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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Saturday, August 24, 2002

    You are 27% geek
    You are a geek liaison, which means you go both ways. You can hang out with normal people or you can hang out with geeks which means you often have geeks as friends and/or have a job where you have to mediate between geeks and normal people. This is an important role and one of which you should be proud. In fact, you can make a good deal of money as a translator.

    Normal: Tell our geek we need him to work this weekend.

    You [to Geek]: We need more than that, Scotty. You'll have to stay until you can squeeze more outta them engines!

    Geek [to You]: I'm givin' her all she's got, Captain, but we need more dilithium crystals!

    You [to Normal]: He wants to know if he gets overtime.

    Take the Polygeek Quiz at Thudfactor.com

    (via GruntDoc)

    I do act as a translator between geeks and normal people every day. Only we call the geeks "consultants".

    posted by Sydney on 8/24/2002 06:05:00 PM 0 comments

    Crazy Lariam: Wolf Blitzer says he always avoids Lariam, the malaria drug, when globetrotting. His physician friends tell him it will mess with his mind. The Wolfman is telling us this because the drug is being investigated for possible ties to the Fort Bragg domestic violence incidents. Lariam is known to have the potential to cause psychiatric disturbances, but the rates of these complications are low (link requires New England Journal of Medicine registration.):

    Severe neuropsychiatric reactions (psychosis or convulsions) in response to prophylactic doses of mefloquine have been infrequently reported (in 1 in 10,000 to 1 in 13,000 users). Milder neuropsychological adverse events (anxiety, depression, nightmares, sleep disturbances, and cognitive changes) that are disabling enough to result in drug discontinuation have been reported in 1 in 140 to 1 in 250 users. However, six randomized, double-blind trials and seven prospective comparative studies failed to find significant differences in the rates of adverse events or drug discontinuation between subjects taking mefloquine and those taking other antimalarial drugs.

    A rate of 1 in 10,000 to 13,000 makes it unlikely that the drug was responsible for the Fort Bragg murders. That is, unless it was fish Lariam. Then anything’s possible.
    posted by Sydney on 8/24/2002 07:34:00 AM 0 comments

    And The Hype Goes On: The CDC and CNN continue to feed the fire of West Nile hype, using phrases like “fearing the virus could soon reach the West Coast,” (they've always said it eventually would) and recommending that hunters avoid touching dead birds, even though it isn’t known to be transferred from dead birds to people. They go on to catalog the most recent cases, two of whom died, but most of whom haven’t even required hospitalization. Jeesh. And these are the people who think they could calmly handle a smallpox outbreak with limited vaccination.
    posted by Sydney on 8/24/2002 07:29:00 AM 0 comments

    J’Accuse: A reader accuses me of being mistaken about the FDA and regulation of so-called dietary supplements. Worse than that, he accuses me of lying:

    Your recent quote crystallized the response that was needed on this issue. The quote claims:

    "... food supplements are unregulated ... "

    Bzzt. False. Bald faced lie.

    The actual law that applies to food supplements requires:

    1.) Supplements must be safe, according to the same standards as are used for food.
    2.) Claims for supplements must be accurate, e.g. "truth in advertising"
    3.) Supplement packaging must be clearly different from drug packaging.

    The FDA is required to issue and enforce the regulations to make this law take effect. They have done issued regulations. Food supplements are regulated. Those who claim otherwise are using the big lie technique. Tell your lie loud enough and often enough and people will think it is true.

    I do not lie - not even under a mistake. My accuser is parsing terms. Herbal medicines are drugs. They aren’t food. They aren’t even vitamins. Yet, they aren’t subjected to the same regulatory standards that other drugs are. They aren’t even subjected to the same regulatory standards as other over the counter drugs. I stand by my statement that they aren’t regulated, although to be accurate I should have said "aren't regulated like the drugs they are". Here’s how the FDA describes their oversight duties when it comes to herbal medicines:

    FDA regulates dietary supplements under a different set of regulations than those covering "conventional" foods and drug products (prescription and Over-the-Counter). Under the Dietary Supplement Health and Education Act of 1994 (DSHEA), the dietary supplement manufacturer is responsible for ensuring that a dietary supplement is safe before it is marketed. FDA is responsible for taking action against any unsafe dietary supplement product after it reaches the market. Generally, manufacturers do not need to register with FDA nor get FDA approval before producing or selling dietary supplements. Manufacturers must make sure that product label information is truthful and not misleading.

    FDA's post-marketing responsibilities include monitoring safety, e.g. voluntary dietary supplement adverse event reporting, and product information, such as labeling, claims, package inserts, and accompanying literature. The Federal Trade Commission regulates dietary supplement advertising.

    In contrast, other drugs have to prove their safety and their efficacy before being brought to market. Even when problems come to light, the FDA has trouble tracking down the reports,as in the recent ephedra case:

    The FDA has long sought the records as part of its probe of ephedra, which has been linked to dozens of deaths. Three weeks ago, the FDA asked the Justice Department to pursue a criminal investigation - one Justice lawyers themselves had been urging.

    "Metabolife has refused and resisted us at every step of the way," Crawford said. "News that so many reports exist greatly heightens our concern."

    Allowing drugs to come to market without scrutinizing them or even inspecting them for safety, and reserving the prerogative of inspection only after damage has been done is hardly “regulation”.
    posted by Sydney on 8/24/2002 07:20:00 AM 0 comments

    Friday, August 23, 2002

    Making Sperm Fun, or Talking Down to Men? You be the judge.

    posted by Sydney on 8/23/2002 06:42:00 AM 0 comments

    Another Over-Hyped Disease: USA Today indulges in angst over the paucity of preventive methods for Lyme disease. Truthfully, it just isn't common enough or deadly enough to make prevention desirable:

    But an effective vaccine may prove elusive, Fish says. Companies "may not want to take on (development of) a vaccine for a disease that is treatable and has a relatively low incidence. ... It may not be economically feasible, and there are problems of liability."
    posted by Sydney on 8/23/2002 06:42:00 AM 0 comments

    Adoption With a Twist: There are actually adoption agencies for left over embryoes from in vitro fertilization clinics.
    posted by Sydney on 8/23/2002 06:41:00 AM 0 comments

    Wipeout: Why I'm reluctant to commit to electronic medical records, although I like these.
    posted by Sydney on 8/23/2002 06:40:00 AM 0 comments

    With Charity for All: DB’s MedRants had a post yesterday about “luxury primary care” otherwise known as “boutique medicine”. DB likes to call it “retainer medicine”, which is a more apt term. Patients pay physicians an upfront fee for the privilege of having them attend to them for the year. The fee can be anywhere from a relatively modest $1500 to $20,000. In return, physicians provide twenty-four hour access seven days a week. The rub is that the patients still use their insurance coverage for office visits and for other healthcare expenses, and they aren’t really getting anything more than what most doctors already provide. The catalyst for DB’s post was a flurry of letters to the editors in the New England Journal of Medicine this week in response to an article in April that denounced the practice. The gist of the article was that physicians have an obligation to society to insure that medical care is evenly distributed.

    I’m not so sure about that. I believe that each individual physician has a duty to provide care to someone in clear need regardless of race, politics, or ability to pay; but no one is obligated to provide free or discounted care to those who don’t need it. That’s the problem with our system today. Somewhere along the line, we’ve devolved from a system in which charity care was reserved for those who were deserving of charity, to a system in which everyone is considered deserving of charity, regardless of their ability to pay. How else to explain this letter in response to the “luxury care” article from two Palm Beach matrons?

    We cannot believe that this kind of medical practice is legal. As Medicare patients, we are entitled to access to our physicians with nothing more than a 20 percent copayment.

    That last sentence says it all. Even our wealthiest citizens feel themselves entitled to discounted healthcare, and it’s all Medicare’s fault. Medicare was designed to help the impoverished elderly, but it has expanded into an entitlement program non pareil and into a regulating body whose power over doctors and hospitals is nothing short of tyrannical. Consider the history of “balance billing.” In the beginning of Medicare, doctors were allowed to bill patients for whatever part of their usual and customary fee was not covered by Medicare fees. That reasonable measure fell long ago to the sword of Medicare regulations:

    Medicare in particular has been hostile to balance billing. At one time, balance billing of Medicare beneficiaries was the norm, and physicians could bill patients for the portion of fees Medicare did not cover. To counteract this practice, Medicare has gradually introduced penalties for physicians who do not accept the Medicare reimbursement as full payment, and today most physicians are not allowed to bill patients for the balance.

    Medicare has pursued this policy for a number of reasons. First, Medicare wants to keep health care costs for its beneficiaries under control. In addition, Medicare has strived to create what it believes to be an adequate payment system, a perception that would be undermined if balance billing were allowed.

    In many states, commercial insurers and Medicaid programs have followed Medicare's lead. For example, in Massachusetts, the state-regulated Blue Cross program successfully lobbied for a ban on balance billing. The legislature also imposed balance-billing bans for Medicaid. Many commercial insurers include a prohibition of balance billing in their terms of participation for individual physicians. Thus, providers are often not able to obtain their usual and customary fees by charging patients the balance for a service once the insurer has paid its share.

    Medicare sets the sub-standard of reimbursement by which all the other third party payers live. Now, not only do Medicare beneficiaries think of health care as an entitlement for which they owe nothing, but the insured feel that way, too. The only people in this country who have to pay for their healthcare now are those who are unfortunate enough not to have insurance, yet not unfortunate enough to qualify for Medicaid. They are the least able to afford it, and are in truth more deserving of discounted fees than the insurance companies and government. That’s the crux of our problem. Our professional relationship and duty is with the patient, but our financial relationship is with these large corporations and government bureaucracies, who don’t care a fig for the patient or their health. The patient, in turn, doesn’t care a fig for the cost. It’s time we recognize that not everyone is equally deserving of medical charity and return the financial responsibility of paying the doctor where it belongs - with the patient.

    I’ll leave you with a few other select comments from the letters inspired by the article:

    The current system of primary care is the creation not of doctors and patients, but of those who pay for care — in general, insurance intermediaries acting on behalf of employers or governments. -a group of doctors who are practicing luxury care

    Certainly, most people believe that food and shelter are more important than medical care, yet there is no expectation that builders have an obligation to provide for the equitable distribution of housing or that supermarket chains have an obligation to provide for the equitable distribution of food. - a Boston physician

    Finally, could you comment on the 13th Amendment to the U.S. Constitution and its applicability to persons holding the M.D. degree? - a Virginia physician

    Medicare Part Deux: Not only is Medicare a tyrant when it comes to setting physician fees, they also are a very punitive organization, accusing doctors of fraud if they disagree with a chosen billing code for a patient visit (also known as an “evaluation and management, or “E/M” code). A reader e-mailed an article from the Annals of Emergency Medicine which proves what physicians have long known - Medicare’s coding system for billing services is needlessly confusing and complex. Even coding experts can’t agree on proper codes for visits:

    To determine the reliability of the federal government's E/M coding system, Raymond E. Jackson, MD, and his team of investigators from William Beaumont Hospital System in Royal Oak, Mich., sent emergency department medical records to several coding specialists to determine their level of agreement in assigning codes. Two sets of charts were sent to multiple specialists at four different coding agencies (inter-agency) and a third set was sent to several coding specialists within the same coding agency (intra-agency). The records were blinded so coders were unaware of what codes others had assigned.

    ...The study shows poor agreement among coding specialists on which codes they assigned to emergency department medical records. In 6 percent of the medical records, the study found no agreement at all among the four different coding agencies, and in only 15 percent of the cases did coding agencies have complete agreement.
    (emphasis mine)

    Remember that the next time you read about a hospital or physician being accused of “fraud”.
    posted by Sydney on 8/23/2002 06:23:00 AM 0 comments

    Thursday, August 22, 2002

    Exploding Anthrax: Researchers have taken Russian "phage therapy" a step further and developed a protein that makes anthrax bacteria explode. Added bonus: it’s “natural” since the protein in question comes from a naturally occuring virus. Testing to begin soon in higher mammals.

    posted by Sydney on 8/22/2002 07:16:00 AM 0 comments

    Coming to America: A history of West Nile in America from a 2001 New England Journal of Medicine editorial.
    posted by Sydney on 8/22/2002 07:16:00 AM 0 comments

    Testing West Nile Drug: A physician in New York is running a clinical trial to see if interferon, a drug already used for hepatitis, can combat West Nile virus. He began his study several years ago, but couldn’t get enough patients in his native New York, so he’s been borrowing patients from other places, like Louisiana. The study, by necessity, is a small one, so it's results won't be that reliable. Fortunately, West Nile virus isn't as much of a real threat as it's being made to seem, so there won't be all that many occasions to resort to any therapy.
    posted by Sydney on 8/22/2002 07:13:00 AM 0 comments

    More Alt Med: "Alternative" medicine practioners from around the world are going to convene at the NIH for two days to look at the effect of herbal medication on the heart and brain. That should be interesting. The article doesn't say how they'll "look at" the issue. Two days isn't long enough to do any studies., or even to collate all the existing studies into anything meaningful. I've got a feeling it's just a bull session. Got to agree, though, with this assessment:

    "Pharmaceutical companies have their faults, but at least what they make is regulated and the (Food and Drug Administration) requires them to test for impurities."

    Meanwhile... An “alternative medicine” in China is in danger of extinction. I never knew ant-eaters had so many uses:

    "In China, its meat is very popular, while its scales and blood are mixed with herbs. The formula is believed to prolong life and strengthen the sex drive," says Thanit Palasuwan, head of the anti-wildlife poaching unit at the forestry department.

    Some Chinese medicine recipes also use pangolin scales to cure lymph node malfunctions, kill pain, or increase milk in breast-feeding mothers, said Suda Loh, a herb-shop owner in Bangkok.

    In Nepal, some people consider the animal's meat a delicacy and make its scales into rings as charms against rheumatic fever. They also believe its flesh has aphrodisiacal value and that an extract of its uterus can safeguard against miscarriages.

    posted by Sydney on 8/22/2002 07:10:00 AM 0 comments

    What’s An Alternative? Ross over at the Bloviator has a discussion going with one of his readers about the dichotomy between “alternative” medicine and “allopathic” medicine. Both terms are inadequate. “Alternative” medicine has come to mean all treatments that are not within the mainstream of medicine: from herbal supplements to massage therapy to crystal therapy to chiropractic manipulation. Some of these are worthy treatments, some are not. “Allopathic” medicine is an even worse term. It was coined by Samuel Hahnemann in the 19th century to contrast conventional medical practice with his own homeopathic approach. In reality, there is no “alternative” or “allopathic” medicine. There are therapies that work, and there are therapies that don’t work. There are therapies that are based on wild conjecture and theories, and there are therapies that are based on observation and experience. Any of these can fall into the categories of “alternative” or “allopathy.”

    Somehow the notion that “alternative medicine” is superior to conventional medicine has taken root in many people’s minds, including some congressmen and doctors. For some, it’s the idea that alternative medicines are “natural” that is so appealing; for others it's the illusion that they are taking control of their illness, and for many it's because conventional medicine has failed them.

    Take herbal medications. Because they are derived from herbs, many people think that taking them is akin to eating mint or basil grown in the garden. Never mind that the herbal supplements on the health food store shelves are in fact drugs, and unsupervised drugs at that. The truth is, conventional medicine also relies on drugs derived from nature. Digoxin, a heart medication, comes from the leaves of the foxglove plant; aspirin is derived from a chemical found in willow bark, wintergreen, and the meadowsweet plant; most of our narcotics are derivatives of morphine and other chemicals found in the poppy; there are cancer drugs that come from the periwinkle and the Yew tree; and the majority of antibiotics are derived from bacteria and fungi that live in the soil. The list goes on and on. Both herbal medication and conventional medication are manufactured in chemical factories. There is no inherent purity to the herbals just because they are labeled “herbal”. The difference between these conventional medicines and the herbal supplements are: 1) the conventional medications are manufactured in a form that insures adequate and reliable concentrations in the body, herbal medicines are not; and 2) conventional medications are tested for efficacy and safety, herbal medicines are not. Those who convince themselves that herbals are superior by virtue of their very nature are only fooling themselves. Unfortunately, some of those fools are congressmen, and they have unleashed their foolishness on the unsuspecting public by allowing herbals to circumvent safety standards that other drugs must meet.

    Many more people turn to unconventional methods for a sense of control. The herbals they buy at the health food store may not work any better than the prescription drug the doctor gives them, but if so, it was their choice, not someone else's. Similarly, following elaborate diet regimens like those of Dean Ornish to combat heart disease, confers a sense of control and mastery that taking an aspirin a day or having your coronary arteries rotor-rooted doesn't. It may not be as effective as taking an aspirin a day, or having a procedure, but no matter. It gives you a feel-good feeling. The idea that lifestyle management and diet are the sole provence of alternative medicine, however, is false. Since the days of Hippocrates conventional medicine has advocated diet and lifestyle modification for a variety of conditions: obesity, gout, diabetes, heart disease to name a few. We still do. Following the diet and lifestyle prescriptions, however, requires willpower and hard work on the part of the patient. Too often, the will is weak, and the modifications fail. Sometimes they are only partially successful. In those cases we have to rely on drugs to give treatment a boost. The idea that conventional medicine and medical doctors ignore the importance of diet, self-care, and the emotional and life-style causes of disease is only a perception, not a reality. The difference between conventional medicine and alternative medicine in this respect is simply that conventional medicine has alternatives to turn to when these fail or when a disease isn’t responsive to them. Alternative medicine practioners, in contrast, usually only tout one treatment - their treatment.

    The most common reason for turning to alternative medicine is because conventional medicine has failed. You see this in the terminal cancer patients who turn to crystal therapy, or faith healing, or travel to Mexico for a miraculous cure; in arthrititis patients who undergo "bee sting therapy;" and in dementia patients whose well-meaning relatives load them up with all sorts of herbals to improve the mind. They are desperate people in search of a cure, and as such deserve protection from hucksters who would use that desperation to turn a quick profit.

    It’s true that there is much in modern medicine that is based on theory and speculation more than hard evidence. Estrogen replacement therapy to prevent heart disease fell into this category, as does the use of cholesterol lowering drugs to reduce heart disease in healthy people. It is also true that there are some alternative medicine practices that are of benefit. Chiropractic manipulation and acupuncture for pain come most easily to mind. (Although some practioners go too far when they suggest that chiropractic manipulation and acupuncture can cure allergies and the like.) Conventional medicine, however, is at least based on some understanding of the drug or treatment involved and the way it interacts with the physiology and biology of the human body. Too often, "alternative" medicine is just whistling in the wind. More importantly, conventional medicine is willing to scrutinize and reconsider its theories and therapies and discard them when they are disproven. "Alternative" medicine does not. Now tell me, which is the better approach?
    posted by Sydney on 8/22/2002 06:15:00 AM 0 comments

    Never Mind.... Experts now think the data on genes and breast cancer exaggerated the individual risk of breast cancer in women with certain genetic mutations. It’s all the more unfortunate because some women elected to have prophylactic mastectomies based on an estimated risk of cancer of 80%. Turns out the risk may be as low as 20%. Truth is, no one really knows the risk. When we will ever learn? We continue to take these studies at face value rather than scrutinizing their methods and their results before applying them to real life. Doesn't do much to foster trust in conventional, "evidence-based" medicine, does it?
    posted by Sydney on 8/22/2002 06:11:00 AM 0 comments

    Pox Israeli Update: Israel expands its smallpox vaccine campaign.
    posted by Sydney on 8/22/2002 06:11:00 AM 0 comments

    Wednesday, August 21, 2002

    JAMA's weekly art history lesson.

    posted by Sydney on 8/21/2002 07:29:00 AM 0 comments

    Fun with Cell Biology: CELLS alive! (lifted from the Washington Post)
    posted by Sydney on 8/21/2002 07:29:00 AM 0 comments

    Sanctuary! Sanctuary! There’s a hospital in Seattle whose mission is to provide care to felons, fugitives, drug addicts and homeless people.(via Horologium, via Jim Miller) That’s a noble objective, and one that most hospitals already embrace. Hospitals in the United States aren't allowed to deny care to anyone. We have laws about that sort of thing. However, the Seattle hospital has taken this worthwhile mission of medical charity a step further and defined itself as a sanctuary from the law for the criminally inclined. The results are predictably horrendous:

    An analysis ordered by the hospital's former public-safety director last year showed that the risk of being robbed at Harborview and its surrounding clinics and offices was 10 times higher than in the rest of King County. The risk of being assaulted was five times higher.

    Across the board, Harborview had higher levels of risk for every major crime than the national, state and local averages for those crimes.

    Hospital officials don’t want the fringe-elements among their patient population to be offended or frightened by the sight of uniformed, armed guards, so they don’t let their security guards wear uniforms, and the only weapon they carry is a collapsible metal baton. The patients, however, are another matter:

    Last year, the nightly weapons checks picked up more than 2,100 objects that could be used as weapons, including 32 guns, 1,591 knives and other sharp-edged tools, 197 pepper-spray canisters and 318 other "makeshift" objects.

    And that’s only what’s confiscated in the night. With childlike naivete the hospital administration believes that the sun protects against the evil that lurks in the heart of men. They only allow searching for weapons at night, between the hours of 8PM and 5AM - the only hours, presumably, when bogey men walk the earth. Not surprisingly, it isn’t a safe place to be an employee or a patient:

    Emergency-room nurse Charles Wiley remembers the chill that ran through him after treating a suicidal man who had his stomach pumped.

    "He said, 'Charles, I'm going to track you down. I'm going to kill you. I'm going to kill your family. You will regret this day that I was in the emergency room.' It's been 18 months, and thank God nothing's happened."

    ....Last month, a patient threatened to stab a man with a syringe because the man refused his request for a cigarette on the sidewalk outside the emergency room.

    ..Dozens of angry people swarmed into the emergency room following a shooting. At least two people in the crowd were carrying guns, and one man waiting in the ER pulled a gun when the crowd swarmed in.

    ...Earlier this year, medical staff did not notify police or public safety after discovering that a male psychiatric patient had possibly assaulted a 21-year-old female psychiatric patient. Safety officers learned of the incident only when a sexual-assault examiner approached them.

    When the same patient was sexually assaulted by a different male patient six days later, reports indicate, the supervisor for the unit told staff not to cooperate with the investigation into the incident

    .. But in November, after a nurse was abducted while walking to her car and subsequently raped, the hospital told employees that public safety had stepped up uniformed and undercover patrols in the neighborhood. In fact, it had not, according to former Sgt. Cerda and others with first-hand knowledge of the situation.

    The hospital adminstration has allowed the concept of sanctuary to be hijacked by the criminal element amongst them, both patients and staff. No one, regardless of their moral depravity, should be denied medical care, but neither should moral depravity be condoned and tolerated.

    True Medical Charity: Meanwhile, half a world away, the Israelis set a better example of medical charity, as described by Larry Miller:

    Downstairs, before we left, the head of the hospital, an Israeli named Audrey, was showing me the children's waiting room. I couldn't help but notice, all around, an Arab woman with her son, an Arab family over there checking in, Arab children playing with the toys while waiting. The doctor saw the look on my face and laughed. "Oh, yes, we treat everyone." I guess I was astonished. She just shrugged. "We're Jews. This is how we live. It's also for the future. They're not going anywhere, and we're not going anywhere. There will eventually be peace. There has to be." When? A month? A year? A hundred years? More? She didn't know. I had to say it. You're incredible. You take everyone, you treat everyone, no one goes first, no one goes last, you just go in order of who needs help. That's, like, Mother Teresa stuff. "We're not saints, we're just doing our jobs. It's not easy, I admit. And it gets hard when they cheer when the bodies are brought in." I looked at her. What did you say? She sighed. "Yes, it gets hard when they cheer."

    They may put up with the cheering, but I’m sure they check people for bombs before letting them through the doors.
    posted by Sydney on 8/21/2002 07:19:00 AM 0 comments

    Please Disregard Our Moral Bankruptcy: Kaiser Permanente officials in Oregon have sent a memo to staff doctors soliciting volunteers to kill terminally ill patients. They’re concerned that some Kaiser patients had to wait to be killed while substitutes were found for their original physicians who balked at the idea. Time is money, after all. (again, thanks to Jim Miller)
    posted by Sydney on 8/21/2002 07:16:00 AM 0 comments

    Those Resourceful Special Forces Update: The Army Special Forces guys from a few weeks ago are in trouble for taking animal antibiotics:

    Military officials, who declined to release any details about the sinusitis patient or to permit Goff to be interviewed, said the Army's surgeon general was especially concerned that publicity about the practice reflected unfavorably on the quality of military medicine. "This is a very sensitive subject around here," one Army spokesman said.

    It doesn’t really reflect badly on military medicine. The patient just didn’t want to take the time to see a doctor. It was easier and more convenient to pick up fish antibiotics. He was probably picking up fish food or something anyway. The Army’s surgeon general is being terribly sensitive about this. True, taking medication meant for animals isn’t the safest thing to do, but it’s hardly an indictment of army medicine that someone tried to treat themselves. That sort of thing happens in civilian life,too. The Army’s reaction is more a reflection of their own insecurities than anything else. Like all captive patients (HMO members, college students), armed forces members tend to be disparaging about their medical providers. They don’t feel they have a choice in who their doctor is, so they have little confidence in them and are quite vocal about it. Thus the easily-bruised egoes of the medicos.
    posted by Sydney on 8/21/2002 07:14:00 AM 0 comments

    Alternative Medicine Watch: Gingko, an over the counter herbal medicine that claims to preserve mental functioning, and which had sales of $240 million in the US in 1997, gets a trial - and loses.

    Neither patients nor observers noticed any difference between those who had taken gingko and those who had taken placebo. The study was only for six weeks, but as the authors point out, the manufacturer claims benefits can be found in as early as four weeks:

    Our study has limitations. It is certainly possible that higher doses or longer periods of exposure than used in this study are necessary to detect changes; however, we administered the compound following the manufacturer's instructions. The manufacturer's label indicates that ginkgo should be administered at a dose of 120 mg/d and that doses of greater than 120 mg show no additional benefit. This is also the dose suggested by the German Commission E. The daily dose in the present study was 120 mg/d. The label also states that a noticeable benefit should be apparent after 4 weeks of usage. The present study evaluated cognition after a 6-week interval. Moreover, there was no indication of a statistical trend toward significance for any of the compounds on any of the measures.
    posted by Sydney on 8/21/2002 07:10:00 AM 0 comments

    Tuesday, August 20, 2002

    Quackery Alert: James S. Gordon, MD, alternative medicine advocate and health care advisor to politicians, has an article in the Washington Post today touting alternative medicine as superior to conventional medicine. Dr. Gordon exposes himself as ill-informed and biased:

    The signs and symptoms of crisis in our health care system have become front-page news in recent weeks. Treatments that were routine -- widely accepted by physicians and embraced by the public -- have proven inappropriate, possibly dangerous and wasteful.

    The federally funded Women's Health Initiative appears to have demonstrated that the hormone replacement therapy (HRT) that was supposed to prevent heart disease in menopausal women actually increases its likelihood.

    True, I suppose, but coming as it does after that inflammatory opening paragraph, it suggests that the increase in heart disease is higher than it is. In fact, there was only a difference of seven percentage points between hormone users and placebo users when it came to the incidence heart disease.

    A well-executed study on the surgical treatment of osteoarthritis of the knee (published in the New England Journal of Medicine) showed that a placebo group -- patients who only thought they had surgery -- actually did as well as those who were operated on.

    This is true, but the results may be as much a testament to the placebo effect as to the ineffectiveness of the surgery. It’s also a testament to the fact that traditional medicine is willing to let the cold light of truth shine on its treatment approaches.

    And, a few weeks ago, a lead article in the New York Times reported on several major studies that show that more conventional health care and more medical specialists do not necessarily produce improvement in health status for both older people and newborns.

    This, too, is true up to a point. What the newborn study actually showed was that communities with with more than 4 neonatalogists per 10,000 births had no improvement in neonatal death rates. Those communities with less than 4 neonatologists per 10,000 births, however, had greater neonatal mortality rates. The specialty care does improve outcomes, it just doesn’t do so infinitely as the supply of specialists increases. It’s true that more specialty care doesn’t necessarily translate into better care, but it’s also true that no specialty care can lead to worse care.

    This cluster of disturbing findings is simply the most recent and visible manifestation of the limitations and counterproductiveness of an approach to health that places overwhelming emphasis on expensive and often side effect-laden surgical and pharmacological treatments, an approach that has largely devalued prevention, self-care and the perspectives and techniques of the world's systems of traditional medicine and healing.

    This “cluster of disturbing findings” are only disturbing if one’s mind is already made up that modern medicine is bad. It’s true that modern medicine emphasizes procedures and pharmacological treatments, but it does so with good cause. The “world’s systems of traditional medicine and healing” have done nothing to improve mortality from infectious diseases or cancer, it has been advancements in medication, immunizations, and surgery that has saved lives and improved longevity. “Traditional medicine and healing” may be fine for palliation, but they haven’t, as a body, had the success that modern science-based medicine has had. If they did, the developing world would enjoy the best health instead of the worst.

    Over the last several years we have learned that the treatments we routinely provide are, even when appropriately used, the fourth leading cause of death in our country.

    Says who? Certainly not the CDC:

    Preliminary 2000 data

    Ten Leading Causes of Death in the U.S.:

    Heart Disease: 709,894

    Cancer: 551,833

    Stroke: 166,028

    Chronic Lower Respiratory Disease: 123,550

    Accidents: 93,592

    Diabetes: 68,662

    Pneumonia/Influenza: 67,024

    Alzheimer's Disease: 49,044

    Nephritis, nephrotic syndrome, and nephrosis: 37,672

    Septicemia: 31,613

    Note that “accidents” is listed as the fifth leading cause of death. This includes accidents of all sorts, from auto accidents to people who fall down the stairs and break their necks. Modern medicine can hardly be held responsible for those.

    Dr. Gordon sees our failure to cure cancer as an indictment against modern medicine, sees potential side effects of medication as a reason not to use them, and sees chronic illnesses of aging such as heart disease and osteoarthritis as further evidence that medicine is failing people. He says that Americans, sick of all of these failures, are turning to alternative therapies:

    According to one study, published in the Journal of the American Medical Association in 1998, 42 percent of all Americans are using other than conventional therapies as alternatives or complements to conventional medicine. They are making 200 million more visits to "complementary and alternative health care providers" -- acupuncturists, chiropractors, massage therapists and others -- than to primary care physicians.

    One reason there are so many more visits to “alternative care providers” is that they keep their patients coming back. If someone sees me for back pain, I see them two or three times. In contrast, the chiropractors keep them coming back weekly for months, sometimes even years, for “adjustments.” Ditto the acupuncturrsts and the message therapists. This inflates the numbers of visits without any clear benefit. The difference between primary care physicians and alternative medicine providers is that we acknowledge when our therapy isn’t helping.

    The good doctor goes on to extoll the virtues of alternative medicine therapies that are even more unproven than the medical treatments he attacks. His commission on alternative health care has done nothing to foster investigative scrutiny of the treatments he praises. In fact, two of the commission members have written a minority report that details their concerns about the lack of objectivity among the commission members, most of whom, like Dr. Gordon, make their living selling alternative therapies to the public.

    There is much to be improved upon in our current health care system, but Dr. Gordon’s approach, is far from the answer.

    posted by Sydney on 8/20/2002 08:50:00 AM 0 comments

    Small Savings: Researchers are claiming that everyone benefits if we would all get flu shots:

    On average, a person who comes down with the flu loses 2.8 days at work, meaning about 398 dollars in lost wages, the study concluded, based on previous studies and Labor Department statistics.

    Researchers said that visiting a doctor and getting a flu shot would save about dlrs 30. Using one of three symptom-shortening antiviral medications resulted in similar savings.

    We would save even more money if we never took vacations and if we worked through the weekends. I have to agree with the CDC official on this one:

    While flu vaccine is beneficial to healthy adults and may get them back to work sooner, the priority should be vaccinating more of the highest-risk people, flu expert Dr. Carolyn Bridges at the federal Centers for Disease Control said.

    "When you look at vaccination of healthy adults, the bulk of economic benefit is decreased absenteeism; the benefit for the elderly is reduced medical costs and fewer complications that require hospitalization," she said. "That's something important we need to consider when we're allocating our resources."

    For the past two years the makers of flu vaccine have had trouble manufacturing enough to adequately immunize those at highest risk. It's hard to believe they can supply enough to immunize the entire population. Word is that everything will be fine this year, but it would be a pity if those most in need of the vaccine's protection should go without because it was depleted by healthy people trying to save a few bucks in lost pay.
    posted by Sydney on 8/20/2002 06:34:00 AM 0 comments

    SimBioterror: Software engineers are working on a computer simulation training tool for terrorist attacks:

    The new computer program was inspired by the wildly successful game in which players built virtual cities. But this simulation takes a much more realistic approach: How should public officials react to a possible bioterror attack, when thousands of lives are at stake?

    The program, called Weapons of Mass Destruction Decision Analysis Center, is being developed by Sandia National Laboratories as a way to simulate a war- room environment in the event of a terrorist attack.

    ...In one demonstration, a player must decide if there has been an anthrax attack in San Francisco.

    On a screen are different charts and graphs: Some show reports of people getting sick in different hospitals, while others show the number of deaths.

    "You're looking for something unusual," research analyst Todd West said, pointing to changing numbers and charts on the screen.

    The sudden rise in the number of serious flu cases could be due to a unusually strong influenza strain. But then one clinic says it suspects one patient may have been exposed to anthrax.

    City officials could decide to alert the public and activate vaccine distribution centers.

    Acting immediately, even without conclusive evidence of an attack, could save lives. But there could be mass panic and serious political fallout if it turns out to be a false alarm.

    As it turned out in the demonstration, a decision to call a press conference and distribute anti-anthrax medication saved many lives, although the bioweapon still killed thousands.

    At the end of the simulation, the program lists the different outcomes from different kinds of decisions. But there is no score.

    "That's the game part I don't want, where there is a winner and a loser and there's a score," Vitko said. "Much more important is the experience."

    It's sad that we need wargames for public health officials, but I'm glad that there's someone out there who's thinking of and developing such things.
    posted by Sydney on 8/20/2002 06:25:00 AM 0 comments

    You Name It, We'll Study It: Nutritionists are trying to set water consumption standards:

    Now the group that sets the nation's nutrition standards is studying the issue, too, to see if it's time to declare a daily fluid level needed for good health - and how much leaves you waterlogged.

    But we don't really need volumes of scientific study to tell us how much water to drink:

    Until then, "obey your thirst" is good advice, says Dr. Heinz Valtin, professor emeritus at Dartmouth Medical School..

    "Obey your thirst," will still be the best advice even when all the research has been finished.
    posted by Sydney on 8/20/2002 06:24:00 AM 0 comments

    Upclose and Personal: Daniel Taylor of Dreaded Purple Master has been hospitalized. He’s in the intensive care unit with a cerebral hemorrhage. His wife has been posting updates on his condition, which are also insightful observations on the plight of the patient in modern medicine. Streams of doctors come in and out, the cardiologists and neurologists argue over the best treatment approach, test after test has to be endured, and all the while few take the time to tell the family what’s going on. It isn’t a very flattering picture of the profession, but it’s one that we should all take to heart.
    posted by Sydney on 8/20/2002 06:23:00 AM 0 comments

    Monday, August 19, 2002

    Satire or Reality? Sometimes it's hard to tell:

    The Home Office said it was taking "infringement action" against Cambridge University researchers who injected mice with the stimulant methamphetamine and subjected them to loud music, including tracks by dance act The Prodigy.

    Several mice died and others suffered brain damage in the experiment, whose results were published in the journal NeuroReport last year.

    Animal-rights activists condemned the experiment. The British Union for the Abolition of Vivisection called it "tasteless and horrific."

    I thought that experimental mice were generally sacrificed as a part of the experimental routine, so I'm not sure if the fuss is over the fact that some of the mice died or whether it's about torturing them with bad music.

    (Note: Ignore the post just below this. I forgot to put in a quotation mark and fouled things up so badly I can't get blogger to edit it and delete it, so it just has to stand as a testament to my mistake.)


    posted by Sydney on 8/19/2002 01:20:00 PM 0 comments

    Satire or Reality? Sometimes it's  
    posted by Sydney on 8/19/2002 01:18:00 PM 0 comments

    Uneven Accompaniment: A recent study suggests that doctor's visits go better when the patient is accompanied by a friend:

    In the examination room, companions helped facilitate better doctor-patient communication, helped the patient to remember the physician's advice and instructions, helped the patient make decisions and expressed their own concerns to the physician.

    In fact, according to patients, their companions favorably influenced three out of four of their medical visits, particularly by helping them better communicate with their doctor, the authors note.

    Doctors also agreed that their patients' companions were an asset during the medical visits, the researchers report. Six out of every 10 physicians said that the patients' companions helped them better understand their patients, and 46% said the companions helped increase the patient's own understanding.

    That's true up to a point. I would add, however, that an unwanted companion in the exam room does far more harm than good. Many's the time I've entered a room to find a spouse in the corner chair and the patient sitting sullenly on the table, arms crossed, and decidedly uncommunicative. At a later date, when he returns, alone, for a follow-up visit, he's generally more relaxed and forthcoming. It's only then that we get at the true heart of the matter, and invariably the patient will admit that he was angry at his spouse during the initial visit for highjacking his appointment. (I use the generic "he". Spouses of both sexes are equally culpable.)
    posted by Sydney on 8/19/2002 07:55:00 AM 0 comments

    Stem Cell Summary: A nice run down of the state of stem cell research.
    posted by Sydney on 8/19/2002 07:43:00 AM 0 comments

    Shakedown: The Department of Health and Human Services is investigating the finances of several AIDS activist groups. Said groups recieve government funding, and said groups were very rude to HHS Secretary Tommy Thompson:

    HHS officials describe the congressional request for information on the groups' funding as routine and one that, in any case, the department is duty-bound to honor. Observers both inside and outside the department, however, say that some people at HHS are genuinely angry and are seeking to prevent what they view as disrespectful behavior in the future.

    Thompson was heckled on the third day of the weeklong conference when he delivered a speech on the U.S. government's overseas AIDS activities. Protesters blew whistles, chanted "Shame, Shame," rhythmically jabbed their fingers and eventually surrounded Thompson on the stage. He read his address to the end but his remarks were entirely inaudible. Handouts in both English and Spanish criticized the government for not spending enough on care and treatment of people infected with human immunodeficiency virus (HIV) in poor countries. At the bottom of the flier was a list of 12 organizations.

    The request for the investigation came from Congress, some of whose members were shocked and disappointed that the activists behaved in such an unseemly manner. It is a pity that the activits felt compelled to behave like adolescent thugs. The description of their behavior sounds like an agressive shakedown for more funding. While their actions were physically threatening and distatestful, it appears their motivation was to grab the spotlight more than anything else:

    The heckling of Thompson was especially dramatic because it occurred in a movie-theater-sized space and went on for half an hour. (The Spanish health minister was heckled into inaudibility at the conference's opening ceremony, but that protest took place in a cavernous sports arena and lasted only 10 minutes.) Nevertheless, the quasi-ritualized nature of the protest was evident in what happened in the hours after it.

    Afterward, one group of protesters held a scheduled news conference in the media center to explain their action. About a dozen activists, including numerous hecklers, met with Thompson in a previously scheduled meeting at his hotel.

    According to several people there, the secretary was told that the protesters' vehemence was not directed at him personally. Anthony S. Fauci, head of the National Institute of Allergy and Infectious Diseases and a key Thompson adviser, mentioned that Larry Kramer, a founder of ACT-UP, used to call him a "murderer" but was now his friend. An hour-long discussion of AIDS policy ensued.

    AIDS activists need to learn to behave as mature adults rather than spoiled children. While such behavior gets them press attention, it isn't necessarily the kind of attention they need. People aren't more likely to think kindly upon them when they see this sort of protest on the evening news. Such behavior only serves to strengthen prejudicial stereotypes about homosexuals and does nothing to foster acceptance and understanding in the community at large. While the actions of Congress and the HHS come across as punitive, they are justified in reconsidering their funding relationship with groups that resort to abuse in an attempt to garner even more money from them. Note to AIDS activists: Consider changing the name of "ACT UP" to "GROW UP".

    posted by Sydney on 8/19/2002 07:09:00 AM 0 comments

    Sunday, August 18, 2002

    Alcoholic Milk: An Israeli company is in trouble for selling a mixture of alcohol and milk in the dairy section of grocery stores:

    The milk drink, which comes in chocolate, orange, and coconut flavors, has proved popular among teenagers and even children, but the company claimed it was aimed solely at young adults over 18. The ministry also warned that pregnant women should avoid all alcohol or they could develop fetal alcohol syndrome, in which babies could suffer brain and developmental damage.

    ....Food and Nutrition Service director Dorit Nitzan-Kalusky said she learned of the Tara product from a physician who treated a young child who slept for 24 hours straight after drinking Extramood. She immediately ordered it removed from all supermarket, pharmacy, and kiosk shelves.

    Doesn't even sound tempting.

    posted by Sydney on 8/18/2002 03:24:00 PM 0 comments

    Nurse for a Week: In an effort to promote interest in nursing as a career, nursing summer camps are springing up.
    posted by Sydney on 8/18/2002 03:16:00 PM 0 comments

    Alternative Medicine Abroad: Dough balls for pain may be OK, but watch out for the diarrhea treatment:

    However, Dr Akaash said that the Dharmi did cause harm to some patients, particularly when faced with a severe case of diarrhoea.

    "They seem to believe that a person should be denied fluids in this instance. Less fluids in would mean less fluids out. But this sometimes resulted in death."
    posted by Sydney on 8/18/2002 08:17:00 AM 0 comments

    Battling the Bulge: Insurance companies are beginning to offer bonuses to pharmacists if they dispense generic drugs in place of brand name drugs:

    Blue Cross and Blue Shield of Illinois says it is only trying to counter the marketing muscle of drug companies, which spend billions of dollars on splashy television ads that tout their latest wonder drug and employ thousands of sales representatives to court physicians.
    "We don't want to have all of these commercials driving what everybody is taking," said Brad Buxton, Illinois Blues senior vice president of health-care management. "We are simply trying to encourage what is already a healthy relationship between a pharmacist and the patient. If there is a generic drug that is as good as a brand-name, patients could save $40 to $60 a prescription."

    Health insurers have long touted the pocketbook benefits of choosing generic drugs, and charging consumers higher co-pays for brand-name drugs is one way they encourage that. Targeting pharmacies is a new approach and one that will be closely watched, especially by drugmakers, which say the plan puts patients' health at risk.

    It will be up to the pharmacist to tell the consumer that he or she is being paid a bonus if a generic is chosen.
    posted by Sydney on 8/18/2002 07:37:00 AM 0 comments

    Maybe They're Exposed to More News Stories: Girls are more obsessed with weight than boys.
    posted by Sydney on 8/18/2002 07:31:00 AM 0 comments

    Fountain of Youth: According to CNN, more Medicare-age patients are having plastic surgery to look younger. Yet another argument for making the program needs-based. Although Medicare probably isn't paying for the procedures, the fact that we subsidize the other healthcare of people who are wealthy enough to afford this sort of thing should give us all pause.
    UPDATE: Another viewpoint on vanity and aging.
    posted by Sydney on 8/18/2002 07:19:00 AM 0 comments

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