"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
Flu Factoid: According to a lecture I attended today, every influenza pandemic since 1890, when they started tracking global temperatures, was associated with a global cooling trend. It might not mean anything, but it's interesting. posted by Sydney on
9/29/2006 08:21:00 PM
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Tales from the Exhibit Hall: Speaking of the pharmaceutical industry, the exhibits at the Assembly have to be seen to be believed. They are living testaments to the excesses of advertising. Cameras are forbidden in the exhibit hall, however, so words will have to do.
There is a huge O in one exhibit for a sleeping pill with a real live beautiful princess pretending to sleep in its curve. Kristi Yamaguchi was there to tell us why she and her family are immunized against influenza. (Shouldn't be basing the decision to immunize on evidence based medicine rather than celebrity endorsement?) The makers of new statin Crestor have a large display touting their GALAXY project, which they describe as a global research initiative to determine the importance of statins in improving cardiovascular disease and death. They have enlisted many top cardiologists, including those who are seen and heard in the media most often, such as Dr. Paul Ridker and Dr. Steven Nissen (who is not half as critical of statins as he is of NSAIDs) to participate. I think it's called Galaxy because it has all those cardiology stars on board.
The Lunesta people have a huge set up that mimics sitting under a beautiful night sky. Doctors can sit there in comfortable chairs and watch a television advertisement for the drug.
There are people dressed up as sandwiches, people dressed as arteries, and muscles, and even a pancreas. There are, of course, lots of free pens (not that there's anything wrong with that!) and lots of questionable information. I'm sure the exhibitors pay a pretty penny to have their exhibits at the Assembly. Those are the dollars that make the niceties of the conference possible. posted by Sydney on
9/29/2006 05:11:00 PM
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Thoughts on My Profession: This conference, the yearly American Academy of Family Physicians Scientific Assembly is, as always, very good. Unlike most conferences, you don't have to sit all day listening to one lecture after another. You choose them like you would a high school or college curriculum. And there are plenty of good CME topics and lectures from which to pick and choose.
I've been concentrating my efforts so far on the evidence based medicine lectures. Each of the lecturers in this series has made an effort to weigh the research evidence in an unbiased way. For instance, what is the best treatment of chronic kidney disease, congestive heart failure, or diabetes? So far, none of the speakers at the lectures I've attended have admitted to any drug industry ties, though the series is supported by grants from the pharmaceutical companies. And, to the Academy's credit, they've doubled the continuing medical education credits attendees can claim to encourage attendance at these sorts of lectures.
However, even given all of that, the take home message of all of them so far has been to load up patients with drugs at the earliest possible stages of disease. I'm oversimplifying, but only a bit. The chronic kidney disease message was don't be afraid of polypharmacy. Ditto the congestive heart failure message. Ditto the diabetes control. Putting someone on four drugs to control their hypertension is fine as long as it lowers their blood pressure. Oh, and while you're at it, put them on a statin because it might delay the progression of kidney disease, too. If they have diabetes, don't be afraid to put them on three more drugs to control their diabetes. If they have heart failure, be sure to add a beta-blocker. And you know what? If that beta-blocker makes their heart rate go down too low, put a pace maker in. It's worth it if you can get them to stay on the beta-blocker.
Whew. The problem here is that the composite patient with all of those diseases is not a rare bird. He's the American robin of American medicine. Most diabetics at some point will also have hypertension and chronic kidney disease and eventually heart failure. Follow the recommendations of the evidence and they could end up on nine or ten different medications. This is not necessarily a good thing. The studies which support each of these recommendations were done on pristine populations - people who had either hypertension or diabetes but not both. And the real kicker is, that there are no studies comparing the fates of patients taking all of the medication recommended by the evidence with those taking none, or only the minimal required to improve their functional capacity. This is an important distinction, because much of the evidence based therapy is aimed at preventing death or hospitalization, not at making the patient feel better.
More drugs means more potential for side effects, interactions, and medication errors (Both on the part of patients in taking them correctly and on the providers in refilling them correctly. It's hard to keep track of long lists.) There may be a very real downside in taking all of those we recommend for each separate condition, but no one has done the studies to find out. And why would they? Medical research funding is dominated by pharmaceutical companies. They aren't going to pay for a study to find out if people shouldn't be taking their drugs.
Road Blogging: I bought a Sony Vaio SZ220 to replace my Dell Inspiron laptop that I use at work for the EMR. (Or EHR, if you want to be trendy about it.) It came with a 30-day trial offer of Cingular's wireless WAN service. I'm blogging this on the Pennsylvania Turnpike en route to Washington, D.C., where earlier today my comrades marched on the Capitol. I'm skipping the political content of the meeting and focusing on education and shopping.
The wireless WAN isn't too bad. The connection is slower than DSL - too slow to be useful for the also-slow VPN that lets me connect to the office. One could go into a coma waiting for the delay time between functions. But, it's adequate for blogging.
By the way, $11 to travel the Pennsylvannia Turnpike from the Ohio border to the route 70 exit is over-rated. It has to be one of the worst insterstates in the nation. What do they do with that money? posted by Sydney on
9/27/2006 01:45:00 PM
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Something strange is happening in the NHS [National Health Service]. Something important is quietly dying. I don't think it is too fanciful to call it the spirit of medical professionalism. And we, the medical profession, are watching it die. Far from being privatised, medicine in England has become ever more a creature of the state.
All that has really changed ... is who does the kicking and who is kicked. Increasingly centralised decision making, driven by a political imperative for constant reform, has left us victim to 'a patchwork of mutually contradictory ideas struggling for dominance.'
We, too, are at risk for this, with each new government mandate and "quality assurance" initiative. The people who pay the bills are deciding the definition of "quality" in medicine, and it is too often a politically based, not medically based, definition. posted by Sydney on
9/24/2006 08:03:00 PM
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Leading with the Heart: This past week saw the publication of research in the New England Journal of Medicine which could prove to be the turning point in stem cell therapy, although it didn't get as much media attention as one would expect given all the hype we've been privileged to receive over the past couple of years. You know, the therapy that will make Christopher Reeves walk again (and breathe, and live). The headlines that did appear were mixed:
There were three studies published in the Journal. All of them involved injecting patients' own bone marrow cells into a coronary artery that had become clogged and caused a heart attack. All of them measured the ejection fraction of the heart before and after stem cell injection to determine the extent of improvement. Two of them showed improvement in the hearts' function. One of them didn't. One would think that two out of three would weight the headlines toward the positive, but adult stem cells don't have the press relations that embryonic stem cells have.
First the study in which there was no improvement. In this study, all of the selected patients had heart attacks that involved the anterior wall of the heart, and which caused ST elevation on their EKG's. Both are associated with poorer prognosis in heart attack victims. All of the patients underwent angioplasty and stent placement. Half of them, that is 50, then received injections of their bone marrow cells into the affected coronary artery within a week of their heart attack. Six months later, their ejection fractions had increased to the same degree as the 50 patients who did not receive any injections, given the margin of error of the measurements.
The second study, which did show improvement, had the same sort of patients and control subjects with three exceptions - the heart attack did not have to involve the anterior wall, the control group received placebo injections rather than no injections, and the bone marrow cells were a heterogenous mix of different types rather than one isolated type (The unsuccessful study used only mononuclear bone marrow cells, which are one of many different types of stem cells found in the marrow). Four months later, there really wasn't much difference in the improvement of ejection fraction, again within the margin of error. However, after a year, there was substantial improvement in other measures - six percent of the controls died, for example, compared to only 2% of the stem cell treated patients. Forty percent of the controls had either died, had another heart attack, or required another angioplasty by the end of a year, compared to only 23% of the treated patients. Something went right there.
The last study was a little different. The patients in this study had heart attacks up to three months before the stem cell injections. They used the mononuclear stem cells, but from two different sources - bone marrow cells and circulating blood. They thus had three groups of patients for comparison - patients who received sham injections, patients who received bone marrow stem cells, and patients who received stem cells found in their circulatory system. After three months, the change in ejection fraction was about the same in the two groups given the margin of error in measurment. (Do you get the feeling that measuring the ejection fraction isn't the greatest gage?) During that three month period, there were no deaths, heart attacks, or episodes of congestive heart failure in the bone marrow recipients compared to 4% of the controls and 9% of the peripheral blood recipients. (The sample size, however, was very small - only 23 in the control group, 34 in the peripheral blood group, and 35 in the bone marrow group.) They also measured how the patients felt by assessing what's known as the NYHA classification. The authors say that the bone marrow recipients had significant improvements in their NYHA classification compared to the other two groups, but when compared to the margin of error for the measurements, they didn't, really. The bone marrow recipients score dropped from 2.23+/-0.6 to 1.97+/-0.7. Compare that to the change for the placebo group - from 1.91+/-0.7 to 2.09+/-0.9. In other words, none of the groups had much of a change in their functional status after three months.
Interestingly, at the end of three months, this study did something different. The researchers injected the controls and the peripheral blood recipients with bone marrow cells to see if things would improve for them. They did. Both groups had absolute increases in their ejection fractions that exceeded those they had in the first three months of the study. They were very tiny increases, however, of only 2-4 percentage points.
So, what's the verdict? It certainly seems that the adult stem cells made some difference, especially in the second study, which was not only the longest period of observation, but also used the greatest mix of stem cells. There's something in that bone marrow that heals the ailing heart, we just aren't sure yet what it is, how it works, or how long it takes. posted by Sydney on
9/24/2006 07:31:00 PM
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Mobile Medpundit: I understand that Medpundit can be accessed via mobile phone browsers at this site. I don't have a mobile phone browser, but here are the instructions that came via email:
Simply point your mobile phone browser to here and use the keyword "medpundit". Similarly, send an SMS to 415-676-8397 and use keyword "medpundit" to get the latest headlines in SMS.
411Sync is a mobile search company that lets users access content from their cell phones using SMS, WAP and Email. Users can also configure alerts to notify them when your blog is updated.
Canadian Truth: A Canadian explains Canada's healthcare system. The health policy wonks here in the U.S. often tout Canada's system as the gold standard, and claim that having the government assume all of our healthcare cost will save money because none would be going to the extravagant salaries of insurance company CEO's. Think again:
Just three years into government–run hospital care in British Columbia, in 1952, the government noted that "the demands for additional beds and better standards of service are being put forward on all sides, presumably with the assumption that someone other than the proposer will pay for them. It seems the government is expected to satisfy these demands at no additional cost to the people."
In the past 30 years, total per capita health–care spending in Canada more than doubled in real dollar terms; health spending was 10.4 percent of GDP in 2005. The private sector's share of the "single–payer" system has increased 27.7 percent since 1975. If it hadn't, our infamous waiting lists and other rationing would be worse. People paying out–of–pocket and private insurers have picked up the slack and will continue to do so—to the benefit of our health.
The idea that a state government can pay for virtually every health–care service and save money doing it can be called many things–just don't call it Canadian. posted by Sydney on
9/24/2006 08:31:00 AM
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