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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 22, 2003

    Hiatus: I'll be away for a few days, with no access to a computer. While I'm away, enjoy any of the excellent blogs to the left, or peruse this collection of entertaining medical sites. Blogging will resume Wednesday.

    posted by Sydney on 3/22/2003 09:30:00 AM 0 comments

    Crud: What is this ailment called Kuwaiti crud?

    "This is going to make witty conversation difficult," I said. My voice, already a pathetic croak from the upper respiratory affliction known as "Kuwaiti crud," sounded small and strangled through the mask.

    I heard a reporter on NPR last night apologize for his voice by explaining he had the “Kuwaiti crud”, too. But here it's described as a sandy fog:

    At night, the sand looks like a thick fog in the light of a lamp. Soldiers call it ``Kuwaiti crud.'' It is so fine that it creeps through every available opening, clogging machinery and making it hard to breathe.

    Turns out it’s a cough and congestion from inhaling sand:

    The Kuwaiti crud is like a low-grade cold. It starts with a mild sore throat, often after a bad dust storm such as the two-day gale that raged last week.

    The cold is followed by a slightly runny nose and a deep cough from the chest.

    It causes little trouble during the day but can be torture at night, when the coughing and hacking can keep troops, and their healthy tentmates, from getting much sleep.

    The medics’ treatment of choice has been a green pill called Guaifenesin, a decongestant, and Sudafed. Soldiers say it will whip the crud in a couple of days.

    There are other forms of crud, too. The article mentions “Korea crud” and the “Kabul crud”:

    During clinic hours, Gardon treats bumps, bruises, chest pain, and an influenza bug his staff has nicknamed the "Kabul crud." US soldiers are susceptible to these viruses because they've never been exposed to them. Poor sanitation increases the risk of infection. "People defecate in the alleys and streets. It dries and the pathogens get caught up in the dust so it becomes airborne," Gardon says.

    Actually, “crud” is a term we often use to describe an annoying illness, be it a mild case of diarrhea and nausea or a lingering cold. But, in the case of “Kuwaiti crud”, the word is very apt. According to the American Heritage Dictionary, “crud” is as follows:

    1. Slang a. A coating or an incrustation of filth or refuse. b. Something loathsome, despicable, or worthless. c. One who is contemptible or disgusting. 2. A disease or ailment, imaginary or real, especially one affecting the skin.

    Not only is it a condition caused by coating or incrusting the lungs with a loathesome substance, but the method of delivery of those sand particles is in line with the original Middle English:

    crudde, possibly from Old English *cruden, past participle of crdan, to press, drive.

    Kuwaiti crud: The wind-forced pressing of sand particles into the nasal passages and lungs to form a loathsome incrustation of the linings of said passages causing an ailment consisting of cough, runny nose, and hoarseness. Treatment: Decongestants. Prevention: Wearing veils and masks. Now we know why Arab women submit to the veil so easily.
    posted by Sydney on 3/22/2003 09:22:00 AM 0 comments

    New Hope: There may be a diagnostic test for the mystery pneumonia:

    Researchers found that antibodies in blood from recovering SARS patients stopped test tube growth of a virus extracted from the noses of other patients.

    This information could be used to develop a simple nasal swab test to diagnose the condition and distinguish it from the run-of-the-mill flu. It also suggests that the disease is indeed caused by the paramyxovirus since that's the virus that's inhibited by the recovering patient antibodies.

    In other news, it looks like the disease is successfully being contained by infection control practices:

    Dr. Gerberding said that even without knowing what causes SARS, control measures appear to have been effective. The only people known to have been infected are those who have had close contact with another infected person. These are either people who stayed in a certain Hong Kong hotel, hospital workers caring for SARS patients, or members of patients' families. "The fact that we have been able to prevent spread to the community suggests that the infection control, isolation practices in the hospital have been effective," she said. "In Vientnam, for example, there have been no new cases reported in the last 24 hours and that suggests that we may have limited spread beyond the first generation of individuals."

    That's good news.
    posted by Sydney on 3/22/2003 09:11:00 AM 0 comments

    Patient Ed:(WARNING: Graphic video images. Blood and such.) What it means to give consent for a central venous line.
    posted by Sydney on 3/22/2003 09:10:00 AM 0 comments

    Breached Barrier: Researchers have developed a drug delivery system that can surmount the blood-brain barrier, the toughest wall of defense in the body:

    First the team coats the liposomes with a polymer called polyethylene glycol (PEG), without which they would be purged from the blood within minutes. Next, antibodies that latch on to some of the brain-capillary receptors are tehtered to a few of the PEG strands. The antibodies trick the receptors into letting the liposomes pass, where they can deliver their cargo to brain cells.

    They think they might even be able to use this to deliver gene therapy to neurons. I don’t know if I’d want someone to mess around with the genes inside my head, but I suppose if I were terminally demented, it might be worth a shot. (But then, how would I give my consent?)
    posted by Sydney on 3/22/2003 09:07:00 AM 0 comments

    Connected: The Department of Health and Human Services is planning to test a system of bioterror updates via Palm handhelds for physicians using ePocrates, the handheld drug database so popular with physicians. Mac users are out of luck, though. The program will rely on the DocAlerts system, which communicates the latest drug recalls and warnings through internet updates, and it isn’t available for Macintosh.
    posted by Sydney on 3/22/2003 08:18:00 AM 0 comments

    Frontline: Grunt Doc describes what it was like to be a Marine battalion physician, and hopes they get more trauma training than they did in his day. I don't know about the Marines, but the Army has beefed things up:

    Col. Tom Knuth, an Army general surgeon, had been awake for nearly two days, yet he was alert and meticulous as he made his rounds at Ryder Trauma Center.

    Chad Howell, a combat medic and weary trainee, gave him the updates on his patients: one man's jaw had been shattered in a motorcycle accident, the other had been beaten over the head with a metal pipe.

    Knuth patted the doctor on the shoulder and told him his report was weak. Knuth needed more details.

    ''Yes sir,'' Howell responded, though he trailed groggily, ``I just came back on shift after a three-hour nap.''

    Knuth is the director of the Army Trauma Training Center at Ryder, at Jackson Memorial Hospital in Miami. He is one of the permanent Army staff members, who, with Ryder's civilian staff, teach and train Army medics, nurses and doctors in trauma intervention.

    The program, which was developed after Sept 11, uses a civilian trauma center to train Army medical personnel in trauma care. Excellent idea. In peace time, Army facilities have a definite dearth of trauma, but community hospitals never have a shortage of it.
    posted by Sydney on 3/22/2003 08:12:00 AM 0 comments

    Freemarket Cost-Cutting: Thanks to Business Word for pointing out this Forbes story about drug markets and the turn toward the use of free-market forces to control costs, which are soaring:

    The country's prescription drug bill, $82 billion in 1996, climbed to $192 billion last year

    Unfortunately, most of that cost is not born by the people who use the drugs, but by insurance companies and employers:

    "It's already a crisis. It's hurting the bottom line," says General Motors health czar L.L. (Woody) Williams. Drugs now account for 31% of the $4.5 billion a year General Motors spends on health care. Verizon Communications expects to spend $600 million on drugs in 2003. At Eastman Kodak prescription drugs will eat up $100 million of the company's $320 million health budget this year. "Employers can't sustain this," says Karen Ignagni, president of the American Association of Health Plans.

    This disconnect does its greatest damage at the point of drug promotion. No ad campaign could go wrong when it’s touting a product that is essentially free for its target audience:

    Drugmakers spend $2.3 billion a year on ads aimed at consumers, up from virtually nothing in 1990. This is on top of the money they spend sending 90,000 salespeople out to call on physicians and the $12 billion worth of free samples they hand out. (The numbers come from market researchers NDC Health, IMS Health and Verispan.) [Not to mention the money they spend on toys and food and fancy exhibits to entice doctors -ed.] But if the anti-free-market types think that the nation's newfound attention to price will quell the advertising volume, they're probably going to be in for a surprise. It is not too hard to get doctors, who have not a nickel of their own at stake, to prescribe lavishly. Persuading patients to dig into their own pockets, in contrast, is going to demand some intense salesmanship.

    Take, for example, the ulcer drug, Prilosec:

    AstraZeneca's famed purple pill, Prilosec, and other so-called proton-pump inhibitors are the most effective heartburn drugs ever invented, so potent that Prilosec has been nicknamed "purple crack." Proton-pump inhibitors are the top drug category, with 2002 sales of $13 billion. A lot of those pills, skeptics say, went to people who have little more than a few bouts of heartburn and could get by on generic versions of Zantac.

    "Drug marketers have convinced every American who belches occasionally and has a little heartburn after their third cannoli that they must immediately begin taking the little purple pill."

    I can attest to this. Before Prilosec came on the market, I had few people who failed therapy on Zantac. Now, it seems to be the norm. Many people come in requesting Prilosec. They turn away my offer of Zantac, and say they would rather have that purple pill they saw on television. Zantac, you see, has an over-the-counter version as well as a higher dose prescription version. As a result, Zantac gets equated with older, less effective antacids such as Maalox. When I tell them that Prilosec is much more expensive, the reply is always the same - a shrug and an “It only costs me $5.” Now, how do you argue with that?

    So, although I put on a sympathetic face when my patients complain that their insurance companies are making them accept greater responsibility for their drug costs, I applaud the change. It’s the only way that costs are going to be controlled.
    posted by Sydney on 3/22/2003 08:04:00 AM 0 comments

    Friday, March 21, 2003

    Obesity Nation: What the man on the street thinks of the obesity epidemic.

    posted by Sydney on 3/21/2003 08:38:00 AM 0 comments

    Probing Preferences: A recent study in JAMA proves what most practicing physicians already know. Men prefer blood tests over colon probes:

    For the study, which appears in the March 19 issue of the Journal of the American Medical Association, Sirovich and her colleagues used data from the U.S. Centers for Disease Control and Prevention on 49,000 men from 50 states.

    The researchers found that 75 percent of men aged 50 and older reported having had a prostate cancer screening test at least once, while only 63 percent had colorectal cancer screening.

    I have trouble convincing some people with family histories of colon cancer to have a colonoscopy. I've even had people with known colon polyps who refuse to go through the colonoscopy again. Very few people request a colonoscopy. But, I have a lot of men who specifically request the blood test for prostate cancer. Someday, we might have a blood test or stool test (less favored by patients than blood tests, but favored more than colonoscopies) to screen for colon cancer. Time will tell.

    posted by Sydney on 3/21/2003 08:30:00 AM 0 comments

    Count Your Cancer Sticks: Researchers say that the number of cigarettes you smoke is directly related to cancer risk:

    Analyzing data from a lung cancer prevention study of 18,314 people, researchers discovered lung cancer could be accurately predicted based on a person's age, gender and the number of cigarettes smoked per day.
    For example, Bach said, a 51-year-old woman who smoked a pack a day for 29 years but hasn't smoked for the last nine had a 0.8 percent risk of lung cancer, less than 1 in 100 over the next decade. By comparison, a 68-year-old man who has smoked two packs a day for 50 years - and continues to smoke - has a 1 in 7 risk.

    This is new? For years, doctors have expressed a patient's health risk by the number of cigarettes they smoke. We refer to people having a "40 pack year history of smoking" which could be a pack a day for forty years, two packs a day for twenty years, or four packs a day for ten years. I guess associating it with a mathematical model gives it more credence.
    posted by Sydney on 3/21/2003 08:26:00 AM 0 comments

    Globalization: Sharing germs and defenses, my Tech Central Station column on the mystery pneumonia.

    UPDATE: The latest count of suspected and probable cases is 306 cases worldwide with 10 deaths.

    UPDATE II: And here's the tally of suspected and probable US cases. (13 cases, no deaths.) It's important to realize that these suspected cases aren't necessarily proven cases. Sometimes, people are dropped from the tally when a different source, such as bacterial pneumonia, is identified.
    posted by Sydney on 3/21/2003 08:15:00 AM 0 comments

    Quirky Museum Watch: Here's a great link to the Mutter Museum, America's premiere medical oddity collection. Check out the "big colon." They claim it's human. (Hat tip to Bagger)
    posted by Sydney on 3/21/2003 08:08:00 AM 0 comments

    Doctors and Managers: This week's BMJ is devoted to the often adversarial relationship between doctors and those who try to manage the business of medicine. Although, unlike Britain, most doctors in the United States are independent practioners who run their own businesses, there are a growing number of US physicians who are employed by hospitals or hospital-run networks of physician practices,so the issue has some relevance to American medicine as well. Having sat through a four hour meeting with the managers who run my hospital-owned network of practices, I'd say that the practice of medicine is distinctly ill suited to being run as big business. Physician practices are small businesses, with small profit margins. They do best when they're kept small. Private physician practices don't have to worry about five million dollar loans. Private physician practices worry about seeing the sick and providing the best possible care, not about improving bond ratings. The more I see of medicine by MBA, the more I'm convinced it's bad for everyone -businessman, doctor, and patient alike.
    posted by Sydney on 3/21/2003 08:05:00 AM 0 comments

    Opacity: China hasn’t exactly been forthcoming about the mystery pneumonia within its borders. Earlier, they told the World Health Organization that the epidemic peaked in February and was on a decline, but it turns out that they had a recent outbreak in one of their military hospitals. They are apparently intentionally stifling the news:

    Health statistics in China concerning a wide range of diseases are regarded as politically sensitive and so are often misrepresented or never made public. This week the government ordered Chinese journalists not to report on the outbreak of the strange pneumonia, a reporter at a large newspaper in Guangdong said.

    Reminds me of some of my patients who refuse to acknowledge their medical illnesses. On the other hand, Michael Ledeen says it may just be that the Chinese don’t trust their doctors.
    posted by Sydney on 3/21/2003 07:51:00 AM 0 comments

    Thursday, March 20, 2003

    Weird Science: Science from the twilight zone.

    posted by Sydney on 3/20/2003 07:36:00 AM 0 comments

    Expert Opinions: Research suggests that we repeat mammograms too often:

    A study released Tuesday challenges the medical protocol of advising women whose mammograms show questionable-but-benign lumps to return for follow-up examinations.

    Nearly all such women fail to develop breast cancer from such lumps, researchers said.

    "There is a problem in that the recommendation is being applied more often than experts in the field think it should be," senior study author Dr. Patrick Romano, associate professor of medicine at the University of California, Davis, told United Press International. Overuse of these short-interval follow-up mammograms "might be that radiologists are very conservative when they find an abnormality," he added.

    Romano's team studied 58,408 postmenopausal American women who were screened for breast cancer as part of the Women's Health Initiative, an ongoing, long-term national study launched in 1991.

    Of the participants, 5 percent or 2,927 women were advised to undergo a short-interval follow-up after their initial mammograms. After two years of such follow-up, the rate of newly diagnosed breast cancers among these women with suspicious-but-benign lumps was remarkably low -- only 1 percent compared with 0.6 percent and 0.5 percent, respectively, for patients whose initial mammograms were characterized as benign or negative

    That’s because practicing radiologists have a strong sense of self-preservation. They don’t want to have to explain to a jury why that equivocal, benign appearing area on the mammogram turned out to be cancer, no matter how small the risk of that is. Trial lawyers have the benefit of always having 20/20 hindsight, and it’s far too easy to go back to a mammogram that appeared benign before the diagnosis of cancer and find fault with the reading. The jury doesn’t care if the overall incidence of cancer in these cases is 1%, they only see a woman with a cancer death sentence, or a family deprived of its wife and mother. Doubtful that this study will change any of that.
    posted by Sydney on 3/20/2003 07:35:00 AM 0 comments

    Contagion: How contagious is the new "mystery bug" from Southeast Asia? Very:

    Seven people who came down with a mysterious form of pneumonia, including two who have died, spent time on the same floor of a Hong Kong hotel before the outbreak prompted a global alert, officials said Wednesday.

    One was a 64-year-old medical professor from Guangzhou, China, who died in Hong Kong on March 4, and one was a 78-year-old woman from Toronto, who died after returning to Canada, according to a Hong Kong government spokeswoman.

    The other visitors of the Metropole Hotel who became sick were three Singaporean women, two of them age 23 and one 33; a 72-year-old Canadian man; and a 26-year-old Hong Kong man who had gone to the hotel to see a friend, said Dr. Margaret Chan, director of the Hong Kong Health Department.
    posted by Sydney on 3/20/2003 07:33:00 AM 0 comments

    Say What? The Institute of Medicine released a report this week on the dangers of emerging infections. While they make valid points about microbial resistance and the need for better vaccines against some diseases, this statement is puzzling:

    A pandemic of influenza could kill hundreds of thousands of people and devastate economies, but there is no good system in place for even tracking such an outbreak, let alone controlling it, the panel said.

    If anything, the recent outbreak of "mystery pneumonia" and its rapid containment has proven how effective the World Health Organization can be in curtailing emerging infectious diseases. What could have quickly become a global epidemic has so far been confined to Southeast Asia thanks to the WHO's global public health network.
    posted by Sydney on 3/20/2003 07:27:00 AM 0 comments

    Passing the Buck: 60 Minutes ran a piece last weekend on the Jesica Santillan case. They detailed what went wrong:

    The events were set in motion when Dr. Jaggers received a phone call in the middle of the night. Carolina Donor Services, the local agency responsible for placing organs with compatible recipients, said it had found a donor in Boston for another one of Jaggers’ patients. Dr. Jaggers said he couldn’t use the organs for that patient, and asked the agency if the heart and lungs would be appropriate for Jesica Santillan. Several hours later, he was told he could have the organs.

    Carolina Donor Services says Dr. Jaggers was informed of the donor’s blood type. Dr. Jaggers has no memory of them talking about it. He did not ask for any blood type information, he says, because “I had satisfied in my own mind that if they had offered the organs for me that she was a match.”

    He is still agonizing over that conversation. “I'm ultimately responsible for this because I'm Jesica's doctor and I'm arranging all this,” he says. “But honestly, I look back, and yeah, if I'd made one more phone call or if I had told somebody else to make a phone call or done something different, maybe it would have turned out differently. But you know, those are all 20/20 hindsight.”

    As soon as Dr Jaggers found out that a heart and lungs were available for Jesica Santillan, he sent a member of his transplant team, Dr. Shu Lin, to procure them from the New England Organ Bank in Boston. While he was there, Dr. Lin was informed of the donor’s blood type at least three times. Incredibly, he’d never been told Jesica’s blood type, and so he didn’t know the organs were a mismatch. And that was yet another flaw in the system,

    According to Dr. Duane Davis, head of Duke’s transplant unit, that was not a part of the process. “Should we as a group have made it mandatory that the procuring surgeon knew that? Yes. But it wasn't Dr. Lynn's fault that he didn't know, because that information wasn't conveyed to him,” Dr. Davis says.

    From the donor to the recipient there must have been at least a dozen doctors and nurses from Duke who were involved. Why did not one among them see that the donor didn’t match the recipient?

    Dr. Davis notes that there was an initial misassumption, and no one later went back to check it. The initial mistake, Davis says, was made by Dr. Jaggers. “I would say that it’s routine for those of us who do this on a regular basis to ask what the blood type is,” Dr. Davis says.

    Nonetheless, he acknowledges that it was a failure of the system as well as the individual.

    What may be most disturbing is that UNOS, the national organization that oversees Carolina Donor Services and the New England Organ Bank, already had firm policies in place that should have prevented what happened to Jesica Santillan. Their policy requires that the blood types of donors and recipients be matched before releasing any organs.

    Lloyd Jordan, who runs Carolina Donor Services, admits that the company did not ensure that there was a match. “We could have requested her blood type, and I wish we had, but we did not do that,” he says.

    Yesterday, Carolina Donor Services backtracked. Unlike Dr. Jaggers, they aren’t willing to admit culpability.
    posted by Sydney on 3/20/2003 07:25:00 AM 0 comments

    Thank You: Thanks to everyone who emailed condolences about my son. He's doing fine. It was an elective surgery, so his health was never in danger, but going to the hospital and having surgery is a scary thing for a little kid. He asked me the night before if he was going to die. Maybe it was because he was told he would be "put to sleep." Or maybe it was because his older sister told him he couldn't eat anything after midnight because he might throw up and drown in his vomit. At any rate, he went through it like a trooper and is well on the road to recovery.
    posted by Sydney on 3/20/2003 07:12:00 AM 0 comments

    Wednesday, March 19, 2003

    All Good Things: JAMA's weekly art history lesson has come to an end for this blog. Reading it now requires a subscription.

    UPDATE: Blogsphere to the rescue. Out of Lascaux has an excellent art history lesson on one bellicose woman.

    posted by Sydney on 3/19/2003 12:26:00 AM 0 comments

    Blogging Lite: Posting will be light to non-existent today. My son is having surgery, and motherhood takes precedence. Have a good day.
    posted by Sydney on 3/19/2003 12:14:00 AM 0 comments

    Tuesday, March 18, 2003

    Mystery Bug Update: Scientists in Germany and Hong Kong say it might be a paramyxovirus, the same family that causes mumps and measles. This is still preliminary, and not a firm diagnosis, but it's the front-runner so far.

    posted by Sydney on 3/18/2003 10:41:00 PM 0 comments

    By Any Other Name: One of my patients called today requesting a referral to a dermatologist to have her wrinkles ironed out. She wanted me to "phrase the diagnosis in a medical way" so her insurance would cover it. I demurred and told her that we doctors call "wrinkles" by the same name as everyone else. Later, I remembered Dr. Alice and her paean to the diagnosis code book. So, I took down the book and looked up "wrinkles." Sure enough, there's a fancy medical term for it - cutis laxa senilis. Loosely translated, that's old, loose, skin. Gotta love that ICD-9 book.
    posted by Sydney on 3/18/2003 09:50:00 PM 0 comments

    Falstaff Nation: On Shakespeare, valor, and smallpox - my Tech Central Station column.

    UPDATE: As if to prove my point, I got a notice in the mail today from my state health department that was timed to coincide with the CDC's educational mailing on smallpox. This is what the director of my state's health department has to say in the first sentence of his letter:

    I,...declare that potential complications of the smallpox vaccination may pose a threat to the health and welfare of the citizens of Ohio.

    Granted, there's a qualifying "may" in there, but it's an opening remark that can only be interpreted as discouraging.
    posted by Sydney on 3/18/2003 08:52:00 AM 0 comments

    Designed for Safety, Except Sometimes: Computerized systems may make things faster, but they aren't necessarily safer, as shown by a recent problem with Kaiser's computerized prescriptions:

    Kaiser officials said Monday that a power outage affecting its computers on Thursday caused errors in some of the prescriptions dispensed to 4,700 patients. After sharp-eyed pharmacists discovered the embarrassing mistake late Friday, a battalion of pharmacists, nurses and other workers spent the weekend frantically trying to reach every patient via phone, courier-delivered letters and even home visits.

    Notice it was the human eye that caught the error. And you would be hard pressed to find a human who could give out 4,700 wrong prescriptions by mistake.
    posted by Sydney on 3/18/2003 08:26:00 AM 0 comments

    Around the World with the Mystery Bug: Everywhere around the globe, patients with fevers and coughs who have been traveling abroad are being quarantined. There’s one in England:

    Today the Chief Medical Officer for England, Professor Sir Liam Donaldson, said a suspected case had come into the UK.

    "We are watching this outbreak extremely closely," he told the BBC. "But the latest development is this morning a patient has been admitted to hospital who came in on a plane yesterday from Hong Kong.

    "At the moment we are not sure whether the case is linked but we are treating it as a possible link to the outbreak in the Far East."

    Several in the United States:

    Doctors in the USA have notified the Centers for Disease Control and Prevention of several patients who may have a mysterious pneumonia-like illness that has killed seven in Asia and two in Canada, an agency official said Sunday.

    One in Israel:

    A 33-year-old man was hospitalized yesterday in Tel Aviv's Ichilov Hospital with flu-like symptoms, after returning home from Hong Kong. The man had complained of fever, cough, headache and pains in his muscles.

    The Health Ministry spokesman said yesterday that the cause of the condition had not yet been established in lab tests and that the man had not developed pneumonia. The decision to hospitalize the patient had come as a precautionary measure as the man had returned from Hong Kong, the spokesman said.

    And two in Australia:

    Two Victorians are being treated as suspected cases of the pneumonia-like illness which has been linked to nine deaths around the world.
    Department of Human Services spokesman Bram Alexander today said a 47-year-old woman was being treated at Ballarat Base Hospital, while a 44-year-old man was in a stable condition at Royal Melbourne Hospital.

    ..Both Victorian patients had recently returned from overseas and had been in Asian countries, during the 10 day danger period, Mr Alexander said.

    According to the New Scientist a dozen countries have isolated people with the symptoms:

    Unconfirmed cases have now emerged in the UK, Australia, Switzerland and Slovenia, all connected with travel to the Far East. Health authorities on all continents are taking the risk of importing the disease extremely seriously. The US, South Africa and Russia, amongst others, have put their health authorities on nationwide alert.

    In fact, it isn’t even certain that those are all cases of the same illness. It’s tempting to read all of this and think that we’re in the midst of some horrible epidemic, but what we’re in the midst of is an attempt to prevent a horrible epidemic. Not enough is known about the illness to predict how it would behave if it spread around the globe. One thing we do know is that it’s highly contagious, and sometimes fatal:

    The illness, which originated in Guangdong province, sickened about 300 people in China, with five dying. In the subsequent wave in other countries, about 200 people have become ill, including 43 new cases reported Saturday in Vietnam. There have been fewer than 10 deaths in the second wave, although many people are still critically ill.

    Five out of three hundred isn’t a terribly high mortality rate, but it’s still higher than we’re used to for most of our easily caught infectious diseases. What really has public health authorities worried is the possibility that this could be the beginning of a major influenza epidemic, the likes of which we haven’t seen since 1918. That’s why they’re taking so many precautions to prevent its spread and to try to identify the cause. So far, nothing has been isolated, but some things have been ruled out, including the previously reported Influenza B:

    ..However, WHO officials said yesterday that tests for influenza A -- the more virulent of the two forms of the influenza virus -- have all been negative. The Chinese Health Ministry reported the Guangdong patients showed no evidence of the "bird flu" strain of influenza A that killed a few people and many chickens in 1997.

    A few patients hospitalized in Hong Kong in the recent wave of cases have antibodies in their blood suggesting recent infection with influenza B, the milder form of the virus. Such a finding is common in winter, however, and the investigators doubt it is the explanation.

    There is a long list of other candidates, with a family of microbes called the paramyxoviruses "certainly ranking on the top of most people's thoughts," said Klaus Stohr, a WHO virologist and epidemiologist who is helping to direct the investigation.

    It's just going to take a little more time. And until they know what's causing it, there's no way to tell if everyone who's being observed right now actually has the new pneumonia or just a bad case of some older, well-known bug.
    posted by Sydney on 3/18/2003 08:18:00 AM 0 comments

    Contrariness: Contrary to experience, a new study claims that estrogen replacement therapy is worthless:

    "Estrogen plus progestin did not have a clinically meaningful effect on any aspect of health-related quality of life," said the NEJM article. No difference at all was seen between the women on the drug and the placebo group in mental health, depression or sexual satisfaction. A benefit in sleep disturbance and pain was observed, but researchers said it was too small to be "clinically significant" and was restricted to the first year of use.

    The study looked at several parameters of “well-being”: quality of life and functional ability, depression, sleep disturbance, sexual functioning, cogntive function, and menopausal symptoms. Only rates of menopausal symptoms were significantly different among estrogen users:

    We examined the effects of estrogen plus progestin on the relief of symptoms among all women who reported moderate-to-severe vasomotor symptoms at base line (1072 women in the estrogen-plus-progestin group and 974 women in the placebo group).At the one year follow-up,76.7 percent of the women in the estrogen-plus-progestin group had improvement in the severity of hot flashes,as compared with 51.7 percent of the women in the placebo group (P<0.001);71.0 percent of the women in the estrogen-plus-progestin group had improvement in the severity of night sweats,as compared with 52.8 percent of the women in the placebo group (P<0.001).

    To me, that says that for some women, estrogen therapy works, since that's why we prescribe it, to treat menopausal symptoms, not to cure every ailment and dissatisfaction in life. There are so many other factors that can affect one’s overall well-being besides menopause that those other parameters are worthless. Estrogen isn’t a panacea, despite what advertisements may have once claimed. And it was never prescribed that way by the majority of doctors.

    Another flaw in the study is that they didn’t look at the incidence of vaginal atrophy in users and nonusers, which can be quite painful. They looked, instead, at sexual satisfication, which isn’t at all the same thing. A woman can have no sex life at all and call herself satisfied if she’s come to terms with it. A better question would have been, “Is sex painful?”

    The shame of this is that the study will be touted by the media as proof that estrogen therapy is completely unwarranted when it’s considered alongside last year’s over-hyped findings (by the same group of researchers, by the way) on estrogen side-effects. And physicians, too busy to scrutinize the study, will by into the hype and discourage more women from using the drug, and perhaps refuse to prescribe it. And all the while, they'll say they're practicing "evidence-based medicine." Yet, in the end, this study is akin to asking the same questions of aspirin users and deciding that aspirin isn’t an effective drug because it doesn’t improve overall well-being. All in all, a very shoddy piece of work.
    posted by Sydney on 3/18/2003 07:55:00 AM 0 comments

    Monday, March 17, 2003

    Unintended Consequences: Physician report cards make physicians reluctant to take on those most likely to have bad outcomes:

    The surgeon said that agencies monitoring surgical outcomes had been putting tremendous pressure on surgeons to produce good results. He was referring to ''report cards'' on cardiac surgeons. Over the past decade, while surgeons with higher-than-expected mortality statistics have lost operating privileges, others with lower-than-predicted rates have taken to advertising on the radio. Because the surgeon and his colleagues had been aggressive about treating very sick patients like P., they had incurred higher mortality rates and had been penalized by the state department of health. This was an insult he could no longer countenance, and so he had decided that all high-risk surgeries would be transferred to another hospital.

    And it isn’t just this one surgeon:

    In a survey a few years ago, 63 percent of cardiac surgeons in New York State said that because of report cards, they were accepting only relatively healthy patients for coronary-bypass surgery. Fifty-nine percent of cardiologists confirmed that it had become harder to find a surgeon to operate on their most severely ill patients. ''Hospitals getting cited are turning down high-risk patients,'' Dr. Eugene Grossi, a professor of surgery at N.Y.U. School of Medicine, recently told me. ''Some of the so-called best hospitals are only doing the most straightforward cases.''

    ....Were surgeons' numbers improving because of better performance, or was it because patients like P. were not getting the operations they needed?

    Last January, researchers at Northwestern and Stanford tried to answer this question. Using Medicare data, they studied all elderly patients in the United States who had heart attacks or had coronary-bypass surgery in 1987 (before report cards were used) and 1994 (after they took effect). They compared New York and Pennsylvania, states with mandatory surgical report cards, with the rest of the country.

    What they discovered was that there was a significant amount of ''cherry picking'' in the states with mandatory report cards. For example, they found that between 1990 and 1993, patient health-care expenditures over the year before coronary-bypass surgery dropped by 7 percent in New York and Pennsylvania but stayed roughly the same in the rest of the country, suggesting that coronary-bypass operations started being performed on healthier patients. This was matched by a drop in the number of operations for sicker patients, who experienced ''dramatically worsened health outcomes'' as a result, including more congestive heart failure and recurrent heart attacks.

    The researchers concluded that surgical report cards in New York and Pennsylvania led to substantial selection bias by surgeons and that patients generally were worse off for it.

    This isn’t good. It’s never good to practice medicine by statistics, which is what “report cards” are. They shift the focus of the physician from the individual he’s treating, who has his own sets of risks and benefits to consider, and the likelihood of his individual outcome, to the overall statistical outcome of a population. It's like the high school student who obsesses about his grade average rather than what he's actually learning.

    posted by Sydney on 3/17/2003 08:49:00 AM 0 comments

    Innovation: The inventor of the first heart-lung bypass pump died last week. His original device cost about $24:

    In 1950, Dr. Glenn and third-year medical student William H. Sewell fashioned a crude heart pump out of such materials as glass tubing, valves bought at a dime store, and a motor from a child's Erector set.

    In a groundbreaking operation, Dr. Glenn used the device to successfully divert blood flow from the heart of a dog for about an hour. The makeshift device, assembled with about $24 worth of parts, is considered the forerunner of heart-lung bypass machines and the artificial hearts that have captured headlines in the last two decades. Three years after Dr. Glenn's operation on the dog, the first human open heart procedure was conducted in Detroit using a heart bypass pump based on the Yale device.

    He adopted the dog as a pet.
    posted by Sydney on 3/17/2003 08:41:00 AM 0 comments

    Mystery Bug Update: Turns out the WHO isn't sure if the rash of recent pneumonias are related:

    Nine deaths from atypical pneumonia have been reported in China, Vietnam, Hong Kong and Canada. The WHO is treating the cases as one emergency, although it is not clear if they are related. The first cases were reported in southern China late last year.

    Mr Bekedam said: "At the moment, there is no proof of a clear linkage." The WHO said on Saturday that 150 new suspected cases had been reported over the past week. It said that they occurred in Indonesia, the Philippines, Singapore and Thailand.

    They also say that the pneumonia strain occuring in China appears to be treatable. Still no need for panic.
    posted by Sydney on 3/17/2003 08:29:00 AM 0 comments

    Doing His Bit: Senator Frist not only got his smallpox vaccine, but he learned to administer it, too:

    "It is my hope that I will never be called upon to use the skills I've learned today," he said. "However, as long as there continues to be a risk of attack on our homeland, it's critically important that health professionals and front-line responders do our best to be prepared."

    After Friday's training and completion of appropriate documentation, Frist, R-Tennessee, will be commissioned by the U.S. surgeon general as a member of the Reserve Corps of the U.S. Public Health Service.

    So, how do the rest of us sign up for the Medical Reserve Corps? They have a website, but there's no information on how to volunteer. In fact, it looks like whether or not there is a Medical Reserve Corps to join depens on where you live:

    Local officials will develop their own Medical Reserve Corps units, because local officials know best what their individual community needs.

    No wonder I haven't heard of it. Last I checked our local public health officials still weren't taking bioterrorism very seriously. They were planning to have medical students tell them what kind of program would best reach practicing physicians to educate them about recognizing bioterror threats. No offense to medical students, but they really aren't in a position to know what works best for a practicing physician yet.
    posted by Sydney on 3/17/2003 08:16:00 AM 0 comments

    Sex, AIDS and Africans Update: Roger Bate looks at the AIDS and dirty needle research:

    USAID is obviously worried since it will be responsible for distributing much of President Bush's proposed $15 billion five-year initiative to combat AIDS in Africa. There are more than 28 million people in Africa with HIV, and USAID has already spent $2.3 billion of U.S. taxpayers' money in AIDS prevention and treatment since 1986, much of it on condoms, including over $25 million on condoms last year alone.

    Medical infrastructure - or, more precisely, a lack thereof - has always been a major cause of the spreading of AIDS and other diseases. It appears that combating this failing, by providing doctors and nurses competent in providing injections, and clean syringes and needles for those injections, may be the best way to help reduce new AIDS cases in Africa.

    If the source of African AIDS really is dirty needles, then lets hope this Western aid money is spent where it needs to be to combat the disease. It certainly would be a lot easier.
    posted by Sydney on 3/17/2003 08:12:00 AM 0 comments

    Silly Research: Moira Breen takes on the silly second hand smoke causes cavities study.
    posted by Sydney on 3/17/2003 08:06:00 AM 0 comments

    Angst: I thought it was just me. That too little sleep and too much coffee had made me edgy. But, I see from my latest tour of the blogosphere that others have been feeling the same. This constant procrastination is nerve wracking. Every morning, my local newspaper shouts out headlines that make our defeat seem inevitable.(Like most regional newspapers it relies on the New York Times for national and international news, and it reprints all the Times' regular columnists on the editorial pages.) Every day, I get a stronger impression that our leaders have gone wobbly. That they’re listening too much to those very vocal, very earnest, but also very mistaken critics. It makes me fear for the future. And it makes me edgy.

    And it isn’t just the blogosphere. I’ve noticed my patients are becoming increasingly unsettled, too. At first, it was just the friends and relations of men and women in the military who complained of difficulty sleeping and feeling sad. Now, people with no connection to the military are bringing up the war during their visits. And the incidence seems to increase every time there’s an announcement of a diplomatic delay. My last patient on Friday said that she just couldn’t stop sighing. That was why she was there. Sighing too much. And thinking too much about the coming war.

    And let me be clear. This generalized anxiety isn’t because of fear of impending war and its possible consequences. It’s because of the interminable uncertainty. Each delay makes us wonder how serious our leaders are about this situation. Each delay makes us worry that the enemy is gaining strength, both here and abroad. Enough is enough. Act already.
    posted by Sydney on 3/17/2003 07:58:00 AM 0 comments

    Sunday, March 16, 2003

    The Gray Lady is a Snoop: Once upon a time, the New York Times, like many companies, had a company doctor - a doctor who was available on the premises to attend to employees' medical needs. Then, one day, the New York Times fired the doctor. They say it was “restructuring.” She says it was because she repeatedly refused to bow to their pressure to betray patient confidence. She sued, but now she has lost. Evidently, in New York, you can get fired for anything, even if it’s refusing to do something illegal:

    Dr. Horn, who was the newspaper's corporate physician, claims in court documents that she was fired because she wouldn't comply with the company's requests to see confidential patient medical records. She also claims that a vice president for human resources told her to try to curtail the number of workers' compensation claims filed against the company by misinforming patients about whether their injuries were work-related.

    The requests violate the AMA's Principles of Medical Ethics. And the New York State Dept. of Health also advised Dr. Horn that following the requests would violate legal and ethical duties to patients under state rules, according to court documents.

    The court decision reveals even more about the Times’ management:

    According to Horn, on “frequent occasions” personnel in the Times' Labor Relations, Legal and Human Resources Departments directed her to provide them with confidential medical records of employees without the employees' consent or knowledge. She also claims that personnel in the Times' Human Resources Department instructed her to misinform employees whether their injuries and illnesses were work-related so as to curtail the number of workers' compensation claims filed against the newspaper.

    I realize that the management of a newspaper is completely different than the men and women who write the paper, but this sort of behavior doesn’t speak well of the paper’s publisher. And now, under the new HIPAA laws, it would be a federal crime to reveal those patient records without their consent. Shouldn’t it also be illegal to coerce someone to hand over those records without consent? And, though it may not be illegal, it certainly is unethical. Remember that the next time you read about Enron and other corporate malfeasance in the Times.

    posted by Sydney on 3/16/2003 12:43:00 PM 0 comments

    Smallpox Vaccine Advice: from the expert of all experts, D.A. Henderson:

    Q: Do you have any advice for physicians who are hesitant about receiving the vaccine or giving it?

    A: We have made an effort to educate the population about what the vaccination is like and the possible complications. Because vaccinations stopped in 1972, we probably don't have many physicians under the age of 60 who have ever vaccinated or have ever seen a vaccination reaction. However, in the course of providing this education, I think people have tended to overreact to just how dangerous the vaccine is and may have overemphasized those dangers. For example, it's not true to say that anybody with HIV is going to have a serious problem. It means that some proportion of those who are immunosuppressed may have more serious reactions than others.

    We also talk about pregnancy as being a contraindication for the vaccine. But that is based primarily on the fact that it has been recommended that no pregnant woman receive a live virus vaccine of any sort. But if you look at the studies, it's pretty hard to make out a case for women in pregnancy experiencing all but the most minuscule possible risk to themselves or their infants.

    I think it needs to be kept in mind that this is a relative risk, it's not an absolute certainty that if you have any of these conditions you are going to have serious reactions.

    Q: What is your view on vaccinating the general public before a smallpox outbreak is detected?

    A: There are those who feel keenly that they should have the right to judge for themselves whether or not they are willing to take the risk [posed by the vaccine].

    And it's complicated in another way. Do we have a precedent for licensing a commercial product and then not permitting access by the public? Nobody could think of any precedent for this at all.

    The president has said he would not recommend [vaccination for the general public], and I would not recommend it. But if there are those who want [the vaccine], it will have to be explained to them that they do pose a risk to other people.

    But the risk is small. Four of us got together and produced a paper published in JAMA [Oct. 16, 2002] on contact vaccinia. What impressed us was that those who are transmitting the vaccinia were, by and large, very young kids in close contact with other very young kids or with their home caregivers. I think there were only a couple of instances where adults transmitted the disease to someone else. In both cases, they were in extremely close contact, like a wrestler who was wrestling with somebody else. But the thing that impressed us was how seldom it occurred.

    Remember that the next time you read about hospital officials refusing to vaccinate their staffs, or, as in the case of San Francisco General Hospital, barring them from vaccination. And remember that the next time you read statements in the media that make the vaccine sound as dangerous as the disease.
    posted by Sydney on 3/16/2003 12:33:00 PM 0 comments

    Celebrity Medical Watch: Johnny Cash's pneumonia.
    posted by Sydney on 3/16/2003 12:30:00 PM 0 comments

    Pneumonia Alert: The mysterious pneumonia that has been going around Asia has now touched North America and Europe, thanks to air travel. The WHO has issued a global disease alert, and the CDC is tracking contacts of a doctor from Singapore who fell ill shortly after visiting the US. Canada reports nine infections and two deaths. No one’s sure what the infecting organism is - viral or bacterial - but it seems to be highly contagious among close contacts and to cause serious, life-threatening complications. It has an incubation period between two and seven days.

    The CDC’s press release is here, and recommendations for healthcare providers can be found here.

    Don’t panic, though. Not every fever or cough is likely to be this virulent pneumonia. Only 150 cases have been identified world wide. The advisory is an attempt to stop the spread from continent to continent. However, if you’ve been to Asia recently, or on an airplane, or in close contact with someone who has been ill and been to Asia or on a flight, you might want to get that cough checked out.

    CLARIFICATION: The illness usually begins with a high fever and cold symptoms, not just a cough. Like the flu.

    UPDATE: Officials in Hong Kong say it's probably a strain of influenza:

    They have so far revealed that it is a "B" strain version of flu. He said: "The rate of infection is very high. At first it's a respiratory illness and it deteriorates into pneumonia. There is a possibility it can mutate or it may be a virus that is known to us."

    But Hong Kong Government officials said the illness was not related to a strain of "bird-flu" that killed a man in February.
    posted by Sydney on 3/16/2003 01:02:00 AM 0 comments

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