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    Tuesday, March 07, 2006

    Celebrity Medical News: Dana Reeves, widow of Christopher Reeves, has died of lung cancer. She leaves behind a thirteen year old son.
     

    posted by sydney on 3/07/2006 09:22:00 PM 2 comments

    Grand Rounds: Is in session in the emergency room.
     
    posted by sydney on 3/07/2006 09:16:00 PM 0 comments

    Who Do You Trust? Looks like people don't have much confidence in healthcare reform:

    Overall, about 30% of those surveyed say they trust the Bush administration's ability to come up with good policies for improving and reforming the U.S. health-care system. But Americans aren't much more confident in Republicans (31%), Democrats (45%) and Sen. Hillary Clinton (41%) to reform the health-care system.

    Personally, I'm more worried about each party's ability to confront and contain political Islam than their ability to reform our healthcare market. It's by far the greater threat.
     
    posted by sydney on 3/07/2006 08:40:00 PM 12 comments

    New York Times Scoops New England Journal: The New York Times today published the results of its own research on abortion rates and parental notification laws. Their original work looked at abortion rates among teenagers in 6 states thathave passed parental notification laws before and after the laws. Their research found that the laws resulted in little impact in abortion rates among minors:

    The analysis, which looked at six states that introduced parental involvement laws in the last decade and is believed to be the first study to include data from years after 1999, found instead a scattering of divergent trends.

    For instance, in Tennessee, the abortion rate went down when a federal court suspended a parental consent requirement, then rose when the law went back into effect. In Texas, the rate fell after a notification law went into effect, but not as fast as it did in the years before the law. In Virginia, the rate barely moved when the state introduced a notification law in 1998, but fell after the requirement was changed to parental consent in 2003.


    They say they're the first to look at this data, and they got a comment from an economist whose research is devoted to the impact of consent laws:

    There are ongoing trends that are pushing both birth rates and abortion rates down significantly, and those larger trends are more important than the effect of these laws," said Ted Joyce, an economist at Baruch College in New York who has studied parental involvement laws. He found they had limited effects on small subgroups of minors but little impact over all.

    Funny, that's not what he says in this week's New England Journal. Dr. Joyce didn't mention - or couldn't without breaking a news embargo - is that he, too, has looked at trends since 1999, and the results of his work are in this week's NEJM. (The print version has already been mailed and delivered, but it won't appear online until later this week. ) His study is much narrower than that of the Times, focusing only on Texas and choosing to highlight the difference in abortion rates among 17 year olds the year before Texas passed a parental consent law and in the two years after the law was passed. The paper's conclusion is that consent laws do limit access to abortions, and especially amongst older teens, and that it resulted in more late-term abortions among 18 year olds. The authors see their data as a warning against passage of more consent laws: "Although the observational design of the study makes it impossible to confirm causality, these findings are relevant to an assessment of the likely effect of pending legislation to extend such laws."

    It looks like the Times managed to publish a more balanced and objective study. As their numbers point out, the rate of abortions were already declining fast in Texas before the notification laws took effect. And it would appear from trends in other states that there's probably something else at work here than consent laws . Perhaps it's the Roe effect. Or, perhaps parental consent laws don't make much difference because it's the parents are more eager for their kids to have abortions than the kids are:

    But providers interviewed in 10 states with parental involvement laws all said that of the minors who came into their clinics, parents were more often the ones pushing for an abortion, even against the wishes of their daughters.

    "I see far more parents trying to pressure their daughters to have one," said Jane Bovard, owner of the Red River Women's Clinic in Fargo, N.D., a state where a minor needs consent from both parents. "As a parent myself, I can understand. But I say to parents, 'You force her to have this abortion, and I can tell you that within the next six months she's going to be pregnant again.' "

    Renee Chelian, director of Northland Family Planning Centers in the Detroit area, said she had had to call the police on parents who wanted their daughters to have abortions, "because they threaten physical violence on the kids."


    This has been my experience, too. College age women are the ones who seek abortions on their own and don't tell their parents. Minors are invariably hauled in by their parents for a pregnancy test and then told they're going to get an abortion - or else. Parents today came of age after Roe v. Wade. They take it for granted that abortion's a legitimate option. Many of them feel it's the best option. After all, they know they're the ones who will ultimately be raising that baby.

    P.S. Regardless of where you fall in the abortion wars, can't we all agree that it's in the best interest of a child to have a parent's consent before undergoing an invasive medical procedure? It always seem so cavalier to argue that children can be responsible for their own medical care after an invasive procedure like that.

    UPDATE: In the comments:

    Twenty plus years ago my attorney wife was dealing with a rash of 12 and 13 year olds having children. To her surprise they did not understand even the most basic issues concerning pregnancy. She tried to bring a basic health class to this subgroup and was told she would be sued and loose her job if she persisted. The statement by a group was "she was interfering in the reproductive rights of these women."

    These are not women, they are children and we need to protect them with all of our resources.


    Precisely. Which is why the New York Times study should be embraced by both sides of the abortion debate, rather than disparaging it as partisan. The pro-abortion side can stop painting notification laws as dangerous to the health of children by denying them abortion services - clearly they aren't. And the anti-abortion side can rest easy in the knowledge that the laws will continue to be on the books. If the Times hadn't run its own statistical study, then Dr. Joyce's study would have been the one to make headlines. Instead of "Consent Laws Make No Difference," but "Consent Laws Result in More Late Term Abortions." That headline may still run, but the most important thing about parental notification laws is not their ability to stop abortion. It's the important role they play in protecting the health of children by requiring parental awareness of an invasive medical procedure.

    UPDATE II: Emily in the comments notes that the press is reporting the New England Journal research as showing that consent laws lower abortion rates. Even the New York Times is reporting this, but only via the AP.
    Emily has more at her blog.
     
    posted by sydney on 3/07/2006 12:07:00 AM 4 comments

    Monday, March 06, 2006

    In the Genes: Macular degeneration, a common cause of blindness in the elderly, appears to be due to genetic malfunction:

    Previous work had shown that several variants of a gene called Factor H significantly increase the risk of AMD.

    Factor H controls production of a protein that helps shut down the body's immune response to infection once it has been successfully fought off.

    People with these inherited variants of Factor H are less able to control inflammation caused by infectious triggers, which may spark AMD in later life.

    ....A genetic analysis of 1,300 people quickly identified a second gene, Factor B, as playing a significant role.

    While Factor H is an inhibitor of the immune response to infection, Factor B is an activator.

    Because of the complementary roles of the these two genes, a protective Factor B variation can protect against AMD, even if one carries a risk-increasing variant of Factor H, and vice versa.

    The researchers found 74% of the people with AMD had either the Factor H or Factor B risk factor or both - but no protective variants of either gene.

    Lead researcher Dr Rando Allikmets said "I am not aware of any other complex disorder where nearly 75% of genetic causality has been identified.


    Here's a picture of Factor H in the retina. And here's a schematic of the Factor B protein.

    At the moment, the only treatment we have for macular degeneration is to try to arrest the development as it occurs, and we aren't all that great at doing that. The good news about this finding is that we might some day be able to develop drugs that can prevent it from happening. The drawback is that since they would have to work on gene expression, they're likely to have body-wide side effects.
     

    posted by sydney on 3/06/2006 08:44:00 AM 2 comments

    Clone Wars, Continued: Michael Fumento dissects 60 minutes.
     
    posted by sydney on 3/06/2006 08:20:00 AM 2 comments

    Reality Check: A checklist of bird flu facts.
     
    posted by sydney on 3/06/2006 07:54:00 AM 0 comments

    Sunday, March 05, 2006

    Oscar Night: I haven't watched the Oscars in years and have no intention of breaking my streak this year, but if I could nominate or vote, this would be my pick. It was by far the best movie from 2005 that I watched. Gripping, suspenseful, and timely.

    And yet, I can't recall reading any reviews of it. Perhaps because its director was Wes Craven, the industry labelled it as a horror flick. It isn't. It's a psychological thriller, with the explicit theme that we should never give in to intimidation. The best line is spoken by the heroine, as she reveals to the villain that a scar on her chest came from a sexual assault:

    "Since then I've spent all of my life trying to convince myself of just one thing."

    "What?," he says with a smirk, "That it wasn't your fault?"

    "No. That it would never happen again," she says as she stabs him in the throat with a pen.


    Second best line delivered by the heroine (a hotel manager) to an employee: "None of our clients are assholes, they are just clients with special needs."
     

    posted by sydney on 3/05/2006 07:14:00 PM 0 comments

    Biting Words: The Toronto Sun on Canadian healthcare:

    When all is said and done, the philosophy on which Canada's ailing medicare system is based is this.

    That Canadians are perfectly content to eat sawdust, as long as they can be assured that no one is ever going to be allowed to buy a steak.


    Ouch.
     
    posted by sydney on 3/05/2006 05:56:00 PM 1 comments

    Heart Healthy Podcast: Dr. Helen, who has had her own brushes with heart health, has a very interesting and informative heart health podcast up.
     
    posted by sydney on 3/05/2006 05:52:00 PM 0 comments

    Speaking of Spin: Glenn Reynolds was asked by a reporter about blogs, PR releases, and ethics. He correctly points out that the mainstream media and professional journalists are not immune to press releases, and quotes (within the context of his own book) Daniel Boorstin on the subject:

    Most reporters aren’t scoop-hungry investigators. They’re wage earners who want to please their editors with as little effort as possible, and they’re happy to let you provide them with ideas and facts for publishable stories. That is why most publicity is positive for people and their businesses.

    You’re still not convinced? Go to the library and glance through a few days’ issues of several newspapers, including the Wall Street Journal, USA Today, and some local papers. You’ll discover that the same stories appear over and over again. That’s because they were initiated by the companies being covered, not by an eager young reporter looking for a scoop.


    This is especially true in science and medical journalism. Here's Exhibit A from my local paper - a story about a wonderful new procedure being performed at a local hospital. The procedure is transmyocardial revascularization, in which lasers are used to burn tiny holes in the heart muscle:

    Other standard treatments for angina include stents, which are placed in arteries to improve flow, and open-heart bypass surgeries.

    But sometimes those procedures don't work, or they're not options, Espinal said. That's when TMR can help.

    Patients undergoing TMR get 20 to 40 tiny laser holes in the portion of their heart that's not getting enough blood flow. The holes seal over immediately, Espinal said.

    No one's sure exactly why TMR works. But doctors think the holes might reduce pain by deadening nerves and stimulating the body to send more blood to the treated area.

    Studies have shown that TMR is more effective than medicines alone in treating extreme angina. At least one study published in the New England Journal of Medicine found that people who underwent the procedure also had fewer cardiac events a year later.

    Steele still suffered pain after undergoing bypass surgery and getting nine stents placed in his arteries during a five-year period.

    But he noticed improvement immediately after his TMR procedure earlier this month.

    ``I don't get the pains I got before,'' he said.

    He now plans to start playing golf again this spring -- something he hasn't been able to do for three years.


    The procedure does seem to improve symptoms better than medical therapy does, but it doesn't necessarily improve mortality. (In this much smaller study it did.) Either way, the biggest improvement the surgery claims is symptom improvement, and it could just be that we're seeing a placebo effect rather than any real improvement in the blood flow to the heart. It's happened before with cardiovascular surgery, as this letter to the editor noted:

    In the era before direct coronary revascularization, internal-thoracic-artery ligation was touted as a method to increase myocardial blood flow and relieve anginal symptoms. Initial reports by Ellis et al. and Kitchell et al. indicated that 68 to 75 percent of patients had clinical improvement, including approximately 35 percent who had complete relief and 42 percent with objective improvements, as measured electrocardiographically. These investigators were honest and intelligent but not impartial observers. Double-blind studies conducted later by Cobb et al. and Dimond et al. demonstrated that a sham thoracotomy alone could decrease the need for nitroglycerin and increase exercise tolerance and that it produced subjective improvement in more than 35 percent of patients. These results are similar to the improvement among 34 percent of the patients in the British study of transmyocardial laser revascularization mentioned by Lange and Hillis.

    When perfusion scans do not correlate in time or magnitude with the patient's clinical improvement, the more subjective data on improvement of symptoms must be approached with great skepticism. As was the case in earlier studies, the thoracotomy incision alone may have an important effect directly or indirectly on the patient's perception of pain. The fact that a patient has already undergone the surgical procedure of last resort has a high likelihood of affecting a physician's choice of treatment plans, and thus study outcome.

    It may be completely correct that transmyocardial laser revascularization benefits patients with chronic angina. However, given the substantial morbidity and mortality (9 to 15 percent mortality among the patients who were crossed over to transmyocardial laser revascularization in the studies by Frazier et al. and Allen et al. discussed by Lange and Hillis), the potential for a placebo effect must always be remembered.


    The newspaper article doesn't mention the moribidity and mortality rates. Read the story (which was a large, above the fold front page feature in the print version) and you come away with the idea that this is the best thing since sliced bread. And where do you think they got the idea for the story? From the hospital's PR department, of course. It was a very nice, free ad for their new surgery department.
     
    posted by sydney on 3/05/2006 05:34:00 PM 0 comments

    Markets at Work: When Medicare agreed to pay for lung surgery for emphysema, a lot of people thought it would prove to be a costly mistake, but it didn't turn out that way. Instead, patients and doctors realized the procedure wasn't worth the risk and money: "

    . To test whether federal health spending actually helps patients, Medicare has been requiring more and more of the nation's retirees to participate in clinical trials to measure the effectiveness of a growing range of treatments, before agreeing to pay for them. Now, the outcome of the first and most extensive Medicare trial yet indicates that the public, armed with the data developed, may make surprisingly conservative decisions.

    It was a study of a risky but popular operation for patients with advanced emphysema, and after its results were announced in May 2003, Medicare agreed to pay for the procedure.

    Some health economists were alarmed. The operation and months of rehabilitation can cost more than $50,000 and, they predicted, tens of thousands of patients could end up having the procedure. It could cost Medicare as much as $15 billion.

    What happened instead was a complete surprise. After seeing the clinical trial's results - no lengthening of life for most patients and a nearly 10 percent mortality risk from the operation itself - many patients and the doctors who refer them to surgeons seemed to lose their enthusiasm.


    Not everyone is happy with the outcome, however:

    The main critics seem to be lung surgeons, who say that the study's findings are being interpreted in an overly negative light and that too many seriously ill people stopped seeking treatment.

    The procedure in question is lung volume reduction surgery, and before Medicare required a formal study of its effectiveness, it was very popular, largey on the basis of anecdotal evidence:

    The procedure's popularity was growing, as surgeons told of patients who had been tethered to oxygen tanks and so ill that they had to stop and rest every few steps. After the operation, according to the reports, many improved so much that they could walk steadily, even uphill, and breathe on their own.

    Patients were posting testimonials on Web sites, hospitals were advertising, and doctors were referring their advanced emphysema patients to surgeons.

    Some doctors, like Dr. Joel Cooper, a lung surgeon, published reports of his patients that were so promising that his medical center, Washington University, could hardly keep up with the demand. And Dr. Cooper, now at the University of Pennsylvania, still stands by the operation, saying in a recent interview that lung volume reduction surgery patients "are among the most grateful patients we have."

    But back in 1997, noting the surgery's risks and the opinion of some doctors that it did not work at all, Medicare officials proposed a marked change in policy. There would be no more payments except for patients who enrolled in an agency-sponsored clinical trial.

    Many surgeons and patients balked. Dr. Cooper refused to participate in the trial, saying he could not in good conscience randomly assign patients to the control group who would receive no treatment. Congress held hearings and listened to complaints that desperately ill patients would suffer. Representative Jim Ramstad, a Minnesota Republican, predicted the study would "negatively affect the lives of thousands of older Americans who suffer from the disease."

    Patients and their families, along with reporters, called Medicare, an agency spokesman recalled, asking "Why aren't you paying for this lifesaving miracle?"


    The study essentially proved that people who had the surgery could walk further without getting short of breath, but they died at the same rate as those without the surgery. The surgeons thought this was a good result, and they expected to see an influx of customers. And perhaps if their specialty society had hyped it more, they would have. But, for most people, performing surgery on the chest is a very big deal, and they want more improvement for the risk than the relatively small percentage differences shown in the study.

    It just goes to show how important it is to have access to good data - and not just the hype - when making costly medical decisions. One reason it worked in this case is that the doctors who take care of patients with emphysema are not the same as the doctors who perform (and profit from) the procedure. The other is, that there's no large corporation that stands to benefit from putting the most positive spin on the studies. If pulmonologists were responsible for performing the procedure, or if the procedure required a special surgical device manufactured by only one company , chances are there would have been more emphasis on the positive than the negative and we would have seen an increase in demand. Just as we've seen with oncologists and herceptin.

    Posession of the facts and of good data is essential to making good treatment decisions, but we still have to be on guard for the spin.
     
    posted by sydney on 3/05/2006 04:29:00 PM 2 comments

    Fashion Trends: Anyone who has ever travelled the highways and byways of the American Midwest is familiar with the cement goose tradition, those popular lawn ornaments that people dress for all occasions. In the rainy Spring season, they wear little yellow rain coats, in the summer, perhaps a bikini or a Cleveland Indians outfit. There's a cement goose in our town that for the past couple of years has been wearing a burka. Every time I drive by it, I find myself wondering if it's a pro-Islamist statement or an anti-Islamist statement. I had the same reaction when I saw this fashion story in today's New York Times.

    Normally, the clothing that makes it down the fashion runways bears about as much relation to clothing worn by women in the real world as the cement geese have to real world geese, so it's hard to take anything seriously that appears on the runways of New York and Paris. It would be a more ominous harbringer of things to come if fashionable women were obscuring themselves behind veils as they went walking on the street. But this designer's explanation suggests perhaps the statement is more pro-Islamist than we are apt to believe:

    "It was a kind of a joke," said the designer Jun Takahashi of his decision to wrap his models in eyeless cloth hoods. "I didn't want any distraction from the line."'

    Isn't that the same reasoning behind religious mandates that women be covered behind a veil? To prevent them from being distractions from the important daily duties of men?
     
    posted by sydney on 3/05/2006 03:53:00 PM 2 comments

    Thursday, March 02, 2006

    Shenanigans: If this is true, it doesn't speak well for Proctor and Gamble:

    In 2002, Sheffield entered into a contract with P&G to collect Actonel data – the purpose of which was to determine how the drug prevented bone fractures, and how this related to change in bone resorption (the rate at which bone is removed) and bone mineral density. Consistent with research protocols in collecting data, Blumsohn was blind to which research subjects received Actonel and who got placebos. To later analyze the data, he needed its key, P&G’s “randomization codes.” Despite his repeated requests over 18 months, P&G denied him access to the data, even as it published ghost-written abstracts in his name falsely implying the therapeutic equivalence of Actonel to Merck’s Fosamax, the industry leader.

    Proctor and Gamble says the claims aren't true, or at least some of them aren't. No comment on the "ghost writing" thing:

    "Dr. Blumsohn asked to see the data directly, was provided access to this data on two specific occassions at his request, appeared satisfied with the additional access he was granted, and then he willingly presented the data at two medical meetings."

    Procter said it would provide data for independent review, and in an additional statement said that in hindsight, it should have spent more time communicating directly with Blumsohn "so we could have avoided these issues around how the study conclusions were reached."

    Blumsohn and a colleague received a $250,000 research contract from Procter in 2002 to analyze Actonel's relationship to fractures and impact on "bone turnover," the WS J reports.


    I had no idea research paid so well.
     

    posted by sydney on 3/02/2006 08:59:00 AM 3 comments

    Wednesday, March 01, 2006

    Bush Hates Family Doctors: That's the gist, anyways, of this NPR story about community health centers. Seems that even as the Bush Administration pushes to build more community health centers in poor urban and rural areas, there aren't enough doctors to staff them:

    "The question was, whether or not it would be possible to expand these community health centers if there wasn't anybody there to staff them," said Roger Rosenblatt, a professor of family medicine at the University of Washington. Rosenblatt and colleagues polled all of the nation's health centers to find out.

    He says the news they got back -- published in this week's Journal of the American Medical Association -- was ominous: "There were large numbers of vacancies, particularly for family physicians, at a time when the number of students going into family medicine had decreased 52 percent in seven years."

    Adding to the problem, says Rosenblatt, is the fact that the administration is proposing to cut or freeze the few federal programs that help pay for the training of family doctors. The president's budget for Fiscal 2007 would eliminate the primary care training programs under Title VII of the Public Health Service Act, and it would provide no increase for the National Health Service Corps. The NHSC provides scholarships and loan-repayment programs for medical students who agree to practice in areas with doctor shortages.

    Rosenblatt says that expanding one program while cutting others makes little sense. "I think the administration hasn't got a clear comprehensive picture about how all these parts are tied together," he said. "You have to have a workforce to provide the care. Just having an edifice or the organization isn't enough."

    ....And while President Bush likes to talk about market solutions to solving the nation's health care problem, study author Rosenblatt says the fact that some 46 million Americans have no health insurance, and the very need for the government-funded health centers, shows that the "the market doesn't work in medical care."


    Seems the market is working all too well in this case. It's just not giving the results these guys want. Medical students choose specialty fields because they promise better financial rewards than primary care. The lowest doctors on the income scale are pediatricians, family physicians, and internists - in that order. And once they become primary care doctors, they'd rather practice in a comfortable setting like the suburbs than out in the sticks where the hours are demanding and the risks much greater. Where one's forced to practice John Wayne medicine. The study itself makes that clear:

    Major perceived barriers to recruitment included low salaries and, in rural CHCs, cultural isolation, poor-quality schools and housing, and lack of spousal job opportunities.

    The trick is to get family medicine (and pediatrics and general internal medicine) to be as attractive as specialty medicine and rural and poor urban areas to be as attractive as suburbia. One way would be to pay primary care doctors better. (Like that's going to happen.) Or the field more "glamorous." (Even less likely.) Specialty fields are attractive not just because they pay more, but also because a more narrow field of knowledge to master. That doesn't make them easier to learn, but many people feel much more comfortable knowing a lot about a little than a little about a lot. Once technological advances made specialization necessary, it was inevitable that primary care would suffer. As for making rural areas as attractive as suburbia, well, sorry, I can't think of any way to do that. You have to have a special nature to love rural living. And I confess, I don't have it.

    But back to the medical specialty problem. One of the problems, (the "glamour" side of the equation) is that family medicine and primary care in general gets short shrift in medical students. Many of the best medical schools have no departments of family medicine, and their departments of pediatrics and internal medicine are devoted primarily to the subspecialists - the pediatric endocrinologists, pulmonologists, geneticists, etc - who begin in peds and internal medicine before going on to do their specialist fellowships. There's very little exposure to primary care medicine. My medical school happened to be one that was founded with the mission to increase the number of primary care doctors in my state. And yet, primary care got short shrift there, too. Among the faculty. Among the residents. I remember my senior year, a resident telling me "a peanut" could go into primary care. And that was almost twenty years ago, before the decline began.

    There's no good answer to the shortage of primary care physicians, barring forcing medical students to enter the field, which would be a mistake. The only thing worse than not having enough primary care doctors is having plenty of them who all hate their jobs. And make no mistkae, that's what people mean when they talk about "policy solutions" and the market not working. They mean forcing their choices on others.

    It's all the more to be pitied because primary care really is rewarding in ways that specialty care can never be. There's never a boring day. There are aggravating days, yes. And exhausting days, as in any field. But where else but family medicine can you go from the sad decline of old age to the wonderful delight of a newborn baby within the space of 15 mintues? Variety is the spice of life and family medicine has it in spades. It just won't make you rich.
     

    posted by sydney on 3/01/2006 09:30:00 PM 6 comments

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