: Napoleon and David. This is a better David painting.
    posted by Sydney on 12/14/2004 07:04:00 AM 0 comments

    The Nose Knows? Researchers say they can predict Alzheimer's with a smell test:

    The nose is the newest clue to Alzheimer's disease. A simple scent test could determine whether a case of mild, short-term memory loss will develop into the progressive neurological disorder.

        Specific scents are the key.

        Strawberry, smoke, soap, menthol, clove, pineapple, natural gas,lilac, lemon and leather: People with mild cognitive impairment who cannot identify these scents will develop Alzheimer's disease, according to research from the American College of Neuropsychopharmacology.

    Details are sparse. The findings were presented at a meeting, not published, and the news article is skimpy on specifics:

    Dr. Devanand offered the odor-identification test to 150 patients with mild cognitive impairment twice in one year. Sixty-three healthy seniors were tested once. He followed up on the groups' progress after five years.

        His research found that the 10 scents "proved to be the best predictors for Alzheimer's disease.

    Interesting, and very useful if it pans out to be true. But very rarely do these conference reports end up being reproducible.
    posted by Sydney on 12/14/2004 06:54:00 AM 0 comments

    Nominations: Tommy Thompson's replacement at HHS will be former Utah governor and current EPA head Michael O. Leavitt:

    The agency has a budget of more than $500 billion and 67,000 employees. The HHS secretary oversees Medicare and Medicaid, the mammoth government health programs for the elderly, poor and disabled, as well as the Food and Drug Administration, the Centers for Disease Control and Prevention, the National Institutes of Health and the Indian Health Service.

     "I look forward ... to the implementation of the Medicare prescription-drug program in 2006, medical-liability reform and finding ways to reduce the cost of health care," Mr. Leavitt said in the Roosevelt Room. "I am persuaded that we can use technology and innovation to meet our most noble aspirations and not compromise our other values that we hold so dear."

    posted by Sydney on 12/14/2004 06:47:00 AM 0 comments

    Reader Mail: On euthanasia:

    I have been following you line on this troubling topic. We have been fortunate enough to travel to Europe and they do have a very different concept on end of life care. That topic would fill a number of pages.

    One issue you have not addressed is the strain on the care givers to carry out these life ending orders. We were faced with that issue when an older relative in the advance stages of dementia quit eating. The question became, do we insert a feeding tube? After a 30 minute discussion with the nurse/adminstrator concerning pain and other issues the answer was yes.

    Then an interesting thing happened, she thanked me on behalf of the staff. They are the ones that must carry out these orders. They are the ones that hear the dying person's moans and watch as they starve to death and suffer from not having fluids.

    Death came about six weeks later, but all involved knew we had done what was right in both letting nature take it course, but also providing a needed level of care.

    It is easy to give these orders when you do not have to deal with the reality of dealing with a living human being, it is difficult when you knew that person as a loving, productive member of society.

    Yes, and that's true of active euthanasia as well. The doctors who give the orders don't have to carry them out. The nurses who have to carry them out can assuage any guilt they might feel by telling themselves they're just carrying out orders. The lack of ultimate responsibility just makes it all that much easier psychologically. If the doctors who ordered the killing also had to administer the drugs, it would be much harder to implement involuntary euthanasia such as that in the Gronigen Protocol. After all, how do you look someone in the eye after you've just killed their baby? Anyone with a conscience couldn't.
    posted by Sydney on 12/14/2004 06:15:00 AM 0 comments

    Monday, December 13, 2004

    A New Era at Medpundit: Today, for the first time since I paid to get rid of automatic blogspot ads, I've opened the blog to advertising. I've been considering it for a while, but I was leary of the Google Ads because their robotic-crawler nature meant an alternative medicine I didn't believe in or endorse could pop up. That happened once in the very remote past with Blogspot ads. An ad for an herbal remedy that claimed to prevent smallpox ran across the top of the blog for several days before I managed to get rid of it. Didn't want that to happen again.

    But, beginning today, in a mutual experiment in medical blog advertising, a button for the medical software company AdvancedMD appears to the right. And unlike the herbal smallpox preventive, they're legitimate.


    posted by Sydney on 12/13/2004 07:42:00 PM 0 comments

    Ukrainian Medical Mystery: CodeBlueBlog doubts that dioxin is behind Viktor Yushchenko's illness. Here's a description of acute dioxin poisoning which fits Yushchenko's symtpoms to a tee:

    In humans, the acute toxicity of TCDD is known from accidental release due to runaway reactions or explosions. Essentials of diagnosis are: -eye and respiratory irritation, -skin rash, chloracne, -fatigue,nervousness, irritability. A process accident in 1949 was followed by: -acute skin, eye, and respiratory tract irritation, -headache, dizzines, and nausea. These symptoms subsided within 1-2 weeks and were followed by: -acneiform eruption, -severe muscle pain in the extremities, thorax, and shoulders, -fatigue, nervousness, and irritability, -complaints of decreased libido, -intolerance to cold. Workers also exhibited: -severe chloracne, -hepatic enlargement; -peripheral neuritis; -delayed prothrombin time; -increased total serum lipid levels. A follow-up study 30 years later found persistance of chloracne in 55% of the workers.

    Since Yushchenko reportedly ingested the dioxin, the irritation would also be found along the length of his intestinal tract, which is what his doctors reported earlier. Unfortunately, there's not much information out there on acute dioxin ingestion, since it's something that most people try to avoid. Most of the literature deals with either chronic, low-level exposure in the environment or with inhalation exposure from industrial accidents. They do have a very long half-life and tend to accumulate in the fatty tissue, so it isn't all that hard to believe that the Austrians were able to detect it this far out. And when his physician says that it's "out of his system" he could have been referring to his circulatory system. The symptoms of acute toxicity fade away as the dioxin leaves the circulation and gets stored in the fat. But long term complications, such as cancer and birth defects remain very real risks.

    It would be premature to dismiss it, or to cast aspersions on his physician.

    ADDENDUM: As for the possibilty of Yurshchenko having acne rosacea, it's unlikely. Acne rosacea usually has a much slower progression. Yurshchenko's face changed dramatically in just a few months' time - even faster since he didn't have the facial lesions when he first sought treatment in Austria.

    UPDATE: Detailed info on dioxin at RangelMD.

    UPDATE II: More doubts about the poisoning claims, this one with links to European reports of threats against one of Yushchenko's original doctors. (via Solomonia dot com)

    Note: Welcome Instapundit readers. And yes, I corrected my grammatical typo.
    posted by Sydney on 12/13/2004 01:54:00 PM 0 comments

    PKWS: Yet another syndrome.
    posted by Sydney on 12/13/2004 08:30:00 AM 0 comments

    Color Codes: If you live in certain areas of Florida and wear one of those yellow Lance Armstrong bracelets, you might want to take it off before you go to the hospital.
    posted by Sydney on 12/13/2004 08:28:00 AM 0 comments

    Whither the Flu? One of my most prolific email correspondents asked me this week-end what's being done to make sure a vaccine shortage doesn't happen next year. Beats me. Some companies are trying to come up with an alternate flu vaccine that won't be as easily derailed as the current one, but there have been setbacks.

    What is the CDC and the Administration doing? There's probably not much they can do. They have no authority over manufacturers of drugs and vaccines. The FDA's influence only goes as far as safety and efficacy.

    Does the CDC have any plans for distribution of vaccines in the event of another shortage? They seem to think they've got a pretty good system now, but it's woefully inadequate. I've been instructing my patients to call the local health department for flu vaccine information, since the CDC announced that's where they would be directing supplies, but most of them come back to tell me that the they get no help from the health department when they call. Then there are stories like this, about some areas having surpluses of vaccine, so much so that they don't know what to do with it.

    Their handling of the shortage thus far has been disappointing, to say the least.
    posted by Sydney on 12/13/2004 08:20:00 AM 0 comments

    Bioethics on the Web: Here's a fair and balanced - and quite informative bioethics newsletter from the Southern Hemisphere.
    posted by Sydney on 12/13/2004 08:00:00 AM 0 comments

    Sunday, December 12, 2004

    History Lessons: Doctor Bob at The Doctor Is In has an informative and thoughtful look back at the history of euthanasia in the West. It is an inglorious one. He also notes that even a utilitarian should be able to find some good in allowing the disabled to live:

    What are the chances that Dutch doctors will find a cure for the late stage cancer or early childhood disease, when they now so quickly and "compassionately" dispense of their sufferers with a lethal injection? Who will teach us patience, compassion, unselfish love, endurance, tenderness, and tolerance, if not those who provide us with the opportunity through their suffering, or mental or physical disability? These are character traits not easily learned, though enormously beneficial to society as well as individuals. How will we learn them if we liquidate our teachers?

    (via American Digest.)

    posted by Sydney on 12/12/2004 09:08:00 PM 0 comments

    Childhood Depression: Perhaps its more a cultural illness than a medical illness.
    posted by Sydney on 12/12/2004 09:27:00 AM 0 comments

    Wild Claims: Pfizer has had to pull a TV ad because it suggested the drug can make men horny:

    “Remember that guy who used to be called ’Wild Thing?”’ the ads say as a middle-aged couple shop, looking in the window of a lingerie store. “The guy who wanted to spend the entire honeymoon indoors?” Later, blue horns sprout from the frisky man’s head with “He’s back” written on his forehead. The horns morph into the letter “V” of Viagra.

    Good grief. The FDA was right to have them pull the ad. Viagra doesn't do anything for libido, it just increases the blood flow to the essential organ. You're on your own when it comes to desire.

    posted by Sydney on 12/12/2004 09:24:00 AM 0 comments

    Never Mind: Recently, a group of researchers announced at a conference that oral contraceptives protected their users from the likes of strokes, heart attacks, and cancer later in life. Their oral paper got press-released and published in the newspapers. Now, the researchers who originally gathered the data, but who did not have anything to do with the conference paper, say those findings were wrong:

    Prentice, the chief number cruncher for the health initiative, did not believe it bore out such sweeping conclusions. First of all, the data were collected on women 50-79 years old -- many of whom would have been around 40 when the pill hit the market.

    So he and his colleagues reanalyzed the numbers to verify the Wayne State findings. They found that the association between the pill and a lower incidence of disease was really a factor of age.

    "When you're comparing a 79-year-old women who never used oral contraceptives to a 62-year-old woman who did, the age difference is much more likely to explain things than who used the pill," said Garnet Anderson, a biostatistician at Fred Hutchinson who helped examine the data.

    posted by Sydney on 12/12/2004 09:14:00 AM 0 comments

    Phone Help: Today's newspapers say that Medicare phone lines are horribly inadequate:

    Medicare's toll-free telephone line, one of the federal government's main methods of disseminating information about new prescription drug benefits and drug discount cards, gives accurate answers less than two-thirds of the time, congressional investigators say.

    In a test of the service, investigators from the Government Accountability Office found that 29 percent of callers received inaccurate answers, while 10 percent received no answers at all.

    ..."We found that 6 out of 10 calls were answered accurately, 3 out of 10 calls were answered inaccurately, and we were not able to get a response for 1 out of 10 calls," the report stated.

    In another recent report, the accountability office found that Medicare provided even less accurate information to doctors who inquired about the proper way to bill for treating Medicare patients.

    In response to 300 test calls, the office reported, customer service representatives gave correct and complete responses to only 4 percent of the billing questions. About 54 percent of the answers were simply wrong, and 42 percent were incomplete or partly correct, it said.

    From my experience, that sounds about right. What's more, it's also true of every other insurance company. It just isn't in their best interest to give us the correct answers, and so no effort gets spent to correct the situation. Believe me, they all operate like the insurance company in The Incredibles. So, if Medicare is forced to change its ways, can we get the other insurance companies to change, too?
    posted by Sydney on 12/12/2004 09:10:00 AM 0 comments

    Strange Mascots: The British anti-salt campaign uses a slug to drive home the message to children. (via Cronaca.)
    posted by Sydney on 12/12/2004 08:54:00 AM 0 comments

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