"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
Spirit of Volunteerism: Here's someone who embodies the selflessness of the true spirit of volunteerism - a nurse who is getting an experimental Ebola vaccine:
Steve Rucker, a registered nurse at the National Institutes of Health, broke with his lunchtime routine yesterday, forgoing his usual visit to the cafeteria and opting instead to roll up his sleeve for a shot filled with the biological essence of Ebola -- one of the world's deadliest and goriest diseases.
Surrounded by a gaggle of doctors and scientists, Rucker stepped into medical history at 12:10 p.m., becoming the first person ever injected with an experimental vaccine designed to protect against Ebola, the disease that was highlighted in the real-life thriller "The Hot Zone" and that continues to take a bloody toll in Africa.
"I've had better lunches," Rucker quipped as the shot's 100 trillion strands of synthetic DNA began to make their way into the cells in his arm.
Rucker is a pioneer in a high-tech effort to beat Ebola. If the vaccine works in people as it has in monkeys, it could fell one of the world's most horrid infectious scourges.
Alas, health officials say, despite weeks of advertisements and other pleas, only two people have volunteered to be part of the effort.
"People freak out about Ebola," said Margaret McCluskey, the director of nursing at the NIH's vaccine research center, where the new vaccine -- the first for Ebola -- awaits 25 more people to participate in initial safety tests.
The other volunteer is the gardener in one of the researchers' neighborhood. The gardener and the nurse deserve to be congratulated, taking the risk of a vaccine which confers no conceivable benefit to themselves. Altruism lives.
The making of the vaccine itself is a fascinating biotech story:
With nearly atomic precision, researchers at Vical, a biotechnology company in San Diego, made the strands to mimic those found in the Ebola virus -- but with key components removed, including the part that triggers illness and the part that might allow the DNA to recombine with the DNA of some other virus to make a new and potentially disease-causing bug.
....The DNA enters subcutaneous skin cells, which use it to make Ebola proteins. Immune-system cells attack those proteins and then are primed forever to fight a real Ebola infection even more vigorously.
The long-term plan is to follow the DNA shot with a booster made of an adenovirus engineered to contain Ebola DNA. In a test of four monkeys given that one-two punch, all four were unfazed by an Ebola attack, while four monkeys given dummy shots all died, said virologist Anthony Sanchez of the Centers for Disease Control and Prevention, which helped develop the vaccine. posted by Sydney on
11/20/2003 08:08:00 AM
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Wednesday, November 19, 2003
Medicare Drug Plan Pitfalls: Here's an item that says the new Medicare drug plan will disenfranchise the poor:
It would largely eliminate Medicaid’s supplemental — or “wrap around” — role under the new Medicare drug benefit. As a result, substantial numbers of poor elderly and people with disabilities would be forced to pay significantly more for their prescriptions than they now do. Those who could not afford the higher co-payments could lose access to some of the prescription drugs they need. In addition, in cases where Medicaid covers a prescription drug but the private plan that administers the Medicare drug benefit in the local area does not provide that drug under Medicare, poor elderly and disabled beneficiaries who now receive the drug through Medicaid could lose access to it. Given their limited incomes, such people generally would not be able to afford such drugs on their own.
The elimination of Medicaid wrap-around coverage has been added in recent days in the conference in order to save money by reducing Medicaid costs. The resulting savings have apparently been used elsewhere in the drug bill to satisfy more powerful constituencies.
That's our Congressmen. Always with an eye toward the good of the middle class.
posted by Sydney on
11/19/2003 08:05:00 AM
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Canadian Recall: The FDA wants those of you who get your medications from Canada to know that some inhaled asthma drugs have been recalled by the Canadian government:
As a precaution, the Food and Drug Administration (FDA) is alerting U.S. residents to the recent recall of certain GlaxoSmithKline “Diskus” medicines sold in Canada to treat asthma and chronic obstructive pulmonary disease (COPD). The three asthma products – Ventolin Diskus, Flovent Diskus, and Serevent Diskus -- were recalled in Canada November 12th, 2003, because the products’ drug delivery system may not function properly and may deliver too little of the drug – or none at all. Canadian patients are being advised to return the affected product to the pharmacy or physician’s office where it was obtained in order to get a replacement.
Incentives: Don Johnson at The Business Word is taking on today's New York Times editorial page, which was medicine central. First, there's this editorial which argues that the pharmacological education of today's doctors has been bastardized by the pharmaceutical industry, which is the major financer of medical conferences of every ilk. The writer, a former editor of the New England Journal of Medicine says:
So it is not merely that the pharmaceutical industry is using doctors to sell its products. Medical schools and other educational institutions are not teaching doctors how to use drugs wisely and conservatively. Until they insist that the pharmaceutical industry stick to its own business (which can include advertising but not education), we are unlikely to get the help we need from our doctors in controlling runaway drug expenditures.
I don't know about medical schools today, since it's been nearly twenty years since I was a student. (I don't remember drug companies at my medical school. They were in the hospitals, but not the school, so pharmacology was taught without their influence.) But, it's certainly true that today's continuing medical education is dominated by the drug industry. It's getting increasingly harder to find a conference that offers speakers without a pharmaceutical company sponsorship. And sometimes, the promotion of a drug is so blatant, it leaves everyone in the audience shaking their heads. It's definitely a problem that should be addressed somehow.
Over at Business Word, the suggestion is to pay doctors to go to non-pharmaceutical sponsored lectures. That probably wouldn't go over well with the public - using tax dollars to educate a class of people most considered pampered to begin with. And, the problem goes deeper than sponsorship of meetings. Most researchers and academics support their work with grants from pharmaceutical companies. No matter what the venue, they're likely to have a bias toward their particular sponsor. If public money must be used, then perhaps it should be used for funding research grants and to support residency training programs so they wouldn't have to rely on the pharmaceutical industry.
Don's also asking if the healthcare voucher proposal put forth in this op-ed would serve us better than our current system. He thinks it would. There's no way of knowing without trying it, but as a system that's divorced from employment and that would require insurance companies to offer catastrophic coverage it sounds like a good start. posted by Sydney on
11/18/2003 09:23:00 PM
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Digital Radiologists: Here's something I've been meaning to blog about for a while - computer aided readings of mammograms, called computer aided diagnosis, or CAD for short. A lot of my patients have been asking me about it, since one of the mammography centers in our area is offering it for an additional $25 (patient pays, not insurance companies). Kodak just recently got FDA approval for its device:
The computer-aided mammography device uses algorithms to highlight suspicious areas on digitized images that radiologists then examine more closely for possible disease.
Clinical trials determined that 39% of missed breast cancers might have been detected almost 15 months earlier using its technology, Kodak says.
For an example of how the computer interpretation differs from a radiologist's interpretaion, click here. The computer doesn't replace the radiologist, it just double-checks his work. Is it worth it? It certainly detects more cancers doing it that way:
CAD marked 31 of 32 cancers (case-based sensitivity=96.8%). On a film and lesion basis, CAD identified 31 of 32 (96.8%) malignant calcifications and 29 of 42 (69.0%) malignant opacities, the only cancer not identified by CAD being depicted as an isolated opacity.
But, it also has a much higher rate of false positives:
CAD marked 348 areas (153 microcalcifications and 195 opacities) in 88 of 108 non cancer cases, with a case-based specificity of 18.5% (20/108). Considering all six readings, cancer was identified in 164 or 174 of 192 readings (85.4 vs 90.6%, c2 2.03, df=1, p=0.15) and recalls of non-cancer cases were 108 or 159 of 648 readings (16.6 vs 24.5%, c2 11.7, df=1, p<0.001) at conventional or CAD reading, respectively.
Since breast cancer is one of those cancers that often turns deadly no matter how early it's caught (depending on the type), it might not be worth that extra hassle and extra money. It's a matter of personal choice. posted by Sydney on
11/18/2003 03:40:00 PM
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Self-Determination: A reader makes this point about the Schiavo case:
I think the point that is getting missed by the "is she alive/in a PVS/ aware or whatever" debate is the fact that an independant judiciary, after interviewing a number of people including her family and friends, decided that Terry had made it clear that she would not want to live in the condition she was in — whatever you want to call it. The panel did not substitute their judgement for hers, they attempted to apply her previously communicated desires to the situation she is in right now. In the system of medical ethics I was taught, patient autonomy trumps beneficence and non-malefecence and for a group of elected state officials to override that is troubling to me at best.
Patient autonomy does trump all else in situations like this, but my impression from reading the news accounts is that Terri Schiavo's wishes were not known, and that the court relied on her husband's testimony as to what she would have wanted. (He stands to inherit a substantial amount of money if she dies, and he denied her usual and customary rehab after her initial brain insult, so he's a questionable witness.) That impression could be wrong, since it's based on news accounts, not the trial transcripts. The only reporting I could find about the trial itself was devoted entirely to the question of whether or not she was in a persistent vegetative state.
If she indeed made it clear that she wouldn't want to be fed in a condition like this, then her family's wrong, and her husband's right. But, in this case, her wishes weren't known and the courts have decided that her husband has the last word (which is in fact what the law is in most states when a spouse is incapacitated and hasn't left instructions) even though he has obvious conflicts of interest. Maybe the law needs to be rewritten to account for such conflicts - which is what the Florida legislature is trying to do.
The moral of the story is that living wills and powers of attorney for healthcare are important to have even if you're young. And you should share those documents and your wishes with your family. posted by Sydney on
11/18/2003 08:36:00 AM
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Monday, November 17, 2003
Reading Minds:John Ray is looking at the use of functional MRI to detect latent racism. My understanding is, they're about as accurate as a lie detector test. posted by Sydney on
11/17/2003 08:04:00 AM
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Sunday, November 16, 2003
Lite Reading: Some things just beg to be shared. Like this book that I came across yesterday in the public library. It’s a book of poems by a French woman who once lived and worked in a Benedictine Abbey - the Abbaye Saint Louis de Temple at Limon-par-Igny. The forward says the poems were written “during a time of enemy occupation, hunger, cold, frustration,” so they must have been written around the time of World War II. But, it was this poem that made me check out the book so I could share it with the kids:
The Prayer of the Cat
Lord,
I am the cat.
It is not, exactly, that I have something to ask of You!
No-
I ask nothing of anyone -
but,
if You have by some chance, in some celestial barn,
a little white mouse,
or a saucer of milk,
I know someone who would relish them.
Wouldn’t You like someday
to put a curse on the whole race of dogs?
If so I should say,
Amen.
The rest of the poems are just as representative of their respective animals. Check it out.
And then, there was this passage from a biography of Martha Washington that I’ve been reading, that’s too good not to be shared. It’s a letter from a physician who was called to Mount Vernon when George Washington took ill. He arrived late. The body had already been laid out on the dining room table. But, in the spirit of Frankenstein, he was undaunted:
When the great and excellent man died, Thomas Law....and his lady....called on me to visit the General as a friend and physician, for he was dying of croup. I departed in the fullest confidence of being able to relieve him, by tracheotomy. When we arrived to my unspeakable grief, we found him laid out a stiffend corpse... The weather was very cold, and he remained in a frozen state, for several days. I proposed to attempt his restoration, in the following manner. First to thaw him in cold water, then to lay him in blankets, and by degrees and by friction to give him warmth, and to put into activity the minute blood vessels, at the same time to open a passage to his lungs by the trachea, and to inflate them with air, to produce an artificial respiration, and to transfuse blood into him from a lamb.
Now, that might have been politically motivated.
CLARIFICATION: The doctor never did get to test his experiment. Better heads prevailed. posted by Sydney on
11/16/2003 05:36:00 PM
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Waiting Room Reading: Ran across this article while the children were getting hair cuts. It includes this disturbing revelation:
For long-established giants like U.S. Steel, GM, or Ford, simply walking away from crushing benefit and pension obligations isn't an option. Last year, for example, benefits for retirees cost Ford over $2 billion, which is more than the company's earnings so far in 2003. For smaller manufacturers like Eastman Machine, paying for health benefits is a bigger worry than new competition from China. "One of the reasons we're looking at outsourcing is medical costs," explains Stevenson. "Energy and taxes are peanuts compared with the cost of health insurance, and it's something I have no control over." Insuring his employees and retirees costs nearly $80,000 a month, up from $40,000 five years ago. Revenues, meanwhile, have remained flat at about $30 million. posted by Sydney on
11/16/2003 05:00:00 PM
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Life: Rangel isn't satisified (you might have to scroll down, his links are broken) with my response to the Schiavo case. Judging by my email, neither are many of his readers who tell me I'm not fit to be a doctor. Well, folks, there are areas in medicine in which the science is in its infancy. Understanding being and consciousness is one of those areas. No matter how certain Rangel thinks it is, it's an area rife with uncertainty. He takes issue with my mention of the locked-in syndrome:
Comparing a patient with locked-in syndrome where a small area of injury in the pons or brainstem leads to complete paralysis with a patient in a persistent vegetative state (PVS) like Terri Schiavo who's entire cerebral cortex is irreversibly destroyed by anoxia is what I call comparing "apples to oranges". The locked-in patient has a cortex is still intact and hence the conscious mind is assumed to still be intact as well. The premise is further bolstered by the fact that these patients can still communicate via eye movements and blinking and it is in this way that Dr. Smith's literary hero Jean-Dominique Bauby (who suffers locked-in syndrome from a stroke to the brainstem) is able to "write" his introspective book "The Diving-Bell & The Butterfly ".
Persistant vegetative state is, in fact, not the easy diagnosis that Rangel makes it seem. Jean-Dominique Bauby (who by the way died shortly after his book was published), was only able to move one of his eyes. By Rangel's logic, if he had been deprived of the use of both his eyes, he would have been dead. He certainly would have fit the criteria for being in a persistent vegetative state. There is no other objective means to identify the difference between the two states.
Rangel, in fact, makes many more assumptions than I do. (In fact, I make no assumptions. I acknowledge the limitations of science in this case.) He assumes that PSV is an easy diagnosis. He assumes that anoxic damage to the brain obliterates all consciousness. He assumes that the MRI and CT scans tell us how well a brain functions. Even functional MRI and PET scans which measure the activity of brain areas haven't been perfected enough to do that. In such a state of uncertainty, in a situation as uncertain as Terri Schiavo's it's better to err on the side of life. Now, obviously, Rangel disagrees with that. But our differences lie in our philosophies, not in science. He's fooling himself if he thinks otherwise.
But the most jarring, and baseless, of his accusations (and some of the email I've gotten) is that my stance is politically motivated. Yeah, that's right. I'm angling for the Republican presidential nomination. posted by Sydney on
11/16/2003 02:07:00 PM
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