Subtle Messages II: One of my patients told me she wouldn't go back to her gynecologist because she wanted to send her to physical therapist to "learn to fall." It was hard not to laugh. I know that preventing falls in the elderly is very important, but she's a healthy, active 50-something, and I just had a mental image of a bunch of middle-aged women in a work-out room falling down over and over again.
On a more serious note, though. Isn't there such a thing as acting too early for prevention? Is a 50 year old going to remember how to fall when she's 80? Heck, would a Hollywood stunt man remember how to fall if it took him by surprise at any age? posted by sydney on
9/07/2006 09:32:00 AM
Cognitive Dissonance: When push comes to shove, obstetricians often chose a Cesarean section to avoid the risk of malpractice litigation. What will they do now?
Babies are up to three times more likely to die soon after delivery if their mothers choose a Caesarean section rather than a normal birth, a big American study has shown.
.....The team studied more than 5.7 million live births and nearly 12,000 infant deaths in the United States from 1998 to 2001. They counted deaths among babies that occurred within 28 days of birth, called neonatal deaths.
They conclude in the journal Birth: Issues in Perinatal Care that the neonatal death rate for Caesarean birth among low-risk women was 1.77 deaths per 1,000 live births. The comparable rate among vaginal births was 0.62.
A particularly drug-resistant tuberculosis discovered in eastern South Africa is likely to have spread beyond the rural area where 52 of the 53 people first diagnosed with the new strain have died, the doctor who discovered the super bug said.
The extent of the new outbreak is unknown because tests are expensive and specialized.
With their letter, the scientists joined mounting criticism from AIDS activists and South African opposition parties of Tshabalala-Msimang, often called "Dr. Beetroot" because of her advocacy of the use of beetroot, garlic, lemon and the African potato in the fight against AIDS. Mbeki also has been accused of ignorance and poor judgment in addressing an epidemic that threatens to cripple Africa's economic and diplomatic powerhouse.
.....The group said it was deeply concerned by the proliferation of unproven remedies marketed in South Africa, some with the support of the minister of health.
The noted that at the 16th International AIDS Conference in Toronto last month, the South African government exhibition "featured garlic, lemons and African potatoes, with the implication that these dietary elements are alternative treatments for HIV infection."
The network said: "Jenni is angry that, having fought so hard to become liberated and independent, women are now being trapped into caring for dependent parents.
That's why Jenni, age 56, is pro-euthanasia. She no longer has to fear being trapped into caring for a dependent infant. It's those elderly parents that are the obstacle to freedom now. Parents of baby boomers, be afraid. Be very afraid.
Lipitor Coup, Redux: Remember that recent study that suggested high, expensive doses of Lipitor can prevent strokes? It's a success for Pfizer:
Pfizer Inc. , the world's largest drug company, is using the results of a study it sponsored to persuade doctors to switch patients to pricier doses of its blockbuster drug, Lipitor . And according to the latest sales figures, the marketing pitch is working.
...For the week ending Aug. 18 , prescriptions for higher doses of Lipitor jumped 12 percent , according to John Boris , a Bear Stearns analyst, promising a 2 percent revenue increase for Lipitor for the third quarter .
The Pfizer-sponsored study on Lipitor's impact on stroke was written by 11 authors who were either company employees or reported financial ties to it. The New England Journal of Medicine article linked daily , 80 milligram Lipitor doses with a 16 percent reduction in the risk of a repeat stroke.
An editorial, also published last month in the journal, could provide another driver for Lipitor revenue growth. The study adds to ``gathering momentum" that could convince insurers to count statin use as a measure of ``quality" after-stroke care, according to the editorial. Dr. David M. Kent , the editorial's author, reported receiving grant support from Pfizer .
I don't mind saying I told you so. American medicine - doing our best to keep your healthcare expensive.
For many premature, severely underweight babies, life will be filled with challenges.
As these babies grow up, they are more likely than normal-weight babies to have problems walking, hearing, speaking and seeing.
They are more likely to need regularly prescribed medication, special diets, physical therapy, and special educational arrangements.
They are at greater risk for cerebral palsy, asthma and a low IQ.
But guess what?
These kids grow up to think they're doing just fine, according to research in this week's edition of the journal Pediatrics.
In interviews with 130 young adults who were born at normal weight and 143 young adults who were born weighing between 1.1 pounds and 2.2 pounds, Canadian researchers found little difference in how the two groups viewed their health-related quality of life.
People, (that is, doctors) who aren't living their lives, judge it differently:
The findings were greeted with ``some skepticism and disbelief,'' the study points out. According to the naysayers, the positive responses had to be due to ``denial and self-deception.''
Come, come now. You're suffering. You just don't know it. The study actually found the former preemies to have more physical disabilities as adults, but they didn't let their limitations color their lives:
Extremely low birth weight young adults reported more functional limitations in cognition, sensation, mobility, and self-care, compared with control subjects. There were no differences between groups in the mean self-reported, health-related, quality of life or between impaired (n = 38) and nonimpaired (n = 105) extremely low birth weight subjects.
The specialists, most of them anyway, don't know what to do with me. Medical practice is all about snapshots: Measure the patient's condition, prescribe the treatment, then measure again. That approach works for static, on-off problems with easy fixes. But pain isn't static, it isn't on-off, and there are no easy fixes. Chronic pain is like a living, breathing thing with a mind and will of its own; it grows and moves and adapts. The snapshots--and most of the specialists--miss that. So each doctor clicks the shutter and applies the relevant specialty's preferred fix: this drug, that surgery, some new exercise program. Afterward, when I still hurt, they tend to get frustrated. That's usually when I'm diagnosed with Failed Patient Syndrome.
But there's an upside, he says:
Sometimes the pain itself seems to have medicinal value; it brings strange pleasures in its wake. Good food tastes better than it did before.
...Work feels more satisfying, even though it's much harder to do...For the first time, I know the satisfaction of doing the very best I can do. Pain gave me that.
And pain gave me one more good thing: It taught me to live in the present, not the past and future.
Despite the counted blessings, the piece still comes across as overwhelmingly pessimistic. And he admits that before the pain, he spent a lot of time focusing on "past regrets and future wants" rather than enjoying the here and now. Which leads to a question - do naturally pessimistic people experience more pain than the naturally optimistic? posted by sydney on
9/05/2006 07:37:00 AM
Drugged Stents: Looks like the drug-coated metal stents that are used to keep clogged arteries opened - and to prevent future clots - might not be doing the latter:
Studies released Sunday at the World Cardiology Congress in Barcelona raised new concerns about the risks that may accompany the drug-coated stents, which were introduced in 2000 as an improvement on bare-metal stents.
....A Swiss-Dutch study tracked 8,146 patients and found that recipients of drug-coated stents were at increased risk of thrombosis, or blood clots, that can occasionally result in death.
Two other Swiss studies, analyses of presented and published information discussed at the cardiology conference, also found that first-generation drug-coated stents had higher links to thrombosis compared to bare metal stents.
In bare metal stents, heart cells naturally grow to cover the stent, providing a natural biological lining. But in the drug-coated versions, the drugs prevent tissue growth _ which is both their intent and their possible downfall. ... A thick growth of cells is undesirable, but a thin layer of cells lining the artery is essential. In some instances, drug-coated stents have prevented this minimal protective cell layer from growing, leaving exposed metal, which essentially can act as a clot magnet.
The information is from a conference, so we have to take the reporter's and reserchers' word for it, but it does sound like the cheaper plain stents might be better or at least just as good as the drug-coated ones. Everyone was singing their praises not so long ago. posted by sydney on
9/04/2006 02:10:00 PM
An obesity pandemic threatens to overwhelm health systems around the globe with illnesses such as diabetes and heart disease, experts at an international conference warned Sunday.
"This insidious, creeping pandemic of obesity is now engulfing the entire world," Paul Zimmet, chairman of the meeting of more than 2,500 experts and health officials, said in a speech opening the weeklong International Congress on Obesity. "It's as big a threat as global warming and bird flu."
..."We are not dealing with a scientific or medical problem. We're dealing with an enormous economic problem that, it is already accepted, is going to overwhelm every medical system in the world," said Dr. Philip James, the British chairman of the International Obesity Task Force.
Bigger than bird flu, bigger than global warming. There are certainly more people suffering from obesity than bird flu, and the evidence for global warming isn't as solid as the evidence for obesity, but "overwhelming every medical system in the world?" This may come as a shock to people, but the hospital beds aren't populated exclusively by obese people. Sure, there are some, but take a tour of an average ICU or medical floor and you'll find just as many thin as fat patients. The growing aging population will overwhelm our medical systems before the growing fat population does.
Within a few moments after my arrival at the dispensary this morning, the crash phone rang. After an inexcusable delay the ambulance got off to the field almost as another entered bearing a poor boy who had stepped into the propeller of a B-24. He was conscious but with deep lacerations over the right frontal area. On further examination under local he proved to have a compound fracture of the skull with several deeply depressed fragments and a lacerated brain. I removed the loose fragments and elevated the depressed ones, filled the thing full of sulfonamide and sewed him up tight. This was my maiden voyage into intracranial surgery - what a place for an obstetrician! God help him from here on. [emphasis mine-ed.]
As Chad Kingsbury watches his daughter playing in the sandbox behind their suburban Chicago house, the thought that has flashed through his mind a million times in her two years of life comes again: Chloe will never be sick.
Chloe has been fortunate to survive an embryo culling. She does not carry the gene for colon cancer that runs in her father's family. Does that mean she is 100% guaranteed to never ever have colon cancer? No, it doesn't:
About 75 percent of all colorectal cancer occurs in people with no known predisposing factors for the disease.
This belief that cancer is completely hereditary is one of the most obstinante ones I encounter in my practice. Patients will tell me they don't need colonoscopies or mammograms or pap smears because cancer doesn't run in their families. This is especially true of colon cancer and breast cancer screening. We've done such a good job of publicizing the increased risk for those with positive family histories of these two cancers, that we've completely obscured the fact that most of these cancers arise spontaneously.
Laugh of the Day: It's not nice to laugh at other peoples' pathologies. But the comment war between Lee Seigel (aka "sprezzatura"), the recently suspended culture critic of the New Republic, and one of his critics is laugh out loud funny (Begin at 16:57:44 on 2006-08-27.) What is it about the writing life that makes people so narcissistically nuts? posted by sydney on
9/02/2006 04:56:00 PM
What We're Up Against: My specialty board puts out a monthly journal that, for the most part, has very good review articles on various topics. Its table of contents with hyperlinks arrives once a month in my email. Today, I clicked on the first link in the email and got this. Only afterwards did I see the little "paid advertisement" notice above the link. Sheesh. posted by sydney on
9/02/2006 02:21:00 PM
Friday, September 01, 2006
Privacy: Finally got around to restricting drug reps' access to my prescribing data. It can be done here, but may take up to 90 days to go into effect. posted by sydney on
9/01/2006 10:08:00 PM
More than Best: The oppression of the breast feeding workers. I agree that of all the choices for feeding babies, breast milk is the best, but this article is more than a little over the top:
Doctors firmly believe that breast milk is something of a magic elixir for babies, sharply reducing the rate of infection, and quite possibly reducing the risk of allergies, obesity, and chronic disease later in life.
The "sharply reducing" is not an accurate characterization. A better term would be "slightly reduces," at least when it comes to infections and allergies. For obesity and chronic disease, a better term would be "theoretically."
But for lower-income mothers — including many who work in restaurants, factories, call centers and the military — pumping at work is close to impossible, causing many women to decline to breast-feed at all, and others to quit after a short time.
It is a particularly literal case of how well-being tends to beget further well-being, and disadvantage tends to create disadvantage — passed down in a mother’s milk, or lack thereof.
One would think we were living in the age of Les Miserable. Does anyone but the most strident La Leche League activist seriously think formula fed children are at a measurable lifelong disadvantage?
Dr. Ruth Lawrence, a member of the committee on breastfeeding at the American Academy of Pediatrics, said: “If this rule is going to continue, the airlines need to provide some sort of alternative that will allow a mother to safely bring home her pumped milk. If it’s a working mom, she needs every drop of that precious golden fluid for her baby when she can’t be there.”
There's a guilt trip for you. Who wouldn't feel bad about depriving their child of that "precious golden fluid?" Do doctors in high places ever stop to think of the effect their hyperbole has on ordinary people?
Judging by the comments, most people buy into this idea that breast milk isn't just the best option, it's the only option. Except for this lone voice of reason:
I don’t get why all of this is a big deal. I breast fed three babies, each for more than a year, never took off from work and never pumped. They got formula when I was at work and the rest of the time, including in public and all through the night, they breast fed.
Formula isn’t poison. The point isn’t to avoid babies getting it but to make sure that they do get breast milk with all the antibodies, etc. What is the point of making things a bigger hassle for women than it has to be? I did what was easiest and cheapest.
P.S. This is a gem, buried deep in the article:
Wealthier women can spend their way out of work-versus-pumping dilemmas, overnighting milk home from business trips and buying $300 pumps that extract milk quickly, along with gizmos that allow them, in what seems like a parody of maternal multitasking, to pump while driving to and from work.
McCann said he discovered that the county's insurance office had gotten access to his medication records in violation of federal medical privacy law, known as the Health Insurance Portability and Accountability Act, or HIPAA.
``They could have at least asked me to sign off on this so they could have asked my physician to provide documentation on why the medication was prescribed, but they didn't,'' he said.
The longtime public employee said his doctor prescribed three drugs -- one used as an anti-anxiety medication -- to treat restless leg syndrome and has never suggested that he see a psychiatrist.
The county ``jumped to conclusions,'' McCann said. ``They had no way of knowing what the drug was prescribed for; they just looked at the name and said, aha!''
McCann said he was told by Caremark, the Nashville-based company that manages the county's pharmacy benefits, that the county had access to his records twice, two days before he was ordered to see a psychiatrist and in mid-May, about 10 days before his unpaid administrative leave with the county ended.
He was fired for insubordination and arguing with his supervisors. That should be enough grounds without snooping in his medical files. posted by sydney on
9/01/2006 08:54:00 AM
Two men who had even higher levels of the modified T cells experienced a dramatic recovery. In one, a liver and armpit tumor that had developed from spreading melanoma cells shrank, and in the other a lung tumor disappeared. Both men remain healthy 18 months after treatment. posted by sydney on
9/01/2006 08:47:00 AM
Genetic Revolution Hope: Here's something you never see, two patients with metastatic melanoma are cancer free after being treated with genetically engineered immune cells:
The researchers infused 17 patients suffering from metastatic melanoma with their own white blood cells that had been removed and genetically engineered to fight tumours.
The patients' T-cells had been modified with genes that code for receptors designed to recognise melanoma cells.
The cancer was eliminated in two male patients, the researchers say. In one case a 52-year-old man had a tumour in his armpit disappear and another on his liver shrunk enough to be surgically removed. He remained disease-free 19 months after treatment, the study says.
Another patient, a 30-year-old man, had a lung tumour recede and showed no signs of disease 18 months later.
"The tumours went away and both of the patients are now completely disease-free over a year and a half later," says Rosenberg who is chief of surgery at the NCI. Before the experiment, the patients had advanced skin cancer that was not helped by standard therapies and they were expected to live just three to six months, he says.
Even though it failed in most of the patients, you just never see that kind of response in melanoma to conventional therapy. Now the question is, what is it that was different about the two people who responded? posted by sydney on
9/01/2006 08:41:00 AM