"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
Evolution of influenza A virus is commonly viewed as a typical Darwinian process. In this mode of evolution, the virus’ main surface protein, hemagglutinin (HA), is thought to continually change to evade human immune response, resulting in new dominant strains that eliminate all competitors in a series of rapid successions. Unexpectedly, however, the study found that the periods of intense Darwinian selection accounted for only a relatively small portion of H3N2 flu evolution during the ten-year period examined.
The study found that much of the time the H3N2 virus seemed to be “in stasis”; that is, the HA gene showed no significant excess of mutations in the antigenic regions (those recognized by the immune system). During these stasis periods, none of the co-circulating strains is significantly more fit than others, apparently because multiple mutations are required to substantially improve the virus’ ability to evade the immune system. As a result, an increased variety of strains accumulates. Ultimately, however, one of the variants will come within one mutation of achieving higher fitness and becoming dominant. Once the crucial last mutation does occur, virus evolution shifts from stasis to a brief interval of rapid Darwinian evolution, where the new dominant virus rapidly sweeps through the human population and eliminates most other variants.
Money Can Buy You Anything: One very rich Missouri couple is bankrolling the campaign to make embryonic stem cell researchers a constitutionally protected interest group:
Proponents of Missouri constitutional amendment to protect embryonic stem cell research have broken every record on political spending for statewide races, with one billionaire couple bankrolling nearly all of the $28.7 million campaign.
That total price tag is staggering when compared to even the most expensive campaigns in Missouri history. The stem cell campaign is already more than twice as costly as any campaign for a Missouri ballot measure.
The amount spent by proponents of the stem cell measure is greater that the total spent by all candidates combined in any race to date for statewide office, including governor or U.S. senator.
...More than 97 percent of the money, or $28 million, has come from Jim and Virginia Stowers, founders of American Century mutual funds. After surviving cancer, the two donated more than $1.5 billion to form the Stowers Institute, which seeks to find cures for disease through stem cell research.
The Stowerses have declined interviews throughout the campaign. On Monday, the couple's spokesman described their political spending as an extension of their philanthropy.
"They are cancer survivors who are able to fund research that benefits the whole of Missouri," said David Welte, a Kansas City lawyer who represents the couple.
The hope for a cure is understandable, but about all their money is likely to buy is a good living for embryonic stem cell researchers for years to come. posted by Sydney on
10/28/2006 07:57:00 PM
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Center LeCharles Bentley and free safety Brian Russell were the most recent players stricken in what Browns General Manager Phil Savage on Friday called a ``staph infection outbreak.''
Since 2003, linebacker Ben Taylor, tight end Kellen Winslow Jr. and receiver Braylon Edwards have also contracted forms of staph. All but Taylor's case came in the past 13 months.
The team had an infection control team from the Cleveland Clinic come to their clubhouse to inspect it and help make it bacteria-free. They decided the infections didn't come from the clubhouse, a conclusion with which some people do not agree:
``Something's going on around here,'' Winslow said Friday. ``Other people had it and they need to do something.''
But details of the cases reveal that most of them occurred after having joint surgery. One case was caused by an infected cut. Staph aureus is a bacteria that resides on the skin. That's why it's a common cause of skin infections. There is no way to eliminate it. However, pro sports teams may have something under their feet that invites germs to spread from person to person - artificial grass:
In recent years, the St. Louis Rams and Washington Redskins also have dealt with staph infections. Savage said the Browns have discussed the conversion to Field Turf, which they have in their indoor facility, as a possible factor.
``It's like grass, but a guy sweats and he spits and all that rubberized material is down in there,'' Savage said. ``It's something the high-ups are probably looking into on a leaguewide scale.''
Omaha's tough new anti-smoking ordinance banning the practice in nearly all public places comes with an even tougher enforcement policy.
The Nebraska city's elected leaders and police department are urging residents who see violations to call the 9-1-1 emergency system for an immediate response.
Let's hope they don't miss a robbery or shooting because they're busy arresting smokers. posted by Sydney on
10/23/2006 08:20:00 AM
1 comments
Sunday, October 22, 2006
From the Bodies of Babes: Embryonic stem cells have been coaxed into producing insulin, in the petri dish anyways:
Emmanuel Baetge, the chief scientific officer at Novocell and the senior author of the paper, said the cells were “not fully mature” but rather seemed similar to the beta cells in a human fetus. Those cells also do not respond to glucose, a capability gained after the baby is born.
He said the insulin-producing cells had been derived by taking the embryonic stem cells and adding and subtracting various growth factors in a series of stages that mimicked the process that cells in an embryo go through to become a pancreatic cell. The process takes 16 to 20 days, he said.
Dr. Baetge said that the company hoped to begin testing its cells in animals in 2008 and that if all went well to begin clinical trials in human patients in 2009. Such timeline projections by companies often prove overly optimistic.
In these operations, defects on the nose were reconstructed using skin from the arm, and in some cases, from the arm of another person. But unlike a skin graft where the skin is completely lifted from the distant site of origin, for a brachial rhinoplasty it was required that the arm be left in contact with the face "for the space of ten or fifteen days, or until union had taken place; and it was not until then that the arm was released from its situation." posted by Sydney on
10/22/2006 10:49:00 PM
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Defying the Odds: Normally, when a 102 year old person presents with a surgical condition, the surgeons throw up their hands and say, "Sorry. Nothing to be done. You won't survive the surgery," and the patient is given pain medication to control their pain until the quietly slip away. But not this patient:
A previously healthy 102-year-old woman was admitted with abdominal pain and a 3-day history of vomiting. She lived with relatives, but cared for herself, and was able to garden.... Abdominal radiography revealed dilation of the small bowel... Computed tomography showed an obturator hernia... The hernia was surgically reduced, and an infarcted segment of the small bowel was resected. Postoperatively, despite complications of urinary sepsis and delirium, she recovered well. Twelve months later, she was still living at home, caring for herself, and able to sweep the floor at the age of 103 years.
Israeli Flu Vaccine: Israel halted influenza vaccinations after four people died shortly after receiving them. All four had chronic heart conditions, so it's difficult to say with certainty that the vaccine had anything to do with their deaths, however, three of them were immunized at the same clinic:
One victim was a 67-year-old resident of Petah Tikva who was vaccinated at a Kupat Holim Meuhedet clinic in the city. The others were 52, 70 and 75 years old, and were all residents of Kiryat Gat who were vaccinated at the same Kupat Holim Leumit clinic in their city.
Coincidence? Who can tell? No autopsies were performed. But perhaps it would be prudent to check to see if their immunizations came from the same vial. (There are usually 10 doses in a vial, so if the vaccine was responsible, you would think there would be 10 victims from the same clinic. Unless they used the more expensive single dose vials.)
Paint Me Pretty: In the days before photography, it must have been extremely difficult to find a good likeness of a person. Imagine having to sit still for a portrait, let alone finding a talented artist to render a true likeness. Compare this portrait of Martha Washington to this portrait.
The rich were lucky. They could afford the best artists to render themselves beautiful. (And wouldn't the artist be motivated to show their subjects in the best light so they could get referrals for more paintings from their friends?)
But photography did away with all that conceit. Consider these portraits made at the dawn of photography:
Ulysses S. Grant:
William Tecumseh Sherman: (I don't think the ravages of Civil War made him look this way. The information placard next to the painting in the National Portrait Gallery says that the artist was somewhat intimidated by him at first because of his reputation during the war.)
Song of Himself: Genetic researcher J. Greg Venter is still mapping his DNA, but is close to publishing it in what must be the most complete autobiography ever:
Institute staffers are close to finishing an almost complete readout of Dr. Venter's DNA. The biologist plans to release his genetic code to the world through a computer database, and last week finished a 469-page draft of an autobiography discussing his days as a medic in Vietnam, his two divorces, and what he's found in his DNA. He's chosen the title, "A Life Decoded." posted by Sydney on
10/19/2006 09:49:00 AM
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Questioning the Conventional Wisdom: The Cochrane Group, a very good source of unbiased evidence based medicine, says that mammograms may do more harm than good:
Concerns have been raised that breast cancer screening might lead to some women undergoing unnecessary treatment.
Researchers looked at international studies on half a million women.
They found that for every 2,000 women screened over a decade, one will have her life prolonged, but 10 will have to undergo unnecessary treatment.
My experience has been that the false positives and unnecessary procedures have gone up dramatically since radiologists began to use computers to double-check their mammogram readings. But, my patients never express regret in being over-treated. The dangers of false positives are a tough sell. Most people want everything done just to make sure they're OK and that nothing gets missed. The problem is that those unnecessary procedures cost money. Most of the time, it's the government's or the insurance company's money, so no one cares. Until their premiums or taxes go up. Maybe with each insurance premium increase or tax raise, the public should get an itemized bill explaining exactly why the increases are necessary, and where the money is going.
One Man's Poison: Shocking news today. Medicine is poisonous:
Harmful reactions to some of the most widely used medicines -- from insulin to a common antibiotic -- sent more than 700,000 Americans to emergency rooms each year, landmark government research shows.
Accidental overdoses and allergic reactions to prescription drugs were the most frequent cause of serious illnesses, according to the study, the first to reveal the nationwide scope of the problem. People over 65 faced the greatest risks.
``This is an important study because it reinforces the really substantial risks that there are in everyday use of drugs,'' said patient safety specialist Bruce Lambert, a professor at the University of Illinois at Chicago's college of pharmacy.
Even so, the study authors and other experts agreed that the 700,000 estimate was conservative because bad drug reactions are likely often misdiagnosed.
The study found that a small group of pharmaceutical warhorses were most commonly implicated, including insulin for diabetes; warfarin for clotting problems; and amoxicillin, a penicillin-like antibiotic used for all kinds of infections.
....Those age 65 and older faced more than double the risk of requiring emergency room treatment and were nearly seven times more likely to be admitted to the hospital than younger patients.
This should surprise no one. Every treatment has its risks. Everytime a doctor prescribes a medication, he's weighing the risk of the medicine against the risk of the disease it's treating. That's why we don't lik to prescribe antibiotics for viral infections. Does this mean we should avoid amoxicillin, insulin, and coumadin? No. Amoxicillin made that list because it is the most commonly prescribed antibiotic. Coumadin, which inhibits blood clotting, made the list because it not only has a narrow therapeutic range, but its levels are easily influenced by other drugs and even diet. The dosage that works today may be overkill tomorrow if the diet changes or you take the wrong drug. Unfortunately, the most common use of coumadin is to prevent strokes in elderly people who have atrial fibrillation. It isn't the best age group for the drug since they are more liklely to suffer from polypharmacy not to mention falls. Oh, and the very elderly (over 75), also are intrinsically at greater risk of bleeding to begin with (bleeding ulcers, cerebral hemorrhages, etc.) Studis maintain that the risk of stroke in elderly patients with atrial fibrillation is greater than the risk of bleeding from their anti-coagulant, but I sometimes have my doubts. And insulin? Well, one of the prices we pay for adhering to strict guidelines for diabetes care is that we have more episodes of dangerously low blood sugars.
So, it would seem we have somewhat of a paradox here, does it not? Practicing quality guideline medicine sometimes does more harm than good. It is important, however, to put these numbers into perspective. 700,000 injured people a year is an awful lot of people (it's more than the Iraqi war dead!), but as a percentage of emergency room visits and injuries, it's not so impressive:
Over the 2-year study period, 21,298 adverse drug event cases were reported, producing weighted annual estimates of 701 547 individuals... or 2.4 individuals per 1000 population... treated in emergency departments.
That translates into 0.24% of emergency room patients. They don't tell us how many people turned up in the emergency room with conditions that required treatment with those drugs, but I suspect the percentage of emergency room patients in that time frame who were in need of them drugs was far greater than those harmed by them. posted by Sydney on
10/19/2006 09:15:00 AM
2 comments
Januvia Jazz: There's a new diabetes drug coming our way, Januvia:
Januvia is the first in a new class of diabetes medicine known as DPP-4 inhibitor. The drug works by enhancing the body's own ability to lower blood sugar, or glucose, when it is elevated.
...According to Dr. John Amatruda, vice president of clinical research for Merck, the drug's label will also reflect that its side-effect profile is similar to placebo, or fake pill. Those side effects include runny nose, sore throat, upper respiratory tract infection and diarrhea. Unlike current diabetes drugs on the market, DPP-4 inhibitors don't cause weight gain, which is seen as a major benefit, as the majority of diabetes type 2 patients are already overweight or obese.
"We now have an option for physicians of a new and novel drug which has powerful glucose lowering efficacy without causing many of the side effects of current agents," Amatruda said. "And it can be used both alone and in combination."
Sounds wonderful. It even has its own website, where we get a glimpse of the drug rep talking points:
Approximately twice as many patients got to A1C goal of <7% with JANUVIA
JANUVIA provides powerful A1C lowering through combined reductions of both PPG and FPG throughout the day
Oh, and it will cost $4.86 per tablet.
According to this review, it lowered A1C levels by 1%. So, I'm guessing you can't rely on it to bring a 10 down to a 7.
Its novelty is in its mode of action. It inhibits an enzyme that destroys a class of hormones called incretins. Incretins are produced in the gut in response to eating. They in turn increase the amount of insulin produced by the pancreas. More incretins, more insulin; more insulin, lower blood sugar levels- especially after eating. We already have a drug that acts by pretending to be an incretin. It's called Byetta, and it comes from Gila monster spit. Its disadvantages are that it is a shot, and that it causes nausea. Advantage Januvia for being a pill, for having no more nausea than a placebo, and for working by enhancing the body's own incretin levels. Now we just have to hope those DPP-4 enzymes don't have any other important functions we aren't aware of. It's the long-term, unkown side effects you have to be wary of.
That Lancet Article: A survey researcher says that the Lancet's Iraqi death toll research is bogus, and explains just where the researchers deviated from the standards. Most shocking is his interaction with the lead researcher:
Curious about the kind of people who would have the chutzpah to claim to a national audience that this kind of research was methodologically sound, I contacted Johns Hopkins University and was referred to Les Roberts, one of the primary authors of the study. Dr. Roberts defended his 47 cluster points, saying that this was standard. I'm not sure whose standards these are.
Appendix A of the Johns Hopkins survey, for example, cites several other studies of mortality in war zones, and uses the citations to validate the group's use of cluster sampling. One study is by the International Rescue Committee in the Democratic Republic of Congo, which used 750 cluster points. Harvard's School of Public Health, in a 1992 survey of Iraq, used 271 cluster points. Another study in Kosovo cites the use of 50 cluster points, but this was for a population of just 1.6 million, compared to Iraq's 27 million.
When I pointed out these numbers to Dr. Roberts, he said that the appendices were written by a student and should be ignored. Which led me to wonder what other sections of the survey should be ignored.
It's the student's fault! Isn't it always?
With so few cluster points, it is highly unlikely the Johns Hopkins survey is representative of the population in Iraq. However, there is a definitive method of establishing if it is. Recording the gender, age, education and other demographic characteristics of the respondents allows a researcher to compare his survey results to a known demographic instrument, such as a census.
Dr. Roberts said that his team's surveyors did not ask demographic questions. I was so surprised to hear this that I emailed him later in the day to ask a second time if his team asked demographic questions and compared the results to the 1997 Iraqi census. Dr. Roberts replied that he had not even looked at the Iraqi census.
And so, while the gender and the age of the deceased were recorded in the 2006 Johns Hopkins study, nobody, according to Dr. Roberts, recorded demographic information for the living survey respondents. This would be the first survey I have looked at in my 15 years of looking that did not ask demographic questions of its respondents. But don't take my word for it--try using Google to find a survey that does not ask demographic questions.
Either Dr. Roberts and his colleagues didn't know how to set up a research survey correctly or they set it up deliberately to be inaccurate, knowing that few in the media or general public would know enough to challenge them. Or maybe they let the student design and carry out the whole study without supervision. Either way, it reflects badly on them.
(By the way, my original post has been updated a few times with more links to questions about the survey.)
UPDATE: More interesting background on the lead researcher, Dr. Les Roberts, via Tim Blair- he's a very active Democrat. Not that there's anything wrong with being a Democrat. It's just that it raises suspicion about the motives of both his methods and his timing in its publication. Wouldn't it be a different story altogether if the headline were not "Public Health Researcher Estimates Iraqi Death Toll at 650,000" but "Democratic Office Seeker Estimates Iraqi Death Toll..."?
UPDATE II: Beware of politicians (and public health types) preaching morals.
Burnham: This was a ‘cohort’ study, which means we compared household deaths after the invasion with deaths before the invasion in the same households. The death rates for these comparison households was 5.5/1000/yr.
What we did find for the households as a pre-invasion death rate was essential the same number as we found in 2004, the same number as the CIA gives and the estimate for Iraq by the US Census Bureau.
Death rates are a function of many things—not just health of the population. One of the most important factors in the death rate is the number of elderly in the population. Iraq has few, and a death rate of 5.5/1000/yr in our calculation (5.3 for the CIA), the USA is 8 and Sweden is 11. This is an indication of how important the population structures are in determining death rates. (You might Google ‘population pyramid’ and look at the census bureau site—fascinating stuff.)
PajamasMedia: During the same period, Iraq is at war with Iran and itself. Public-health infrastructure was poor, although perhaps not as poor as today. Does it seem plausible to you that the baseline (or pre-war) mortality rate is accurate?
Burnham: Yes as above. Yes as being the right number, and Yes as what we need it for—comparisons in the same households before the war.
Not to mention when entire families are wiped out by a totalitarian government, no one is left to tell the tale.
PajamasMedia: The Lancet Study comes up with a post-war mortality rate almost double that Saddam’s Iraq. In fact, it is roughly equivalent to the mortality rate in Hungary is 13/1000. Does that rate seem plausible, given Hungary’s superior infrastructure and almost 50 continous years of peace? Is it possible that both the pre- and post-war mortality rates are too low? Why not?
Burnham: There are many old people in Hungary , 40% are over age 55 vs. 9.3% in Iraq over 55. That’s the difference.
Doesn't 9.3% sound like an awfully small percentage? What happened to all of those Iraqis who would be in late middle age and old age now? Did they emigrate? Or did something more nefarious happen to them?
PajamasMedia: Historical comparisons might be helpful here. 650,000 violent deaths is about 150,000 more than the number of soldiers who died (violently and by disease) during the American Civil War, a conflict which involved a population larger than Iraq’s, and lasted a year than the current conflict has been going on. There is nothing in Iraq that looks like Shiloh, Antietam, Gettysburg, Cold Harbor, etc. What makes you believe that Iraq is deadlier than the American Civil War?
Burnham: What we are reporting is cumulative deaths over a 40 month period throughout an area of 26.1 million, not a 1-2 day battle field event.
Maybe he was tired or rushed when he read that question, but he certainly didn't answer it. posted by Sydney on
10/18/2006 06:16:00 AM
2 comments
Preparedness Preparations A town in Maryland has made their flu shot campaign a biodisaster drill:
In addition to helping people prepare for the flu season, the clinic was a drill, of sorts, designed to prepare county agencies to distribute medications or vaccines in the case of a large-scale medical emergency such as a pandemic influenza outbreak or bioterrorism attack.
The clinic marked the beginning of the county's second annual Community Readiness Week. It was held on Columbia Gateway Drive, a loop of road about two-thirds of a mile long that was closed off for the day - except for the customers, who coughed up as much as $20 a dose.
As vaccine seekers made their way around the loop, they stopped at various stations to sign consent forms, pay and get their shot or nasal mist - all without setting foot outside their cars. The process from signing to shots or spray took up to an hour and a half, some of the freshly vaccinated said before driving away.
Every 20th vehicle car received a bonus - an emergency-readiness kit that included flashlights, hand-cranked radios and antibiotic hand wipes.
....Borenstein, wearing a vest that read "Incident Commander," ran the event with help from police, fire, public works and emergency management officials. From a command center in the Howard County Health Department in the Columbia Gateway complex, she monitored the flow of traffic on television monitors fed by video cameras at each of the stations.
As different stations backed up throughout the day, Borenstein used hand-held radios to shuffle volunteers around and keep the flow of cars moving steadily.
"This is the perfect exercise for us," said Chief Joseph A. Herr of Howard's Fire and Rescue Services. "Part of the problem is how do we handle large numbers of people."
At the end of the clinic, the county had vaccinated people at rate of about 362 an hour.
Speaking Out: The American Heart Association guidelines that suggest pushing cholesterol down to the lowest possible values should be standard of care has come under much needed scrutiny:
Until 2004, an LDL cholesterol level of less than 130 milligrams a deciliter was considered low enough. But the updated guidelines recommend that high-risk patients reduce their level even more — to less than 100 — while patients at very high risk are given “the option” of reducing LDL cholesterol to less than 70. Patients often have to take more than one cholesterol-lowering drug to achieve those targets.
Except that it has quickly gone from being an "option" to being a mandate, at least among cardiologists. I routinely get scolding letters from cardiologists for not adding more drugs to my patients already complicated regimens to achieve LDL levels of less than 70. I have to agree with the authors of the review:
“This paper is not arguing that there is strong evidence against the LDL targets, but rather that there’s no evidence for them,” said Dr. Rodney A. Hayward, a study author, adding that this was largely because of the way clinical trials had been devised and carried out.
“If you’re going to say, ‘Take two or three drugs to get to these levels,’ you need to know you’re doing more benefit than harm,” said Dr. Hayward, who is director of the Veterans Affairs Center for Health Services Research and Development and a professor at the University of Michigan Medical School. He said he was particularly concerned because there was little long-term safety data about the drug combinations used to lower cholesterol.
The review is really a critique of the evidence used by the National Cholesterol Education Program Adult Treatment Panel III when they issued their guidelines. The crux of the argument in favor of chasing LDL levels to less than 70 amounts to this:
Recent clinical trials nonetheless have documented ... that for every 1% reduction in LDL-C [low-density lipoprotein cholesterol] levels, relative risk for major CHD [coronary heart disease] events is reduced by approximately 1%. HPS [Heart Protection Study] data suggest that this relationship holds for LDL-C levels even below 100 mg/dL [2.59 mmol/L].
The authors of the review then proceed to demolish every "recent clinical trial" cited by the NCEP. In addition, they fail to find any other trials that support the conclusion. Instead, they find diminishing with ever lower levels, "just as when a piece of paper is serially torn in half and half is thrown away, the halves that are thrown away get smaller and smaller."
They also point out that the studies compare patients who reached LDL levels of <70 to all those who did not reach that level. The problem is that the "all those who did not" is a very wide and ranging category - from people who are just a few units away from the goal (and thus at smaller risk) to those who are a hundred units away (and at higher risk of having heart disease):
In medicine, modest deviations from "ideal" levels (for example, a hemoglobin A1c level of 7.5% vs. a goal of <7% or a sodium level of 132 mmol/L vs. a goal of 135 to 145 mmol/L) often result in trivial risk. Marked deviations from treatment targets, however, are often associated with dramatic and often logarithmic increases in risk. In fact, a recent report from the Framingham Heart Study suggested that this is true for a variety of cardiovascular risk factors, including cholesterol levels. If the only comparison made is between those who reach the strict goal and all others, we can mistakenly think that not achieving the treatment goal results in moderate risk when almost all of the risk is caused by more substantial deviations from the goal.
And finally, thankfully, they address the downsides of treatment. Every treatment has its risks and cholesterol lowering drugs are no different:
The articles we reviewed often advocated for tight LDL cholesterol goals without discussing possible risks, patient burden, and societal costs associated with the treatments needed to reach those goals. This is particularly important because achieving moderate clinical control is often easy whereas achieving the ideal goal often requires substantial costs and patient burden, such as polypharmacy. Many treatments also carry at least some risk for harm. Therefore, failure to recognize this phenomenon can result in promoting unsafe treatment recommendations for those with small to moderate deviations from the proposed treatment goal.
Which is exactly what medicine has been doing for the past several years, not only in cholesterol management, but in diabetes management and hypertension management.
P.S. The review is also a very good lesson in how to interpret studies critically. It could be a template for a class in critical reading of research papers.
Why I Hate Insurance Companies: Saw a new patient a while back. Had no complaints, that's exactly what she said, "I don't really have any complaints," but she did want to stop smoking. So we talked about it and she left with a prescription for a smoking cessation drug. Got a call today, very irate, says I should have charged her for something other than smoking cessation, like the rotator cuff problem she mentioned. Yes, it's true, that was mentioned, in the context of "things that have been wrong" otherwise known as the past medical history. No need for treatment, an orthopedist was taking care of it. So where did she get the idea that I should have charged her for something I didn't address? Her friendly insurance company representative who not only told her I not only should have charged for some other service, but that she "couldn't believe a doctor would be dumb enough to bill for smoking cessation." There's a name for billing for something you don't do. We call it fraud. Do those insurance companies even bother to train their customer reps? Grrrr. posted by Sydney on
10/17/2006 06:52:00 PM
4 comments
Monday, October 16, 2006
So Much for those Billions: United Healthcare's billionaire doctor CEO has been caught up in the stock options scandals:
The stock options scandal claimed its biggest corporate chief Sunday, with UnitedHealth Group Inc. saying Chairman and Chief Executive Officer William McGuire would step down because an outside report found that his option grants "were likely backdated."
...The report by a firm hired by the company's board said McGuire's huge awards of stock options got a boost because they were issued on one day but priced as if they'd been issued earlier, when the stock price was lower.
Saintly Miracles: We have a new saint today with American connections - Mother Theodore Guerin, the hierarchy defying French nun who brought Catholic religious education to Indiana. Here are her miracles:
In 1908, Sister Mary Theodosia Mug was ailing from a crippled arm and breast cancer when she prayed over Mother Theodore's crypt under the Sisters of Providence church. Just hours later, her symptoms subsided; she lived an additional 35 years and died a natural death.
Nearly a century later, in 2001, Sisters of Providence employee Phil McCord prayed in the congregation's church after it appeared he was headed for a cornea transplant. The non-Catholic says he offered a mention of Mother Theodore in the hopes that she would put a good word in to "the big guy" for him. Because of McCord's prayers or for some other reason, the swelling in his eye quickly lessened, as well as his need for a transplant.
In the end, he had some scar tissue around his eye removed and now has 20/20 vision. His physicians have been unable to explain the healing.
"I'm not a theologian. I don't understand all of the implications of what happened to me or how they determine it to be a miracle," McCord said this year. "I just leave it to those who are more learned in that area. All I know is that it's my story. I'm sticking to it."
It's hard to say whether that was an infection or breast cancer in 1908, but that last miracle is a modern one. According to this report, the corneal scarring was a result of cataract surgery. There's no interview with the doctors, but here's the patient's account:
While his left eye responded to surgery, a subsequent operation on his right eye caused its cornea to swell. Drops and medicine did not help. McCord could see only lights and shapes out of that eye.
A specialist in Indianapolis confirmed what McCord's local physician said: He needed a corneal transplant.
A cornea harvested from a cadaver would be sewn into place. Recovery might take one to two years. Surgery had a 60 percent to 70 percent chance of success.
All this preyed on McCord's mind one fall day in 2000 as he walked across campus to his office.
He heard beautiful music coming from the church, where the organist was practicing. He slipped inside to gather his thoughts.
"I had really no intention of going in and praying or anything. It just sort of evolved ...," he says. "I finally got to the point when I went, 'OK, God, if you're listening ...' "
Raised a Baptist and the son of a lay minister, McCord is a "believer" but not a churchgoer. He became comfortable with Roman Catholic worship after being exposed to it through work, and occasionally would stop by the church to think. This day he remembered that Catholics sometimes call on people to intercede.
"It suddenly occurred to me that maybe Mother Theodore was listening. She always had a soft spot for employees," he says. "I thought, 'Well, what can it hurt?' "
A 15- to 20-minute rambling conversation ended with, "Well, OK, anyway, if you can help me get through this, guys, I will be really grateful."
McCord sat in the now-quiet church for a while longer, and gradually felt better.
When he left, his prayer for strength had been answered.
McCord woke up the next morning with less heaviness in his eye. A check in the mirror showed less irritation. His eyelid wasn't as droopy.
Returning to the specialist about two weeks later, McCord told the doctor that, while it may be wishful thinking, he thought his eye was better.
Looking from McCord's eye to a medical chart, the doctor said only "Hmmm."
"Hmmm what?"
The specialist asked what the local physician had done.
"He didn't do anything. I haven't seen him."
"Oh. So what did you do?"
"What can I do? Well, I said a prayer."
"Oh. OK. All right. Well, you're right. Your eye is better."
A corneal transplant was not needed.
"Hurray! I'm saved!" he thought.
Again, there's no interview with the doctor, and no timeline for the post-op injury and its recovery, so it's hard to assess if this is a miracle, or a result of a tincture of time, which itself can heal corneal edema. At any rate, it's nice to have a little ecumenical miracle in these religiously divided times. posted by Sydney on
10/15/2006 06:21:00 PM
1 comments
Old Fashioned Medicine: Once upon a time, general practitioners used to perform minor surgeries such as hernia repairs, appendectomies and tonsillectomies at their home offices or in the patient's home. That was before surgery and anesthesiology became the sophisticated specialties that they are today. Yesterday is today at England's National Health Service:
Minor surgery such as hernia repairs and varicose vein removal will be carried out in family doctors’ surgeries instead of in hospitals under plans to be announced by Patricia Hewitt, the health secretary, this week.
Ministers believe that up to half of the 45m hospital outpatient appointments can be dealt with by GPs and nurses in local health centres. It will save the National Health Service money by freeing up hospital beds which cost about £300 a day. Ministers say surgery in local health centres will make better use of highly trained GPs and be more convenient for patients.
Lord Warner, the minister for NHS reform, said: “The rationale behind providing care closer to home is to make better use of highly specialist skills . . . this will involve (having) GPs who are as skilled with the scalpel as they are with the stethoscope.”
Dr. Crippen is not amused. Nor would I be. Will they hold in-office surgeries to the same standards as in-hospital surgeries? How many GP's possess surgical skills and knowledge? Few in this day and age I imagine. But, that's what happens when politicians dictate the practice of medicine.
Counterfeit Alert: There are counterfeit glucometer test strips on the loose, according to the FDA. The test strips are the little blood collecting-sensing strips that go into the small computers that diabetics use to check their blood sugar at home. They are quite expensive - about one dollar per strip in these parts. Does it matter if they're counterfeit? A counterfeit strip may not be as accurate since each strip is designed to work with a specific type of glucometer. I know when I once bought the wrong type of test strip, I had trouble calibrating the glucometer with them. They just didn't work. So, if you're a diabetic, you might want to check the lot numbers of your strips and compare to those on the alert website in the first link.
1. The test strip is preferably a porous membrane in the form of a non-woven, a woven fabric, a stretched sheet, or prepared from a material such as polyester, polyamide, polyolefin, polysulfone, or cellulose. 2. A test strip is manufactured by mixing 40 g of an anionically stabilized (3.8 parts by weight sodium lauryl sulfate and 0.8 parts by weight dodecyl benzene sulfonic acid) water-based hydroxyl elastomer, containing about 5% by weight colloidal silica and 5 g of finely ground titanium dioxide. Then I g of tetramethylbenzidine, 5,000 units horseradish peroxidase, 5,000 units glucose oxidase, 0.12 g tris, and 10 g of water (hydroxymethyl) aminomethane (buffer) are mixed into the batch. 3. After mixing to ensure a homogeneous blend, the batch is cast onto a polyethylene terephthalate sheet for added structural integrity in a carrier matrix, and dried at 122°F (50°C) for 20 minutes. 4. Next, 100 mg of 3-dimethyl amino benzoic acid, 13 mg of 3-methyl-2-benzothiazolinone hydrazone, 100 mg of citric acid monohydrate-sodium citrate dihydrate, and 50 mg of Loval are added in dry form to a 50 ml tube. 5. These dry materials are mixed with a spatula, then 1.5 g of 10% water solution of carboxymethylcellulose is added and mixed thoroughly with the above solids. 6. Next, 2.1 g of dialyzed carboxylated vinyl acetate ethyl copolymer latex is added and thoroughly mixed.
The latex copolymer had been dialyzed (separation of larger particles from smaller particles) by placing about 100 g of carboxylated vinyl acetate/ethylene copolymer emulsion into a membrane tubing. The filled membrane was soaked in a water (distilled) bath at 68°F (20°C) for 60 hours to allow low molecular weight particles, unreacted monomer, catalyst, surfactant, etc. to pass through the membrane. During the 60 hours the water was continuously changed using an overflow system. The remaining dialyzed emulsion was then used in preparing the reagent layer. 7. Then 0.18 ml of glucose oxidase is pippeted to the tube as a liquid. Next, peroxidase is pipeted as a liquid to the tube and tartrazine is pipeted to the tube. The resulting mixture is mixed thoroughly. This mixture is allowed to stand for approximately 15 minutes. 8. A polished-matte vinyl support prior to being coated with the above solution was cut to form cell rows and then wiped clean with methanol. The mixture is pulled into a 10 ml syringe and approximately 10, 6 mm drops are placed on each cell row. The coated cell row is heated in an oven at 98.6°F (37°C) for 30 minutes followed by 113°F (45°C) for two hours. This process of coating and spreading the mixture is repeated for each cell row. The cell rows were then cut into strips of the desired size. 9. These strips were packaged with absorbent packs of silica gel and dried overnight at approximately 86°F (30°C) and 25 mm/Hg vacuum.
Just Wondering: If everyone pays the same price per vial for the influenza vaccine and the needles and syringes with which to adminster them, why do reimbursement rates vary so much - $14 in Puerto Rico vs. $25 in San Francisco? (And I believe everyone does pay the same price, although those in Puerto Rico may have to pay more in shipping. The manufacturer's and distributors don't ask where you live before telling you the price.) posted by Sydney on
10/13/2006 07:43:00 PM
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And Then They Stuck Me Seven More Times and Dug the Needle Around in My Skin: That's the most common complaint I hear about having blood drawn. But here's a vein mapping machine that makes the first time a charm:
The Vein Viewer is a 5-foot-tall mobile machine with a computer at its base that locates subcutaneous veins and projects their images onto the surface of the skin, using infrared light.
Rainbow says it is the first hospital in the Great Lakes region to use the Vein Viewer, made by Memphis-based Luminetx. "Our goal, right now, is one stick in the [blood] vessel," Deptola said. "It doesn't always happen the first time because the vein blows or you just can't find it. With the Vein Viewer we want to improve our record to 100 percent on the first try."
Knowing that finding another source of light was the lynch pin to this challenge, ML scientists developed the vein viewer device, which uses night vision goggles (NVGs) equipped with special filters, developed by the Air Force, to see infrared light as it passes through a patient’s body. During initial experiments, using a TV remote control infrared light source and standard military NVGs, ML scientists realized that they could clearly see infrared light as it was partially blocked by blood in veins. This provided users a clear view of the network of veins in fingers, hands, lower arms, and feet. Their research showed that this capability to view veins was due to the absorption of infrared light by deoxygenated hemoglobin traveling in veins, while bone, muscle and other tissue transmit or scatter the infrared light rather than absorbing it. Additional experiments proved that a needle beneath the skin would also be visible because metal blocks infrared light.
Natural Hazards: The source of the spinach E.coli contamination might be the cows next door:
The strain of pathogenic E. coli O157:H7 was found in three cattle fecal samples collected at one of four ranches under investigation, the officials said. The ranch is within a mile of produce fields.
....But Reilly said investigators don't have a "smoking cow" and cannot say for certain whether the cattle tested were indeed the source of the contamination.
Cows do produce a prodigious amount of manure. And with rain and run-off, it isn't hard to imagine the E. coli strain getting into the irrigation water. posted by Sydney on
10/13/2006 04:22:00 PM
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About one in four doctors use some form of electronic health records, suggesting that a technology frequently billed as a way to improve the quality and efficiency of care has yet to win widespread acceptance, according to a study released yesterday.
Fewer than 1 in 10 use such records in the most effective way -- as part of a system that collects patient information, displays test results, helps doctors make treatment decisions and allows health-care providers to document prescriptions and medical orders electronically, the study found.
This is why:
Researchers attributed the slow adoption rates to the expense of the systems and the disruption they cause initially, forcing doctors to change the way they work.
"There is very compelling evidence that at the end of the day, once you have good implementation and you're done, your systems work better," Jha said. "But getting there is not easy, and both the financial and disruptive elements have held a lot of doctors and hospitals back from taking this on."
They are expensive. A complete system - that integrates billing, e-prescribing, records, and tech support can cost anywhere from $20,000 to $50,000 per physician. And that doesn't count the hardward. And yes, it is very stressful for all concerned to make the switch. Some staff members and doctors are never able to fully make the switch and end up having to be replaced. (Well, the staff members anyway. ) My electronic medical record is a very basic and simple one, yet when one of my staff members is gone and I have to have a temp in their place who isn't familiar with the system, it slows down the office so much that I often think it would have been better to just close it down for the day or week and save myself the wages.
There are other obstacles as well, which boil down to regional trends. In Ohio, for example, the state pharmacy board has decided to make it difficult to send prescriptions electronically. Physicians must purchase a pharmacy board approved electronic medical record in order to send prescriptions. Many of the top electronic record programs are not on the list. That 's an obstacle that elminates one of the greatest incentives for electronic records.
Also, in many regions, hospitals are emerging as the dominant forces in selection of electronic records systems. They're seeking to have integrated networks in which everyone in the community (or hospital community anyways) uses the same hospital-based electronic record. That means that each doctor's medical records are housed on the hospital's servers and that everyone in the hospital (or at least every doctor in the hospital and probably lots of administrators) has access to them. Some doctors embrace this idea, but others are leary of having their patient records owned and controlled by someone else. Many are waiting to see how this shakes out. No one wants to invest tens of thousands of dollars in a system only to have it prove to be useless when community standard becomes a hospital-approved and sponsored record. Nor do they want to jump into a hospital partnership that could go south in a couple of years if it proves too much of a financial burden for the hospital. posted by Sydney on
10/13/2006 08:45:00 AM
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Public Health Gone Amok: The non-raison d'etre of the trans-fat ban :
Well, in this new age of public health, authorities are using regulation to try to curb chronic diseases such as heart ailments, diabetes and cancer -- much the way they did decades ago to wipe out infectious disease by mandating inoculations, chlorinating water and making such diseases reportable to the government.
The problem is that chronic diseases are primarily linked to lifestyle factors -- and government intervention into people's lifestyles is not only intrusive, it simply won't work.
That is, the Board of Health is acting as if TFAs were an imminent health threat -- like E.coli in spinach. They're not.
Second, as the hyperbole about TFAs has escalated -- New York Times columnist Nicholas Kristof recently claimed, absurdly, that TFAs in Girl Scout cookies have killed more Americans than al Qaeda -- physicians and scientists have largely remained mute on the topic. Silence is interpreted as agreement -- and the momentum for bans builds.
Third, the food industry has turned the fear of TFAs into a brilliant marketing strategy -- trumpeting the "No Trans Fats" claim on labels. Unsuspecting customers will conclude the products are healthier -- and maybe even think they are reduced in calories -- when in fact there are no health benefits. In fact, all fats, saturated or not, contain 9 calories per gram. There are no caloric savings from replacing TFAs with other fats. posted by Sydney on
10/13/2006 08:26:00 AM
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Wednesday, October 11, 2006
Lancet Strikes Again: I admit, this headline caught my eye. 655,000 dead in Iraq is an impressive number. Then I read the first sentence and saw that the number was gathered by public health researchers and it lost some credibility. The American public health community has a decidedly left leaning cast to it. It is more politically homogenous than any other medical specialty. How homogenous are they? Well, you won't find statements like this on the website of any other medical speciality. One is obliged to assume that the researchers started with a bias.
Then I read that it was published in The Lancet and I lost all interest. This is the journal that gave us the infamous MMR-causes-autism study and that published a similarly discredited tally of Iraqi casualities before the last American election. In the ranks of medical journals, I place them on a par with The Guardian.
Robert Blendon, director of the Harvard Program on Public Opinion and Health and Social Policy, said interviewing urban dwellers chosen at random was “the best of what you can expect in a war zone.”
But he said the number of deaths in the families interviewed — 547 in the post-invasion period versus 82 in a similar period before the invasion — was too few to extrapolate up to more than 600,000 deaths across the country.
Donald Berry, chairman of biostatistics at M. D. Anderson Cancer Center in Houston, was even more troubled by the study, which he said had “a tone of accuracy that’s just inappropriate.”
Kudos to the two New York Times reporters for taking the time to run the study by a couple of statisticians.
And neither does Michael E. O'Hanlon of the Brookings Institution, which also tracks Iraqi deaths.
"I do not believe the new numbers. I think they're way off," he said.
Other research methods on the ground, like body counts, forensic analysis and taking eyewitness reports, have produced numbers only about one-tenth as high, he said. "I have a hard time seeing how all the direct evidence could be that far off ... therefore I think the survey data is probably what's wrong."
The full survey is here. The researchers spent two months canvassing households in various regions of Iraq asking about deaths in the family. Sometimes they were able to confirm the reports with death certificates, sometimes they weren't. They didn't ask if the dead were combatants or non-combatants. They were afraid to ask that question. Afraid for themselves and for those they were asking. They interviewed 40 households in each of their selected regions, then extrapolated the 600,000 figure from the number of deaths they had recorded in their interviews. The margin of error of +/-200,000 speaks for itself. It's not reliable.
And sorry, but the defense that it's as soundly designed as can be expected for these kinds of public health surveys is a weak one. Retrospective, interview-based studies like this are poor designs. It may be the standard way of gathering data in the public health field, but that doesn't make it the best methodology, and it certainly doesn't make its statistics sound. For too long the field of public health has relied on these types of shotty shoddy numbers to influence public policy, whether it's the number of people who die from second hand smoke or the number who die from eating the wrong kinds of cooking oils.
I wonder if that research team was willing to go to North Korea or Libya and I think they wouldn’t have the guts to dare ask Saddam to let them in and investigate deaths under his regime.
No, they would’ve shit their pants the moment they set foot in Iraq and they would find themselves surrounded by the Mukhabarat men counting their breaths. However, maybe they would have the chance to receive a gift from the tyrant in exchange for painting a rosy picture about his rule.
They shamelessly made an auction of our blood, and it didn’t make a difference if the blood was shed by a bomb or a bullet or a heart attack because the bigger the count the more useful it becomes to attack this or that policy in a political race and the more useful it becomes in cheerleading for murderous tyrannical regimes.
UPDATE: From Dani in the comments section, the editor of The Lancet, expressing his opinion, to which he is certainly entitled. However, his obvious passion (is it necessary to shout when using a microphone?) casts more than a shadow of doubt on his ability to be unbiased in selecting articles for publication that cover the same topic.
Spending on Medicaid, a state-federal partnership, rose by an average of just 2.8 percent in fiscal year 2006, the lowest rate in a decade. Meanwhile, state revenues increased at a 3.7 percent clip.
That's good news for patients, who could see more services covered, and for health care providers, who could conceivably get a raise, according to officials from the Kaiser Family Foundation.
The lettuce has been cleared, but Mexico still won't allow it across the border, which has some politicians steaming:
"Mexico telling us that they are not going to eat our lettuce because of possible water contamination would be like the United States banning tourism in Mexico," said Rep. Sam Farr, D-Carmel, referring to diarrhea travelers sometimes experience in Mexico as a result of the country's water. "What are they thinking?"
Severe forms of the itchy skin condition, psoriasis, should be considered a risk factor for heart attack, a new study suggests. Researchers who studied medical records for more than 680,000 British patients found that people in their 40s with severe psoriasis were more than twice as likely to suffer a heart attack than people without the skin disease.
...Based on their findings, the researchers predict that 1 out of 623 people with severe psoriasis in their 40s will have a heart attack related to their psoriasis each year, Gelfand said. For mild cases, 1 in 3,646 people in their 40s would have a heart attack each year.
Those are the first and last paragraphs of the newspaper article. Here's a caveat from the center:
People with psoriasis are more likely to smoke and to have diabetes, high blood pressure and high cholesterol. But the researchers found that even when they took those risk factors into account, psoriasis still increased the risk of heart attack.
....Dr. William Weintraub, a cardiologist and research director at Christiana Care Health System in Newark, Del., questioned the study's importance for patients.
"Severe psoriasis is relatively uncommon, and the risk for heart attack with mild psoriasis is relatively minor," said Weintraub, who was not involved in the study.
The study defined severe psoriasis as any case that required the use of oral medication for the disease. Mild psoriasis was defined as those cases only requiring topical medications. That's not an extremely stringent definition. Some people with mild psoriasis opt for systemic therapy because they can't stand their disease while others with severe psoriasis forego it because they fear the side effects. And how do they know the difference in heart attack rates isn't due to the treatment, rather than the disease? At any rate, the differences in heart attack rates was not that impressive between groups, whether or not they had any sort of psoriasis:
There were 11 194 MIs (2.0%) within the control population and 2319 (1.8%) and 112 (2.9%) MIs within the mild and severe psoriasis groups, respectively.
A discussion in the current Journal of Medical Ethics shows that there is a growing interest in using their bodies for medical experiments. They would be especially useful in studying the long-term effects of transplanting animal organs. The patients often survive for years, and if a virus affected their brains or other vital organs, very little harm would be done.
Some bioethicists have even contended that PVS patients are actually dead and can be treated as cadavers.
The ethicists apparently suffer the same confusion the media suffer when it comes to the definition of persistent vegetative state. It is not brain death. I've detailed the ambiguous nature of its definition before, and recent events in South Africa suggest that in many cases (up to 60% in one man's practice) it's neither persistent nor completely vegetative.
Yet, in their journal, two of the four papers on the topic use the term "living dead" to refer to these patients. What a neat turn of phrase. It not only misrepresents their pathology, but it robs them of their humanity and turns them into the equivalent of monster movie zombies. posted by Sydney on
10/08/2006 11:25:00 PM
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Saturday, October 07, 2006
Beware the Baracuda: Think twice before eating the shark or barracuda fillets, especially if they were caught off oil rigs. They might bear ciguatera fish poisoning:
The condition is caused by eating fish containing toxins produced by the dinoflagellate Gambierdiscus toxicus, a one-celled plantlike organism that grows on algae in tropical waters worldwide. Because these toxins are lipid soluble, they accumulate through the food chain as carnivorous fish consume contaminated herbivorous reef fish; toxin concentrations are highest in large, predatory fish such as barracuda, grouper, amberjack, snapper, and shark. Because fish caught in ciguatera-endemic areas are shipped nationwide, ciguatera fish poisoning can occur anywhere in the United States.
What does it do? Besides causing vomiting and diarrhea, it makes the hot feel cold and the cold feel hot. That must be a strange, strange feeling. posted by Sydney on
10/07/2006 10:40:00 PM
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When asked what choices they would make if they could complete their education again, only 37.6% indicated they would choose primary care. Over one-third (33.8%) indicated they would choose a surgical or diagnostic specialty, while 28.6% indicated they would not choose to go into medicine at all.
This is sad. No wonder the number of medical students entering primary care is down. If the doctors they meet in the course of their training are so obviously unhappy, you can't expect them to chose the field. posted by Sydney on
10/07/2006 10:04:00 PM
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Misunderestimating the U.S.: That shameful infant mortality rate of ours, which is so often used as a stick with which to beat us into admitting we are an inferior nation, turns out to owe much to preterm infant deaths - even more so than previously thought:
Callaghan and other researchers examined birth and death certificates for about 28,000 U.S. infants that died in 2002.
About 4,600 of those - or 17 percent - were attributed only to preterm birth. But the researchers also grouped in more than 5,700 other deaths that were attributed to preterm-related conditions including respiratory distress syndrome, brain hemorrhage and maternal complications such as premature rupture of membranes.
In that counting, nearly 9,600 births - or 34 percent - could be classified as preterm, Callaghan said.
The researchers believe that figure is conservative and likely underestimates the true picture.
Experts have generally understood the burden of preterm birth on infant deaths, but the new study sorts out the data and provides specific numbers, said Carol Hogue, an Emory University professor of maternal and child health.
The Eyes are Upon You: Sometimes, when a new patient comes to the office asking for drugs of potential abuse, you get a feeling that they aren't legitimate, but have no way of proving it. They may say they're visitng family and pulled their back out while lifting the suitcase, or that their insurance changed and they had to find a new doctor, and doggone it, they're out of their prescription amphetamine for their adult ADD. It's hard to deny them their request based on a gut feeling that they're lying. Short of saying, "Sorry, I think you're lying," which, of course, opens a whole 'nother can of worms, the doctor is stuck. In Ohio, that situation will soon have a new out:
About 2,300 retail and mail-order pharmacies that sell to Ohio patients will be required to electronically report prescription sales twice a month to create the database, which has the ability to store 30 million to 35 million prescriptions.
Doctors and pharmacists then will be able to get a report via the Internet to see if patients are visiting multiple physicians and pharmacies to obtain the same types of drugs - commonly called doctor shopping. And law enforcement will be more easily able to uncover criminal activity.
I recently discovered that one of my suspected liars was indeed lying when her insurance company sent me a profile showing she had been going to other doctors in my neighborhood every two weeks for the same drug. I began to suspect her when she stopped by two weeks after her initial visit and said she needed her Adderall refilled two weeks early because she was going to Myrtle Beach and wouldn't be in town when it ran out. I told her she didn't need to worry about treating attention deficit disorder while lying on a beach. It would be OK if she missed a few doses. It would have been nice to be able to look her up during her initial visit when she requested refills to begin with.
Now that they have their database, will they ease up on letting doctors send prescriptions to the pharmacy electronically? posted by Sydney on
10/04/2006 07:38:00 PM
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Breastfeeding Wars: Ann Althouse notes a story that isn't critical of breastfeeding, but just doesn't affirm one of it's theoretical benefits, and gets slammed in her comments section. What is it about breastfeeding that brings out the worst in people? One of her commenters has the answer:
All of these parenting issues, not just breastfeeding, seem to bring out the cattiness. I suppose it's because most of us feel a little insecure about what we're doing and so we get defensive if someone makes a different choice. Breastfeeding is probably just the most noticeable because it is more visible than some other parenting choices.
(And yes, I'm breastfeeding as I type this. The current baby is 1 and I can now use both hands while he eats! Do I get a prize for that???)
Yes, you do!!! For you won't refuse to speak on the phone to the doctor you just paged because you are breastfeeding the baby. (An especially annoying thing for the doctor if she just happens to be breastfeeding while returning your call.) posted by Sydney on
10/04/2006 05:49:00 PM
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Young Hearts: A study in today's Journal of the American Medical Association suggests we should be doing EKG's on young athletes. That's pretty radical. The conventional wisdom has been that EKG's are not good screening tools. They provide good information when people are having symptoms - passing out, chest pain, paliptations, but as predictive tools they are lousy. So what is it about this study that changes that?
The study looked at athletes in the Veneto region of Italy, ages 12-35, from the years 1979 to 2004. The region has an ethnically homogenous population of 4,379,900. In 1982, Italy began requiring that EKG's be performed on all young people as part of their pre-participation sports exams. The Italian guidelines povide clear rules for what constitutes a positive screen in a young athlete:
Family History
Close relative(s) with premature myocardial infarction or sudden death at <50 years Family history of cardiomyopathy, coronary artery disease, Marfan syndrome, long QT syndrome, severe arrhythmias, or other disabling cardiovascular diseases
Personal History Syncope or near-syncope Exertional chest pain or discomfort Shortness of breath or fatigue out of proportion to the degree of physical effort Palpitations or irregular heartbeat
Physical Examination
Musculoskeletal and ocular features suggestive of Marfan syndrome Diminished and delayed femoral artery pulses Mid- or end-systolic clicks Abnormal second heart sound (single or widely split and fixed with respiration) Heart murmurs (systolic grade ?2/6 and any diastolic) Irregular heart rhythm Brachial blood pressure ?140/90 mm Hg on more than 1 reading
Electrocardiogram
Left atrial enlargement: negative portion of the P wave in lead V1 ? 0.1 mV in depth and ?0.04 s in duration Right atrial enlargement: peaked P wave in leads II and III or V1 ? 0.25 mV in amplitude Frontal-plane QRS axis deviation: right ?+120° or left –30° to –90° Increased voltage: amplitude of R or S wave in a standard lead ?2 mV, S wave in lead V1 or V2 ?3 mV, or R wave in lead V5 or V6 ? 3 mV Abnormal Q waves ?0.04 s in duration or ?25% of the height of the ensuing R wave, or QS pattern in ?2 leads Right or left bundle-branch block with QRS duration ?0.12 s R or R' wave in lead V1 ? 0.5 mV in amplitude and R:S ratio ?1 ST-segment depression or T-wave flattening or inversion in ?2 leads Prolongation of heart rate corrected QT interval >0.44 s in men and >0.46 in women Premature ventricular beats or more severe ventricular arrhythmia Supraventricular tachycardia, atrial flutter, or atrial fibrillation Ventricular preexcitation: short PR interval (<0.12 s) with or without delta wave First-degree (PR ?0.21 s, not shortening with hyperventilation), second-degree, or third-degree atrioventricular block
It also happens that since 1979, the medical establishment in the Veneto area has been studying the hearts of dead athletes in great detail:
Since 1979, all fatalities occurring in young people aged 35 years or younger in the Veneto region have been collected and investigated in the setting of a prospective clinicopathological study. The medical centers participating in this research project constituted an active network that served 94.4% of the population and permitted an accurate monitoring of fatal events occurring in this well-defined geographic area. (Participating centers are listed at the end of this article.) Regional newspapers were also systematically used at the coordinating center (The Institute of Pathological Anatomy, University of Padua, Padua, Italy) for daily monitoring of articles on sudden death in young people that occurred in the Veneto region, either sports-related or sports-unrelated.
Athletes and nonathletes who died a sudden death were examined postmortem by the local pathologist or medical examiner at each collaborative medical center to rule out extracardiac causes of death by routine autopsy. The entire heart was subsequently forwarded to the Institute of Pathological Anatomy for detailed morphological assessment, including macroscopic examination and histopatogic study of coronary arteries, ventricular myocardium, and the specialized conduction system as reported in detail elsewhere.... Clinical history, athletic activity, and the circumstances surrounding the cardiac arrest were investigated in each athlete who had a sudden death. According to the 1995 World Health Organization classification,1 cardiomyopathies included dilated, hypertrophic, restrictive, and arrhythmogenic right ventricular cardiomyopathy.
The researchers looked at the incidence and causes of sudden death in young athletes before the 1982 screening guidelines, early in their implementation, and later, when they were standard of care. The incidence rates did go down during those successive years.
The authors claim this decline is due to the ECG portion of the pre-sports physicals, but there's no data to confirm that. The history and physical portion, may be just as important, and may be providing the real benefit. It also may be why here in the States, our rates of sudden cardiac death in young athletes are the same as in Italy, even though we don't routinely perform EKG's (we only recommend EKG's if the history or physical suggest a problem):
An accompanying editorial raised questions about the study, noting that the sudden cardiac death rate before Italy’s screening program was high compared to rates found in other studies. And the lowest annual death rate achieved after screening was similar to the U.S. rate for high school and college athletes from 1983-93.
The editorial also noted that different heart conditions are the most frequent cause of exercise-related sudden death in the two countries.
“I think we have to be very cautious,” said editorial co-author Dr. Paul Thompson of the University of Connecticut. “You can actually cause problems by screening. There are a lot of abnormalities out there that, if left alone, won’t actually do harm, and screening could lead to people getting procedures done that aren’t necessary.”
He added: “There’s a large medical-industrial complex willing to embrace screening, and they just happen to sell the tools used for screening.”
Drs. Gaetano Thiene and Domenico Corrado, co-authors of the Italian study, said their country’s higher mortality rates can be explained by the older age and higher proportion of men compared to the U.S. athletes. posted by Sydney on
10/04/2006 07:26:00 AM
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Making Lemonade: The winners of this year's Nobel Prize in medicine took an experiment gone wrong and turned it into success:
To produce the proteins used in cellular processes, the necessary DNA gene is copied onto a strand of genetic material known as messenger RNA, whose job is to carry the information from the nucleus into the main body of the cell. There, it is used as a template to make a specific protein.
Messenger RNA normally exists as a single strand, unlike the usual double-stranded helix of DNA.
Other researchers had observed that injecting extra messenger RNA into cells either did nothing or, paradoxically, actually inhibited protein production.
Researchers trying to enhance the red color of petunias, for example, inserted the messenger RNA for the red pigment. To their astonishment, petals came out white.
Fire and Mello explained how this occurred. They found that the protein-making ability was silenced when researchers inadvertently added a double-stranded form of RNA that was present as a contaminant when the RNA was synthesized in the laboratory.
Working with the humble nematode Caenorhabditis elegans, Fire and Mello showed that when double-stranded RNA bearing the gene for a specific protein was injected into a cell, it sparked a kind of housekeeping, in which the messenger RNA for the same gene was chopped up and destroyed.
Soldiers on operations say they would rather receive a more serious injury and go to the top American military hospital in Ramstein, Germany, than end up in a NHS hospital.
They now half jokingly refer to getting "a Boche rather than a Blighty" in reference to the wounds that would send them home. Ramstein has an outstanding unit for brain surgery, and neurological intensive care beds in Britain are in short supply. "The blokes see it that if you are unlucky you get wounded and go to the UK at the mercy of the NHS, but if you get a head wound you get sent to Ramstein in Germany where the US has an outstanding medical facility," said an officer serving in Afghanistan.
Would they really rather get shot in the head than go to the NHS? Or is it that wry British humor that's so often lost on us here in the States? posted by Sydney on
10/02/2006 08:50:00 PM
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....the legal system in the way my trial practice professor had explained it to me more than a quarter century before -- that trial isn't about finding the truth or doing justice. It's just one of the ways to resolve a dispute. And mediation is its alternative.
I've always thought of our justice system as a way to get the truth of a matter. And I'm sure most of us think of it as a means for justice. How else to explain all those activist lawsuits? There must be some lawyers who see at as a sword of justice rather than just dispute resolution, no? posted by Sydney on
10/01/2006 05:59:00 PM
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