"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
Copy-Cat Loser: The courts, at least, have recognized that Claritin and Clarinex are the same drug:
Schering-Plough has argued in court that one of its patents protects desloratadine -- the chemical Claritin becomes when it is broken down by the body. It claimed its desloratadine patent lasts until 2004 and that Claritin copycats should therefore not be allowed on the market at least until then.
But Bissell, in his ruling on summary judgment motions by the combatants, decided that the desloratadine patent claims were invalid.
Alternative Medicine Update:Chelation therapy, the alternative medicine practice of using the chemical EDTA to bind heavy metals in the blood to treat heart disease, gets its own large, prospective study this spring. Quackwatch has a nice review of the subject: what it is, the theories behind it, and how it's currently practiced. As it stands now, the doctors who use this aren't basing their practice on any sort of evidence, only on theory. The study by the NIH is a welcome one, especially since it's apparently being designed by someone who has no vested interest in the outcome. posted by Sydney on
8/10/2002 05:17:00 PM
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And the Hype Goes On: The hype about West Nile virus never seems to end. Seven people, mostly very elderly, have died from it, and all of them lived in mosquito-infested Louisiana. The media reports continue to be over-the-top on this. Seven deaths wouldn't be big news for any other disease. I've yet to see the newspaper story, for example, that calls for better pneumonia vaccination rates in the elderly because seven of them died in one state from the disease. The hype feeds on itself. Patients are more likely to request testing for the virus for symptoms they may have passed off as a run-of-the-mill virus before the media reports; and doctors, for the same reason, are more likely to order the tests. Take this woman:
In Indiana, a 46-year-old woman who was hospitalized for four days with flu-like symptoms turned out to be infected with West Nile virus, said Dr. William Dannacher, the health officer for Wabash County. She has since recovered and been discharged, he said
Normally, a case like that would be treated as an unspecified viral illness and no special testing would be done, especially since she recovered uneventfully. I doubt very much that her physicians also tested for other potential viral culprits. Let's face it, there are a host of infectious agents out there carried by insects. West Nile isn't the only one, and it isn't really much of a threat, either.
Patient Confidentiality: The Department of Health and Human Services has unveiled its final policy on privacy rules for patient medical records. The whole issue revolves around protecting patient confidentiality in an era of computerized records that are easily transmitted from one place to another. Some of the rules are good, some are questionable:
When they take effect, for the most part next spring, the rules will require a host of new protections, including guaranteeing that people may inspect their medical records and correct mistakes, find out who else has looked at them, and seek penalties against anyone who misuses the information.
I've always wondered about the the right to "correct mistakes" in a medical record. What constitutes a mistake? What if a patient reviews their medical record and objects to a diagnosis of depression or somatoform disorder? Does he have the right to force the doctor to change the diagnosis? If the doctor refuses, is he going to end up in court defending himself?
The final regulations, however, omit a requirement that patients' written permission must be obtained before their personal health information can be handled by doctors, hospitals, pharmacies and insurance plans -- a protection that lawmakers and two White Houses have contemplated for years.
In some ways this is good. If I refer a patient to a specialist, I want to be able to discuss the case with him and to exchange information in writing to facilitate patient care. The way the rules were written by the Clinton adminstration, the specialist and I both would have had to get written permission from the patient to do that. We'd also have to get permission to give insurance companies information when we have to argue with them about paying the bills (which is the rule rather than the exception). Since the lack of payment on behalf of the insurance company doesn't inconvenience the patient, only the doctor, it's not too hard to imagine how difficult it would be to get a patient's permission to share that information.
The rules go further than the administration previously considered to rein in the use of medical information for the marketing of products, particularly prescription drugs, by companies that gain entree into individuals' records.
That's good. Patient confidentiality should always trump marketing.
The final rules keep a controversial provision that Clinton had endorsed over the objection of civil rights groups, allowing law enforcement agencies relatively unfettered access to people's records without telling them.
That's just plain disturbing. As a physician, I've always understood that law enforcement is not privy to my patient's medical information. In fact, physicians are only justified in reporting a patient to authorities if there is a clear and present danger to others.(For example, if someone divulged that he was going to shoot his co-workers or his boss, I would be obligated to tell the police.) To allow law enforcement unrestricted access to medical records is more than a violation of civil rights, it's a violation of human decency. posted by Sydney on
8/10/2002 08:59:00 AM
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Senator for Smallpox Vaccine: At least one senator understands the smallpox vaccine issue. Maybe there's hope that we will all be offered the option of smallpox vaccination after all. Senator Frist is a physician, and when he talks on medical issues, his colleagues listen. posted by Sydney on
8/10/2002 08:37:00 AM
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Domestic Distress: The surgeon in Boston who had his license suspended for leaving a patient on the operating table while he went to cash a check, had a deadline to meet in his domestic partner settlement payments:
Dr. David Arndt was ordered after a court battle to pay Dr. Stephen Goldfinger, a psychiatrist, a portion of his income for 15 years after they broke up in 1994, court records show.
Arndt challenged the agreement and lost. He was ordered to pay court fees and other costs up to $25,000, and to continue to make support payments up to $500,000 to Goldfinger.
.....Court records say that Arndt, 41, and Goldfinger met in 1983 and began living together. Goldfinger, 10 years older and more established in his profession, paid many of Arndt's expenses while he studied to be a doctor, the records say.
It's hard to imagine why an established psychiatrist would need the money at precisely a certain date and time. He certainly wouldn't starve if the payment were a day late. There must be a lot of bitterness there. As a record mogul once said during his own domestic partner dispute: "There's nothing so sad as good loving gone bad." posted by Sydney on
8/10/2002 08:33:00 AM
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More than one-fifth of people recently infected in the United States and Canada with the virus that causes AIDS have strains that do not respond to some of the best anti-viral medications, according to a study in today's New England Journal of Medicine.
That would be 20% of recently infected people, but the study made no such claim:
Over the five-year period, the frequency of transmitted drug resistance increased significantly. The frequency of high-level resistance to one or more drugs....increased from 3.4 percent during the period from 1995 to 1998 to 12.4 percent during the period from 1999 to 2000..., and the frequency of multidrug resistance increased from 1.1 percent to 6.2 percent...The frequency of resistance mutations detected by sequence analysis increased from 8.0 percent to 22.7 percent, and the frequency of multidrug resistance detected by sequence analysis increased from 3.8 percent to 10.2 percent.
About twenty percent of newly-infected HIV patients have a virus with a gene mutation for resistance, not actual resistance. For some reason, more of them still responded to the drugs. The numbers of resistant infections are still quite small: 12% to at least one drug, and only 6% to a multi-drug regimen. Still, it could represent a trend and bears watching.
The most striking aspect of the study, however, is the small number of patients involved. The subjects were culled from ten large North American cities: Baltimore, Birmingham, Dallas, Denver, Los Angeles, Montreal, New York, San Diego, Seattle, and Vancouver between the years 1995 to 2000, yet only a total of 377 newly infected HIV patients were enrolled. That’s an astonishingly small number for a disease of epidemic proportions, which makes this statement by the San Jose Mercury even more boilerplate than it already is:
In the past two decades, an estimated 457,667 Americans have died of AIDS, according to the Centers for Disease Control and Prevention. The figure is greater than the number of Americans who died in World War II. A total of 784,032 AIDS cases have been reported in the United States, and hundreds of thousands more are HIV-positive but have been able to keep the disease at bay.
World War II only lasted three years and killed 405,399 Americans in that short time. AIDS took twenty years to claim more than that. In fact, let’s put this whole AIDS mortality into proper perspective. In one year551,833 Americans died of cancer, and 725,192 Americans died of heart disease. AIDS doesn’t even make the top ten list of yearly mortality figures.
That’s not to say that AIDS and HIV may not be more prevalent than we think. In all likelihood they are. We don’t test people with anywhere near the frequency that we should. We’ve decided, with the help of AIDS activists, that it’s more desirable to protect the sensibilities of an individual than it is to protect society at large from a potentially deadly communicable disease. If we tested for HIV with the same frequency that we test for hepatitis, syphillis, gonorrhea, and chlamydia, we would know a whole lot more about its natural history, and we would make a whole lot more head way in preventing its transmission. posted by Sydney on
8/09/2002 07:29:00 AM
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Botox Potential: Botox may not be limited to the rich and pretty. It may have value in relieving spasticity of the hands following a stroke. If a stroke is severe enough, it not only leaves a limb paralyzed, but it also takes away the ability of the brain to instruct muscles to relax. The result is that some groups of muscles tense up and form the contractures you sometimes see in stroke patients and cerebral palsy patients: the curled up fist, or the straightened leg with the pointed-down toe. In this experiment, the researchers injected Botox into selected finger and wrist muscles of stroke patients to block the chemical transmitters that make the muscles contract, and compared the response to placebo injections. Both the patients and the study investigators compared the responses to the injections in terms of their overall improvement, their ability to perform self-selected tasks (hygiene, dressing, changing hand position, or relieving pain), and their perception of their muscle tone improvement. The botox group reported more improvement in all categories than the placebo controls. It’s a testimony to the power of the placebo effect that not only the patients, but the investigators as well, noted some improvement in all areas in those injected with saline, although the improvement wasn’t as marked as it was in the botox group. The New England Journal website has a link to a video, of a patient before and after the injections. (Subscription required for viewing.) The improvement isn’t astounding. The contractures are still obvious, but he is able to do more with his hand than he could before the injection. All in all, it seems a promising treatment possibility. Even if the study was funded by the maker of Botox.
P.S. Could they have possibly found a better poster-girl for the drug than the patient described in the Washington Times? Suffers a stroke at the tender age of twenty during childbirth, and now thanks to the miracle of Botox, able at last to change a diaper. (Although that’s one maternal privilege most of us wouldn’t miss.) posted by Sydney on
8/09/2002 06:07:00 AM
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Warning! Warning! Hawaii's Supreme Court has ruled that doctor's are liable for damage done by a patient while under the influence of a drug, if the doctor failed to warn the patient about side effects. Now, doctors should warn patients about potential side effects of their drugs, but the case that begot the Supreme Court’s decision is a bit much:
On Aug. 5, 1997, Hawaii Permanente urologist Robert Washecka, MD, prescribed prazosin hydrochloride -- a generic form of Minipress -- to treat his patient Jerry I. Wilson.
The physician told Wilson on Aug. 5 to take a two milligram tablet of prazosin at bedtime and to continue that regimen for three days -- Aug. 5, 6 and 7. Dr. Washecka also told Wilson if he didn't experience any side effects during the first three days, he should on the fourth day -- Aug. 8 -- take a two milligram tablet of prazosin in the morning and another two milligram tablet at bedtime, according to court documents.
Wilson said he took the first three prazosin doses at bedtime and had no problems. He said he took his third bedtime dose at 2 a.m. -- technically the early morning hours of Aug. 8 -- and then took his first morning dose at about 7:45 a.m. on Aug. 8.
Wilson then drove to work.
As he headed to downtown Honolulu, he felt nauseated and dizzy, according to court documents. He then began to hyperventilate and allegedly fainted and hit the car in front of him. His car then veered right onto a sidewalk striking Kathryn McKenzie, a child, and seriously injuring her.
The McKenzies sued Wilson, but they went an extra step and sued the Hawaii Permanente Medical Group, where Dr. Washecka is employed.
The McKenzies and Wilson said the prazosin caused the fainting and that ultimately the physician was responsible because he negligently prescribed prazosin, negligently prescribed an excessive dose of prazosin and failed to give Wilson sufficient warning about the possible side effects. Kaiser disagrees with all of those claims. It will be up to a lower court to decide those issues.
By what stretch of the imagination did Dr. Washecka negligently prescribe that medication? He told the patient to look for side effects and he gave him the correct instructions for taking it, which the patient ignored. Mr. Wilson wants to avoid culpability for his own actions, and the McKenzies (and/or their lawyers) want to go after the deepest pockets they can reach. posted by Sydney on
8/09/2002 06:05:00 AM
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Patchy Medicine: The low-down on medication patches. (Word of warning: the patches don't eliminate the side effects of medication, as the article implies. Patients still get headaches on nitroglycerine patches and they can still have mood swings on testosterone patches.) posted by Sydney on
8/09/2002 06:03:00 AM
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Thursday, August 08, 2002
New Blog: I’ve been meaning to mention Jim Miller’s blog “On Politics”. It’s an insightful site and he often has links to a variety of topics from medicine to astronomy to politics. He has a link today to this story about evidence based medicine. Evidence-based medicine means basing treatment, and especially preventive treatment which requires commitment to long-term drug use, on therapy that’s been proven in well-designed clinical trials, rather than on supposition and theory as is so often the case:
"Don't just stand there, do something!" will continue to be the battle cry of most doctors and patients. On the other hand, it's going to be a little bit harder from now on to say of interventions aimed at improving health that they're so obviously beneficial that only a compulsive fussbudget could demand proof.
Now, all we have to do is get more and more physicians to scrutinize the results of those studies critically. Too often we’re taken in by statistical manipulations, like “odds ratios” and “hazards ratios” that exaggerate the import of a study’s results. We end up favoring treatments even when their benefits are marginal. We need to learn to be more critical of the author’s conclusions. Especially in an age when those studies are funded more and more by drug companies with a vested interest in the results. posted by Sydney on
8/08/2002 07:40:00 AM
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Americans who watched hour after hour of television after the Sept. 11 terrorist attacks were more psychologically distressed later than the rest of the population, according to the first nationwide study of how the attacks affected mental health
New Yorkers who watched in horror as the World Trade Center towers collapsed on September 11 suffered symptoms of psychological distress greater than other Americans, according to a study published this week in the Journal of the American Medical Association.
Researchers were not surprised to find that New York City area residents reported the highest psychological stress levels of any Americans sampled in the immediate aftermath of the attacks. Eleven-percent of New Yorkers surveyed reported stress symptoms.
Three percent of residents surveyed in the Washington D.C. area, where a plane slammed into the Pentagon, similarly reported elevated stress.
Four-percent of Americans living in other parts of the country reported symptoms, as well.
New York City residents faced higher rates of post-traumatic stress in the two months after the September 11 attacks, a new study shows, but the nation as a whole did not see a rise in psychological problems in the wake of the terrorist strikes.
Each of those statements is true, but just reading the headlines and the opening sentences would give you vastly different impressions of the gist of the report, which found that:
The prevalence of probable PTSD was significantly higher in the New York City metropolitan area (11.2%) than in Washington, DC (2.7%), other major metropolitan areas (3.6%), and the rest of the country (4.0%). A broader measure of clinically significant psychological distress suggests that overall distress levels across the country, however, were within expected ranges for a general community sample. In multivariate models, sex, age, direct exposure to the attacks, and the amount of time spent viewing TV coverage of the attacks on September 11 and the few days afterward were associated with PTSD symptom levels; sex, the number of hours of television coverage viewed, and an index of the content of that coverage were associated with the broader distress measure. More than 60% of adults in New York City households with children reported that 1 or more children were upset by the attacks.
In other words, the only people who were significantly stressed out by the whole thing were those who had to live through massive destruction on their doorsteps. They had to smell the smell and inhale the dust of what was essentially a crematorium for weeks afterwards. Is it any wonder they had higher levels of stress? The rest of us, despite our anger and horror, weren’t anymore stressed than we normally would be. Even in New York, the rate of anxiety wasn’t all that high. Eleven percent is a small minority considering the heinousness of the attack. The human spirit never ceases to amaze in its resiliency.
Someone Should Tell these People: In San Francisco, however, there are psychologists who are convinced that the attacks left us with a rainbow of angst in epidemic proportions:
Symptoms such as anxiety and heightened stress are what one therapist is calling, in the title of her book, "The September 11 Syndrome."
"I wouldn't hesitate to say it's happening in epidemic proportions," said the book's author, Harriet Braiker.
The multicolor wave of warnings may create a "rainbow of angst" that keeps people from sleeping or being productive at work, Braiker says.
Unfortunately this perception of an epidemic of anxiety is based on biased sampling. Another psychologist explains how she reached the conclusion we are in the throes of an anxiety epidemic:
"People are really worried about their mental health," said Tessa Ten Tusscher, who runs Bay Area Psychological Testing Associates.
Last May, Tusscher participated in National Anxiety Disorders Screening Day by offering free testing, and a line formed outside her office before the doors opened.
"Since (the screening), I've been getting loads of calls," she said. "I'm turning patients away by the bucketful because I can't accommodate them all."
Only the already anxious are likely to stand in line for free anxiety screening. posted by Sydney on
8/08/2002 06:48:00 AM
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Cloning Update: Kentucky is getting worried that state resident Panos Zavos is collecting subjects for human cloning:
"It's disturbing, an affront to the community," Fletcher said. "Activities like this point to the need to conclude the debate over legislation."
State Sen. Tom Buford, R-Nicholasville, predicted that reports of couples coming to Lexington for cloning evaluations would encourage the legislature to pass an anti-cloning bill when it meets next year. posted by Sydney on
8/08/2002 06:25:00 AM
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Hepatitis B Update: A new hepatitis B drug has been recommended for approval by an FDA advisory board. Full approval is still pending, but adefovir dipivoxil, which was developed for HIV and proved too toxic at doses needed for that disease, proved effective in decreasing viral loads of active hepatitis B patients at lower less toxic doses. It still has the potential to cause kidney damage, though, and that will need to be looked into, but it looks promising. posted by Sydney on
8/08/2002 06:24:00 AM
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Skin Product Allergy: Certain lines of skin products with an anti-bacterial agent called methyldibromo glutaronitrile are causing rashes. posted by Sydney on
8/08/2002 06:21:00 AM
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Wednesday, August 07, 2002
JAMA’s Weekly Art History Lesson: The museum evidently wouldn’t give them permission to put an image of the painting on the web, but here’s a link to the picture, and here’s Therese Southgate’s essay. posted by Sydney on
8/07/2002 06:19:00 AM
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West Nile Hype: ABC News is blaming West Nile virus on global warming, among other things. The experts they interviewed express shock that the virus made its way to America. Why would they be shocked? We live in a very mobile world. It isn’t inconceivable that some mosquitoes made their way over in an airplane, is it? Birds, which carry the virus, also are very mobile, and their migratory patterns could also help explain the spread. As for the claim that “before the emergence of West Nile virus in the United States, diseases such as malaria and yellow fever were considered "foreign" or "exotic" infections”, that’s ridiculous. It’s true that in modern times we rarely see yellow fever or malaria, but that’s because we’ve been good at spraying for mosquitoes and draining swamps. Before that, yellow fever and malaria were both very much alive in this country. Philadelphia had a deadly yellow fever epidemic in 1793 that killed 4,000 people, and another one in 1798. In fact, yellow fever was a problem all along the south Atlantic coast and the Gulf of Mexico:
Between 1817 and 1900, yellow fever had struck nearly every summer in cities on the southeastern and Gulf coasts. New Orleans was yellow fever's favorite American target. The New Orleans epidemic of 1853 killed nine thousand people. After city authorities incorporated the Reed team's discoveries, New Orleans suffered only one yellow fever epidemic--the epidemic of 1905, the last outbreak of yellow fever in the United States.(Dr. Reed discovered yellow fever was caused by mosquitoes.)
Malaria, introduced after 1650, became the Chesapeake's most virulent pathogen. Slaves carrying the most lethal variants of malaria came from Africa to the New World, and mosquitoes spread it to the European and Native American population. Once established, malaria was impossible to eradicate without draining the mosquito-infested swamps, although colonists were unaware of the mode of transmission of the disease in any case. Malaria profoundly affected public health in the southern tidewater region, and it was a primary reason colonists in the Chesapeake Bay region lived shorter lives than did New Englanders. Malaria also encouraged wealthy whites to live in Charleston during the unhealthy summers, leaving their rice plantations to be run by overseers.
If we see an increase in mosquito borne illnesses, it’s less likely due to global warming, than it is from reluctance to spray pesticides and a fondness for preserving wetlands.
posted by Sydney on
8/07/2002 06:17:00 AM
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Diseased Prairie Dogs: There's been an outbreak of tularemia, a bacterial illness that can be transmitted to people, among prairie dogs in Texas and South Dakota. Some of the little beasts may have been shipped to pet stores around the country and the world. (People keep them as pets?) Usually, tularemia is a disease of small mammals, but there are concerns that terrorists could aerosolize it and use it as a bioweapon in much the same way anthrax was. The prairie dogs, however, are a natural outbreak. How do people get it?
Humans become infected with F tularensis by various modes, including bites by infective arthropods, handling infectious animal tissues or fluids, direct contact with or ingestion of contaminated water, food, or soil, and inhalation of infective aerosols. Persons of all ages and both sexes appear to be equally susceptible to tularemia. Certain activities, such as hunting, trapping, butchering, and farming, are most likely to expose adult men.
Manly Women: Oprah Winfrey gave this topic a public relations bonanza a few years ago, but testosterone for libido enhancement is still a hot topic. It’s never been studied in postmenopausal women, only in younger women who had their ovaries removed surgically. (A good synopsis of the study can be found here.) The LA Times article does take the time to mention this, and to list the side effects, as well as mention that androgens aren’t easily measured by blood tests, but only after gung-ho statements like this:
As many as 40% of women complain of some type of sexual dysfunction, studies have shown. Given this figure, androgen replacement should be given the same kind of attention as estrogen replacement, says Dr. Glenn Braunstein, who is testing Procter & Gamble's testosterone patch at Cedars-Sinai Medical Center.
"Some women develop significant symptoms of androgen insufficiency: low libido, low quality of life," he says. "Some symptoms improve with estrogen replacement. Hot flashes are clearly improved by estrogen. But once the estrogen is taken care of, if libido stays low and [a blood test shows] free testosterone is low, giving androgen is probably in order."
Where does that 40% figure come from, anyway? 40% of women who are post-menopausal? 40% of married women? 40% of women who were surveyed in the cafeteria? Or is it just somebody’s guess? And by the way, there are no reliable laboratory standards to diagnose androgen deficiency. The most disturbing aspect of the whole debate is the touting of a pill for what is a very complex problem. Loss of libido can be due to a combination of many factors, some of which are difficult to tease out: an unhappy marriage, depression, physical changes with menopause, as well as hormonal changes. The problem is, whenever there’s the promise of an easy fix with a pill, people are reluctant to confront the more difficult causes. I’ve noticed this with Viagra.
Testosterone, however, isn't as safe as Viagra. It has the potential to increase cholesterol, and there are concerns that it could increase the risk of breast and liver cancer, although the issue has never been studied. However, it is known that 5 to 35 percent of patients who take it develop acne, male-pattern hair growth, clitorimegaly (an enlarged clitoris) and voice deepening. In addition, research so far has found its effects on libido to be unreliable. Even in the study I linked to earlier, the effects were modest:
The mean composite scores on the sexual functioning index [a questionnaire on their feelings about sex] increased from a mean of 52 at baseline to 72 in the placebo group, to 74 in the 150-µg group, and to 81 in the women who received the 300-µg per day dose of testosterone. The percentage of women who had sexual intercourse at least weekly increased from 23 percent at baseline to 35 percent in the placebo group and the 150-µg group, and up to 41 percent in the 300-µg group.
You could argue that the increase in weekly sexual intercourse is a measure of its efficacy, but the women may have been having sex more often during the study in an effort to test the patch they were wearing. The study doesn’t say whether or not they enjoyed it.
The most interesting result, however, was this:
The percentage of women who reported masturbating at least once a week was 3 percent at base line, 5 percent during placebo treatment, and 10 percent during treatment with either 150 or 300 µg of testosterone per day.
Personal Magnetism: A report from England of the complications that can occur when children use magnets to imitate body piercing:
The surgical registrar requested an abdominal film and this revealed a collection of small objects massed in the lower abdomen. On further inquiry the girl admitted to swallowing a number of small magnets over a period of time while imitating tongue piercing. She was rehydrated overnight and at laparotomy she was found to have five perforations in the small bowel and one in the caecum. The mass of magnets was resting extra-luminally. Peritoneal lavage was performed and the perforations closed. She was given antibiotics and transferred to the intensive care unit where she remained for one week before transfer to a general ward. After a further week as an inpatient she was discharged home.
It was recognised during this cluster of cases that there was the potential for these magnets to attract each other across loops of bowel.
...The sequence of events involved in the case of perforation can be hypothesised but is most likely to have begun with two magnets in adjoining loops of bowel attracting each other and trapping the intestinal wall between them. The degree of obstruction created could cause the initial vomiting while the irritation to the mucosa could result in diarrhoea. As the mucosa thinned the bowel would perforate, allowing the magnets to join together extra-luminally and resulting in leakage of bowel contents into the peritoneal cavity.
The magnets involved are neodymium supermagnets. My kids have some of these. They are indeed powerful. They can hold their attraction even through our wooden kitchen cupboard doors. (I've now thrown them away.) posted by Sydney on
8/06/2002 07:39:00 AM
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If you don't know what causes something.... blame it on a virus.
Hazardous Delivery: Combining birth and baptism is dangerous for the baby. I always wondered how they kept them from drowning. Apparently, they don't always. posted by Sydney on
8/06/2002 07:37:00 AM
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New Jersey Blob Update: They know what it is, but not how it got there. (I still think it's part of the surfacing material that bubbles up to the top in hot weather. We have the same blobs in the parking lot of our local Target store; a parking lot, by the way, whose surface looks a lot like that one in the picture. posted by Sydney on
8/06/2002 07:35:00 AM
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It's Not Just the Politicians: A study in the British Medical Journal finds that medical researchers have a tendency to slant their conclusions in favor of their sponsors:
'Authors' conclusions in trials funded by for-profit organisations alone significantly favoured experimental interventions compared with trials without competing interests.'
Lise Kjaergard said: 'I don't think this is a deliberate attempt to distort results. But it is a bias, and it happens. There is no such thing as complete objectivity when interpreting results, and all competing results need to be declared and allowed for.'
Keep that in mind when reading stories about last week's obesity study. It was funded in part by the drug company that makes the weight loss drug, Xenical. posted by Sydney on
8/05/2002 05:54:00 AM
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Statin Hype: Dr, Paul Ridker, co-inventor on a pending patent application on the use of markers of inflammation of coronary disease and author of a paper in the NEJM a couple of years ago that touted said marker, is profiled on the CNN health website for his work. The article says that the CDC and the American Heart Association will soon put out guidelines recommending that everyone be screened for elevated levels of the marker, C-reactive protein. The guidelines aren’t finalized yet, but the Associated Press version mentions a possible implication of screening:
Inflammation can be measured with a generic $10 test that looks for high levels of a chemical called C-reactive protein, one of many that increase during inflammation. Experts expect it quickly to become a standard part of physical exams. As a result, many people ordinarily considered at low risk probably will be put on statin drugs, which lower inflammation as well as cholesterol
Please say it isn’t so. Last week, the American Heart Association recommended that we screen everyone over 20 for cholesterol, potentially putting many more people at risk for complications of statin therapy for a longer duration of their lives. Now, they’re thinking of expanding the uses of statins even more, without considering the cost in dollars or side effects of having such a large number of people on drugs for most of their lives; not to treat a disease, but to reduce a risk. Even worse, they are contemplating a recommendation that is based on limited data. As the CNN article points out:
Still, some important details remain to be settled. One is population-wide data on CRP levels and their connection to heart disease. Ridker is finishing a large study, to be released later this year, that traces this relationship with CRP readings from tens of thousands of people.
"Paul has got data now that slam-dunks it," says Dr. Richard Milani of the Ochsner Clinic in New Orleans.
Another gap is rock-solid evidence that lowering inflammation truly prevents heart attacks and saves lives. Ridker hopes to prove this with a study to begin this fall that will compare statin drugs and dummy pills in 15,000 middle-aged men and women with normal cholesterol and above average CRP
Why not wait until the studies are finished before putting out guidelines? I don’t have access to all of the journals that come up in a PubMed search of C-reactive protein and coronary artery disease, but I do have access to the New England Journal of Medicine article that started it all. The results in the abstract state that treating someone with normal cholesterol but a high C-reactive protein with a cholesterol lowering drug, specifically a statin, prevented heart disease. In truth, the people with high C-reactive protein values and normal cholesterol who took a statin had a 3% incidence of heart attacks compared to a 5% incidence in people who took placebo. That’s not much of a difference. Especially when you’re recommending that someone take a drug for the rest of their lives to achieve it. Furthermore, an aspirin a day could prove just as effective, or more so, in preventing heart disease in people with elevated inflammation markers alone. We don't know. No studies have been done to compare the two.
Undue Influence? The American Heart Association seems to be involved in a lot of dubious guideline writing lately. Earlier this year they had to withdraw their recommendation to use the clot-busting drug alteplase in strokes when it was revealed that they had recieved $11 million dollars from the company that makes it. Then, there was there recommendation that everyone over 20 be screened and treated for high cholesterol levels; a recommendation that has the potential to boost the use of statins significantly. And last week, when I was examining the rising prices of drugs, the American Heart Association’s name kept coming up:
The price of Plavix, a drug that inhibits blood clotting, rose 16.8 percent (more than six times the rate of inflation). The drug is favored by cardiologists to keep cornary artery stents open after placement. In addition, the American College of Cardiology together with the American Heart Association recommended it in 1999 as the drug of choice for heart attack patients who couldn’t take aspirin. Not coincidentally, Plavix sales rose 128 percent in the first quarter of 2000.
Zestril prices rose 14.6 percent (more than five times the rate of inflation). Zestril belongs to a class of drugs called ACE inhibitors (angiotensin converting enzyme inhibitors.) ACE inhibitors are exceedingly popular and urged on physicians as a drug of choice in many situations: diabetics with high blood pressure, diabetics without high blood pressure, people who have heart disease, nondiabetics with high blood pressure, and people with congestive heart failure. In 1999, the American Heart Association and American College of Cardiology recommended their use in all heart attack patients whose blood pressure could tolerate them.
Bristol-Myers Squibb is one of the American Heart Association’s top donors. They also happen to be the makers of Plavix, a statin (Pravachol) and two ACE inhibitors. They certainly seem to have hit the jackpot on the basis of the AHA guidelines. The top donor list (donations of $1 million dollars or more) also includes AstraZeneca, Aventis, and Parke-Davis (all makers of ACE inhibitors), Novartis (maker of an ACE inhibitor and a statin), and Pfizer (maker of a statin). Maybe it’s all just a coincidence, but given their record with alteplase, it’s hard to give them the benefit of the doubt.
posted by Sydney on
8/05/2002 05:42:00 AM
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Marin County Mamms: Marin County has a higher incidence of breast cancer than the rest of the Bay Area. It’s hard to tell from the ABC story how significant the increase is, but the Northern California Cancer Center says the incidence in Marin County in 1999 was 230/100,000 compared to the rest of the Bay Area at 155/100,000. Sounds like a significant increase, but they may just have an older population, not withstanding all of the young women the ABC report trotted out to illustrate the story. (Incidence goes up with age.) The most puzzling aspect of the report, however, is this running theme:
It boasts pristine woodlands, beautiful waterways and, with Mount Tamelpias as a stunning backdrop, some very pricey real estate.
Marin's population is predominantly white, affluent, highly educated and very health-conscious.
"I try to eat organic foods as much as I can," said Lynn Oberlander, a local resident. "I try to get my stress level down. I go to yoga. And I hike and I exercise."
But despite all the advantages, Marin County has the highest rate of breast cancer in America, possibly even in the world.
I didn’t realize that being white, rich, and pampered was supposed to protect you from cancer. In fact, you could make the argument that it increases your risk since you’re likely to avoid other diseases that could kill you before you live long enough to get cancer.
posted by Sydney on
8/05/2002 05:39:00 AM
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Drug War: The war on drugs has turned its guns on physicians:
"We're moving up the food chain right now," said Gregg Wood, a health care fraud investigator with the U.S. attorney's office in Roanoke. Investigators have started with the drug abusers and are working backward. "Most OxyContin gets written at the end of a doctor's pen," Wood said. "Some of these doctors are nothing more than clearinghouses."
A federal grand jury in Alexandria has been investigating William E. Hurwitz and Joseph K. Statkus, sole practitioners who run pain clinics in Fairfax County, and some pharmacies since last year to determine whether they have been conspiring to distribute controlled substances and whether their actions have led to overdose deaths, sources said.
"I will neither confirm, deny nor comment except to say that the growing national plague of Oxy addictions, overdoses and deaths caused by the illegal activity of some doctors, pharmacists and patients has been focused on like a laser beam by this office and other U.S. attorneys' offices," said Gene Rossi, a federal prosecutor in Alexandria. "If any person falls into one of those three categories, our office will try our best to root that person out like the Taliban. Stay tuned."
Sure, there are probably doctors out there who are criminally and cynically selling narcotics, but the vast majority are sincere liberal-hearted people who believe everything their patients tell them. The trend in medicine lately has been to treat pain liberally. We didn’t used to be that way. We used to say “no one ever died from pain.” Now we say that pain is a disease worthy of treatment and eradication just as any other disease. The only problem is, we can’t measure pain objectively. It is a completely subjective symptom. There are clues, to be sure, that a patient is abusing his medication: early requests for refills, escalating requirements, frequently “lost” prescriptions, but recognizing those clues requires a healthy dose of cynicism toward the trustworthiness of the patient. Doing something about it is even harder, as it almost always involves some unpleasantness. Drug addicts do not go gently away. They argue and cajole and persuade and throw temper tantrums. Much easier to convince yourself they’re telling the truth. Even easier when obliterating pain at all costs is the standard of care posted by Sydney on
8/05/2002 05:33:00 AM
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Boutique Medicine: A reader sent me a heads-up on the this article about the rise of boutique medicine in Boston (Boston Globe article. If the link doesn't work, cut and paste this URL: http://www.boston.com/dailyglobe2/216/nation/Custom_medicine_raises_care_and_concerns+.shtml). It's the same old story. Poor insurance reimbursement is forcing physicians to see more patients than they feel comfortable seeing:
Solomon, 61, said he joined MDVIP after Beth Israel Deaconess told him his salary would be cut 40 percent unless he increased his annual patient visits from 3,400 to 5,000. Many academic medical centers are pressuring internists to see more patients.
''I started seeing people on weekends and tucking them into every nook and cranny of my schedule. I would just end up running behind,'' he said. ''I was getting angry at patients. They were becoming the enemy rather than the people being serviced.''
Now he collects a $1,500 annual fee from 580 patients - $870,000 - which he splits with MDVIP. Not all are rich; his enrollees include an MBTA worker and the manager of a restaurant in Lowell. The fee allowed him to see 12 patients this past Wednesday, rather than 25. He finished just after 5 p.m
I would like to see a better solution than boutique medicine for this. We could just all stop accepting insurance and ask the patient to pay for their office visits up front. If only we were organized enough or fed up enough to do it en masse. posted by Sydney on
8/05/2002 05:31:00 AM
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Smallpox Vaccine Debate: The debate continued yesterday on ABC’s This Week. William Bicknell, professor of public health and smallpox vaccine advocate, debated George Peters, head of the CDC National Vaccine Advisory Committee. Bicknell came out ahead:
"We are looking at, with smallpox, between 25 to 40 percent deaths and 60 percent of those who survive significantly disfigured; versus the risk of vaccination is something on the order of the risk of dying ... in an auto accident on any particular day of the year." posted by Sydney on
8/05/2002 05:29:00 AM
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Epidemic Proportions: All last week we were treated to news about the epidemic of obesity our nation is facing and the danger it poses. We certainly have an epidemic of epidemics in this country: an HIV epidemic, a hepatitis epidemic, a West Nile virus epidemic, tobacco-related disease epidemic, a domestic violence epidemic, and an alcohol use epidemic, to name just a few. It’s a wonder any of us are still standing. All of this makes me wonder about the validity of the obesity epidemic. Is it really an epidemic, or do we just accept that it is because that’s what we’ve been told, and because we remember so vividly the few truly obese people we have encountered.
There has always been a perception that obesity is a wide spread problem. A 1934 edition of the respected Cecil’s Textbook of Medicine calls obesity "one of the commonest ailments to which the flesh is heir.....”, and in 1950 the textbook Internal Medicine: Its Theory and Practice called it said, "the commonest disease in the United States.” If art is any indication, being overweight isn’t a modern phenomenon. If most people were thin once upon a time, would there be so many images of heavy people in paintings throughout the ages? Sometimes, it was even the ideal. (Look at this, this, this, and this.)
So how do we know that obesity is really increasing among Americans in the past twenty years, and that it isn’t just perceived as increasing? The statistics that are widely quoted as proving an increase come from the National Health and Nutrition Examination Surveys (NHANES) conducted by the US Public Health Service since 1960. To be valid, comparisons of trends over time should be between similar populations. This can’t be said of the NHANES surveys. Take, for example, the rates of obesity in children. The first survey concentrated on chronic diseases in adults. The second, in 1963 included children ages 6-11, and the third one in 1966 focused on children aged 12-17. It wasn’t until 1971 that the survey began to concentrate on measurements of nutritional status. Even then, there were differences in the populations measured by each successive survey. The surveys in 1971 and 1976 were very similar in their surveyed populations, but by the time the 1988 survey came about, it was recognized that the prior studies neglected significant portions of minority populations. To make up for this neglect, the 1988 survey included disproportionate numbers of minority groups compared to the previous surveys:
As previously mentioned, minority groups can have very different health status and characteristics, and thus black Americans and Mexican Americans were selected in large proportions in NHANES III. Each of these groups comprised separately 30 percent of the sample.
Rates of obesity can vary significantly by ethnic group. Blacks and Hispanics happen to have higher rates of obesity than whites for some reason. If I read that description of NHANES III correctly, 60% of the population surveyed in it were either Hispanic or black. It’s no wonder that the prevalence of obesity in children jumped from 5% to 10% between the 1976 survey and the 1988 survey. The most recent statisics come from NHANES 1999 which is still in progress. The jump of obesity levels in children to 14% in 1999 is based on early samples, not the complete sample population of previous years. This limits the accuracy of the data, as even the NHANES people admit:
Because the sample size for NHANES 1999 is smaller than that of the multiyear NHANES III, additional data from further annual NHANES surveys will be necessary to confirm these findings and to allow more detailed analyses of trends in overweight for population subgroups.
For all we know, those preliminary surveys may be among ethnic groups that have higher rates of obesity to begin with. The “epidemic” may not be as real as the numbers suggest.
The numbers for adult obesity are even more confounded. Not only are they based on the same differing populations, but they also have the added variable of the aging of the baby boomers. As we get older, we get heavier. There’s no denying it. So statements like this from the CDC may not represent as dramatic a change in prevalence as they seem at first glance:
Among U.S. adults aged 20-74 years, the prevalence of overweight (defined as BMI 25.0- 29.9) has increased an estimated 2 percent since 1980.
..In the same population, obesity (defined as BMI greater than or equal to 30.0) has nearly doubled from approximately 15 percent in 1980 to an estimated 27 percent in 1999.
Again, the jump in obesity occurs between the years 1980 and 1999, when the survey's population was radically altered. Add to that the aging baby boomers, and the figures are, in all probability, even less reliable than those for children.
Words Have Consequences: Calling something an epidemic may be useful in getting attention for a cause, but it does have real consequences for society as a whole. Indulging in hyperbole and labeling obesity as an epidemic means that public money is more likely to be devoted to combatting it. That is money taken away from other, more important priorities, like defense and immunizations and education. This is especially problematic when you consider that obesity is first and foremost a condition within the control of the individual. Even assuming, as is most probably the case, that we each have different metabolic rates that make some of us more prone to obesity than others, the fact remains that the only way to combat it is to exercise regularly and to restrict calories.
People don’t want to believe this fundamental truth. Not too long ago a survey confirmed this:
Among those attempting to lose weight, a common strategy was to consume less fat but not fewer calories (34.9% of men and 40.0% of women); only 21.5% of men and 19.4% of women reported using the recommended combination of eating fewer calories and engaging in at least 150 minutes of leisure-time physical activity per week.
I often have patients tell me they can’t understand why they aren’t losing weight. They say, with a straight face, “I don’t eat anything.” Now, we both know that is patently false. If I locked them in a room for two days and denied them any food at all, they would come out at least a couple of pounds lighter than when they went in. Look at concentration camp survivors. People of all shapes and sizes went into them, but everyone who survived to the end of the war came out a living skeleton. The same with famine victims, and shipwreck survivors. When I point this out to them, I only get a blank look. No one wants to admit their personal culpability in the problem.
The obese are unique in this respect among those suffering from self-inflicted health problems. Smokers are usually openly defiant and honest about their habits. Alcoholics generally lie about their drinking, but when they admit they have a problem they take the blame on themselves. Only my obese patients lie about their personal habits then act as if it’s my fault they are still overweight. This is ultimately what is wrong with labeling obesity an epidemic and a disease. It takes the impetus for change away from the patient and transfers it to the medical profession and public health professionals. The very people who are least able to do anything about it. posted by Sydney on
8/04/2002 02:20:00 PM
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West Nile Virus: Louisiana’s governor has asked for a declaration of a state of emergency because there have been four deaths and 54 cases of West Nile virus there. If that’s what it takes to get the money to spray for mosquitoes, then more power to him. It isn’t all that surprising that West Nile is showing up in Louisiana, and showing up there in humans. Louisiana has a lot of swamps. Lots of swamps means lots of mosquitoes. Mosquitoes pick up the virus from infected birds and transmit it to humans. The higher the mosquito population, the more likely the disease will be transmitted to people. Last year, the virus was detected in birds in Louisiana. Is it any wonder that this year the mosquitoes are giving it to people?
It’s also no surprise that the virus is spreading across the United States. It’s been found in a variety of birds, and their migration patterns are quite varied. Even if they didn’t migrate, it would be expected to spread since our country is a contiguous land mass. There’s nothing to prevent birds from spreading it to each other across state borders.
In most cases the illness is mild. Most people don’t even know they have it. The elderly and the immunocompromised, as usual, are especially vulnerable to developing complications and dying. It sounds scary to hear that Louisiana is declaring a state of emergency, but what they really have is a mosquito emergency, not a medical emergency. posted by Sydney on
8/04/2002 08:47:00 AM
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Medical Visas Update: A google search for medical visas turned up a memo that indicates the State Department was concerned about the inappropriate use of medical visas. Secretary Powell sent a memo in November 2001 to consular officers in, among other places, Belgrade, Lahore, Peshawar, and Jakarta. His main concern wasn’t that terrorists were potentially using them, though. It was that the visa recipients were costing American hospitals money:
1. SUMMARY: THIS CABLE ADVISES CONOFFS OF THE POTENTIAL UNINTENDED CONSEQUENCES OF ISSUING VISAS TO FOREIGN NATIONALS SEEKING MEDICAL TREATMENT IN THE UNITED STATES. CONOFFS SHOULD DRAW ON THESE COMMENTS AS THEY REVIEW NIV APPLICATIONS TO ENSURE THAT THE APPLICANTS HAVE OVERCOME PUBLIC CHARGE ISSUES AND FULLY ESTABLISHED THEIR ELIGIBILITY FOR NONIMMIGRANT STATUS. END SUMMARY.
2. VO/F/P RECENTLY MET WITH [A REPRESENTATIVE] OF CHILDRENS NATIONAL MEDICAL CENTER IN WASHINGTON, WHO EXPLAINED THAT THE EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT (EMTALA) REQUIRES HOSPITALS TO RECEIVE AND TREAT PATIENTS WITH EMERGENCY MEDICAL CONDITIONS, REGARDLESS OF THE PATIENTS ABILITY TO PAY OR LACK OF INSURANCE COVERAGE. THE TREATMENT MUST CONTINUE UNTIL THE CONDITION STABILIZES. A PROBLEM ARISES FOR HOSPITALS IN SOME CASES WHEN A U.S. DOCTOR PROVIDES A LETTER TO AN OVERSEAS VISA APPLICANT AGREEING TO SEE THE APPLICANT AT NO COST. AFTER RECEIVING A VISA, THE APPLICANT TRAVELS TO THE U.S. AND MEETS THE DOCTOR, WHO CONDUCTS AN INITIAL DIAGNOSIS AND REFERS THE APPLICANT TO A HOSPITAL, WHICH IS OBLIGATED UNDER EMTALA TO PROVIDE FOLLOW-ON TREATMENT. IN SOME CASES, THE COST OF THE FOLLOW-ON TREATMENT CAN RUN INTO THE HUNDREDS OF THOUSANDS OF DOLLARS, EXHAUSTING FUNDS THAT CHARITIES HAVE RAISED FOR THE TREATMENT OF INDIGENT LOCAL PATIENTS.
3. [THE HOSPITAL REPRESENTATIVE} CITED SEVERAL EXAMPLES, INCLUDING THE CASE OF A YOUNG LEUKEMIA PATIENT WHOSE PARENTS APPLIED FOR A VISA FOR HIM AND PRESENTED A LETTER FROM A MARYLAND DOCTOR AGREEING TO "CARE FOR" THE CHILD. THE CHILD WAS ISSUED A VISA AND TRAVELLED TO THE UNITED STATES, WHERE THE MARYLAND DOCTOR PROMPTLY REFERRED HIM TO CHILDRENS HOSPITAL. THE CHILD'S TREATMENT IS EXPECTED TO COST USD 650,000. THIS FIGURE REPRESENTS NEARLY THE ENTIRE SUM RAISED BY COLUMNIST BOB LEVEY IN THE WASHINGTON POSTS ANNUAL FUND-RAISING CAMPAIGN TO SUPPORT CHARITY CARE AT CHILDRENS HOSPITAL FOR WASHINGTON AREA RESIDENTS. DEPARTMENT HAS RECEIVED SIMILAR REPORTS FROM NEW YORK CITY'S PUBLIC HEALTH SYSTEM. IN A NUMBER OF CASES, TRAVELERS FROM SOME COUNTRIES RECEIVED VISAS FOR TEMPORARY MEDICAL TREATMENT AND INCURRED SIX-FIGURE MEDICAL BILLS AT PUBLIC HOSPITALS.
4. IN LIGHT OF EMTALA REQUIREMENTS, VO ASKS CONOFFS TO BE JUDICIOUS IN GRANTING NONIMMIGRANT VISAS FOR U.S. MEDICAL TREATMENT. PLEASE QUESTION APPLICANTS CLOSELY TO ASCERTAIN WHETHER THEIR MEDICAL CONDITION MAY REQUIRE MORE THAN AN OFFICE VISIT. IF SO, CONOFFS SHOULD PURSUE A LINE OF QUESTIONING TO DETERMINE THE TYPE AND PROVIDER OF FOLLOW-ON TREATMENT THAT WOULD BE NEEDED. IDEALLY, THE SPONSOR HOSPITAL WOULD EXPLAIN IN WRITING UNDER WHAT CIRCUMSTANCES AND AT WHAT COST IT WILL PROVIDE WHATEVER TREATMENT AND HOSPITALIZATION MAY BE REQUIRED FOLLOWING THE ANTICIPATED DIAGNOSIS.
5. DEPARTMENT RECOGNIZES THAT CONOFFS USUALLY LACK THE EXPERTISE TO ASK DETAILLED QUESTIONS REGARDING AN APPLICANTS MEDICAL CONDITION. DEPARTMENT ALSO RECOGNIZES THAT APPLICATIONS FOR MEDICAL VISAS RAISE HUMANITARIAN CONCERNS AND CAN BRING CRITICISM TO OVERSEAS POSTS IF HANDLED INSENSITIVELY. FOR THESE REASONS, EACH MEDICAL VISA APPLICATION SHOULD BE GIVEN A SYMPATHETIC AND THOROUGH HEARING.
6. DEPARTMENT NONETHELESS ADVISES CONOFFS TO BE ALERT FOR MEDICAL TRAVEL WHICH MIGHT RESULT IN UNEXPECTED HIGH COSTS FOR U.S. HOSPITALS. IF NECESSARY, THE APPLICANTS HOST-COUNTRY DOCTOR MIGHT ADVISE WHETHER THE APPLICANTS CONDITION APPEARS TO REQUIRE SURGERY OR HOSPITALIZATION. IN THOSE CASES WHERE FOLLOW-ON TREATMENT WOULD SEEM LIKELY (WHICH SEEMS PROBABLE FOR ALMOST ALL CASES), APPLICANTS SHOULD BE ENCOURAGED TO LOCATE A CHARITY AND/OR U.S. HOSPITAL WILLING TO SPONSOR ANY AND ALL FOLLOW-ON TREATMENT FOR THE APPLICANT. IN THE ABSENCE OF A SPONSORING HOSPITAL, APPLICANTS SHOULD BE DIRECTED TO REQUEST A COST ESTIMATE FOR FOLLOW-ON TREATMENT FROM THE U.S. HOSPITAL AND PRESENT EVIDENCE OF SUFFICIENT FUNDS TO PAY FOR THE TREATMENT.
To be fair, there may have been an earlier memo that warns of the abuse of medical visas by terrorists to enter the country, but it doesn’t seem that’s the case. They are, after all, urged to be sympathetic rather than critical of the application. Even more worrisome is the visa waiver program:
Travelers coming to the U.S. for tourism or business for 90 days or less from qualified countries may be eligible to visit the U.S. without a visa. Currently, 28 countries participate in the Visa Waiver Program: Andorra, Australia, Austria, Belgium, Brunei, Denmark, Finland, France, Germany, Iceland, Ireland, Italy, Japan, Liechtenstein, Luxembourg, Monaco, the Netherlands, New Zealand, Norway, Portugal, San Marino, Singapore, Slovenia, Spain, Sweden, Switzerland, the United Kingdom and Uruguay.
These might all be friendly countries, but the United Kingdom has proven itself a hotbed of Islamic extremist activism, and the Netherlands, according to this Timeprofile on the shoe bomber, is even worse:
Reid had another reason for choosing the Netherlands. The country, says Rohan Gunaratna, an expert on terrorism at the University of St. Andrews in Scotland, has become a center of al-Qaeda activity. posted by Sydney on
8/04/2002 08:22:00 AM
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