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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, March 08, 2003

    Contraceptive Concerns: Glenn Reynolds posted an email from an ob/gyn who's writing a book about contraception and who labors under the impression that we're contraceptively deprived here in the US:

    1) the U.S. is one of the few countries in the world where women don't have access to hormonal implants or combination injections.

    Depo-Provera, although it isn’t a “combination injection,” but only one hormone, is an injectable progesterone contraceptive that is very popular here. And we have Lunelle, a combination of progesterone and estrogen. It isn’t as popular, however, because it has to be injected once a month. (Depo-Provera only has to be injected every three months.) We once had Norplant, an implantable hormonal contraceptive, but it was taken off the market because of weak sales, and because of lawsuits. Women were disappointed in its rate of side effects and the difficulty involved in removing the implants.

    2) the only hormonal Intrauterine device (IUD) available in the U.S. is Mirena, an older type of IUD (more prone to causing side effects.)

    Also not true. We have Progestasert (a progesterone IUD), which is still available ( see here and here) as well as the newer Mirena, which relies on the hormone levonorgestrel, a synthetic progesterone. Both have to be replaced once a year, which limits their popularity. Then we also have the non-hormonal, copper-based ParaGard.

    Lawsuits from the old Dalkon shield IUD have a lot to do with the limited investment in IUD’s in this country, as does the free market. Like the implantables and injectables, these just aren’t as popular as the pill.

    3) although a step in the right direction, the Today sponge is the only brand which contains the highest amount of the spermicide Nonoxynol 9 (N-9). N-9 has been clearly linked to an increased risk of HIV transmission (relevant articles)

    The sponge is also associated with higher rates of pregnancy and other sexually transmitted diseases. It isn’t such a great choice given the other options we have out there. And although it might have been popular with Elaine, it wasn’t all that popular with the majority of women. (Who wants to risk STD’s and pregnancy?) It, too, was taken from the market for business reasons rather than health reasons. The manufacturer didn’t want to shell out the money to upgrade its production plant. Now, if the sales of the sponge had been profitable enough to justify the upgrade, things probably would have been different.

    The truth is that here in the US, our “personal choice” drugs, such as contraceptives are subject to free market forces (with some litigation forces thrown in) rather than government largesse. And the other truth is, that there isn’t all that much room for improvement in birth control. The pill is highly effective, well-tolerated, and easy to take. Hard to beat that. Although a male birth control pill would be a fine innovation.

    UPDATE: Dr. Wendy Kroi, Instapundit’s correspondent on the issue of contraception in America, sent the following reply to my post below:

    Depo-Provera is a progestin-only injection. I was referring to the estrogen-progestin group of injections--no method in this group is currently available in the U.S. Lunelle was introduced in the U.S. in 2000. Regrettably, in October 2002 it was withdrawn from the U.S. market and it is not currently available.

    I thought my post made the distinction between Depo-Provera and Lunelle pretty clear. But, her original statement did not make clear that not all injectable contraceptives are combined hormone products. I thought it important to point out that injectable contraceptives are available here. As for Lunelle, it was the single dose vials that were removed from the market, after concerns about their effectiveness. Multi-dose vials were not recalled. (Although, I'll grant that mutli-dose vials aren't often used.)

    Regarding hormonal implants, the fact that Norplant, an older version, was taken off the market because of lawsuits or side effects, is no excuse to deprive American women of the newer and much improved version of implants like Norplant II (Jadelle) or Implanon. Again, an entire group of contraceptives is not available in the U.S.

    To say that American women are being “deprived” of alternative contraceptives is to suggest that there is some organized effort to keep these products off the market. That isn’t the case. Instead, it’s a complex interaction of business decisions and social concerns. If there were fewer lawsuits and more demand, then companies might be more interested in offering them here. As it stands, they don’t feel they are worth the riskst. And, as free members of society and the only consumers of those products (therefore the ones who are litigating and who influence the demand), American women bear some responsibility for the state of affairs. It is true that we have a fairly stringent drug approval process compared to a lot of other countries, but that isn’t necessarily a bad thing. Especially when you’re talking about drugs for which there are safe, available alternatives.

    Progestasert is the oldest type of hormonal IUD. It was introduced in 1976 and since 2001 it is no longer manufactured*. Mirena has been available in Europe for over 10 years. The fact that it was made available to American women only recently (in December 2000) does not make it a "new" IUD. The truly new hormonal IUDs are the T-LNG14 (the "updated" Mirena--smaller, better design, less side effects) and the FibroPlant-LNG, which is a frameless IUD (no plastic frame, far fewer side effects). Both Mirena and T-LNG14 are frame IUDs--they have a plastic, T-shaped, frame. I was comparing Mirena with the other IUDs in its group, not with IUDs in a different group (i.e., the copper-releasing IUDs).

    Again, I thought the original post at Instapundit didn’t make it clear to the lay reader that there were other IUD’s available to American women, and so I included the copper IUD in the discussion, making clear that it was different from the hormonal IUD’s. She’s right that production of Progestasert has been discontinued. But, again, I have to think it’s due to market forces, and I wouldn’t be surprised if Mirena went the same way, although it is better tolerated than Progestasert. As far as IUD’s go, though, they aren’t popular here largely because of the Dalkon shield litigation in the 1980’s. That scared everyone away - patients, doctors, and manufacturers. And again, as free and full functioning members of our society, American women are just as culpable for that state of affairs as anyone else.

    Regarding your statement that:

    And the other truth is, that there isn‚t all that much room for improvement in birth control. The pill is highly effective, well-tolerated, and easy to take. Hard to beat that.

    In the U.S., there are approximately 5.38 million pregnancies each year. About half, or 2.65 million, are unintended pregnancies. The majority of unintended pregnancies occur in women using birth control. This means approximately 1.4 million unintended pregnancies happen in women using birth control at the time that they become pregnant. It is estimated that about 1 million unintended pregnancies happen because of improper use of birth control pills. Thus, at a minimum, for about 1 million women per year in the U.S. the pill is not highly effective, well-tolerated or easy to take. Additional contraceptive options will, indeed, represent a way to "beat that".

    Well, that depends on how you define “using” birth control pills. If you mean that they have an unused pack of pills in the medicine cabinet, then they aren’t really using it, and you can’t blame the pill for the lack of efficacy. Although I can’t quote any statistics, my experience has been that women who don’t take their pills do so out of ambivalence more than out of concerns about side effects or difficulty remembering to take it. (At least that’s the case in my practice.) Women who take the pill every day as directed (something which the majority of pill users do) avoid pregnancy 99% of the time. Every form of contraception, aside from sterilization, requires some degree of compliance. Even injectables and implantables won’t be effective if the patient doesn’t show up to have them injected or replaced.

    UPDATE II: A reader emailed one more correction:

    You are correct in that Lunelle is still available. However, the following that you wrote is not quite correct.

    "As for Lunelle, it was the single dose vials that were removed from the market, after concerns about their effectiveness. Multi-dose vials were not recalled. (Although, I'll grant that multi-dose vials aren't often used.)"

    The recall of Lunelle was of the pre-filled syringes "due to a lack of assurance of full potency and possible risk of contraceptive failure." No vials were recalled. The vials are single-dose; there are no multi-dose vials. Each vial contains 0.5 mL of the combination--0.5 mL is the amount injected each month. The 0.5 mL vials are available in boxes containing 1 vial, 3 vials, and 25 vials.

    One last thing, some useless knowledge, hopefully for a smile. The inventor of the copper-eluding IUDs was a Chilean named Jaime Zipper.

    That is worth a smile.

    posted by Sydney on 3/08/2003 10:21:00 PM 0 comments

    Best Medicine: Well, this made me laugh.
    posted by Sydney on 3/08/2003 08:39:00 AM 0 comments

    Dubious Data: Researchers say that people with short thighs are more likely to develop diabetes:

    The researchers found that the average thigh length of men and women with normal glucose tolerance was 15.8 inches. It was 15.4 inches for those with insulin resistance and 15.1 in those with diabetes.

    Asao noted that leg length is determined by both genes and nutrition. While the thigh continues to grow until about age 20, how long it will get is determined by about age 4.

    Two earlier European studies have looked at overall leg length and found a link with the risk of diabetes. The latest study is the first to examine this in a large group of Americans and to focus on the thigh.

    Other researchers said that while the results are intriguing, they do not suggest anything people can do to avoid the risk of diabetes.

    "I would not go out and get my thighs stretched, if that's possible," said Dr. Russell Luepker, head of epidemiology at the University of Minnesota.

    I wouldn't go out and get my thighs measured, either. Who can measure leg length accurately to within 0.4 to 0.7 inches? Not many of us. It's often hard to hit the landmarks for measuring parts of the body accurately. This is especially true in the overweight, who (surprise!) are already at risk for diabetes. The article doesn't mention if the researchers controlled for weight in their subjects, nor does it mention the margin of error in their thigh measurements.

    Besides, screening for diabetes is very easy. It's a simple blood test, and we have no way to prevent the disease in those who are risk for developing it in the future.
    posted by Sydney on 3/08/2003 08:36:00 AM 0 comments

    Patent Perfidy: Boing Boing (which really is a directory of wonderful things) points out that a judge has told the maker of Paxil to cool their absurd patent claims:

    Basically SmithKline is saying that [generic drug maker] Apotex can't make Paxil because at a crystalline level, contamination from them making another drug will cause minute amounts of *their* patented drug to be produced as a side effect. (the judge makes an observation that people will infringe upon the patent by ingesting it even if Apotex was not)"

    Derek Lowe has more to say about similar shenanigans.
    posted by Sydney on 3/08/2003 08:34:00 AM 0 comments

    Abortion Attitudes: A reader asks:

    Under what circumstances would a partial birth abortion/dilation & evac be performed? And why would this procedure be chosen over a saline abortion?

    A good friend of mine, some two years ago, learned the son she was carrying had a number of severe congenital abnormalities incompatible with life, including severe spina bifida (exposing the cervical cord and/or brainstem, if memory serves) as well as lung, kidney and ureter malformations. She elected to have labor induced but without the saline injection, thus giving live birth to a 26-wk infant. She and her husband were thus able to hold their son as he died shortly after birth. She described it as a "painful but beautiful" experience and said she could not imagine doing it any other way. Was she a special case, or is this a procedure open to anyone?

    The late term abortions are done under just about any circumstance, from the unwanted normal pregnancy to cases of fetal deformity. The dilatation and evacuation procedure is quicker and has fewer risks and maternal side effects than the saline injection, which can take over twenty-four hours to perform.

    Whether or not someone choses an abortion or an induction depends on how a woman feels about the fetus. If she views it as an incovenient something with no connection to life at all, she’s more likely to opt for a quick disposal and to go see an abortionist rather than an obstetrician. If she thinks of it as a terminally ill child, then she’s more likely to opt for the induction and the chance to see and touch the baby she’s parting with. She’s also more likely to have been to an obstetrician in the latter case. Most obstetricians aren’t abortionists.

    The move to ban partial-birth abortion is probably partially due to the “ick” factor, but I think more largely due to the fact that these procedures are done after the twelfth week of gestation, when the fetus is clearly human and not just a bunch of cells. Logic would dictate that all the late-term methods would be banned, but it's easier to get political support for banning the obviously gruesome.

    This is why pro-abortion groups are so threatened by the ban. They understand that logically, all late-term procedures that destroy the fetus should be included in the ban. They believe that abortion should be available on demand at all stages of fetal development, so they don't want society to view the fetus as a person worthy of its protection. The ban on partial-birth abortion is the first step in offering that protection to the fetus, even the unwanted fetus.
    posted by Sydney on 3/08/2003 08:28:00 AM 0 comments

    Friday, March 07, 2003

    Achey, Breaky Heart: A video of an impending heartbreak, and the story behind it.

    posted by Sydney on 3/07/2003 07:38:00 AM 0 comments

    Scrutinizing Guidelines: The BMJ questions the validity of current guidelines for the management of cholesterol in diabetics. The authors review all the current studies on cholesterol therapy and outcomes and find them wanting when it comes to applying them to diabetics. They conclude that our current practice is based more on opinion than evidence:

    Current recommendations to manage dyslipidaemia in diabetic patients are based on observational evidence and expert judgment. The heart protection study showed that simvastatin significantly reduced the risk of major vascular events for diabetic patients without coronary heart disease at any initial low density lipoprotein concentration. It remains unclear whether the benefits of statins are mediated by lowering low density lipoprotein concentrations, whether goals of treatment should be expressed as low density lipoprotein concentrations, and whether a fixed dose of statin, increasing doses of statin, or multiple drugs can be used to achieve these goals with acceptable safety. Recommendations from policymakers and experts should reflect this uncertainty.

    Yes, it should. Yet, the current recommendation to keep the LDL cholesterol to less than 100 in diabetics is often characterized as "practicing evidence-based medicine". It may be based on evidence, but it’s not good evidence.
    posted by Sydney on 3/07/2003 07:37:00 AM 0 comments

    Wonder Drug: Aspirin, the miracle drug for arthritis, headaches, fever, and cardiovascular diseases, now lays a claim for colon polyp prevention in two studies published this week:

    One, directed by Dr. Robert Sandler of the University of North Carolina, involved 635 patients who had had colon or rectal cancer. Half took a regular, 325-milligram pill of aspirin each day, and the others took a placebo. This study ended early, because the results were so definitive: after patients had taken their assigned pills for an average of 31 months, 17 percent of those taking aspirin had new polyps, compared with 27 percent in the placebo group.

    The other study, directed by Dr. John Baron of Dartmouth-Hitchcock Medical Center in Lebanon, N.H., involved 1,121 patients who had already had polyps, which had been removed. These patients were randomly assigned to take a placebo, a regular aspirin or a low-dose, 81-milligram aspirin each day.

    Three years later, at the study's end, 38 percent of the patients taking the baby aspirin had polyps, compared with 47 percent of patients taking a placebo and 45 percent of those taking regular aspirin. The researchers said they were baffled by the baby aspirin's superiority to the regular aspirin in the outcome, and by the little difference in results between the regular aspirin and the placebo.

    The studies are here and here. Aspirin is cheap and at low doses it's well-tolerated. It's worth taking once a day if you have a history of colon polyps or previous colon cancer. Besides, it’ll decrease your risk of strokes and heart attacks, too.
    posted by Sydney on 3/07/2003 07:32:00 AM 0 comments

    Supporting Bad Habits: Chris Rangel on guideline-driven hospital support of drug addiction:

    With all the constant demands to "talk to her doctor" and "see who ever is in charge" I probably spent several hours dealing with this one case while I had over 20 other patients (many who where much sicker than this patient) to see and treat. Would it have been easier to just give this patient her Demerol and go about my way? Patients such as her have a tendency to raise all hell. They contact the hospital administration and the patient care advocate. You get constant pages from nurses, nursing supervisors, patient care advocates, the hospital administration, and even members in the hospital legal staff office who all wonder what the hell is going on! At each step I have to pause and explain and then document it in the chart and on and on and on. To hell with it! Just give the patient her narcotics! Right!? Wrong. This is not the correct thing to do.

    I contacted an anesthesiologist from the pain control service (though he said that they were no longer accepting Medicaid). I contacted a member of the psychiatry staff to evaluate the patient for substance abuse. All of this took more time but this was the ethical thing to do. Finally after hours of this crap the patient (realizing that she was not going to get the narcotic she wanted) left "against medical advice" (without signing the AMA form). Before leaving she proclaimed to her nurse that she was, "going to come back to the ER this evening and find a doctor who will treat her pain!"

    Her drug abuse must be stopped at some point for her own good. Unfortunately the system makes it very easy for patients such as this to continue their cycle of abuse. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made it a priority to treat pain as the "sixth vital sign" but they don't have much to say about the treatment of drug seeking patients. To refuse to treat a patient's "pain" is more likely to be seen as poor clinical practice

    Even worse, there are advocacy groups out there that coach people on how to use legal threats to get their drugs.
    posted by Sydney on 3/07/2003 07:30:00 AM 0 comments

    Salesmen All Are We: Reading Derek Lowe's description of pitching a project called to mind the daily tightrope walk that is the practice of medicine:

    So presenting a project is an exercise in what to leave out. You want to give an accurate impression of things (well, most people do; there are exceptions.) After all, if the whole thing does go down in flames in another couple of months, you don't want bewildered managers ringing your phone because they thought everything was fine. But you also don't want to drag in every possible complication, because that'll make it look like resources should be pulled away now before any more time gets wasted.

    The same holds with medical practice. Every time we prescribe a drug, we have to toe a fine line when discussing the side effects. Just about anything could happen, but detailing every single possibility, no matter how remote, makes people leery. Far better to dwell on the most probable. Sometimes this approach is sabotaged by the pharmacy, especially the large chain stores such as CVS, which provide a computer list of every possible side effect under the sun. It might help protect them from liability, but it doesn’t do much for patient compliance.

    And the same holds for the art of diagnosis. Sometimes, there’s a long list of differentials to consider when you’re trying to diagnose a complaint, but it’s not always in the best interest of the patient to share all of those possibilities. Lymphoma may be way down the list in terms of probability for a new lump in the neck, but you can bet that if you mention it, along with the more likely reactive lymph node, there’s a good chance that lymphoma is going to be the only thing the patient hears. Information has to be given out judiciously to be effective.
    posted by Sydney on 3/07/2003 07:24:00 AM 0 comments

    Apologia: Sorry for the lightweight posts lately. It’s partly because my hospital patient census has surged recently, and partly because, like The Bloviator, I’ve been in a funk this past week. Sometime last month, this blog passed its one year mark. (I can’t be sure of the date because when I updated to Blogger-Pro, Blogger ate my archives, but I remember sitting down one weekend in mid-February and beginning the blog.) I still enjoy it, but like everything, it has its peaks and valleys. I want to thank all of you for reading, and for emailing, and for all the alms and Amazon buys. You’ve made the peaks outnumber the valleys by far.
    posted by Sydney on 3/07/2003 07:21:00 AM 0 comments

    Thursday, March 06, 2003

    Medical Blog Alert: Welcome to new physician blog, Feet First. Check out the post on "formication".

    posted by Sydney on 3/06/2003 07:51:00 PM 0 comments

    Something Different: Remember the Alamo
    posted by Sydney on 3/06/2003 09:36:00 AM 0 comments

    Perceptions: I've often wondered how truthful patients are when they communicate to their families about their medical conditions. I have some patients who tell me out and out that they don't tell their families anything because "it's none of their business." This morning, I saw a man in the hospital who I never thought would misrepresent his condition, or my opinion, but I learned otherwise when I accidently overheard his phone conversation with his wife. Our hospital keeps the patient charts in a fold-down desk mounted on the walls outside the rooms. As I was writing my note in his chart I couldn't help but hear him talking to his wife on the phone. "The doctor just left. Hey, is she pregnant? She's getting quite a little belly on her." (Hmmmm. Better hit the tread mill more and the cookies less.) Then he started to tell her what I had told him, none of which was accurate or true. He put words in my mouth I never would have said. Granted, they were all harmless words, but they all made him sound like he's doing better than he is. No wonder families get angry at physicians when things go bad.
    posted by Sydney on 3/06/2003 09:16:00 AM 0 comments

    MedMal Debate: A reader forwarded this response to the commonly heard argument that it was not tort reform, but insurance reform, that has kept California malpractice premiums lower than most other states:

    The response to that argument is that the rates didn't fall because the MICRA caps didn't take effect until 10 years later - after the lawyers ran out of ways to tie it up in the courts. Insurers in California began to reduce their premiums after the caps took effect, not until after they knew the laws were going to stand. Insurance reform just happened to happen around the same time. Caps work - don't let anyone twist the facts to make it sound like they don't. (Well, if they're too high or there are too many exceptions, they might not work, but MICRA style caps WORK.)

    There you go.
    posted by Sydney on 3/06/2003 09:07:00 AM 0 comments

    A Skunk by Any Other Name: Congress is gearing up to ban partial birth abortion. The only defense the opposition can seem to muster is one of semantics:

    LeRoy Carhart, a Nebraska physician who has performed numerous abortions, including the procedure that falls under the GOP description of a partial birth abortion, says a more fitting title for the bill would be the "partial truth abortion ban act."

    He also said if the federal ban is passed, he plans to file a law suit similar to the one filed under his name in 2000, Carhart v. Stenberg, in which a Nebraska law similar to the one before Congress was overturned by the U.S. Supreme Court.

    Carhart, who teaches abortion methods at clinics nationwide, took a potshot at Senate Majority Leader Bill Frist (R-Tenn.), who supports the Partial Birth Abortion Ban Act: "I hope he knows more about heart surgery than he does about abortions because he certainly doesn't know much."

    He added, "This whole issue is about control over women. They have picked one very gross thing about abortion and tried to sell it to the American people as wrong."

    Call it what you will, dilatation and evacuation, or partial-birth abortion, it's still a gruesome procedure. Or as Dr. Carhart prefers, a "gross" one. They aren't even talking about banning all second trimester and later abortions, which is when this procedure is performed. The other alternative at this stage of development is to inject a saline solution into the uterus to suck the life out of the fetus (it dehydrates them.) Both procedures are brutal, especially when you consider that a second trimester fetus is very clearly human.

    posted by Sydney on 3/06/2003 09:00:00 AM 0 comments

    Symbiosis: A microbial threesome.
    posted by Sydney on 3/06/2003 08:38:00 AM 0 comments

    Wednesday, March 05, 2003

    Ephedra Update: Senator Orrin Hatch distinguishes himself once again. The LA TImes reveals the reason the Senator made supplements available without FDA oversight. (link requires registration, but it's free.)

    posted by Sydney on 3/05/2003 02:29:00 PM 0 comments

    JAMA's weekly art history lesson.
    posted by Sydney on 3/05/2003 10:16:00 AM 0 comments

    Wrongful Blame: Sidney Wolfe, the Ralph Nader of American medicine, says that bad doctors are responsible for the malpractice crisis. He lists the numbers of doctors sued in each state that has had recent crises as if that's proof that the doctors are the problem. But in truth, each of those states has a tradition of aggressive trial lawyers, which, of course, drives up the rate of suits, and the rate of settlements. Being taken to court, or even losing or settling a case, isn't necessarily proof of bad medicine. Obstetricians are sued most often for cerebral palsy, which is something beyond their control most of the time. But, then, I don't expect Mr. Wolfe to be critical of the role of trial lawyers, since his organization, Public Citizen Health Research Group, is an arm of Nader's Public Citizen, which has tight financial ties to the AmericanTrial Lawyer Association.
    posted by Sydney on 3/05/2003 10:03:00 AM 0 comments

    Arthritis Risks: The arthritis drug Arava is under fire:

    Of the 2 million rheumatoid arthritis sufferers, thousands try one of the four drugs each year. Tuesday, the FDA's scientific advisers began two days of debate over how big a risk each medication poses and whether stronger warnings or restrictions are needed.

    The consumer advocacy group Public Citizen is pushing for one of the medicines, Arava, to be banned. Reaction within the FDA is mixed. An agency analysis posted on the FDA's Web site Tuesday recommends a ban--citing 54 U.S. cases of liver failure or damage and eight deaths linked to the drug.

    Higher-ranking FDA officials will tell agency advisers today that they disagree, citing additional analyses that argue there's no proof Arava is more dangerous than competing treatments.

    ''There are cases of liver injury that are possibly or probably related to use of Arava, but we also think it continues to have a place,'' said FDA drug chief Dr. John Jenkins.

    Arava works by blocking an enzyme that's involved in autoimmune inflammation. The enzyme is also involved in the synthesis of pyrimidine, one of the buildling blocks of DNA. It's difficult to say if the liver inflammation is caused by the drug, and if it is, if it's a risk that's worth taking. A lot of drugs cause liver inflammation, including the other commonly prescribed analgesics for arthritis pain. Arava isn't the only one to be put under the microscope lately:

    The FDA also is struggling to determine if three other medicines--Enbrel, Remicade and Humira--are linked to 170 cases of lymphoma, a hard-to-treat immune system cancer, reported since 1998.

    Again, it's diffiicult to say whether the association is real, but all of three of these drugs act by inhibiting tumor necrosis factor, a molecule that's used by the body to fight tumor cells. It also seems to be involved in the inflammation process of rheumatoid arthritis. It wouldn't be too surprising if drugs that block tumor necrosis factor also happen to associated with higher incidences of lymphoma.

    Rheumatoid arthritis can be very painful, and very destructive. Compare this picture of a normal (but fractured) wrist, with this picture of a rheumatoid wrist to see just how much damage it does to joints and bones. What all of these newer drugs have in common is that they slow down this joint destruction rather than just treat the pain. The older drugs used for this, such as methotrexate, also have potential for serious side effects, so the matter isn't as clearcut as it might seem at first. It becomes a matter of how much risk we're willing to tolerate to treat a devastating disease, and whether or not these newer drugs are any safer and any more effective than the older drugs.
    posted by Sydney on 3/05/2003 09:00:00 AM 0 comments

    Medicare Reform: President Bush announced his plan for Medicare reform yesterday. He would like to free the program from bureaucratic shackles and increase freedom of choice (applause edited out):

    Compared to people with private health plans, Medicare patients have limited choices. Medicare will pay a doctor to perform a heart bypass operation, but will not pay for drugs that could prevent the need for surgery. Medicare will pay for an amputation, but not for the insulin that could help diabetes patients avoid losing their limbs. Medicare will pay for chemotherapy and cancer surgery, but after private insurancers -- insurers made annual mammograms a standard benefit, it took ten years for Medicare to do the same, and then only because the United States Congress passed a law. Seniors should not have to wait for an act of Congress to get effective, modern health care.

    Nor should Congress be setting standards of medical care, but I doubt if Medicare reform will keep them from meddling in such matters, or keep health activists from crusading for coverage of pet causes, regardless of their merits. But, I digress:

    The framework for Medicare reform I'm releasing today would give seniors the freedom to select one of three broad opportunities. First, seniors who are happy with the current Medicare system should be able to stay in the system and receive help for prescription drugs. To reform the current system, I propose we issue a discount card that will reduce the cost of prescription drugs for every senior by 10 to 25 percent. We will provide an annual $600 subsidy to low-income seniors to pay for prescription drugs. And we will set annual limits on the amount seniors will have to spend out of pocket on drugs at no additional premium.

    Second, seniors who want more coverage will be able to choose an enhanced form of Medicare. This option will include full coverage for preventative care, a comprehensive prescription drug benefit, protection against high out-of-pocket costs, and extra help for low-income seniors to be able to get the drug benefit. Seniors will be able to choose their specialists, their hospitals, and their primary doctors.

    The fee-for-service arrangement would offer seniors similar kinds of choices now enjoyed by the members of Congress, who are given a broad choice among competing health care plans. What is good for the public servants, including members of the House and Senate, is good for America's seniors.

    Third, seniors who want the kind of benefits available in managed care plans, including prescription drug coverage, will have that choice, as well. This option would place seniors in an affordable network of doctors, provide drug coverage, and allow seniors to keep their out-of-pocket costs to a minimum.

    Moving toward this system will take time. And as we make these changes, all American seniors will receive a prescription drug discount card to use right away. And low-income seniors will be eligible immediately for the annual $600 Medicare prescription benefit.

    Leaders of both political parties have talked for years about this issue, about adding a prescription drug benefit to Medicare. And the time for action is now. The budget I submitted will commit an additional $400 billion over that which we have already committed to, over the next decade to implement this vision of a stronger Medicare system.

    I have reservations about giving discounts for drugs to every senior. Not all seniors are needy. Many are very well off. I’m all for prescription benefits for those who need it, but it seems to me if Medicare is to remain solvent as the baby boomers continue to age, there’s going to have to be some limits to the spending, and the best way to do that is to make it needs-tested rather than universal. Of course, that isn’t politically palatable, as Congress is already proving:

    Republican lawmakers showed the same disdain yesterday for President Bush's latest Medicare prescription drug plan as they did his first one a month ago, promising that after two failed attempts by the White House they will write their own plan with bigger benefits for older Americans

    ''The way I see it, we need a universal drug benefit so seniors who want to stay in traditional Medicare get a prescription drug plan that's just as good as those who chose a new option,'' said Senate Finance Committee Chairman Chuck Grassley, Republican of Iowa.

    I wish they’d give more thought to the future.
    posted by Sydney on 3/05/2003 08:41:00 AM 0 comments

    They Get Paid for This? Thanks to a reader for sending this headline about a recent research finding :People with stress disorder and depression pose suicide risk.
    posted by Sydney on 3/05/2003 08:05:00 AM 0 comments

    Tuesday, March 04, 2003

    Public Health Stupidity: Ohio's Department of Public Health has been keeping its smallpox vaccination program a classified secret, in the name of "national security":

    The reason for the secrecy, Health Department officials said, was to keep terrorists from knowing who has been vaccinated, so they couldn't target hospitals where staff members hadn't been given the vaccine.

    Ha! Right. As one critic points out:

    A hospital is a very unlikely target, Taylor said. Airports and malls would offer larger, more mobile populations to infect. And even if hospitals were targeted and every hospital employee were vaccinated, the entire patient population would still be unvaccinated and exposed.

    And another:

    The state's claim of national security strikes Mehlman as ``a little hysterical.'' Other experts across the country call it ``silly,'' ``misplaced'' and simply unnecessary and ineffective.

    The article criticizes the secrecy from the standpoint that it leaves patients not knowing what hospital has workers who have been vaccinated, thus depriving them of the right to protect themselves from getting infected from vaccinated healthcare workers. That concern is unfounded. So far, there has been only one case of contact vaccinia, and that was in a close household contact. The virus in the vaccine is only transmissible through close contact with the vaccine wound, or from contact with clothing or linen that has the scab on it. This can be avoided, especially in the work place:

    Wound dressings have become much more advanced, keeping in moisture to improve healing while blocking bacteria and viruses, including the vaccinia virus used in smallpox vaccinations.

    ``If you've got that (bandage) on the arm, on top of that a shirt, on top of that a white coat, there's no way a virus can get through those things,'' Cooper said. ``I don't think there's any remote way it's going to get through and infect people.''

    To pass vaccinia on to a patient, he said, doctors would have to somehow get a dose of the vaccine under their fingernails -- maybe by scratching the vaccination site -- and then gouge a patient enough to break the skin.

    The reporter refutes this contention by citing another public health official from California:

    ``Barrier dressings are extremely uncomfortable and have to be worn for 10 days,'' he said. ``When you're talking about half a million people, that is just not going to happen. Doctors and nurses will have to remove those dressings just to do their daily grind, and, in the process, they'll come in close contact with lots of very vulnerable immunosuppressed patients.''

    That's just silly. There's no reason a bandage on the upper arm would have to be removed to do one's daily activities. I would hope, that of all people, doctors and nurses are responsible enough to keep their bandages on until the vaccine site heals. And in the past, when bandages weren't as effective, and the cleaning of hospital linens not as stringent as they are today, the transmission of vaccinia from the vaccine to others wasn't rampant:

    Even so, between 1907 and 1975, there have been just 85 reported cases of vaccinia infection due to contact with a vaccinated person. Nine of those 85 patients (11 percent) died.

    We're in the midst of a developing full-blown anti-vaccine hysteria. More and more, it's being treated by the media as something that's as deadly and as contagious as the disease from which it protects us. This is simply bad medicine on the part of public health officials. And Ohio's secretive policy only contributes further to the problem.

    Just why is the state health department being so secretive about their program? Could it be that they're trying to hide just how little they've actually done? More and more, public health departments are proving themselves inadequate to the task of a vaccine program aimed at national security. Perhaps its time to move the program to a different department.

    posted by Sydney on 3/04/2003 08:00:00 AM 0 comments

    Oh, Gloria: I got a letter in the mail yesterday from Planned Parenthood president Gloria Feldt. At first, I was puzzled as to why it would be addressed to me. We subscribe to a variety of magazines at our house, but the only one with my name on the subscription is The Weekly Standard. All the liberal magazines are in my husband’s name. Then, on closer inspection, I saw that it was addressed to me as an M.D. I don't use my professional title outside the sphere of my job. They could only have gotten my name from a data base of physicians, perhaps of women physicians. If Planned Parenthood thinks that the majority of women physicians share their abortion rights passion, they're sadly mistaken. Some of my most conservative aquaintances are women physicians.

    The body of the letter is addressed to “Dear Friend of Planned Parenthood,” and goes on to accuse Congress of undermining Planned Parenthood’s mission. Of course, Ms. Feldt wants me to give money to the organization to help fight this evil. Below is my response:

    Dear Ms. Feldt,

    I received your fund-raising letter today.

    You are right when you say that I probably know someone who has been to Planned Parenthood. I know many. Most of them are my patients. They are the teenagers and the college students who go to you for affordable birth control pills and pap smears. But, I am puzzled by your assertion that someone wants “to destroy an organization so many women have come to trust.”

    You say that if I listen to the news I’ll hear today’s political leaders from the “state Houses to the White House” claiming that “access to contraceptives would encourage immoral behavior among their wives and daughters.” I do listen to the news, Ms. Feldt, and I read it, too. But I don’t recall any such assertions from even the most conservative of politicians.

    You say that our current Congress and the President “seem to feel that their political base is represented by religious political extremist groups like Pat Roberson’s Christian Coalition, and James Dobson’s Focus on the Family,” and that these religious right organizations are “trying to force their beliefs on the rest of us.” I guess the keyword there is “seems,” which really means that this is so only in your opinion. The truth is, according to Opensecrets.org, neither of those two groups has made much in the way of contributions to the current Congress, at least not when compared to Planned Parenthood’s contributions. (In fact, I was suprised to see three Republican organizations listed among the top donors to the pro-choice cause. Evidently, the Republicans aren't as monolithic in their beliefs as your letter portrays them.)

    You say that Planned Parenthood is only concerned with providing contraception, that it has nothing to do with abortion, and it’s being unfairly targeted by anti-abortion activists, and, apparently, by Congress and the President. Your website says otherwise. In fact, it appears that it is Planned Parenthood who is targeting Congress and the President.

    You tell me that you’re counting on my donation to ensure that the poor, the young, and those “just looking for honest answers” will have Planned Parenthood there to help them in the future. If I thought that you would use my donation to help staff your clinics and to provide contraceptive counseling and birth control pills at affordable prices, I would gladly help you. But, I’m having trouble squaring your pleas for money with the nearly half a million dollars you gave away to politicians, and with your blatant political partisanship.

    You may be right. Planned Parenthood’s days may be numbered. But its biggest threat isn’t the current Congress and President. Its greatest threat is your leadership. You’ve forgotten Planned Parenthood’s mission of providing affordable contraception and reproductive health to the poor, the young, and those in need of information. You’ve succeeded instead in turning it into a partisan political action committee. That’s a pity, for your organization really does provide a needed service. Or at least it did, once a upon a time.
    posted by Sydney on 3/04/2003 07:35:00 AM 0 comments

    PMS Musings: The always interesting No Watermelons Allowed has a post on PMS, which he sums up thus:

    IOW they suffer in about every way except pregnancy. And silence.

    I’ve always been skeptical of many PMS claims, especially when it’s used as an excuse for bad behavior. Yet, there’s a certain sort of truth to the phenomenon, at least for some women. Right before their period, when their hormone levels drop very low, some women feel dysphoric, or have trouble concentrating, or just feel plain tired. Others feel that way for about two weeks before their period, at about the time that hormone levels peak. In these cases, I’ve got to think that there’s some sort of influence of reproductive hormones on the brain, especially since antidepressants like Prozac help the symptoms. What that influence is, is still a mystery. (And since the symptoms are described by different women at different points in their cycle, it must be an influence that varies from woman to woman.) Other women have the symptoms throughout the time of their period, but I sometimes wonder if that just isn’t grouchiness because their periods make them feel sick. (Bleeding for a week isn’t conducive to feeling good.)

    Not all women experience PMS, and not all of those who do experience it have it with each menstrual cycle. In the end, no matter how badly we feel physically, we’re still responsible for our own behavior. It may take an extra effort to be civil and polite when we aren’t feeling well, but we’re still capable of it, and still obligated to make that effort. No matter if we’re women or men.
    posted by Sydney on 3/04/2003 07:25:00 AM 0 comments

    More MedMal Victims: How the medical malpractice crisis is affecting Florida medical schools. (via diablogger, who also has some worthwhile observations.)
    posted by Sydney on 3/04/2003 07:20:00 AM 0 comments

    Monday, March 03, 2003

    Go Ahead, Take a Risk: The FDA has decided to allow gene therapy research to continue:

    The suspended trials were a small but marquee group among the more than 200 US gene therapy patient experiments underway, cleverly using a common virus to deliver genes inside cells that could potentially treat cancer, HIV, multiple sclerosis, immune disorders, and other ailments. The use of the virus had actually worked well in treating so-called ''bubble boy syndrome,'' but the cancer cases made clear that the virus can do damage as well.

    But yesterday, a research panel convened by the Food and Drug Administration agreed the technique's healing potential outweighed the cancer risk. They voted, with only one ''nay'' among 21 members, to green-light the suspended trials. The endorsement, however, came with a caveat: Each gene therapy researcher involved in those trials must convince federal officials that all patients undergoing the experimental treatments are amply warned of its cancer risks.

    The gene therapy trials of severe combined immunodeficiency (the "bubble boy" disease), however, won't continue. Too great a risk of cancer in those.

    There was one lone dissenter in the vote to continue the research, however:

    The lone dissenter on that vote was John Coffin of Tufts University, who said that researchers still know little about the biology behind the cancerous side effects, and approvingly cited the cautious approach of another high-profile scientific probe.

    ''We're not going to send space shuttles up until we find out what happened to the Columbia,'' he said.

    It's true that no one understands what went wrong yet with the bubble boy gene therapy experiments, but it's also important to remember that these are experiments, and that they have inherent unknown risks. As long as the patients who are willing to take part in them understand that, then they should be able to go ahead. If we tried to eliminate all risks in experimental therapy, we would have no experiments.


    posted by Sydney on 3/03/2003 07:55:00 AM 0 comments

    Overcoming Stereotypes: Cerebral palsy can be an especially difficult burden to bear. The awkward gait, the slurred speech, often lead others to assume that the person who has it is mentally retarded. But, here's one person who has proved that assumption wrong.
    posted by Sydney on 3/03/2003 07:47:00 AM 0 comments

    Stem Cells: Where the state of the art of stem cell therapy is:

    Adult and embryonic stem cells come with their own particular baggage. Patients' immune systems could reject any cell that isn't from their bodies. Also, embryo-derived cells are prone to mutate as they divide, forming tumors.

    "Controlling what they do is a challenge," says Muschler. "Embryonic stem cells are complicated because they can do so many things, and they don't come with brakes."

    Embryonic cells proliferate easily in lab culture. Adult cells are limited in their ability to renew themselves. Though they have been found in many tissues and organs, they are rare and difficult to isolate and purify. Unlike embryonic research, much work on adult stem cells centers on finding cells with the best "plasticity" - the ability to transform into different cell types - and attaining large enough quantities for therapy.

    "We're really at the beginning of this," says George Trapp, chairman of neurosciences at the Cleveland Clinic. "This isn't a sprint, it's a marathon. We're many, many years, if not decades, from getting therapies applicable to human disease."
    posted by Sydney on 3/03/2003 07:40:00 AM 0 comments

    Housekeeping: I made some changes to the column of links and such to the left over the weekend. Rearranged things so the blogs are at the top, and added a few blogs. In the medical weblog category, check out Psychscape, Code Blog: Tales of a Nurse, and Kill as Few Patients as Possible. And, in the non-medical but enjoyable category, I’ve finally gotten around to adding Loxosceles, always a good and interesting read.
    posted by Sydney on 3/03/2003 07:39:00 AM 0 comments

    Sunday, March 02, 2003

    Blogcritics Update: Blogcritics is back at its old address - www.blogcritics.org. Easily accessible once again.

    posted by Sydney on 3/02/2003 07:40:00 PM 0 comments

    Mad Cow Madness: Iain Murray has an excellent post on mad cow disease - the epidemic that wasn't. And the consequences of being prudent to a fault.
    posted by Sydney on 3/02/2003 03:39:00 PM 0 comments

    Medical Advances: Take a trip to the doctor at various time periods to see how much things have changed. (via Rangel, who via'd code blog)
    posted by Sydney on 3/02/2003 08:46:00 AM 0 comments

    Children of a Prozac Nation: Tim Blair provides a link to this story about the human shields in Iraq, who were not only so naive as to think that Iraq would use them to shield civilians, but also placed supreme confidence in modern pharmacology to alleviate all woes:

    During one cold, rainy night in Milan, we were left without our sleeping bags after an Italian went AWOL with the support bus. Later, a 500 [English pound] donation from a well-wisher in Istanbul was squandered on boxes of Prozac in a misguided attempt to cheer up the war-weary Iraqi civilians.

    They’ve obviously seen too many Prozac ads.
    posted by Sydney on 3/02/2003 08:14:00 AM 0 comments

    Latest MedMal Victim: Orlando's trauma center, which serves all of central Florida, has to stop accepting trauma cases, for want of neurosurgeons:

    The Orlando hospital was faced with closing its trauma center after five of the 12 neurosurgeons that staff it said they would no longer work at the trauma center as a part-time responsibility of their medical practices.

    The remaining seven neurosurgeons, saying they would be too overworked if forced to fill out the schedule, then notified the hospital that they, too, were dropping out of the trauma rotation.

    The neurosurgeons are facing malpractice premiums of $175,000 a year.
    (via Overlawyered)

    ADDENDUM: Even perfect comic-strip physician Rex Morgan, M.D. has had his malpractice insurance premium increase by $40,000, at least in my morning paper.(King Features runs their website two weeks behind, so I can’t link to the comic.)
    posted by Sydney on 3/02/2003 08:13:00 AM 0 comments

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