medpundit

2008-01-01T20:22:00.000-05:00

Year's End, Blog's End: I've been making my annual year end inventory - deciding what to keep and what to toss. It's become obvious in the past several months that this blog is one of the things that it's time to toss. This will be the last post for Medpundit. Truly.

Wishing you all the best in 2008 and the years beyond.

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Pilgrim Medicine

2007-11-22T20:31:00.000-05:00

Thanksgiving Remembrance: Mayflower Medicine.

Genetic Prejudice

2007-11-11T22:02:00.000-05:00

Any Excuse Will Do: Any excuse to justifying prejudice, or to stir up fear mongering of what may come:

At the same time, genetic information is slipping out of the laboratory and into everyday life, carrying with it the inescapable message that people of different races have different DNA. Ancestry tests tell customers what percentage of their genes are from Asia, Europe, Africa and the Americas. The heart-disease drug BiDil is marketed exclusively to African-Americans, who seem genetically predisposed to respond to it. Jews are offered prenatal tests for genetic disorders rarely found in other ethnic groups.

Such developments are providing some of the first tangible benefits of the genetic revolution. Yet some social critics fear they may also be giving long-discredited racial prejudices a new potency. The notion that race is more than skin deep, they fear, could undermine principles of equal treatment and opportunity that have relied on the presumption that we are all fundamentally equal.

"We are living through an era of the ascendance of biology, and we have to be very careful," said Henry Louis Gates Jr., director of the W. E. B. Du Bois Institute for African and African American Research at Harvard University. "We will all be walking a fine line between using biology and allowing it to be abused."

We have been living in an era of ascendant biology since Darwin. Remember eugenics? Jews have been offered prenatal testing long before the mapping of the human genome, as have African-Americans. But prenatal screening is not quite the same as the eugenics movement heyday.

So why the hyperventilating? It turns out that the Times is taking its cue from blogs commenting on studies studies like this. Well, if the blogs say that genetics justifies prejudice, it must be true! I never thought I would see the day that the New York Times took that attitude on its front pages. It must be part of their plan to join the internet age. Here's the part that's gotten the Times convinced that genetics is going to bring back the days of institutionalized prejudice:

There exists a publicly available gene database, The HapMap Project, that contains random samples of genetic sequences from people in China, Japan, Nigeria, and people in the United States with European ancestry. It’s now possible to search the HapMap database for genes that have been linked with intelligence in published scientific studies. In this manner, we can determine if high intelligence genes occur with greater or lesser frequency in the various races.

Now, here’s an interesting point. If even a single gene correlated with intelligence occurs with different frequencies in the different races, this alone proves that there are racial differences in intelligence. How is that? Well, the egalitarian theory holds that every race has identical intelligence. Therefore, whatever genes there are that affect intelligence, they must be distributed exactly equally in all human races. Once even a small race difference is proven, the egalitarian theory is proven false. At that point, it’s only a matter of determining which race has the higher average intelligence based on the genetic evidence.

Oh, please. Here's a take home lesson for everyone on the science of genetics, and one that should never be forgotten - these studies are about associations of genes with traits, not the concrete coding of a trait by a given gene. Just because a locus on a chromosome can be found more often in people with schizophrenia than in the general population doesn't mean that everyone with that genetic code in that spot will have schizophrenia, anymore than it means that every sibling of a schizophrenic will have the disease. Ditto with intelligence. Ditto, too, with cancer risks and most other traits and diseases human genome mapping is linking to genes. The essence of a man is not written into his DNA.

Here's another important point to remember - our science is still young and uncertain:

These genomewide association studies have been able to examine interpatient differences in inherited genetic variability at an unprecedented level of resolution, thanks to the development of microarrays, or chips, capable of assessing more than 500,000 single-nucleotide polymorphisms (SNPs) in a single sample. This "SNP-chip" technology capitalizes on a catalogue of common human genetic variations that is provided by the HapMap Project, which was made possible by the completion of the consensus human-genome sequence...

....The main problem with this strategy is that, because of the high cost of SNP chips, most studies are somewhat constrained in terms of the number of samples and thus have limited power to generate P values as small as 10–7. In addition, most variants identified recently have been associated with modest relative risks (e.g., 1.3 for heterozygotes and 1.6 for homozygotes), and many true associations are not likely to exceed P values as extreme as 10–7 in an initial study. On the other hand, a "statistically significant" finding in an underpowered study is more likely to be a false positive result due to chance than is such a finding in an adequately powered study, and "statistically significant" associations could be attributable to systematic bias (e.g., from confounding due to ethnic ancestry, also known as population stratification). Thus, the sine qua non for belief in any specific result from a genomewide association study is not the strength of the P value in the initial study, but the consistency and strength of the association across one or more large-scale replication studies. Robust replication should permit the identification of true positive results and the weeding out of false positive results.

In other words, take these genome studies that link intelligence and race just as about as seriously as you would take studies linking intelligence to sex, or that predict elections with brain scans.

UPDATE: Best of the Web draws an important distinction:

Note that "the presumption that we are all fundamentally equal" is quite different from the notion "that all races are equal." The former is a moral principle, a premise about the basic dignity of every individual; the latter is an empirical presumption about group averages in measurable traits. Someone with an IQ of 80 is as human as someone with an IQ of 120; and this is so regardless of whether the average IQ of one race is different from that of another.

What worries people like those in the Times story is that racial differences in IQ or other traits seem to lend empirical support to racist theories. But those theories are qualitatively wrong, so that no empirical evidence could make them right. If all individuals are of equal dignity and worth regardless of IQ, then a group is not fundamentally superior or inferior to another group by virtue of differences in average IQ.

It seems that some very smart people mistakenly think that intelligence is a measure of fundamental worth. Maybe they're a little too impressed with their own brilliance.

Veteran's Day Remembrance

2007-11-11T12:25:00.001-05:00

In Remembrance:
Winged Victory

Veteran's Day movie recommendation - Wooden Crosses.

Veteran's Day medical reading - the influence of World War I on heart surgery.

A Word About MRSA

2007-11-03T19:14:00.000-04:00

A Word About MRSA: I've been fielding a lot of doorknob questions about MRSA lately. (Doorknob questions= questions thrown out just as my hand reaches the doorknob to leave the room.) Little wonder. It's been in the news again and again, and has even prompted the closing of schools and cancelling of football games. Despite what some editorialists say, it is being framed as a threat to our children. Here's an example of the typical coverage:

A 16-year-old Springfield High School junior remained in serious condition Friday in the intensive-care unit of Akron Children's Hospital with a drug-resistant staph infection. Michael Forester of Lakemore was hospitalized Oct. 24 and was to undergo surgery Friday, said his mother, Mary Baxter. "The more prayers I can get, the better," Baxter said Friday at the hospital.

On Wednesday, Springfield School Superintendent William Stauffer, in a letter sent to parents, acknowledged that a student had become ill and was admitted to the hospital. The superintendent said rumors that the student has a contagious disease that puts other students at risk and that the high school has an ongoing problem with staph infections are not true. Stauffer could not be reached for comment Friday.

What is this MRSA? A better question might be "What is SA"? The "SA" in MRSA is Staphylococcus aureus, a bacteria that resides in our nasal passages and skin. That is its habitat. Normally, it causes us no problem, but if conditions are right, it can make us quite ill. It's often the culprit behind boils and styes and cellulitis and urinary tract infections. It can also cause more serious infections such as pneumonia (as in the case of the young man in the linked to article above), meningitis, sepsis, endocartditis, and osteomyelitis. It is one of the most common causes of sepsis. Penicillin conquered Staph infections for a little while, but the bacteria acquired resistance within a few years of the antibiotic's introduction. When penicillin became widely used in the community, the population of Staph aureus living in noses and on skin shifted toward those containing an enzyme that could cut the betalactam ring on penicillin, rendering it ineffective. New antibiotics were developed to get around this. One of those antibiotics was methicillin, which brings us to the "MR" part of "MRSA".

We don't use methicillin any longer. We use drugs like Augmentin instead. But, when we say that a Staph aureus infection is "methicillin resistant" we mean that it's resistant to all penicillins, even those that were developed to get around the betalactam-eating defenses of the Staph aureus population. This doesn't mean that it's resistant to all antibiotics, however, just the ones that we typically use for a Staph infections. In the hospital, we often use vancomycin for MRSA infections. In the outpatient setting, we use drugs like Bactrim and clindamycin. In most cases, the infections respond nicely to these drugs. There is, however, concern that the bacteria may one day develop resistance to these, too, as we use them more to treat the growing resistant population of Staph.

So here are the take home points about MRSA:

1) It isn't running amok in our schools like the blob or killer tomatoes. It's living on our skin and nasal passages just as it always has before it developed resistance to penicillin and its cousins.

2) One of the reasons bacteria acquire resistance is because we expose them to antibiotics when we don't need to. Don't insist on an antibiotic for every runny nose, even if the snot is yellow. And don't insist on one of the special antibiotics for MRSA for every pimple or pustule or red scratch. If we overuse our remaining effective antibiotics, we'll only end up with a population of Staph aureus that is resistant to those, too.

3) Don't freak out if you or your child develops a skin infection. Most staph infections are easily treatable. Even most MRSA infections are easily treatable.

4) When you read the newspaper, always remember that they lean to the dramatic in all things. It makes for more entertaining reading.

Trusty Dentist

2007-11-03T18:01:00.000-04:00

Trusty Dentist: Not so trusty with music and a drill.

All Saints Medical

2007-11-01T21:57:00.000-04:00

All Saints' Day: A list of medical saints - albeit an incomplete one.

Lipo-Etching

2007-11-01T21:51:00.000-04:00

Forever Young, Forever Firm: Lipo-etching- maybe not all it's cracked up to be.

Statistics, Politics, and Medicine

2007-11-01T21:43:00.000-04:00

Lies, Damned Lies, and, Well, You Know: The New York Times is parsing Rudy Guiliani's prostate cancer statitistics:

"I had prostate cancer five, six years ago," Mr. Giuliani, a Republican presidential candidate, said in a speech that has been turned into the radio commercial. "My chance of surviving prostate cancer — and, thank God, I was cured of it — in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine."

.... The Office for National Statistics in Britain says the five-year survival rate from prostate cancer there is 74.4 percent. And doctors also say it is unfair to compare prostate cancer statistics in Britain with those in the United States because in the United States the cancer is more likely to be diagnosed in its early stages.

"Certainly, if you intensively screen for prostate cancer, you will find early disease,” said Dr. Ian M. Thompson, chairman of the department of urology at the University of Texas at San Antonio. "And simply because you find it earlier, you will always have longer survival after the disease is diagnosed."

One reason that prostate cancer is diagnosed earlier in the United States than in Britain is that they don't screen for it at all in Britain - at least not at the expense of the NHS. (Which is one of the reasons they spend less on healthcare than the United States. They don't indulge in as much screening as we do.) At any rate, his statistics don't appear to be all that far off the mark, at least for men in their 80's. But even the NHS admits that prostate cancer survival is increasing because more people are starting to have their PSA checked - meaning that slow growing early cancers are being added to the mix, just as happens here in the US. As it happens, even back in 2002, the five year survival rate for prostate cancer in the US was 99% - still a much better figure than the UK's 71%.

But, as the astute bloggers point out, prostate cancer isn't the best example of the benefits of screening. Prostate cancer is, in most cases, slow growing - and although our screening policies detect many early cancers that would never do harm if left undetected, we also end up spending a lot more money treating these same cancers. When given the choice between watchful waiting and removal, many choose removal. (Another reason why we end up spending more and being less healthy in surveys like this.)

But the Astutes take a closer look at cancer in England and cancer in the US:

See this report, entitled "Cancer Survival Rates Improving Across Europe, But Still Lagging Behind United States" (and remember that England's rates, not broken out, are among the worst in Europe).

Taking recent figures, female five-year cancer survival rates are 62.9 per cent on average in the US and 52.7 per cent in England. To compare America's privately insured with England's NHS patients, you'd need to bump up that American survival rate a bit (the uninsured most likely have lower survival rates--otherwise why worry about universal coverage) and bump down the English one (because some Brits have private insurance, and so buy better care).

Nationally, American cancer survival rates are significantly better. Certainly not by the 40-point margin Giuliani implied, but still.

Looks like the truth is somewhere between Rudy and the Times.

Eliminating Cold Medicine

2007-10-29T08:10:00.000-04:00

Take Some Tylenol and Call Me in the Morning: What will we do without cough and cold medicine? I can hear it now, that familiar refrain - "Tylenol doesn't do anything." And it doesn't, at least not for runny noses, sneezes, and coughs, despite what the expert says:

Children’s Tylenol and Children’s Motrin, when sold by themselves, were excluded from the discussions because the medicines in those products, acetaminophen and ibuprofen, respectively, are safe and effective in treating fevers and aches even in young infants.

Tylenol and Motrin are sold in syrupy concoctions that help coughs because the syrup coats the back of the throat and calms cough receptors, said Dr. Ian Paul, a pediatrician at Penn State Children’s Hospital in Hershey, Pa., who consults for industry.

The committee skipped any lengthy discussion of antihistamines like Benadryl, because there is little debate that such medicines are effective for allergies. Benadryl, also known as diphenhydramine, also puts some children to sleep. But nearly all the experts said deliberate sedation should be discouraged.

The medicines that earned the most scorn were those commonly sold to treat coughs, runny noses and congestion, including dextromethorphan and phenylephrine.

None of them have any proven effect on children’s cold symptoms. All have risks.

The advisory panel is right, however, about the effectiveness of the medications. They are effective mostly in that they give a parent something to do so they don't feel as if they're standing by while their child suffers. The number of children injured by the drugs, however, has been exceedingly small:

A study by the Centers for Disease Control and Prevention found that at least 1,519 children younger than 2 had serious health problems from 2004 to 2005 after having been treated with common cold medicines. Three children died, the disease control agency found.

But the argument is, that if they don't do any good in the first place, then why tolerate any risk? But, according to this story, the pharmaceutical companies say the issue is accidental overdosage, not inherent risk in properly dosed drugs:

The Consumer Healthcare Products Association (CHPA), which represents manufacturers and distributors of over-the-counter medicines, said in a statement: "The data clearly show that these medicines are very safe when used as directed and that harm to this age group, while very rare, is attributable in most cases to accidental ingestion an issue of safekeeping that is best addressed through education."

So what to do? My recommendation would be not to use them. Runny noses and coughs aren't in the category of intolerable suffering, and these products aren't likely to be much benefit anyway.

Screening for Autism

2007-10-29T07:56:00.000-04:00

I Screen, You Screen: The American Academy of Pediatrics is recommending that all children be screened for autism. They've only press-released their recommendations, however, so it's difficult to assess them. Wouldn't it be nice if professional organizations actually released their recommendations to their members before they did so to the public? It would make it so much easier for doctors to discuss the news stories with their patients. They're releasing them today at their annual conference, and later in the November issue of their journal, which is not yet available online. (Though it may be in AAP member's mailboxes.)

Part of any well child visit is screening for developmental delays, so one has to wonder what's different about these recommendations. Are they setting lower limits for what's abnormal so that those mild cases of autism (which some argue aren't really autism or even disease) can be treated? If that's the case, then don't be surprised when a couple of years from now there's a upward spike in the number of cases of autism. And don't blame it on vaccines.

Magnet-Free Europe

2007-10-28T22:19:00.000-04:00

Magnet-Free Europe: For some reason, the EU was proposing severe restrictions on the use of MRI scans, a proposal which has been halted- for now. Here's the reasoning behind the original restrictions:

The Directive was drafted by DG Employment, with the aim of minimising workers’ exposure to electromagnetic fields (EMF). Currently eight million MRI patient examinations per year are carried out in Europe, said Professor Dag Rune Olsen, who works in experimental radiation therapy at the Norwegian Radiation Hospital, Oslo, Norway, and is chairman of the physics committee of the European Society for Therapeutic Radiology and Oncology (ESTRO). “But these are likely to have to stop, since the Directive sets limits to occupational radiation exposure which will mean that anyone working or moving near MRI equipment will breach them, thus making it possible for them to sue their employers. Even those maintaining or servicing the equipment may be affected,” he said.

Radiation exposure? MRI's don't emit radiation, they detect the magnetic spin of atoms. The EU is worried that workers will be mesmerized by the MRI's. Sally Szwarc has more.

Spooky Skulls

2007-10-28T21:58:00.000-04:00

Spooky Skulls:Spooky brain pictures. Background here.

Preventing Alzheimer's

2007-10-28T21:48:00.000-04:00

Of Mice and Mazes: Do high blood pressure medications prevent Alzheimer's? They do in mouse brains - in test tubes and in mazes:

The researchers then tested Diovan in mice that were genetically at risk for Alzheimer's disease.

Some of the mice drank water laced with Diovan. Their Diovan dose was lower than that used for people with high blood pressure.

For comparison, other mice got ordinary water without Diovan.

After drinking their assigned water for 11 months, the mice took a memory test in which they had to learn and remember the path through a watery maze.

The mice that drank the Diovan water fared best in the maze test.

But when the researchers tested mice without the dementia gene glitch, Diovan treatment didn't help or hurt the mice navigate the watery maze.

We'll have to wait a while to see how this pans out. What works on mice in mazes doesn't necessarily work on men in mazes.

In Error

2007-10-28T21:35:00.000-04:00

Errors, Errors: The sad story of a medical error and learning to deal with errors.

Inspiring Lives

2007-10-28T18:07:00.001-04:00

Inspiring Lives: Speaking of the supreme champion of eugenics, here's an inspiring story from the days of his reign.

Medical Sci-Fi Contest: Please Meet the Winner! - Medgadget - www.medgadget.com

2007-10-28T18:06:00.000-04:00

Medical Science Fiction: Late to the party, but here are the winners of Medgadget's Medical Sci-Fi Contest. Enjoy.

Eugenics Past and Present

2007-10-28T08:32:00.000-04:00

Eugenics Past and Present: I've been reading an essay from 1907 by David Starr Jordan, a great mind of his time - scientist, peace activist, president of Standford, and eugenicist. The essay is the The Human Harvest, an anti-war argument grounded in eugenics. From a eugenics perspective, wars are bad because they kill the best men, leaving behind the weakest to perpetuate the race- and weaken the human harvest. Even in the service of a profound good the the callousness and cruelty of eugenics:

Startling results may follow from the selective breeding and preservation of paupers. In the valley of Aosta in northern Italy, and in other Alpine regions, is found the form of idiocy known as cretinism. What is the primitive cause of the cretin, and what is the causal connection of cretinism with goiter, a disease of the thyroid glands which always accompanies it, I do not know.

It suffices for our purpose to notice that the severe military selection which ruled in Switzerland, Savoy, and Lombardy for many generations took the strongest and healthiest peasants to the wars, and left the idiot and goitrous to carry on the affairs of life at home. To bear a goiter was to be exempt from military service. Thusin some regions the disease has been a local badge of honor. It is said that when iodine lozenges were given to the children of Savoy in the hope of preventing the enlargement and degeneration of the thyroid gland, mother would take this remedy away from the boys, preferring the goiter to military service.

In the city of Aosta the goitrous cretin has been for centuries an object of charity. There is a special hospice or asylum devoted to his care and propagation. The idiot has received generous support, while the poor farmer or laborer with brains and no goiter has had the severest of struggles. In the competition of life a premium has thus been placed on imbecility and disease. The cretin has mated with the cretin, the goiter with the goiter, and charity and religion have presided over the union. The result is that idiocy is multiplied and intensified. The cretin of Aosta has been developed as a new type of man. In fair weather the roads about the city a re lined with these awful paupers - human beings with less intelligence than the goose, with less decency than the pig.

No acknowledgment that those cretins might have even a glimmer of a soul. The disabled are genetically impure. Eugenics caught up with the goitrous of Aosta. They were forbidden to marry and ceased to be a pollute the public streets. They also became a celebrated example of the power of eugenics to improve the ~~human harvest~~ public health. Many an American eugenicist cited the success of Aosta in ridding itself of goitrous cretins when advocating state eugenic boards.

David Jordan Starr must have been horrified by World War I and it's toll on the best and brightest. he died in 1931, before the supreme triumph of eugenics in Europe. No doubt, he would have argued that eugenics was misused in Europe precisely because the best men had all perished on the battlefields of World War I. But the problem with eugenics is its denial of the humanity of those it deems unworthy - whether they be cretins or those with seizure disorders (they were sterlized, too, under the compulsory sterilization laws) or Jews.

Science (and society) has pretty much given up on the old fashioned eugenics that relied on controlling reproduction the same way one would in plants or livestock. But we still flirt with eugenics using modern methods of RichardDawkins.net>genetic selection. It might not seem like eugenics because it isn't imposed by the state, but it is. It may be framed as a personal choice, but the end result is the same - to cull those deemed inferior or undesirable. Today prospective parents can prevent a Down's syndrome child from being born, or a child with cystic fibrosis. Tomorrow they may be able to de-select the hyperactive child or the child prone to depression. It seems like such a positive thing when framed as a personal choice that improves the life of a family, but is it good to kill off certain traits? Don't we diminish biological diversity when we do that?

Micropractice vs. Reality

2007-10-27T21:41:00.000-04:00

My Long Absence: I have been away too long from the internets and blogosphere. These forced, long absences always leave me a little depressed. But just as I was leaving for a conference in Chicago about a month ago, events forced me into an ideal micropractice. What does that mean? It means I'm short staffed and doing a lot of extra work myself.

There are two schools of thought when it comes to the business of running a medical practice. The conventional wisdom is that it's a waste of a doctor's productivity to do the small things - rooming a patient, getting the vital signs, giving shots, performing EKG's. It's a better use of resources to have someone else do those things while the doctor concentrates on treating the patient. Some physicians take it even farther - they have ancillary staff take the history and they just concern themselves with the exam and plan. (Not being someone who practices this way, I give them the benefit of the doubt and assume that they confirm that history before acting on it.) In theory, this allows them to see more patients. This is basically my style of practice. Except for this short staffed month.

This month, I've been almost practicing the ideal micropractice way. In the ideal micropractice the doctor does everything himself to reduce overhead. At least, that's the original intent, but even the micropractice guru has hired a nurse to help him out. One of my friends has a micropractice, and she keeps telling me that I do, too, but I don't believe I do. Once you start hiring staff, are you really a micropractice or just a solo practice?

The truth of the matter is that micropractices work only for micropopulations. Most people who practice that way limit themselves to 200-500 patients, whereas traditional practices handle 1500-2000. So which is better for the public good? A practice that can treat more patients and provide jobs or one that sees few patients and has no employees?

Talladega Germs

2007-10-14T11:53:00.000-04:00

Talladega Germs: This was some overly cautious and politically foolish advice:

NASCAR fans might seem rabid, but are they actually contagious?

Getting a hepatitis shot is standard procedure for travelers to parts of Africa and Asia, but some congressional aides were instructed to get immunized before going to Lowe's Motor Speedway in Concord and the racetrack in Talladega, Ala.

....Staff who organized the trips advised the NASCAR-bound aides to get a range of vaccines before attending -- hepatitis A, hepatitis B, tetanus, diphtheria and influenza.

Some thoughts: 1) It isn't influenza season, so getting a flu shot now to protect you in Alabama for the weekend is useless. (But not a bad idea if you're thinking forward to January or February 2008.) 2) The hepatitis B vaccine is a series of three shots given over six months. They won't be getting much protection from one shot given just before the trip. Unless the staff is travelling to Alabama with the expectation of one night stands and IV drug needle sharing, the hepatitis B vaccine seems a bit superfluous. (Even for international travel, it's only recommended if a person is expected to have contact with blood or the sex industry.) 3) If there's been an outbreak of hepatitis A among food vendors at the race track, then that makes sense, but evidently that isn't the case. 4) Tetanus is everywhere. Always keep your tetanus booster (which comes included with diphtheria) up to date.

In defense of Congress, the organizers say that their staffers were going to be visiting hospitals and police stations where they had the potential to be exposed to hepatitis. Maybe. But unless they were planning to subdue the criminal elements and nurse the ill themselves, they didn't really need the shots. As it turns out, what they really needed was carpal tunnel splints:

Walker said he hadn't recommended the immunizations, nor were they necessary. He suggested a possible health risk to them was the voluminous notes they took.

"I'm sure they needed to soak their wrists, they wrote so much," he said.

UPDATE: More on the thinking behind the advice:

Homeland Security Chairman Bennie Thompson of Mississippi said he never meant to offend or scare anyone about health risks at the races. The measure was advised to provide congressional staff with the same disease protection first responders get, especially as they head out on a series of fact-finding missions around the country.

"It's not about whether the people have shots. ... Our staffs as they go forward will be going into sterile areas, they will be working in public health facilities, they will be talking to many holding facilities where criminals are being held....

"The NASCAR event is just one date, but after that they will be doing a number of things," said Thompson, adding that the World Series and Super Bowl are two other mass gatherings that are going to be researched for readiness.

During the trip to North Carolina, staffers were to visit a medical facility with patients at the Lowe's Motor Speedway. They were also set to inspect an empty mobile hospital. After the House physician told Republican staffers that shots were not necessary to go to North Carolina, they didn't get them. Democratic staffers reportedly did.

That explains the influenza shots, anyway.

Alzheimer's and duty

2007-10-02T07:21:00.001-04:00

Blessed are the Dutiful: Being a conscientious person prevents Alzheimer's dementia:

The Rush University Medical Center in Chicago examined nearly 1,000 Catholic nuns, priests and brothers.

Those who rated themselves highly conscientious had an 89% lower risk of Alzheimer's than those who thought they were the least self-disciplined.

What do you suppose the term "conscientious" means to a person in holy orders? Does it mean the same to those of us who are non-religious or living in the secular world? To me, conscientious means trying hard not to overlook any detail in a history, physical, lab, or x-ray result. To a nun or brother, it's more likely to mean praying a lot. Not quite the same sort of brain activity.

The full text isn't available without a fee, but here's the abstract. The BBC report provides some details, though:

None of the participants had dementia when the study started in 1994, but 176 went on to develop the disease.

The researchers asked the volunteers to rank themselves on a five-point scale to determine just how conscientious they were. They also carried out medical and neurological tests each year until 2006.

The average score on the conscientious test was 34. Those who scored 40 or higher were found to be much less likely to develop Alzheimer's, and had a slower general rate of mental decline than those who scored 28 or lower.

When the researchers took into account a combination of risk factors, including smoking, inactivity and limited social connections, they still found that the dutiful people had a 54% lower risk of Alzheimer's compared to people with the lowest scores for conscientiousness.

We don't know how significant that "54% lower risk" is, however. It could be the difference between 2 and 1, or between 100 and 50. Take this one with a grain of salt.

The Wife Factor

2007-10-02T06:46:00.000-04:00

Intrusive Homelife: Does it matter if a candidate is glued to his wife?

The fact is that people inside the Giuliani campaign are appalled at the number of times their candidate has felt compelled to interrupt public appearances to take calls from his wife. The estimate from those in a position to know is that he has taken such calls more than 40 times in the middle of speeches, conferences and presentations to large donors. "If it's a stunt, it's not one coming from him," says one Giuliani staffer. "It's an ongoing problem that he won't take advice on."

And in trying to explain his odd behavior, Mr. Giuliani has only dug himself in deeper. On Friday he told David Brody of CBN News that since 9/11, when he and Mrs. Giuliani get on a plane, "most of the time . . . we talk to each other and just reaffirm the fact that we love each other." He admitted he had taken calls from his wife "before in engagements, and I didn't realize it would create any kind of controversy." That's hardly possible. Giuliani staffers say he has been warned over and over again that the phone calls are rude and inappropriate and have alienated everyone from local officials to top donors to close friends.

Consider a spring incident in Oklahoma City. Mr. Giuliani spoke twice at the Oklahoma History Center, first at a small private roundtable for $2,300 donors and then to 150 people who donated $500 apiece. Ten minutes into the roundtable, Mr. Giuliani's phone rang. He left the room to take the call, apparently from Mrs. Giuliani, and never returned. The snubbed donors received no explanation. "The people there viewed it as disrespectful and cheesy," says Pat McGuigan, a local newspaper editor who was asked by the Giuliani campaign to moderate the roundtable.

An hour or so later, Mr. Giuliani was speaking to the bigger group of donors when his phone rang again. While he spoke with his wife, he invited her to say hello to the assembled crowd. "It was remarkable, and was not viewed by the audience in a positive way," public relations executive Brenda Jones told me.

I've been told of many other incidents, from a California fund-raiser to a Florida speech to a gathering with top donors at Bear Stearns in New York. At the Bear Stearns meeting, Mr. Giuliani took a call from his wife and then noting the strained faces of his supporters, he sheepishly tried a joke. "I've been married three times," he explained. "I can't afford to lose another one. I'm sure you understand." (Mr. Giuliani's media office didn't return a call I made to them on Friday afternoon.)

This brought back memories of people I've known. There was the doctor who was always a half hour late coming back from lunch (spent daily with his wife) who used the same excuse about multiple marraiges. There was another who was perpetually behind because his wife paged him several times a day. He always dutifully left the exam room to answer his page, as if every one were an emergency. Judging from the office end of the conversations, they never were - "Yes. Yes. I love you, too."

There was always a general disdain in the workplace for these men. For one thing, it's irritating to the staff who are trying to get a job done only to be constantly delayed by the out of skew priorities of their boss. For another, it sends a loud and strong signal that nothing is as important to these men as their wives. And they are always men, never women, as the inelegant phrase that so aptly describes their emotional servitude proves.

There's probably no hope for Guiliani. He's smitten to the point of delusion. Which is too bad, because there are a lot of people who would vote for Rudy, but not for Judy.

Power of the Gods

2007-09-26T08:20:00.000-04:00

The Power of the Gods: Medical infallibility.

Universal Pander

2007-09-26T08:09:00.000-04:00

The Universal Pander: There's nothing like a presidential election to bring out the healthcare crisis. And, since the presidential primary process is stretching into a two year long spectacle, there's been no shortage of proposals on how to fix our current system. Recently, Dennis Kucinich pointed out that his ideas are the closest thing to what the American people want:

In a CNN poll this spring, 64 percent of respondents said the government should "provide a national insurance program for all Americans, even if this would require higher taxes," and 73 percent approve of higher taxes to insure children under 18. Those results track New York Times and Gallup polls last year, in which about two-thirds of respondents said it is the federal government's responsibility to guarantee health coverage to all Americans.

Such polls allow Kucinich to joke that, far from being in the loony left, "I'm in the center. Everyone else is to the right of me."

Ask the American public a different question about the healthcare system, and you'll get a different answer:

For the fifth time in six years, Harris Interactive has asked the insured public to rate their own insurance plans. Two thirds of them continue to give their plans an A or a B, with only 10% giving them a D or an F. Substantial but not overwhelming majorities continue to say that they would recommend their own health plans to family members who are basically healthy (76%) or who have a serious or chronic illness (68%).

Health insurance companies are like politicians. We dislike all but our own. We should be careful what we wish for, however, for it won't just be our own politicians designing a nationalized health insurance plan; it will be all the others that we dislike, including politicians who believe hospital pork is a public service, that healthcare and personal autonomy are mutually exclusive, and that the right to earn a living takes second place to health insurance.

What are people really wishing for when they say they wish for a single nationalized health insurance program? Security. Our current employer-provided system means that most of us are just a pink slip away from losing our insurance coverage. It also means that, deprived of the bargaining power of large corporations and unions, the self-employed are left with fewer choices and higher premiums. Handing over the whole kit and kaboodle to the government is a seductively simple solution. But it would also be a very expensive solution.

The British are often held up as the standard to which we should aspire. But we don't live under a British style of government. We live under a government that's truly government of the people, by the people, for the people. And what the people want, the people get. Witness the influence of disease activism even now on disease specific government funding and treatment mandates. In England, the government only pays for colonoscopies to check for colon cancer if there are symptoms suggestive of cancer or a family history of colon cancer. In the United States, the Medicare pays for a colonoscopy every ten years for everyone over 50, regardless of symptoms or risk. So do many insurance companies., sometimes if not by choice, by mandate. In England, mammograms are only covered for women between the ages of 50 and 70, and then only every three years. In the United States, we pay for mammograms beginning at age 40, yearly, and with no upper age limit. We just don't have the heart for rationing that they have in other countries.

A common theme in politician crafted health care schemes is that by paying for prevention we will save money, and thus be able to offer limitless healthcare services without bankrupting the country. Both Hillary Clinton and John Edwards have explicitly emphasized the importance of preventive healthcare in their plans- even to the point of patient-directed mandates in the case of Edwards. But if preventive services save money and lives, then why is the United Kingdom, which offers less expansive preventive services than the United States, both healthier and cheaper? (Hint: Dead people neither spend health insurance dollars nor complain about their health.)

Don't be fooled by the promises of health and wealth to be found in government-provided, or even mandated, health insurance coverage. It may bring you health, but it will be at a very steep price - both in money and liberty.

(Note: Next installment, a look at the Republican candidates approach to "universal coverage.")

2007-09-08T23:25:00.000-04:00

Zing the Body Electric: Treating high blood pressure, circa 1907 (click images to enlarge and read the text):

A close-up view of the blood pressure machine:

- from Scientific American, August 24, 1907.

The report sounds so confident:

The important feature is that the cure - the reduction of arterial pressure to the normal value - is permanent, and that the progress of the arteriosclerosis is arrested by the removal of the excess of blood pressure.

Seems kind of silly today, but look - one hundred years on and we're still flirting with the idea.

Here's what else was going on in 1907, and here's an early twentieth century text on treating diseases with electricity.

2007-09-04T08:05:00.000-04:00

Predicting the Flu Future: How will this year's flu season be? We've been remarkably lucky for the past several years with very little activity and relatively mild strains. But if Australia and New Zealand's experience this summer is any indication, this winter we may be in for a bad flu season:

Confirmed influenza cases reached 3,017 in the first seven months of the year, compared with 1,121 in 2006, according to the ministry's notifiable disease surveillance system.

In July, 2,111 cases were confirmed by laboratory tests, the highest monthly tally in at least six years.

"Sadly, some influenza infections have resulted in deaths this season, including in a small number of children,'' said John Horvath, Australia's chief medical officer, in an e-mailed statement today.

The latest Australian flu data is available here. After peaking at the end of July and beginning of August, the number of cases has begun to decline. Our flu season in the northern hemisphere is often smilar to the southern hemisphere's, just six months later. Look for our season to peak at the end of January and beginning of February - and plan your flu shot accordingly - in late October or early November.

P.S. There's a Flu Wiki!

2007-09-03T20:00:00.000-04:00

Orwell's England: In the here and now:

A pregnant woman has been told that her baby will be taken from her at birth because she is deemed capable of "emotional abuse", even though psychiatrists treating her say there is no evidence to suggest that she will harm her child in any way.

Social services' recommendation that the baby should be taken from Fran Lyon, a 22-year-old charity worker who has five A-levels and a degree in neuroscience, was based in part on a letter from a paediatrician she has never met.

...Under the plan, a doctor will hand the newborn to a social worker, provided there are no medical complications. Social services' request for an emergency protection order - these are usually granted - will be heard in secret in the family court at Hexham magistrates on the same day.

From then on, anyone discussing the case, including Miss Lyon, will be deemed to be in contempt of the court.

How did the good doctor come to that conclusion if he never met her?

Miss Lyon came under scrutiny because she had a mental health problem when she was 16 after being physically and emotionally abused by her father and raped by a stranger.

She suffered eating disorders and self-harm but, after therapy, graduated from Edinburgh University and now works for two mental health charities, Borderline and Personality Plus.

....Despite this support, endorsed by other psychiatrists and Miss Lyon's GP, social services based their recommendation partly on a letter from Dr Martin Ward Platt, a consultant paediatrician, who was unable to attend the meeting.

He wrote: "Even in the absence of a psychological assessment, if the professionals were concerned on the evidence available that Miss Holton (as Miss Lyon was briefly known), probably does fabricate or induce illness, there would be no option but the precautionary principle of taking the baby into foster care at birth, pending a post-natal forensic psychological assessment."

That takes "risk assessment" to dangerous levels.

2007-09-02T18:24:00.001-04:00

Google Surprise: Looking for varieties of morning glories on Google got this.

2007-08-31T23:05:00.000-04:00

Man of the People A sensible haircut.

2007-08-31T22:40:00.001-04:00

A Study in Contrasts: Medical professional organization political donations in 1990 and in 2006. The reason? Surely it must be tort reform.

Nurses have a different pattern of giving.

2007-08-31T22:31:00.000-04:00

PSA: Looking for reliable up to date basic information on your prescription drugs? There's a link in the left hand column to

Epocrates MedSearch Drug Lookup

, a public use version of the popular physician PDA tool, Epocrates.

2007-08-31T21:49:00.001-04:00

Second Hand Book Reviews: From The New England Journal, a review of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder, a critique of the cookbook of psychiatric diagnosis. It shaped the thinking of a whole generation of physicians:

As the title of this book — The Loss of Sadness — implies, psychiatrists who are influenced by the diagnostic practices that are encouraged in the DSM have become surprisingly imperceptive to the emotional miseries that life events evoke in their patients. These psychiatrists tend to perceive all such states of mind as major depressive disorder, with the result that they may reach for the prescription pad before they take a history. They practice, with the DSM as their guide, what Sir William Osler once dubbed "penny-in-the-slot therapeutics."

...Concentrating on depression, Horwitz and Wakefield describe how practicing psychiatrists gradually came to think about and treat specific states of demoralization and discouragement that arose from life contexts in the same way they treated pathologic mood disorders....

...The authors note that the DSM-III — by sorting conditions according to their resemblances, rather than by seeking essential differences — medicalized human suffering, diminished attention to human meaning in the field of psychiatry, and hampered communication between patients and physicians. This process encouraged psychiatrists to think only in terms of medications ....

Some would argue that the loss of sadness is a good thing. If all it takes is a pill to eliminate sorrow and anger, then the world's a better place, right? Maybe not. Do poets on Prozac create great works?

2007-08-31T08:44:00.000-04:00

Pulled from the Brink: Remember the girl who survived rabies? How's she doing? Very well:

Twenty-seven months after exposure, the patient continued to have fluctuating dysarthria and gait difficulties, plus an intermittent sensation of cold in the feet. She had no difficulties with her instrumental activities of daily living, including driving. In high school, she took college-level courses in English, physics, and calculus. She scored above average on a national college achievement test, graduated from high school in 2007, and planned to attend a local college in the fall. She had no problems with peer relations or mood disorders.

Alas, others have been unable to duplicate the success of her treatment, so if you are bitten by a bat be sure to get your rabies shots.

2007-08-31T08:27:00.001-04:00

Remembering Katrina: The medical feats we didn't hear about:

Besides rescuers and local first responders, another big story at the Dome was the medical center. Like a Chinook helicopter landing on your roof, that sure was hard to miss. Fifteen doctors and a total of 65 medical personnel set up at the New Orleans Arena, within spitting distance of the Dome. It was primarily for survivors brought in by air and boat, but also for people in the Superdome with medical problems. There was never any shortage of medical care, Dressler and Bush both said.

The Arena medical center cycled through triage and treatment of up to 5,000 injured or sick victims, Dressler said. Those in the worst shape were evacuated to the New Orleans airport and out of the region, those in good shape hydrated and sent to the Superdome. The success of the makeshift medical center was such that there were just six deaths at the entire Superdome complex: four of natural causes, one drug overdose, and one suicide during the week of supposedly rampant anarchy and death.

Triage (there was another medical facility at the airport) may have been the most critical element in limiting deaths once the levees broke and the city flooded. Rescue operations were brisk, but survivors of that kind of trauma aren't always coherent or aware of their own life-threatening injuries, particularly dehydration. Absent care, hundreds if not thousands could have died even after they were rescued and brought to the Dome.

Most of the national media also neglected to mention the seven babies that National Guard physicians delivered, something Maj. Ed Bush said he pointed out repeatedly. Overall, the false claims of up to 200 dead at the Dome, including murder victims, had clueless FEMA officials showing up at the end of the week with a refrigerated 18-wheeler to claim the stacks of bodies.

And questions unanswered.

2007-08-27T08:36:00.000-04:00

Seeking Perfection: The stressed out world of opera singers:

Singers often overuse steroids in the form of cortisone to control inflamed vocal cords — sometimes in amounts that can permanently impair their abilities, say performers and their doctors. Others drink too much. Still others snort cocaine, according to insiders.

That post nasal drip which is just a minor annoyance for most of us, can be devastating for a singer, especially an opera singer who can't hide behind the drums and bass guitar. If someone could come up with a sure-fire cure (that didn't have the side effects and health hazards of steroids) he'd make a lot of money.

2007-08-27T08:24:00.000-04:00

American Medical Reform: The American Medical Association's recommendations for health insurance reform.

2007-08-26T20:17:00.000-04:00

Improving Care: Readers of the New York Times weigh in on Medicare's new policy of refusing to pay for complications of care:

Even the most thoroughly researched preventive regimens continue to have substantial morbidity rates. Hospitals that already adhere to these guidelines (and there are many) will simply pay more and get paid less, without any improvement in their patient care.

And another:

Attempting to draw the line between truly preventable problems and those that are the result of prolonged therapy would seem to be a very slippery slope.

That said, I would happily endorse the proposed Medicare policy change, if we as taxpayers could hold our government and military to the same standards and refuse to pay for any of their “preventable” mistakes.

Heh.

And a practical example:

So, I admit Mrs. Jones, an elderly patient of mine, to the hospital because she has pneumonia. Because of the stress of the infection, she becomes delirious, which puts her at high risk of falling.

In the interest of safety, I restrain and sedate her, which necessitates an indwelling urinary catheter.

One week later, despite meticulous nursing care, Mrs. Jones develops a urinary tract infection and a minor pressure sore on her back because of her debilitated, immobilized state.

My hospital administrator then suggests that I remove the restraints and the catheter and reduce the doses of her sedatives so that the conditions don’t get worse and our hospital doesn’t lose money.

Two days later, Mrs. Jones falls out of bed and breaks her hip.

How, exactly, has the new Medicare policy improved Mrs. Jones’s safety?

2007-08-26T20:11:00.001-04:00

Mortality: A look at those life expectancy figures.

2007-08-26T19:50:00.000-04:00

Decision, Decisions: Of all the centralized planning decisions to make, closing a burn unit in a country that has more than its share of terrorist bombings seems one of the worst that could be made. But maybe not:

"At Rambam we have gathered much expertise over the years in dealing with burns, and we are organized and have conditions that are not available at Tel Hashomer. On average we treat 25-30 cases of serious burns every year. At Tel Hashomer they lack the capabilities and the space for dealing with the injured," Bar-Lavi says.

25-30 cases a year isn't much. That's only about one every two weeks. On the other hand, the country is aiming for a center that can hyper-specialize:

In response, the Health Ministry says the plan is to establish a national center to treat burn victims at Sheba. Such victims, spokesmen said, are cared for in the ICUs of most hospitals, except at Sheba, where there is an infrastructure specifically tailored for burn victims' needs, which operates independently from ICUs.

Health Ministry statistics, based on data received from the 26 hospitals in the country, show that every six days, there is a new case of a serious burn victim, and every three days there is a case of a person suffering burns of medium severity.

2007-08-26T19:37:00.000-04:00

Suffering Spouse Award: The honey experiment:

For biochemist Peter Molan, honey's ancient power to heal is not a matter of faith. So sure is he of the science behind it that he frequently applies the stuff of his research on himself -- and on his wife.

"She had a persistent boil on her buttocks," he explained. Since no standard salves had helped, he liquefied a dollop of a particular variety of honey known as manuka in the kitchen microwave, poured it over gauze and applied it.

The molten honey burned her.

"Fortunately, manuka is effective in treating burns as well as boils," Molan said cheerfully. Within a short time, he said, both boil and burn healed.

Lucky for her.

What about this manuka honey? The Washington Post article quotes some research:

As with other natural health-care products, many of the claims for manuka's efficacy are sweeping and scantily supported. Molan distances himself from the notion, for example, that, once ingested, manuka acts as a rejuvenator. The most promising research, he and many other scientists say, focuses instead on bioactive honey's potency as a topical application.

The South African Medical Journal reported in 2006 on a trial among gold miners in which honey worked as well as, and was more cost-effective than, a standard gel on shallow wounds and abrasions.

The European Journal of Medical Research reported in 2003 that honey had an 85 percent success rate in treating infected post-op Caesarean wounds, compared with a 50 percent success rate for conventional interventions.

The FDA has approved it for topical use. Here's a small study of chronic wounds that responded to it, although this study says that just about all honeys have antibacterial powers, though manuka seemed to be most effective.

Seems like such a gooey option, but for a chronic, poorly healing wound, maybe not a bad choice.

2007-08-26T14:22:00.000-04:00

Invasion of the Garden Snatchers:
Late summer is a depressing time in the garden. Allegedly, it's a time when plants don't need much nurturing since they've done most of their growing, which is good, because it's often too hot and buggy to do much work. But it's also, a time when the plants are past their prime and when wild creatures and devouring insects reign supreme.

What better way to spend a hot, muggy afternoon in the garden than to read J. Henri Fabre. Here's his description of a gruesome menage a trois with a bee, a wasp, and a praying mantis:

Of the scenes of carnage which the Praying Mantis has left in my memory, let me relate one. The thing happens in front of a work-yard of Bee-eating Philanthi. These diggers feed their larvae on Hive-bees, whom they catch on the flowers while gathering pollen and honey. If the Philanthus who has made a capture feels that her Bee is swollen with honey, she never fails, before storing her, to squeeze her crop, either on the way or at the entrance of the dwelling, so as to make her disgorge the delicious syrup, which she drinks by licking the tongue which her unfortunate victim, in her death-agony, sticks out of her mouth at full length. This profanation of a dying creature, whose enemy squeezes its belly to empty it and feast on the contents, has something so hideous about it that I should denounce the Philanthus as a brutal murderess, if animals were capable of wrongdoing. At the moment of some such horrible banquet, I have seen the Wasp, with her prey, seized by the Mantis: the bandit was rifled by another bandit. And here is an awful detail: while the Mantis held her transfixed under the points of the double saw and was already munching her belly, the Wasp continued to lick the honey of her Bee, unable to relinquish the delicious food even amid the terrors of death. Let us hasten to cast a veil over these horrors.

That's from Hunting Wasps, though I read it in the anthology Insect World Of J. Henry Fabre. His work is available for free on the internet here, and on the cheap here, and in used, out of print book form here.

2007-08-26T11:16:00.000-04:00

Sunday Entertainment: Some of the most entertaining reading can be found on the "Letters" page of the Sunday New York Times Book Review, where writers often can't resist the temptation to defend themselves from bad reviews. case in point:

...In the next to last paragraph, Richard Brookhiser wrote: “I cannot recommend this book, however. Kluger’s writing is some of the worst I have ever had to read. ... If I had not agreed to review this book, I would have stopped after five pages. After 600, I felt as if I were inside a bass drum banged on by a clown.”

...Suddenly I understood how mistaken the Book Review’s critic had been about my last book, “Ashes to Ashes,” in his highly laudatory review — and how besotted the jurors were who voted it the Pulitzer Prize for nonfiction, not usually awarded to wretched writers (I being the fortunate exception). How foolish, I thought, the Times columnist Bob Herbert had been for referring to my “Simple Justice” as a “brilliant and powerful book.” And how blind the former Times reporter Anthony Lukas, a garlanded book author, had been for stating that my book “The Paper: The Life and Death of The New York Herald Tribune” was “probably the best book ever written about an American newspaper ... a brilliant piece of social history.” And how insensitive to hideous prose were the judges who placed both those books among the five finalists for the National Book Award in history for the years in which they were issued.

Here at last, I appreciatively recognized, was a critic astute and forthright enough to do for me what no other reviewer had done before: tell me I am a clown, not a writer. How sad I was for the publisher of my four books of social history, Alfred A. Knopf, which has gained its eminence by bringing out books by similarly dreadful authors. How bad I felt for the four eminent writers and scholars — Joseph Ellis, David Kennedy, Justin Kaplan and Dan T. Carter — who had unaccountably offered admiring words about “Seizing Destiny” for the back of the book jacket. And how insensitive Kirkus was for calling it, in a starred prepublication review, “brilliant.”

...It was an honor to be so subtly awakened from my self-deception by Mr. Brookhiser, who has honed his own skills by laboring for 30 years on the staff of National Review, a beacon of insightful commentary as well as fair and balanced judgment. Thanks, too, to your staff for selecting him. As we say out here in Berkeley, that iniquitous den of bluest liberalism, have a nice day.

2007-08-25T21:33:00.000-04:00

Good Morning:

2007-08-25T15:46:00.000-04:00

The Old West: Today we walked along the Western most border of the United States.....

...in 1798.

CORRECTION: It wasn't the western most boundary, but as the plaque says, a point in the western boundary. After this treaty, the boundary stayed in northeast Ohio until it reached the Muskinghum River, then it veered westward to near the current Indiana border.

UPDATE: More pictures of the portage trail area here.

2007-08-24T08:23:00.000-04:00

Our Enemy, The Sun: The FDA on sunscreens:

In addition, the label would also warn that "UV exposure from the sun increases the risk of skin cancer, premature skin aging and other skin damage. It is important to decrease UV exposure by limiting time in the sun, wearing protective clothing and using a sunscreen." Directions would tell people to reapply sunscreen "at least every 2 hours."

The intent of the warning is to alert consumers that sunscreen is only a part of protecting yourself from sun exposure, Holman said.

According to the FDA, the proposal has guidelines for testing that manufacturers need to do to support their claims. Under the rule, sunscreens could have a maximum SPF of 50+ unless test data shows that a higher number is warranted.

In addition, the definition of SPF would change from "sun protection factor" to "sunburn protection factor." This change will prevent "the impression of solar invincibility and a false sense of security," according to the agency's proposal.

The FDA will now require sunscreen labels to tell us how well they protect agains UVA radiation in addition to the UVB protection they already proclaim. Certainly, sunburns and frequent exposure to large amounts of sun are a risk factor for sun cancer. Sun screen is a necessity if, for example, you are spending the day at the beach or on the water, or shirtlessly shingling roofs.

However, as always, all things in moderation. The sun and its UVB radiation is important in vitamin D production. This review article ($$$ required for full article) makes a very persuasive case of the importance of vitamin D to the human body:

Although there is no consensus on optimal levels of 25-hydroxyvitamin D as measured in serum, vitamin D deficiency is defined by most experts as a 25-hydroxyvitamin D level of less than 20 ng per milliliter (50 nmol per liter)....a level of 25-hydroxyvitamin D of 21 to 29 ng per milliliter (52 to 72 nmol per liter) can be considered to indicate a relative insufficiency of vitamin D, and a level of 30 ng per milliliter or greater can be considered to indicate sufficient vitamin D.

With the use of such definitions,it has been estimated that 1 billion people worldwide have vitamin D deficiency or insufficiency. According to several studies, 40 to 100% of U.S. and European elderly men and women still living in the community (not in nursing homes) are deficient in vitamin D. More than 50% of postmenopausal women taking medication for osteoporosis had suboptimal levels of 25-hydroxyvitamin D — below 30 ng per milliliter (75 nmol per liter).

Children and young adults are also potentially at high risk for vitamin D deficiency. For example, 52% of Hispanic and black adolescents in a study in Boston and 48% of white preadolescent girls in a study in Maine had 25-hydroxyvitamin D levels below 20 ng per milliliter. In other studies, at the end of the winter, 42% of 15- to 49-year-old black girls and women throughout the United States had 25-hydroxyvitamin D levels below 20 ng per milliliter,25 and 32% of healthy students, physicians, and residents at a Boston hospital were found to be vitamin D–deficient, despite drinking a glass of milk and taking a multivitamin daily and eating salmon at least once a week.

In Europe, where very few foods are fortified with vitamin D, children and adults would appear to be at especially high risk. People living near the equator who are exposed to sunlight without sun protection have robust levels of 25-hydroxyvitamin D — above 30 ng per milliliter.27,28 However, even in the sunniest areas, vitamin D deficiency is common when most of the skin is shielded from the sun. In studies in Saudi Arabia, the United Arab Emirates, Australia, Turkey, India, and Lebanon, 30 to 50% of children and adults had 25-hydroxyvitamin D levels under 20 ng per milliliter. Also at risk were pregnant and lactating women who were thought to be immune to vitamin D deficiency since they took a daily prenatal multivitamin containing 400 IU of vitamin D (70% took a prenatal vitamin, 90% ate fish, and 93% drank approximately 2.3 glasses of milk per day); 73% of the women and 80% of their infants were vitamin D–deficient (25-hydroxyvitamin D level, <20 ng per milliliter) at the time of birth.

We always think of Vitamin D as being important for bone health, which it is, but it's also an important factor in muscle strength and performance, and it regulates cell growth (which could give it a role in the body's natural defenses against cancer). So how much sun exposure is enough?

Sensible sun exposure can provide an adequate amount of vitamin D3, which is stored in body fat and released during the winter, when vitamin D3 cannot be produced. Exposure of arms and legs for 5 to 30 minutes (depending on time of day, season, latitude, and skin pigmentation) between the hours of 10 a.m. and 3 p.m. twice a week is often adequate....

....exposure to a tanning bed for 30 to 50% of the time recommended for tanning (with sunscreen on the face) is an excellent means of treating and preventing vitamin D deficiency.

If the sun is too scary, however, one may take a vitamin D supplement- but again, in moderation. It's possible to overdose on vitamin D. The author of the review article suggests 800-1000 IU a day.

I'm not often persuaded by claims for vitamins, but after reading that review, I, too, thought vitamin D seemed the elixir of life. And I started taking a vitamin D tablet every day since I'm slaving away in my office between 10 and 3 every day.

UPDATE: One of the comments challentes me to find a fatality from vitamin D overdose. Vitamin D intoxication causes renal failure and elevated calcium levels. Either of those can kill you. The good news is that it's reversible if the cause is recognized and the vitamin D supplements stopped. (See this case.)

2007-08-23T09:15:00.000-04:00

Big Dr. Brother: One of the draw-backs of pay-for-performance schemes is that they hold doctors responsible for patient compliance, something which is very difficult to control, at least at the moment. That might be about to change:

Confidant Inc. of Durham has partnered with packaging company MeadWestvaco to a develop a wireless tracking system that can monitor when patients take their medications.

....."If we can also capture information about patients' prescription adherence, we'll have an even fuller set of data for health-care providers to deliver quality care," said Thomas E. Wall, vice president of business development and marketing.

Patients who deviate from their medication treatment programs risk complications and cost the health-care system about $177 billion a year, according to the National Council on Patient Information and Education. The new tracking product under development could save much of that money, Wall said.

Nothing makes me happier than when my patients comply with my advice, but the last thing I want to do is put my nose in their medicine cabinets. It doesn't require much of a stretch of imagination, however, to envision a future in which third party payers (government and private) link patient compliance to benefits pay-outs (or premium costs). It also doesn't require much of a stretch to imagine physicians in a world of pay-for-performance requiring patients submit to such monitoring. Let's hope common sense and the love of personal liberty prevails.

2007-08-22T22:38:00.000-04:00

Mystery Case: What's your diagnosis?

2007-08-22T22:32:00.000-04:00

Second Hand Book Reviews: From the JAMA review of Biotechnology and the Human Good:

In 1990 Pope John Paul II provided this opinion on technology and Christianity: "It is essential that we be convinced of the ethical over the technical, of the primacy of the person over things, of the superiority of the spirit over matter. The cause of the human persons will only be served if knowledge is joined to conscience." Robert Frost puts it more simply: "It's knowing what to do with things that counts."

Amen to that.

2007-08-22T22:08:00.000-04:00

Cutting Edge: Gastric bypass surgery - safer than you think?

Severely obese people who have weight-loss surgery are less likely to die from heart disease, diabetes and cancer seven to 10 years following the procedure than similarly heavy people who don't have the operation, according to two studies in today's New England Journal of Medicine.

The study did, however, show a higher rate of death from accidents and suicide in gastric bypass surgery patients. The difference in overall deaths wasn't that dramatic when all causes of death were lumped together - 3% of the surgery patients died during the time frame of the study compared to 4% of the control patients.

In a another study in the same issue, the death rate among bariatric surgery patients for all causes was 43 out of 2,010 or 2.1%, while that for the controls (obese people who didn't have surgery) was 53 out of 2,037 or 2.6%.

Weight loss surgery accelerates weight loss, improves blood pressure and diabetes control, but as a life extension measure, it isn't all it's cracked up to be.

2007-08-22T22:00:00.000-04:00

Free Associating: Why does this story remind me of this?

2007-08-22T21:40:00.000-04:00

Perspectives: Same study, different spins:

With Age, Sexuality Becomes Ember of Its Former Flame

Old age and sex make good bedfellows, study finds

So which is it? The first headline is more accurate:

The prevalence of sexual activity declined with age (73% among respondents who were 57 to 64 years of age, 53% among respondents who were 65 to 74 years of age, and 26% among respondents who were 75 to 85 years of age)

2007-08-22T21:33:00.000-04:00

More Healthcare Discussions: This time from the comments at The Spine (comment #30):

In the US single payer will not be rationally managed or centrally administered. It will have a myriad of interest groups chasing a finite pot of money; and Congress, the Executive Branch, and any "Boards" or other entities designated as the real decisionmakers (there to keep the costs down, through market power and rational planning) will form a tripartite hydra-headed policymaking mess. And public demands for care will fuel the rest (and fuel the politicos). Health care will continue to be politicized and pressures will always grow to add more and more benefits while running up costs. And always to extend all those benefits to more and more people: do you think the illegal immigrant eligibility issue will not arise? Benefits paid for by citizens for citizens will ultimately - maybe not at first, in order to get it passed - disappear, because political choices will be made to increase costs by expanding eligibility to more people. And of course, there will always be a need to have more, and more, and more, managers of the system - not care providers, but those who look over the shoulders of those who provide care; they'll be needed to carefully and extensively consider the cost benefit of each victim of the system - and there will be untold numbers of appeals, because we are Americans and used to getting our way with health care. The single payer crowd would like a docile population blanketed by rules and regulations, but how often do you think the single payer system is going to say no, when a dispute over care becomes politicized or media-sponsored? It'll be forced to change by laws, or it will agree to change in order to get something else out of the policy makers.

The upshot is those with little or no political power in this system will suffer the worst in terms of care and access to procedures. We have to keep costs down, the bureaucrats will explain soberly. You may say this happens now, but how will single payer be fdifferent, except to shift the shaft?

Where else will savings be made to pay for the steadily growing costs? Capital programs to renovate or modernize equipment and facilities; drug costs (so that research and development, AS WELL AS profligate marketing, will suffer), and providers themselves will be paid on the cheap (much as they are now whenever medicaid or medicare have problems - or benefit expansions are proposed).

There has got to be a better way of providing medical care than single payer. Those who want it are demanding we move to something that does not compare well in care or cost, really, with societies similar to ours.

That's what I keep asking myself. Why do people think that a single-payer system would be any better than Medicare or Medicaid? The way things work now, Medicare gets the gold (more political clout in the over-65 population) and Medicaid gets the shaft (absolutely no political clout in that population).

2007-08-22T19:38:00.000-04:00

Science in the Service of Tyrants: A Venezuelan initiative to improve its citizens' health:

Moved by claims that it will help the metabolism and productivity of his fellow citizens, President Hugo Chávez said clocks would be moved forward by half an hour at the start of 2008. He announced the change on his Sunday television program, accompanied by his highest-ranking science adviser, Héctor Navarro, the minister of science and technology. “This is about the metabolic effect, where the human brain is conditioned by sunlight,” Mr. Navarro said in comments reported by Venezuela’s official news agency.

Well, if the minister of science says so, it must be true!

2007-08-22T08:26:00.000-04:00

The Morality of Healthcare Spending: Megan McCardle (once upon a time Jane Galt,), is blogging at The Atlantic Monthly, where she continues to deliver the best economics of healthcare blogging:

There is indeed a very compelling moral argument to be made in favor of some sort of government sponsored health care finance, which is simply this: no one should die, or suffer unduly, because they don't have the money to pay for treatment. Some of my libertarian readers will say that this still doesn't give the government the right to take the fruits of our labor by force, but in fact, I find this argument fairly convincing.

However, that doesn't mean that I should therefore be in favor of a single payer system. The fact that some people cannot afford some good, even a really important and valuable good like food or healthcare, is not a good reason to nationalise the production of that good. We do not collectivise the farms in order to ensure that everyone will have food; we give those who cannot afford food the money (or food stamps) with which to buy it. Section Eight vouchers are generally regarded as a much more successful system than housing projects (though arguably they could be better funded and structured.) If we are worried that some people cannot afford healthcare, there is a much simpler solution than constructing a giant government-run system; we could just give them the money to buy it.

I have to say, though, she had a better class of commenters at her old blog:

Saying we can "just give them the money" is an incredibly dull thing to say. Just give them the money? You think Section 8 amounts to the government simply cutting checks? That is a delusional vision of government, and, yes, as your critics have pointed out, it demonstrates either an inability to consider these issues with the necessary intellectual seriousness or a refusal to do so.

What's worse, I'm not convinced that you honestly do understand the moral imperatives at work here. You made it very clear in a Bloggingheads episode that you weren't particularly sympathetic when you dismissed 47 million uninsured as some sort of insignificant minority. And, on a personal note, someone who traffics in assigning moral blame to sick individuals for their illness is beyond deviant. Ugly, ugly, ugly.

And, by the way, your whole taxonomy of the old and the young and the sick and the healthy is just about the most confused, rhetorically bankrupt thing I've ever read, and I have to grad freshman papers. I mean really. That would get you flunked in a high school philosophy class. It's a tautological mess.

Nothing of substance there. Just name calling with fancy words.

2007-08-21T20:04:00.000-04:00

More Popular Than Statins: A rise in pain medication sales is sweeping the country:

Retail sales of five leading painkillers nearly doubled over the last eight years, reflecting a surge in use by patients nationwide who are living in a world of pain [or a world of narcosis- ed.], according to a new Associated Press analysis of federal drug prescription data.

...The amount of five major painkillers sold at retail establishments rose 90 percent between 1997 and 2005, according to Drug Enforcement Administration figures.

More than 200,000 pounds of codeine, morphine, oxycodone, hydrocodone and meperidine were purchased at retail stores during 2005, the most recent year represented in the data. That is enough to give more than 300 milligrams of painkillers to every person in the country.

Well, maybe we can keep those Afghan poppy farmers in legitimate business.

The increase has its price, however:

Unintentional fatal drug overdoses in the United States nearly doubled from 1999 to 2004, overtaking falls to become the nation's second-leading cause of accidental death, behind automobile crashes, the government reported.

The number of accidental drug overdose deaths rose from 11,155 in 1999 to 19,838 in 2004, according to the U.S. Centers for Disease Control and Prevention.

The report was based on death certificates, which do not clearly detail which drugs played the greatest role. But CDC researchers said they believe sedatives and prescription painkillers like Vicodin and OxyContin were the chief cause of the increase.

One of the large pain management groups in our area recently announced that they would no longer be using OxyContin for this very reason. Although I can't find a link to the reference to back this up, their letter announcing the change said this:

The amount of oxycodone prescribed nationally has increased by over 400% for the period between 1997 and 2002. The number of deaths from accidental overdoses of oxycodone rose nearly 350% from the same period, according to the Centers for Disease Control and Prevention.

Keep those figures in mind the next time you read pieces of journalism like this:

Contrary to the old saw, pain kills. A body in pain produces high levels of hormones that cause stress to the heart and lungs. Pain can cause blood pressure to spike, leading to heart attacks and strokes. Pain can also consume so much of the body’s energy that the immune system degrades. Severe chronic pain sometimes leads to suicide.

Acute pain can cause heart rates and blood pressure to go up, but chronic pain doesn't. The body reaches a new set-point, and things calm down. Now, chronic pain can cause depression, but high dose narcotics aren't necessarily the answer to that, either. There are better treatment alternatives than narcing a patient to unconsciousness:

Shealy’s son, David, an auto mechanic, testified that the OxyContin pain relief also came at a price. He said he felt his father was overmedicated — often sleepy. Once, his father backed his truck into a tree.

Shealy died in his sleep early on the morning of May 29, 2003. He had OxyContin pills in his stomach, and his bloodstream contained alprazolam — Xanax — as well. The pathologist at McIver’s trial testified that the levels of drugs were consistent with the prescriptions McIver had been writing — the high levels that so alarmed the insurance agent. Shealy was taking five 80-milligram tablets of OxyContin every 12 hours, plus up to six 30-milligram tablets of Roxicodone every 4 hours for breakthrough pain, plus as much as 2 milligrams of alprazolam every 8 hours. The prosecution’s toxicologist, Demi Garvin, concluded that the OxyContin and Roxicodone caused Shealy’s death by respiratory depression.

...There was something else that might have caused Shealy’s death: he suffered from advanced congestive heart failure. The pathologist testified that he had 90 percent blockage in one coronary artery and 50 percent in another, and a greatly enlarged heart and other organs. He had a scar on the back wall of his heart that indicated he at one time suffered a heart attack. Opioids do not worsen heart disease and would likely have helped, because pain causes stress to the heart.

If he had died of a heart attack, the autopsy would have revealed acute damage to the heart, not an old scar. And his clinical history isn't all that suggestive of death by heart failure. The evidence is most supportive of death by drugs.

Narcotics are great for relieving pain, but they have to be used with utmost care.

2007-08-21T08:16:00.000-04:00

Epidemics of Fat: Commenter Slim Jim hinted at this a few posts back, and now here it is in the morning's newspapers - obesity is linked to a viral infection:

A team at Louisiana's Pennington Center found that a common virus could cause stem cells to change into fat cells in lab experiments.

Researchers told the American Chemical Society conference anti-viral treatments might be possible.

They took some left over fat cells from liposuction, extracted the stem cells from it and infected them with a virus- the common cold virus. The infected stem cells became fat cells. Now, the question is, does the common cold virus make its way to fat cells in the normal course of infecting a human body?

There are skeptics, and justly so:

Not everyone is convinced, however. Dr Colin Waine, of the National Obesity Forum in the UK, said that while it was attractive to chase a "holy grail", more practical measures were the best way to tackle the western world's obesity epidemic.

"Basically, when energy consumed exceeds expenditure, that's when weight increases."

We know what causes obesity. We just keep trying to ignore those basic laws of nature.

2007-08-20T21:55:00.001-04:00

Those Stupid Family Doctors: As portrayed, once again, in the New York Times:

Nearly 73,000 Americans die from diabetes annually, more than from any disease except heart disease, cancer, stroke and pulmonary disease.

Yet, largely because of a misunderstanding of the proper treatment, most patients are not doing even close to what they should to protect themselves. In fact, according to the federal Centers for Disease Control and Prevention, just 7 percent are getting all the treatments they need.

....In part, the fault for the missed opportunities to prevent complications and deaths lies with the medical system. Most people who have diabetes are treated by primary care doctors who had just a few hours of instruction on diabetes, while they were in medical school. Then the doctors typically spend just 10 minutes with diabetes patients, far too little for such a complex disease, specialists say.

Oh, my. "Just a few hours of instruction on diabetes while they were in medical school?" That beggars belief. The average medical student learns about diabetes in anatomy, pathology, physiology, and biochemistry during the basic science years. Then, they encounter it again during their clinical rotations. They learn to treat it and diagnose it during their internal medicine and pediatric rotations. They see complications of it during their subspecialty rotations. And then, when they go to their residency training (at least if they go into primary care), they learn to diagnose and treat it even more. Medical school isn't like high school or college, where every topic is given its fifteen minutes of attention and it's off to the next topic. It's more of an integrated educational experience.

It also beggars belief that that the average internist and family physician doesn't understand the importance of blood pressure control and cholesterol management in diabetics. I assure you, we do. It appears that the model patient in the story, however, didn't:

Mr. Smith, a 43-year-old pastor in Fairmont, Minn., tried hard. When dieting did not work, he began counting carbohydrates, taking pills to lower his blood sugar and pricking his finger several times a day to measure his sugar levels. They remained high, so he agreed to add insulin to his already complicated regimen. Blood sugar was always on his mind.

But in focusing entirely on blood sugar, Mr. Smith ended up neglecting the most important treatment for saving lives — lowering the cholesterol level. That protects against heart disease, which eventually kills nearly everyone with diabetes.

He also was missing a second treatment that protects diabetes patients from heart attacks — controlling blood pressure. Mr. Smith assumed everything would be taken care of if he could just lower his blood sugar level.

Is it true that lowering cholesterol in a diabetic is more important than controlling blood sugar? No, and again no. One comes away from the Times article thinking that treating diabetics with a statin and a couple of hypertensive pills is better than treating the diabetes itself. That would be malpractice.

Diabetes is a complex disease that often goes hand in hand with other diseases (high cholesterol, high blood pressure) that affect the heart and other small blood vessels in vital organs. This is why diabetics (and hypertensives, too), run the risk of kidney failure and blindness and strokes and peripheral vascular disease, in addition to heart disease. Diabetes, high cholesterol, and high blood pressure each act to damage blood vessels, in effect aging them at a faster rate than occurs in a healthy body. It only makes sense to treat each condition aggressively when they are present in an unholy trinity, which they often are.

However, if one were to rank the diseases from the highest risk for the above complications to the lowest risk, diabetes would be number one, hypertension number two, and high cholesterol dead last. It is rare to find someone who has kidney failure on the basis of untreated high cholesterol alone. It is all too common a complication, however, of untreated diabetes and untreated hypertension.

That entire article reads like an advertisement for statins. Maybe it is.

2007-08-20T20:20:00.000-04:00

The Good Cuomo: New York's new State Attorney General is a very busy man. Not only has he been scrutinizing the political shennanigans of the state's governor, but he's put three health insurance companies on notice that their "quality rankings" are suspect. Here are his letters to United Healthcare, Cigna, and Aetna. I don't know if this is something that's an appropriate concern for a state attorney general, or whether it's more of a matter for a state's department of insurance, but the criticisms he levels against the programs are accurate:

Consumers may be encouraged to choose doctors because they are cheap, rather than because they are good.

And to clarify, that's because they are cheap for the insurance company, not necessarily cheap for the patient.

2007-08-20T19:51:00.000-04:00

The Pharma Benefits Dance: Mr. Dr. SS at Health Care Renewal got the go around when he tried to figure out how to appeal a drug denial by his pharmacy benefits management company (aka Medco):

When I went to my neighborhood pharmacy a.k.a. megastore, I was told my health plan did not cover this medication. I possess a BC/BS PPO and Medco card through my employer, a university. The cost of a month's supply of the medication was approximately $160. The pharmacist suggested I contact Medco to find out why Meridia was not covered.

...A Medco representative told me Medco is only a contractor and plan administrator to "my insurer" and does not make such decisions. However, the rep did not know who did.
I next contacted BC/BS. Their rep told me they only covered medical care and not medications, and suggested I call Medco. When I mentioned Medco told me they did not make such decisions, the BC/BS rep had no suggestions.

I called Medco back. The Medco rep this time told me I could appeal the denial and was sending me an appeal form that I should mail back to - Medco. Now, I was really confused.
I inquired why Medco gets an appeal form for denial of coverage if Medco did not make the decision. The rep did not know. I asked for the name of a person at the organization where the form would go. Again, the rep did not know.

I finally called my university's benefits management contact, yet another contractor company (it seems everything is handled by third parties - just a little bit of administrative overhead there?), and that is where this already confusing matter took a very deep turn directly south.
The rep at the university's Benefits Management contractor said that he believed Medco was the responsible party. I informed him Medco said they were not.

In the first actually creative and industrious response from any of these organizations, the rep said he would get a Medco representative on the phone in conference call mode so we might get to the bottom of this.

We got to the bottom all right. The real bottom.

The Medco customer service rep that the University Benefits Management Rep conferenced in was a new individual, not the ones I had spoken to prior. This rep repeated that Medco was just a benefits manager and was not responsible for the denial.

I asked the university's Benefits Management contractor rep if he believed that was the case. He was as confused as I. The Medco rep said I needed to appeal.

I asked the Medco rep for the name or identity of a person or organization where the appeal form would go, so I could contact them directly, as I was a medical doctor with pharma experience as well and wanted to go direct to the source.

The Medco rep replied that "my title would not get me advantage in this matter" or words to that effect.

And it didn't. He never really ever got an answer.

But truly, it is Medco what makes those decisions. That's why they are called a pharmacy benefits manager. The insurance company is paying them to manage this stuff for them.

For the lay reader - if this happens to you, nicely ask your pharmacist to give your physician a call. He and your doctor can either put their heads together to come up with a covered alternative or he can give your doctor the number to call for an appeal. At least, that's how it usually works at my office.

There are times when it doesn't work this way. Sometimes the pharmacist is too busy or too uncaring to intervene or it may be a pharmacy tech who tells the patient about the denial and doesn't know anything but what the computer message tells her to say. If that's the case, then call your doctor to tell him about the denial. It's usually just a matter of calling the pharmacy benefits company and requesting a pre-authorization form be faxed over to the doctor's office.

The key is not to ask any detailed questions of the workers on the phone chain-gang. They don't know who will be responsible for making a decision or who will be getting a form. But they do know how to fax those forms.

Yes, it's a pain to have to make these phone calls and to have to fill out forms and send faxes. And a lot of it could be avoided if the companies made their formularies easier to access. But, my experience has been that even with the notorious Medco, the turn around for approval is 24 hours or less.

2007-08-19T12:25:00.000-04:00

You Broke It, You Bought It: The new Medicare denial model:

In a significant policy change, Bush administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars.

Private insurers are considering similar changes, which they said could multiply the savings and benefits for patients.

Under the new rules, to be published next week, Medicare will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.”

Among the conditions that will be affected are bedsores, or pressure ulcers; injuries caused by falls; and infections resulting from the prolonged use of catheters in blood vessels or the bladder.

It's probably reasonable to expect a hospital and surgeon to remove a left behind sponge at now added charge, but some of these conditions are difficult to avoid. Patients who require chronic urinary catheters, for instance, are notoriously prone to infection despite the best efforts to avoid them. And dying, chronically ill patients are prone to bed sores despite the best efforts to prevent them.

Of course, refusing to pay for things does save money. But does it improve care? In this case, it's questionable.

UPDATE: Physician Executive weighs in.

UPDATE II: Readers of the New York Times weigh in:

Even the most thoroughly researched preventive regimens continue to have substantial morbidity rates. Hospitals that already adhere to these guidelines (and there are many) will simply pay more and get paid less, without any improvement in their patient care.

And another:

Attempting to draw the line between truly preventable problems and those that are the result of prolonged therapy would seem to be a very slippery slope.

That said, I would happily endorse the proposed Medicare policy change, if we as taxpayers could hold our government and military to the same standards and refuse to pay for any of their “preventable” mistakes.

Heh.

And a practical example:

So, I admit Mrs. Jones, an elderly patient of mine, to the hospital because she has pneumonia. Because of the stress of the infection, she becomes delirious, which puts her at high risk of falling.

In the interest of safety, I restrain and sedate her, which necessitates an indwelling urinary catheter.

One week later, despite meticulous nursing care, Mrs. Jones develops a urinary tract infection and a minor pressure sore on her back because of her debilitated, immobilized state.

My hospital administrator then suggests that I remove the restraints and the catheter and reduce the doses of her sedatives so that the conditions don’t get worse and our hospital doesn’t lose money.

Two days later, Mrs. Jones falls out of bed and breaks her hip.

How, exactly, has the new Medicare policy improved Mrs. Jones’s safety?

2007-08-19T12:18:00.001-04:00

Perspective: John Edwards, champion litigator, on his prior job:

At each stop, he let out the same battle cry: a populist attack on big oil, big pharmaceutical companies, big insurance companies and corporate lobbyists in Washington. These he described as being “powerful insiders” that had “rigged the system” against the ordinary working man, leaving him poorer, degrading the environment and blocking access to affordable health care.

“I’ve been fighting these people all my entire life,” said Mr. Edwards, holding forth at Cronk’s Restaurant in Denison. “I fought them in the courtroom, and I’ve beat them and beat them...."

You often hear lawyers describe their job this way. They aren't suing doctors and small business owners or citizens unfortunate enough to have had an auto accident. They're suing insurance companies. But, I can assure you, it isn't the insurance company that sits in a court of law accused of malfeasance.

I know a woman who sued her best friend after they were in a car accident in which the friend was the driver. To this day she can't understand why her friend is her ex-friend. Her lawyers told her she wasn't suing her friend; she was suing her friend's insurance company. Her friend, understandably, failed to see that distinction. It wasn't the insurance company that drove that car and made whatever driving mistake it is the lawyers accused her of to cause the accident. And it wasn't the insurance company whose name was on the court summons. And it certainly wasn't the insurance company that had to defend herself and her driving habits in court.

2007-08-19T08:16:00.001-04:00

The Medicalisation of Sadness: Do we overdiagnose depression? The yes...

A low threshold for diagnosing clinical depression, however, risks normal human emotional states being treated as illness, challenging the model's credibility and risking inappropriate management. When the first antidepressant (imipramine) was developed, manufacturer Geigy was reluctant to market it, judging there were insufficient people with depression. Now, depression is all around, and antidepressant drugs have a dominant share of the drug market. Reasons for the overdiagnosis include lack of a reliable and valid diagnostic model and marketing of treatments beyond their true utility in a climate of heightened expectations.

...and the no....

...Closer examination of prescribing patterns reveals other interesting and health promoting patterns. Firstly, although the number of prescriptions for antidepressant drugs rose sharply during the 1990s, it now seems to have slowed. Secondly, the use of new antidepressant drugs often results in reduced prescribing of less desirable sedatives such as benzodiazepines, as well as the more dangerous tricyclic antidepressants and monoamine oxidase inhibitors. Although there has been much hype and regulatory concern about increased prescribing of the new drugs, there is little hard evidence of harm to a significant number of people. The real harm, as evidenced by the suicide statistics, comes from not receiving a diagnosis or treatment when you have a life threatening condition like depression.

The real action in managing depression is in primary care settings. Large general practice based audits in the United Kingdom, Australia, and New Zealand do not support the notion that depression is now overdiagnosed or treated exclusively with antidepressant drugs. In fact, substantive personal, demographic, geographical, professional, training, and health system capacity barriers remain in place. The net result seems to be that diagnosis of major depression is largely restricted to people with more severe or persistent disorders, those who present many times, those who request treatment, or those who attempt self harm. (emphasis mine)

The "yes" thesis rings more true. The "no" thesis reads like a defense of the pharmaceutical industry. He acknowledges that prescriptions for anti-depressants rose sharply in the 1990's, due to promotion of the drugs. In this country, time in history coincides with the birth of direct to consumer advertising.

Think you might be depressed? The drug companies can help you find out. Pharmaceutical representatives leave similar questionnaires in waiting rooms around the country. For the past several years (at least as long as Prozac has been on the market), there has been a concerted campaign through to convince doctors and patients that depression is underdiagnosed.

It's been my experience that the primary driver of anti-depressant prescriptions over the past decade has been patient requests for them. Most of the time, what drives the request isn't truly depression, but just not being as happy, or at least not as happy as popular culture says we should be. This is the sitcomization of life. A surprising number of people think it's normal to go through life never being disappointed or sad or angry for more than few minutes. If they yell at their kids, something must be wrong with them, and that something must be corrected. It never crosses their mind that perhaps their kids need scolding. Crying is not allowed, not even when the circumstances justify it.

It's very difficult to deny these requests. One can attempt to determine how much the sadness affects the ability to get on with life, but in the end, the degree of sadness and the ability to tolerate it is purely subjective. And so, the prescriptions get written.

2007-08-18T20:38:00.001-04:00

Identical Quads: A biological rarity, the birth of identical quadruplets.

They're Canadian, but there was no room in the NICU's of all of Canada, so their parents traveled 300 miles to give birth here:

A medical team and space for the babies had been organised for the Jepp family at the Foothills Medical Centre in Calgary but several other babies were born unexpectedly early, filling the neonatal intensive care unit.

Health officials said they checked every other neonatal intensive care unit in Canada but none had space.

Makes one wonder how many neonatal intensive care units there are in Canada.

UPDATE: The answer is in the comments. Thanks!

UPDATE II: A Canadian perspective.

2007-08-18T19:46:00.000-04:00

Diagnosing Lear: Or not.

2007-08-16T21:30:00.001-04:00

Disease Vectors: The President's Cancer Panel (not his bloodwork, but an advisory body) says that cancer is caused by disease vectors among us. Not just any disease vectors, but disease vectors with marketing savvy:

But the panel finds that cancer prevention efforts "are compromised by federal, state, and local policies that have decreased the availability and affordability of healthy foods, limited physical education in schools," and created an "environment that discourages physical activity."

Perhaps even more importantly, the panel says, are "ineffective policies" that fail to regulate the marketing practices of "disease vectors" — the tobacco, food, and beverage industries.

Put aside the gross misuse of the term vector and consider the thrust of the argument - that preventing cancer is a matter of lifestyle choices. If only!

Tobacco use is a lifestyle choice that increases the risk of cancer, to be sure. But it's pretty hard to make an argument these days that government encourages the use of tobacco. Between the taxes and the bans, government has come down hard on the industry. And smokers themselves have become social pariahs.

What about other cancers? Cervical cancer has a lifestyle component, but somehow I doubt the Cancer Panel meant to imply that schools (or the government) should teach sexual continence. Skin cancer has a lifestyle component, but there's no mention in the statement about limiting access to tanning beds.

Other cancers - colon cancer, breast cancer, prostate cancer, ovarian cancer, etc., etc., etc. - have little to no lifestyle component to them. It's true that there are no shortage of media reports that bad diets cause cancer and good diets prevent cancer, but the truth is unless you are eating radioactive food, the link between diet and cancer is tenuous at best. As they say in medicine, the link needs more research. Ditto with cancer and exercise.

One would hope that the people who are expert enough to sit on a Presidential Cancer Panel would have more sense than this panel has demonstrated. But then, exercising sense rarely gets the attention that hyperbole gets, does it?

2007-08-16T20:01:00.000-04:00

Home, Sweet Home: Grunt Doc notes this statement by the American Academy of Pediatrics and gets the willies at the phrase "medical home." One of his commentors asks "What the f*ck is a 'medical home???' "

And well he might ask. Here's one definition:

In the advanced medical home model, patients will have a personal physician working with a team of healthcare professionals in a practice that is organized according to the principles of the advanced medical home. For most patients the personal physician would most appropriately be a primary care physician, but it could be a specialist or subspecialist for patients requiring on-going care for certain conditions, e.g., severe asthma, complex diabetes, complicated cardiovascular disease, rheumatologic disorders, and malignancies. Primary care physicians are defined as physicians who are trained to provide first contact, continuous, and comprehensive care (27). Principal care, that is, the predominant source of care for a patient based on his or her needs, can be provided by a primary care physician or medical specialist. In most cases, primary care physicians, with their office care team, are ideally suited to provide principal care and be a patient’s care coordinator – a personal physician, in the advanced medical home model. However, a medical specialist with his or her office care team can fulfill the role of personal physician as defined in this paper if he or she so chooses. Rather than being a “gatekeeper” who restricts patient access to services, a personal physician leverages the key attributes of the advanced medical home to coordinate and facilitate the care of patients and is directly accountable to each patient. Personal physicians advocate for and provide guidance to patients and their families as they negotiate the complex health care system.

And a simpler explanation:

The American Academy of Pediatrics describes the medical home as a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.

In short, "medical home" is the newest craze in medical euphemisms. It's what used to be called a "primary care provider" in the heyday of HMO's. But the phrase "primary care provider" has gotten a little ambiguous what with retail clinics staffed by nurses claiming to be primary care providers and what not. Also, the HMO's tainted the "primary care providers" with the tag of "gatekeepers." This gave the impression that the doctors who were supposed to have the patients' best interest in mind at all times were in the business of keeping said patients away from needed services.

The "medical home" sounds so much cozier, doesn't it? A place where mamma and pappa doctor will keep you healthy and clean. Personally, I prefer the term "personal physician" to "medical home" but I understand why the term has been adopted as a marketing ploy to get the attention of third party payers. It's an attempt to make it clear to these keepers of the purse that there's a value to the continuity of care offered by a personal physician as opposed to the disjointed care of multiple retail clinic visits and non-emergent emergency room visits. (And I'm sure GruntDoc would agree that the non-emergent cases are better seen in the office than in the emergency room.)

The movement is afoot, and enjoying some legislative success. Rumor has it that United Healthcare is poised to support the concept as well. We'll see how it all works out. Most of these types of initiatives are started by doctors in the hopes of improving reimbursement, but they rarely work out that way.

In the meantime count this physician as one who is content to just be a plain old family doctor.

UPDATE: Roy Poses has more details on the United Healthcare angle at his blog. Including a link to this AAFP News item which explains the payment angle:

"This is about physician payment reform and testing the patient-centered medical home model in the marketplace," said AAFP President Rick Kellerman, M.D., of Wichita, Kan.

For some time, the Academy has urged payers and employers to implement pilot programs that would experiment with new payment strategies to reflect the value of primary care, said Kellerman.

....UnitedHealth Group will pay participating physician practices a monthly care-management fee based on projected savings for all patients that select a medical home. In addition, the company will share any excess savings that accrue from the pilot program with the physician practices and -- by way of premium reductions -- with employers.

Color me skeptical. One of things that United Healthcare is doing is supplying a nurse advise line 24/7 and other disease management programs. This means that they will be spending money to provide things that physicians traditionally do as part of their ordinary fee. More money will be spent by adding another layer of people to do these things, not less.

2007-08-16T19:08:00.000-04:00

Of Wine and Wasps: Beware the dregs of wine, especially if you have a bee allergy:

Alcoholic drinks have been described as triggering or initiating anaphylactoid reactions. Although little is known about the pathogenesis of these reactions, wine contains many biologic and chemical components derived from grapevines, yeast, bacteria, and insects (including those of the order Hymenoptera) that might explain the observed symptoms.

We report on five patients who presented with symptoms after drinking grape juice or newly pressed wines (both red and white). Three of the patients had an oral allergy syndrome and facial flushing, one had asthmatic symptoms, and one had anaphylaxis. Skin tests with conventional allergens, including commercial grape extract, egg white, and wines aged for up to 1 year, were negative. None of the patients had a history of ingesting drugs containing sulfites that was concomitant with these symptoms, nor had any of them been stung by Hymenoptera species. Yet all had positive skin tests for specific IgE antibodies (levels >0.35 kU per liter, CAP, Phadia) to Hymenoptera (Apis mellifera and vespula and polistes species) and to an extract of the wine or grape juice under suspicion for causing the symptoms.

I'm not sure I'll ever feel the same about wine again.

2007-08-15T12:51:00.000-04:00

Lipid Low Down: When determining the risk of heart disease based on cholesterol levels, looking at the good and the bad levels is good enough. Looking at the ugly didn't improve the prediction:

Vasan's team followed more than 3,300 middle-aged participants in the Framingham Offspring Study, a major study launched in 1971. Cholesterol measurements were taken in the years 1987 to 1991, when the men and women were free of heart disease.

After a follow-up of about 15 years, 291 participants, including 198 men, developed heart disease.

Measurements of the apo B to apo A-I ratio were compared with measuring the total cholesterol to HDL ratio to see how well each approach predicted the participants' heart disease.

The researchers concluded that the total cholesterol-to-HDL ratio was sufficient and that the other ratio does not substantially improve the accuracy of the prediction.

Apo-B and Apo-A are subsets of cholesterol that have been touted as better markers for heart risk than the conventional good (HDL) and bad (LDL) cholesterols. Time to rethink that position.

In other news, it turns out that there's little to no evidence that increasing levels of good cholesterol reduces the risk of heart disease:

With 40% of all heart attacks and related cardiovascular problems occurring in people who have low levels of so-called "good" cholesterol, researchers have long sought medications to increase the amount of this type of cholesterol in the body's circulation.

But a new review of 31 randomized controlled trials published in the Journal of the American Medical Association suggests that so far, only modest evidence supports the use of most medications to raise levels of high-density lipoprotein (HDL) -- good cholesterol. Some are even harmful.

Moral of the story: When obsessing over your cholesterol, concentrate on the LDL (bad cholesterol) value.

2007-08-09T19:38:00.000-04:00

$$$$: Money makes people do strange things:

The red cross symbol is an icon of relief from disaster. For months, it has also been the subject of a festering disagreement between major American institutions: the health care company Johnson & Johnson and the American Red Cross.

The dispute over rights to the symbol erupted to the surface yesterday in federal court in Manhattan, where J.& J. sued the American Red Cross.

It looks as if Johnson and Johnson might have a good case, even though we identify them more with the script "J" than the red cross. (Actually, judging by this collection of boxes, it's been a very long time since Johnson and Johnson have used the red cross as a trademark symbol.)

2007-08-09T09:47:00.000-04:00

The Voles in Spain...: ....Live mainly on the plain:

Rural northern Spain has been stricken by a plague of millions of voles that have devastated lettuce, potato and barley crops and threaten to invade vineyards, public parks and even urban centres.

Farmers in the high plateau around Leon, north of Madrid, have demanded massive doses of poison to exterminate the ubiquitous rodents. But health workers and environmentalists warn that the cure might be worse than the disease, with poison threatening wildlife and posing a worse risk for humans than piles of dead voles.

Hundreds of exasperated farmers, carrying live voles, protested outside the regional government headquarters in Valladolid this week, breaking a glass door with the intention of freeing the creatures into the offices. But police charged and scattered the demonstrators.

The wretched creatures are eating all the crops and causing some cases of tularemia. They're also providing entertainment for the local urchins:

Local children have developed their own anti-vole technique. "You surround them with two or three of us, then stamp on them or hit them with a stick," said Alvaro Garcia, 11. Every night Alvaro and his friends go hunting in Fresno del Viejo, one of areas near Valladolid worst affected, and despatch some 200 voles.

2007-08-09T09:27:00.000-04:00

State of the Stem in Missouri: Missouri may have passed a law protecting stem cell research, but the state isn't funding it:

This spring, the legislature scratched plans to build an $85-million science center at the University of Missouri. The stated reason: Concern that the labs might one day be used for embryonic research — even though the university's president explicitly stated they would not.

To make sure that embryonic projects would not get funding, lawmakers banned a state science research fund from spending any money on human health — grants will only go to projects involving plants and animals.

It 's hazardous to rely on a state for your income. You never know which way the political wind will blow.

2007-08-09T09:19:00.000-04:00

"Nobody is talking about a free-market approach in health care. The spectrum today is between fascism and Communism.": Some thoughts on reforming health coverage.

2007-08-09T08:56:00.000-04:00

No Reward for Innovation: More and more hospitals are opening up suburban satellite free-standing emergency rooms, but some of them aren't getting paid:

The facility turns one year old today, and though the data are preliminary, the approach seems to be working pretty well. The satellite ER has treated 22,000 patients, cut the traffic (a little) at the main ER for its parent hospital, Shady Grove Adventist, and halved the time ambulances spend waiting to disgorge patients. A full report will be made later this year to the state’s General Assembly, which had to write special rules to allow the ER to open.

One big problem: The federal government has so far refused to pay for Medicare and Medicaid patients treated at the freestanding ER. Without those key sources of hospital revenue, the center lost $3.8 million in its first year.

Now why won't they pay? Did they get caught up in the morass of red tape that traps many a provider when they change their location? (It often takes up to six months to get a payment from Medicare if you change your address or business name, but I've never heard of it taking a year.)

2007-08-08T22:41:00.000-04:00

The Little Red Wagon: When I came home from work last night, my husband was cleaning out the garage. When I left for work this morning, I saw at the curbside, leaning against our trash cans, all disassembled (gasp!) the kids' little red wagon.

Seeing it discarded like that cast a pall over the rest of the day. I haven't thought of that wagon for years, and the kids all outgrew it a long time ago, but it was such a ubiquitous part of the background of our family's early years, that it's impossible not to grieve its passing. It made our long walks possible. It accompanied us to July 4th fireworks in the park and outdoor concerts. We've gone trick-or-treating in it and used it to haul pumpkins and flats of flowers.

It was an endless source of amusement for the kids.

But most of all, that little red wagon is the last souvenir of those days when we were all the center of each other's universe. Everyone's grown enough now to distance themselves emotionally, and soon they'll be distancing themselves physically, too. We'll never see that kind of solidarity again.

Good-bye, little red wagon!

2007-08-08T22:00:00.000-04:00

A Pound of Prevention: The old saying holds that an ounce of prevention is worth of pound of cure, but in reality it's often the other way around:

No one really knows whether preventive medicine will save money in the long run, let alone free up the billions of dollars a year needed to help pay for universal health insurance. In fact, studies have shown that preventive care — be it cancer screening, smoking cessation or plain old checkups — usually ends up costing money. It makes people healthier, but it’s not free.

“It’s a nice thing to think, and it seems like it should be true, but I don’t know of any evidence that preventive care actually saves money,” said Jonathan Gruber, an M.I.T. economist who helped design the universal-coverage plan in Massachusetts.

...Jay Bhattacharya, a doctor and economist at Stanford’s School of Medicine, estimates that to prevent one new case of diabetes, an antiobesity program must treat five people — “not cheaply,” he says. Along the same lines, Mr. Gruber found that when retirees in California began visiting their doctor less often and filling fewer prescriptions, overall medical spending fell. People did get sick more often, but treating their illnesses was still less costly than widespread basic care — in the form of doctors visits and drugs. Louise Russell, an economist at Rutgers, points out that programs that focus on at-risk patients cost the least, but even they are rarely free.

As Dr. Mark R. Chassin, a former New York state health commissioner, says, preventive care “reduces costs, yes, for the individual who didn’t get sick.”

“But that savings is overwhelmed by the cost of continuously treating everybody else.”

Exactly.

2007-08-08T20:50:00.000-04:00

Got Listeria? There is, evidently, a growing craze for raw milk:

Raw milk drinkers may praise its richer flavor or claim it is more nutritious than pasteurized milk. No matter why they drink it, the demand for it is booming. In 2000, the Organic Pastures Dairy Company in the San Joaquin Valley near Fresno became California’s first raw milk dairy with certified organic pasture land. This year its co-founder, Mark McAfee, expects it to gross $6 million — up from $4.9 last year.

His raw milk is sold in 300 stores in California, where it is legal. He also has an $80,000 a month mail order business, shipping creams and cheese as well as milk to all 50 states. He believes he reaches 35,000 customers a week for his raw milk products.

This reader's first thought was, ewww, Listeria, among other things:

Food scientists can hardly believe that so many consumers have turned their back on one of the most successful public health endeavors of the 20th century. In 1938, for example, milk caused 25 percent of all outbreaks of food- and water-related sickness.

With the advent of universal pasteurization, that number fell to 1 percent by 1993, according to the Center for Science in the Public Interest, a nutrition advocacy group in Washington.

Put me firmly in the food scientist column. Here's a sampling of some milk-borne incidents in recent memory, from the FDA:

* July 2004--The Indiana Public Health Department advised consumers to check their refrigerators and freezers for raw milk cheese that may be contaminated with salmonella. Routine product sampling found the bacteria in lot number 139 of "Natural Raw Milk Cheese" made by Meadow Valley Farm after the cheese was distributed to farmers' markets and specialty food stores in parts of Indiana and Wisconsin.

* 2002-2003--Two children were hospitalized in Ohio for infection with Salmonella enterica serotype Typhimurium. These children and 60 other people in Illinois, Indiana, Ohio, and Tennessee developed bloody diarrhea, cramps, fever, chills, and vomiting from S. Typhimurium tracked to consuming raw milk. The milk producer voluntarily relinquished its license for selling raw milk upon recommendation of the Ohio Department of Agriculture.

* 2000-2001--In North Carolina, 12 adults were infected with Listeria monocytogenes linked to homemade, Mexican-style fresh soft cheese produced from contaminated raw milk sold by a local dairy farm. Ten of the 12 victims were pregnant women, and infection with the bacterium resulted in five stillbirths, three premature deliveries, and two infected newborns.

* 1998--In Massachusetts, 66 people received injections to protect against potential exposure to rabies after drinking unpasteurized milk from a local dairy. A cow that died at the dairy was found to be infected with rabies. Transmission of the rabies virus through unpasteurized milk, although not the common route of infection, is theoretically possible, according to the Centers for Disease Control and Prevention.

They say it tastes heavenly. but best not risk a trip to heaven for a sip.

On the other hand, researchers are working on genetic modification of cow's milk protein to fight bacteria, that could make raw milk safe. Something tells me that the food purists wouldn't care much for that either, though.

And here's a sentence you're only likely to read in the New York Times:

“We also bought crème fraîche from the milk club,” he said. “It was nearly as ethereal as our fromager’s in Aix-en-Provence.”

Mai oui!

2007-08-07T08:58:00.001-04:00

How Racist, etc. are You? Take the implicit association test to find out.

2007-08-07T08:22:00.001-04:00

A Black Eye for Transplants: The case of the California transplant surgeon who directed the end of life care for his transplant donor certainly doesn't do much to advance the cause of organ donation:

What happened in Sierra Vista's Operating Room 3 is now the subject of an unprecedented criminal case.

San Luis Obispo County prosecutors filed three felony charges last week against San Francisco transplant surgeon Hootan Roozrokh, 33, alleging he tried to hasten the death of Ruben Navarro in order to harvest his organs.

...The documents paint a picture of disarray in the operating room, with some staffers concerned that Navarro was being mistreated and overmedicated by Roozrokh, one of two surgeons dispatched by the regional group that procures organs for much of Northern and Central California.

....For the most part, organs are not retrieved from patients until they are declared brain-dead. But that night at Sierra Vista, surgeons were attempting a different type of harvesting, known as "donation after cardiac death."

In such situations, patients with irreversible brain damage are removed from life support. Their death is declared when their heart stops beating -- clearing the way for organ removal.

...According to state law and national standards, transplant physicians cannot direct the treatment of potential organ donors before they are declared dead.

But it was clear that Roozrokh was in charge, witnesses told police.

The patient's primary care physician says he had clearly documented in the chart that he thought the patient would live too long off life support to be a viable organ donor. That was just his opinion at the time, but in hindsight, he was right:

Indeed, Navarro remained alive for more than seven hours after being removed from life support. His organs were not viable and were never removed.

....About 20 minutes after life support was removed, Roozrokh "was heard to say they needed more 'candy' " and placed an order for another 100 milligrams of morphine and 40 milligrams of Ativan -- the same doses that had been given to Navarro earlier, the police report said.

The usual dose of Ativan is from 1/2 to one milligram; for morphine - 4 milligrams. Though both can be titrated upward as tolerated, those are very unusual doses.

The cardiac death definition for organ donation seems to be a bit of a sticky wicket. The transplant team has to be called in while the patient is still alive and then wait for him to die so they can take the organs within a suitable time frame. That does put a lot of pressure on them to get the job done. By contrast, when a patient is brain dead, he's considered dead even while his heart continues to pump. No one has to stand around and wait for his heart to stop before they can start taking the organs. There's a lot less room for ethical slip-ups like this one.

2007-08-07T07:59:00.000-04:00

The Starbucks Effect: The brain protective effects of coffee:

"Caffeine is a psychostimulant which appears to reduce cognitive decline in women."

Using tests of memory and thinking skills, Ritchie and colleagues showed that cognitive decline was slower in women aged 65 and over who drank more than three cups of caffeinated coffee or tea a day compared with women who drank one cup or less.

The results were unaffected by potential confounding factors such as age, education, disability, depression, medication, hypertension (high blood pressure), cardiovascular disease and other chronic conditions.

However, until more is discovered about how and why this is so, the authors are not suggesting older women should start drinking more coffee....

Awww, how come? Maybe because of this:

Caffeine consumption did not reduce dementia risk over 4 years.

The abstract only describes the findings in terms of risks rather than absolute numbers, so it's impossible evaluate how truly significant the differences between the coffee drinkers and non-drinkers were, but that last sentence in the results section pretty much says it all. Drinking coffee doesn't preserve the mind.

2007-08-07T07:47:00.000-04:00

An Expense Too Far: The high cost of treating cataracts:

The tab for Harry's surgery, just under $4,000, covers a lot of territory, including the initial and follow-up exams, pretesting, retina testing, IV catheters, monitoring, the labors of both ophthalmologists and technicians, medications and anesthesia....

...in a rabbit.

To compare, my son's cataract surgery in the same corner of Ohio (which was more complicated than the average cataract surgery because he also had a damaged iris) came in at $3,000. But, when you're selling luxury animal medicine, you can charge more.

2007-08-06T20:40:00.000-04:00

Selling Medicine; Selling Hope: Roy Poses harm that can occur when doctors sell their science inappropriately. From the original article:

Breaches of clinical research standards and a federal oversight system that allowed key decisions to be made behind closed doors may have helped draw Mohr into an experiment that was not, her husband says, what she thought it was.

"It was presented to her like this is going to make her knee better," said Robb Mohr, an agronomist who lived with his wife of nine years in a modest vinyl-sided ranch home near Springfield, Ill. "It was supposed to be just a simple thing."

....A two-sentence paragraph halfway through a 15-page consent document that Jolee Mohr signed warns of the possibility of "unknown side effects," including, "in rare circumstances, death."

Further in, after long descriptions of how the product may help, a single sentence states: "We do not expect you to receive any direct medical benefits from participation in this study."

Mohr was in an early-phase study, the prime goal of which was to see whether the treatment was safe, not to provide a therapeutic benefit. If the drug passed muster, other studies would determine whether it was an effective treatment.

Her rheumatologist, Robert Trapp, whose Springfield clinic got payments from Targeted Genetics for each subject he recruited, also defended the study. "The theory behind it seemed good, and the science seemed good," he said. "There's nothing I knew of that could have predicted this."

2007-08-06T20:36:00.000-04:00

Selling Science: A discussion on how to sell science to the masses. As one of the masses (especially in nonbiological fields) I vote for stick to the truth, avoid hyperbole.

2007-08-06T20:13:00.000-04:00

Pay for What? The "pay for performance" program that Medicare is rolling out is supposed to reward physicians for quality care, right? Think again:

Ten large physician practices participating in one of the first Medicare pay-for-performance projects have proven that such programs lead to better performance, according to government officials. But only two practices were able to reduce costs enough to receive any additional pay.

... Two of the participants, Forsyth Medical Group in Winston-Salem, N.C., and St. John's Health System in Springfield, Mo., were able to make the grade on all diabetes measures.

They made the grade, but they didn't get the reward:

But for eight of the large practices, the amount of money they saved Medicare was not enough for them to share in the reward. Only University of Michigan Faculty Group Practice in Ann Arbor and Marshfield (Wis.) Clinic were able to obtain bonuses.

It's really about the money:

In the first year, Marshfield saved the Medicare trust fund just more than $6 million, and the facility is set to receive roughly $4.5 million of that. University of Michigan Faculty Group Practice saved Medicare about $3.5 million and is in line for a roughly $2.8 million payout.

If it were really about quality, the Forsyth Group and St. John's Health System would be the ones getting the bonus, wouldn't they?

2007-08-03T19:38:00.000-04:00

Creative Funding: A tax plan for children's health.

2007-08-03T08:52:00.000-04:00

Vinegar vs. Paps: Washing the cervix with vinegar and looking for abnormal areas may be as efficacious as pap smears:

Researchers from the International Agency for Research on Cancer in France and their colleagues from Tamil Nadu in India used the technique to screen 49,311 women in Dindigul district, India, from 2000 to 2003. When pre-cancerous lesions were found, health care workers gave immediate treatment to destroy the abnormal cervical tissue.

Another 30,958 women received standard care. They were told to watch for signs and symptoms of cervical cancer and encouraged to visit health care facilities where screening was available. These women were tracked from 2000 to 2006.

There were 167 cases and 83 cervical cancer deaths in the women who received the screening, compared with 158 cases and 92 deaths in those who didn't. That represents 25 percent less cervical cancer and a 35 percent lower death rate among those screened.

In the US, we screen with pap smears and do the visual inspection using vinegar and a magnifying lens to direct areas to be biopsied, but that's expensive. It looks like the visual inspection method is already something that's being done in more impoverished areas of the world. The study confirms that it's an effective method for screening in areas where the rates of cervical cancer and dysplasia are high. Would it be effective here? Maybe not. There may be too many false positives to justify using it in the developed world, where cervical cancer rates are much lower.

2007-08-03T08:48:00.000-04:00

License Fees: Puerto Rico's medical licensing board has just seen a sweet deal go sour:

A federal grand jury indicted 88 doctors following an investigation into members of the U.S. Caribbean territory's medical licensing board, who allegedly altered low-scoring tests to certify unqualified candidates.

The doctors, mostly Puerto Ricans who studied medicine in the Dominican Republic, Mexico or Cuba, paid board members bribes of as much as $10,000, according to the indictment. At least 75 were practicing medicine in Puerto Rico, including some at hospitals or emergency rooms, authorities said.

2007-08-03T08:44:00.000-04:00

Under Their Noses: South Korean stem cell researcher Woo Suk Hwang, who was charged with faking his research may have discovered something new after all, without ever realising it:

Researchers said that the distinct "genetic fingerprint" of the stem cells means they may be the first in the world to be extracted from embryos produced by the so-called "virgin birth" method, or parthenogenesis.

This happens when eggs are stimulated into becoming embryos without ever being fertilised by sperm, and has been achieved in animals.

However, before Hwang, no one had managed to produce a human embryo using parthenogenesis which lived long enough to allow the extraction of viable stem cells.

Dr George Daley, who led the analysis, said: "Unfortunately at the time they published their work they did not know what they had done so they had mistakenly isolated these parthenogenic embryonic stem cells, and yet misrepresented them as true clones.

"In fact they had produced the world's first patient-specific embryonic stem cell, and that is very valuable.

"Scientists interested in modelling complex diseases would like to be able to move a patient's own cells into a petri dish in their embryonic form."

2007-08-02T13:46:00.000-04:00

Civil Servants of Very Little Brain: The amazing case from France.

2007-08-01T23:05:00.000-04:00

Eugenics Today: There's an interesting discussion at Asymmetrical Information (there's always an interesting discussion of some sort or another over there) about whether or not today's selective privately-chosen abortions are the same as eugenics. I would argue, yes. They're eugenics on a personal level.

2007-08-01T22:34:00.000-04:00

Ultimate Male Chauvinism: The worldwide preference for boys:

Throughout human history, demographers tell us, nature has provided about 105 male births for every 100 females. This “sex ratio at birth”—stable across generations and ethnic boundaries—may range from 103 to as high as 106 boys for every 100 girls. In only one generation, that ratio has come unglued.

A Chinese census reports ratios as high as 120–136 boys born for every 100 girls; in Taiwan, ratios of 119 boys to 100 girls; in Singapore 118 boys per 100 girls; South Korea 112 boys per 100 girls; and in India, where the practice was outlawed in 1994, the ratio continues to exceed 120 boys for every 100 girls in some areas. Countries such as Greece, Luxembourg, El Salvador, the Philippines, Cape Verde, and Egypt, even among some ethnic groups in the United States (Chinese, Japanese, and Filipino), are showing the same deadly discrimination against daughters.

...Over the last generation, the world has witnessed a drive toward smaller families, and this is directly related to sex selection. With fewer children, the sex of each child matters more. Analysis by Nicholas Eberstadt shows that, in India, each child after the first is increasingly unwanted, such that, with the second child, the desirability of girls to boys is 16% to 40%. By the fourth pregnancy, a girl’s desirability is a sad 9%, compared with 75% in favor of a boy. With these odds, and with cheap sonogram technology and easy access to abortion, is it any wonder India reports that 300,000 to 500,000 girls go “missing” every year due to infanticide and abortion?

In China, at least half of all second or higher-order female pregnancies are terminated owing to sex. The most recent Chinese census shows a sex ratio of 150 boys for 100 girls in subsequent pregnancies. Hence, the fertility-reduction imperative drives the culling of girls.

You often hear people say how much easier sons are than daughters. Could the same thing happen here?

2007-08-01T21:32:00.000-04:00

Tumult in the House: Passions were flying as the House debated health insurance for children:

The bickering devolved into shouting across the House floor Tuesday evening when Republican Rep. Lee Terry told Democratic Rep. Anthony Weiner to "shut up" after Weiner yelled, "We can't trust you," while House Minority Leader John Boehner spoke in opposition to the debate rules.

Democratic members were taunting Boehner as he discussed why Republicans had launched a protest to the manner in which the legislation is being pushed through the chamber. House Majority Leader Stony Hoyer reprimanded his caucus by forcefully shushing members and declaring both sides out of order. Republican Rep. Jeff Flake of Arizona characterized the antics by saying the chamber had turned "into the House of Commons."

Degenerated into the House of Commons. Giggle.

But this is tame compared to past Congressional fights. There was a a generalized brawl with fists, not words and a beating into unconsciousness in the 1850's, and in the 1790's there was a fight with canes and fire tongs.

2007-08-01T21:11:00.000-04:00

Second Hand Book Reviews: Also in JAMA, Grief of My Heart: Memoirs of a Chechen Surgeon:

Dr. Khassan Baiev, who was born in Chechnya and educated in Russia, was busy with his private surgical practice when the first Chechen war broke out in 1994, transforming him into a frontline trauma surgeon. Over the next few years, working underground, he treated countless individuals, regardless of political or religious affiliation, in some of the most challenging situations imaginable. By 2000, he was the only surgeon for nearly 80,000 residents around Grozny.

His experiences include treating Shamil Basayev, later of the Beslan school massacre, and his own kidnapping and near execution. But beware, it's the same book as this, just different titles.

2007-08-01T20:54:00.000-04:00

Brain Shock: Electrical brain stimulation restores speech in a beaten brain:

A 38-year-old man who spent more than five years in a mute, barely conscious state as a result of a severe head injury is now communicating regularly with family members and recovering his ability to move after having his brain stimulated with pulses of electric current, neuroscientists are reporting.

....After being kicked repeatedly in the head during a mugging in 1999, he was sometimes able to move his thumb in response to yes-or-no questions but do little else. He rarely opened his eyes. Yet tests showed that language circuits in the left side of his brain and running through his prefrontal cortex — the rational, conscious areas — were intact.

Brain injuries from blows to the head often sever nerve connections widely throughout the brain but can leave some circuits intact.

Surgeons at the Cleveland Clinic threaded two wires through the man’s skull and into a sub-cortical area called the thalamus. The wires were connected to a unit resembling a pacemaker that was implanted under the man’s collarbone.

.....Soon after the device was turned on, the man showed some improvements. His eyes opened. He became more reliably responsive. Over a period of months, members of the research team then tracked the man’s abilities during stretches when the current was turned on, and periods when it was off, without knowing when the device was activated.

They found a gradual but consistent improvement in speech and movement when the device was on, and a loss of progress when it was off. He began to eat, without the assistance of a feeding tube. He regained some movement in his arms. He began to speak, usually with only a word or two but was fully engaged in the conversation. He recently recited the first 16 words of the Pledge of Allegiance.

More on how deep brain stimulation is performed can be found here.

2007-08-01T20:24:00.000-04:00

What's in a Name: An international collection of names for clostridial diseases.

2007-08-01T20:17:00.000-04:00

Days Gone By: From JAMA's "100 Years Ago" feature, a description of gas gangrene contracted in the Phillipines after a canon wound:

On the second day multiple incisions were made with the object of evacuating pus. On introducing the hypodermic needle to inject cocaine for local anesthesia the pressure within very promptly forced the piston of the syringe back, filling the barrel of the syringe with gas. On withdrawing the needle the gas sizzed out of the tissues.

He survived after an amputation of the gaseous arm. His companion in arms was not so lucky, in treatment nor outcome:

Hot local applications and rectal injections of strong coffee were administered during the night. On the following morning the patient's condition was bad, with no return of circulation in the leg.

Amputation above the knee-joint was decided on....The patient succumbed at the commencement of the operation.

What do you suppose those strong coffee enemas were meant to do? flush the toxin from the body? It's a belief that still has its subscribers. Now as then, coffee is better taken per os than per rectum.

2007-08-01T07:39:00.000-04:00

Joints vs. Cancer Sticks: Neither are good for you, but stick by stick, marijuana does more damage:

A single cannabis joint could damage the lungs as much as smoking up to five tobacco cigarettes one after another, scientists in New Zealand have said.
The research, published in the journal Thorax, found cannabis damaged the large airways in the lungs causing symptoms such as coughing and wheezing.

It also damaged the ability of the lungs to get oxygen to, and remove waste products from tissues

....However, in this study, people who smoked only cannabis were not found to suffer from emphysema, a serious and crippling lung disease which was previously thought to be linked to the drug.

How can marijuana smokers have more damage to their lungs, but less emphysema? According to the abstract of the paper, "emphysema" in this case means "macroscopic emphysema." Macroscopic emphysema refers to the look of the lungs on CT scans. If they have certain characteristics, then they are classified as having macroscopic emphysema. However, the look of the lungs on CT scan isn't a good predictor of clinical emphysema. So don't assume that those joints won't turn you into a pink puffer or blue bloater. (Explanation here.)

2007-08-01T07:20:00.000-04:00

Reasons for Sex: Researchers were able to collect 237 of them(that's all?) But there isn't as much difference between the sexes as conventional wisdom holds:

Meston said she was somewhat surprised by the similarities between the genders. Men were more likely to endorse having sex for physical reasons (such as, "The person was too hot to resist") and to boost their social status ("I wanted to brag to my friends about my conquests.") But there was no difference in the emotional reasons, such as, "I wanted to express my love for the person."

"The stereotype that men have sex for physical reasons and women have sex for love -- our data didn't really support that," Meston said. "These young men and women were having sex for physical pleasure and also for emotional attachment, feeling connected to another person."

2007-08-01T07:12:00.000-04:00

Savior Siblings: A proposal in England to allow in vitro creation of children selected to treat non-fatal illnesses in their siblings.

2007-07-31T22:39:00.001-04:00

The Good Old Days: A gallery of disturbing ads from days gone by. Who knew that Lysol was the secret to a happy marriage? (Advice to readers: Don't try that at home.)

2007-07-31T21:53:00.000-04:00

Summertime Stings: The science behind removing bee stingers - time is of the essence, method not so important. Illustrated instructions here.