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    The Doctor Stories by William Carlos Williams


    Pox Americana: The Great Smallpox Epidemic of 1775-82 by Elizabeth Fenn


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    Raising the Dead by Richard Selzer


    Autobiography of a Face by Lucy Grealy


    The Man Who Mistook His Wife for a Hat by Oliver Sacks


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    Saturday, October 19, 2002

    The V-Book Bites Back I received the following email in defense of The V Book:

    I was dismayed to see you merely reviewing a review, rather than the book itself. I am the co-author of The V Book, with Dr. Elizabeth Stewart, an asst. professor of ob-gyn at Harvard Medical School who directs the Stewart-Forbes Vulvovaginal Specialty Service in Boston.

    The V Book is about as "titillating" than a book about prostate cancer. It does not "masquerade as a book on women's health," as you state; rather, its subtitle clearly states it is very specifically about vulvovaginal health only. Dr. Stewart wrote this groundbreaking book because, based on her two decades as a gynecologist and 12 years of vulvovaginal specialization, she realized that there was a great deal of misinformation--and missing information--among women about their genitalia. No, a woman is not "defined by" her vagina. But neither does she deserve to be kept in the dark about its attendant health concerns.

    And there are many. A suspected vaginal infection is the most common reason a woman visits her gynecologist. There are 10 million office visits a year for vulvovaginal complaints. Few of the many mass market books on women's health cover vulvovaginal concerns in accurate detail. Such issues include yeast infection; STDs such as bacterial vaginosis, herpes and genital warts from HPV; vulvodynia (vaginal pain); painful intercourse; allergies; skin conditions such as eczema; cancers and precancers; preventative measures; safe use of tampons and pads; how concerns change throughout the life cycle; and plain old what's-where physiology--all topics covered in The V Book.

    Such info can be hard to find. Part of the problem, Dr. Stewart points out, is that physicians, even ob-gyns, receive little training in vulvovaginal matters and continue to perpetuate poor standards of care about them. The V Book is entirely footnoted so that it might be of benefit to medical professionals as well as laypeople.

    I would think that a female physician, of all people, would be open-minded about this dimension of a woman's health. Dr. Stewart is hardly trying to "define women by their genitalia"--rather, she just wants them to be aware of, and take care of, what's undeniably there!


    Ouch. She's right. I reacted to the review (which was probably designed to be titillating) and not to the book. Mea culpa. I plan to review the book soon, once my copy arrives and I get a chance to read it. Stay tuned.
     

    posted by sydney on 10/19/2002 04:22:00 PM 0 comments

    Light Blogging Alert: Much to do in the coming week. Halloween costume deadlines, clean-freak in-laws coming to visit, partner away on vacation, so blogging will be light this weekend and coming week.
     
    posted by sydney on 10/19/2002 08:44:00 AM 0 comments

    Clever Acronym Watch: A letter writer to The Lancet has come up with a new research bias, and an acronym for it - FUTON bias (link requires free registration):

    The availability of full-text articles on the internet has greatly improved ease of access to medical information. This development must be seen as a great benefit, but it may have generated a new type of bias.

    Everyday information-seeking activities, especially by junior staff and students, often concentrate on research published in journals that are available as full text on the internet, and ignore relevant studies that are not available in full text, thus introducing an element of bias into their search result.

    This bias I propose to call FUTON (Full Text On the Net) bias. It will not affect researchers who are used to comprehensive searches of published medical studies, but it does affect staff and students with limited experience in doing searches. This bias may have the same effect in daily clinical practice as publication bias or language bias when doing systematic reviews of published studies.


    Can’t you just see the medical students and junior staff sitting at home on their futons, relaxing to their favorite music or watching television while doing their medical research? Much better than sitting in a stuffy medical library pouring over Index Medicus.

    He goes on to make a sensible plea to publishers of medical journals everywhere:

    Publishers of medical journals should feel encouraged to make the content of their journals available as full text to avoid losing out to their competitors. This trend will gain further strength if the journals that make preprints available on the internet or publish internet-only versions of reports are taken into account.

    I second that motion. There are a lot of physicians who don’t have access to well-stocked medical libraries. They practice in remote regions that just don’t have the means or the population to support them. They rely on the internet. Unfortunately, the prices for an online subscription to most of the journals is just as high as their print version, making it impossible to subscribe to them all. They would be doing a good deed by making their papers available on the web. (The New England Journal does this to some extent now. They make important papers available to everyone without registration. They also make articles that are older than six months available with free registration. JAMA makes important papers available for everyone, but they don’t have any free access for old papers.)
     
    posted by sydney on 10/19/2002 08:36:00 AM 0 comments

    Failure of Heart: DB's Medrants had a link to a story about the artificial heart recipient who was profiled by The New York Times last week. His widow is suing the artificial heart company. The New York Times story didn't mention anything about a pending lawsuit, only that during his time in the hospital Mr. Quinn had thought about hiring a lawyer. Both the makers of the artificial heart and the surgeon involved were very open and forthcoming in the story. Usually when a lawsuit is pending, no one says anything. Were they set up, or did the lawyers read the story and chase down a client?
     
    posted by sydney on 10/19/2002 07:57:00 AM 0 comments

    Friday, October 18, 2002

    Endurance: A new, and popular, anesthetized condom. Well, it’s popular with at least one of the two people involved in its use.
     

    posted by sydney on 10/18/2002 07:34:00 AM 0 comments

    The Inner Woman: The United States Preventive Services Task Force, the arbiter of evidence based medicine, has cogitated on hormone replacement therapy and made the results public. Estrogen is a no-no for preventing heart disease and osteoporosis, and not worth its risks. They didn’t consider estrogen as a treatment for menopausal symptoms, though. The worthiness of that remains up to the patient:

    For an individual woman, the balance of benefits and harms may vary. Women considering taking HRT for prevention should make that decision with their clinician in the context of a discussion of benefits and harms of HRT and alternatives to HRT for the prevention of chronic diseases.

    I'd say they struck a pretty good balance, although I disagree with the stance on osteoporosis. A lot of people have begun pushing other, newer drugs for preventing osteoporosis in light of the recent brouhaha over estrogen, but the truth is that those drugs simply haven't been studied and scrutinized as much as estrogen. We can't say with any confidence that they're safer. Still, the decision to take a drug to prevent a possible future illness is something that should be left up to the patient, and should be done with full knowledge of its risks, and how much or how little we know about those risks.
     
    posted by sydney on 10/18/2002 07:19:00 AM 0 comments

    The Outer Woman: Why do so many women insist on defining themselves by their genitalia? In the tradition of Our Bodies, Ourselves and The Vagina Monologues comes The V Book:

    And yet, the V-zone, as the authors of this excellent manual put it, is something that many women have misguided notions about. Too often, they merely walk away from their physicians' offices with tubes of cream or antibiotic pills — and sometimes without a clear diagnosis. "Vagina is hardly a household word," writes Dr. Stewart, a veteran gynecologist who operates a renowned "vulvar specialty" service in Boston. "Vulva and clitoris might as well belong to another language. They are blushers, vaguely subversive, not ready for prime time."

    There are other parts of the body that are equal blushers - the anus, and the penis for example - but no one’s writing books about them. And, although I’ve known men who are little more than walking bags of testosterone, there are no books or plays whose theme it is to define men by their sexual organs. (Puppetry of the Penis doesn’t count.)

    Of course, nothing sells like titillation, and although the V Book masquerades as a book on women’s health, it really is nothing more than titillation:

    Her book has no such constraints. Covering everything from pap tests to pain, vibrators to the existence of the G spot to ranges of absorbency (in grams) in tampons, it explores the basics of "V-Health" as candidly as comfortably as "The Vagina Monologues" publicized the vagina.

    Sisters! We are not defined by our vaginas. We are not empty vessels.
     
    posted by sydney on 10/18/2002 07:15:00 AM 0 comments

    This Week’s Smallpox News: The paper from this week’s JAMA about the risk of contact vaccinia from smallpox vaccine must be getting a lot of press. I know this because my seven year old daughter, who has eczema, asked me tonight if she’s going to get smallpox. I’d link to the paper, but it requires registration, so here’s the Reuters version instead. The conclusions regarding the risks are sensible:

    "A orderly, systematic approach along with careful screening to identify potential vaccinia-susceptible individuals and household contacts and close monitoring for adverse effects are essential to reduce the risk of transmission of vaccinia following smallpox vaccination," the report concludes.

    This would seem to argue for voluntary pre-attack vaccination when we have the luxury to screen for contraindications and educate people on the importance of shielding others from their vaccine site. Yet, one of the authors of the paper, a pediatrician, is quoted by Reuters as being against pre-attack vaccination:

    "The real question," Neff said, "is why are we cascading into a seemingly unstoppable war scenario that causes us to react in an extreme fashion to a real or imagined fear of a bioterrorism event that otherwise would be highly unlikely.

    "If we as health professionals cause serious injury or death as a result of our actions, then if these actions are ill-advised, we stand in danger of losing a very valuable public trust," Neff said.


    We stand in even greater danger of losing public trust if we wait until after an outbreak, when many more lives would be at risk, not only from the disease, but from the vaccine, too.

    UPDATE: Reuters posted this interesting correction to the above link. The correction says it was posted to make "clear the risk is cowpox," but that was pretty clear in their original story. What this one also makes clear is that Dr. Neff, the doctor they interviewed in the original, isn't the main author of the paper. The corrected version also leaves out his comments about "rushing to a war scenario." I suspect that the real correction is that Dr. Neff's views don't represent the views of his colleagues.

    AND ELSEWHERE: Britain is planning to vaccinate key healthcare workers, with plans to expand the program in case of an attack.

    Meanwhile, Israel has been conducting vaccinations of healthcare workers and so far there have been no media reports of adverse reactions. Here's a first person account of smallpox vaccination and overall preparedness from an Israeli hematologist :

    In the event of an actual attack I will probably be called upon to be a care-giver, although, to be frank, I lack almost any medical training whatsoever. I've been instructed in the art of resuscitation, to substitute for an electronic respirator in the event that the number of victims overwhelms the available equipment resources. I'm unsure of how effective and helpful I'll be, but I know that I will do my best if prevailed upon.

    We should take a page from their preparedness manual.
     
    posted by sydney on 10/18/2002 07:08:00 AM 0 comments

    Smallpox History: Newsday has a nice piece on the history of smallpox vaccine and smallpox.
     
    posted by sydney on 10/18/2002 07:05:00 AM 0 comments

    Responsibility: Here’s a study in contrasts in attitudes toward healthcare spending, and unfortunately it doesn’t speak well for physicians. A patient on how paying for medical care changed her:

    "I was more aware of my bills," DeGoory said. "I looked at the explanation of benefits much more carefully ... and just kept track of where I stood. ... When I had a checkup, my physician said she wanted to run a cholesterol test, and I asked why. When she told me why, I was very comfortable having it."

    The doctor :

    "I don't mind if patients consider cost," she said, "but I personally try not to make decisions based on cost. I try not to know anything about anyone's health insurance, so I would have to see how that sort of thing would work out. I would have to have a lot of patients with it first."

    A lot of physicians feel this way. That’s why therapy of marginal benefit gets touted so much.

    UPDATE: Here's the perspective of a self-employed, self-insured patient on the issue:

    Physicians who do not consider costs can create big problems for self-employed patients who purchase their own high-deductable health insurance. On more than one occasion I have payed for expensive tests which, I now realize (and my doctor should have told me) were marginal and probably best avoided. Such gratuitous testing, like traffic tickets that lead to increased insurance rates, can have serious long-term consequences beyond its initial cost.

    For several years after one of these tests I was flagged by "Have you ever consulted a physician for. . . " questions on health-insurance applications. At least one insurance company subsequently wouldn't cover me, and the one that would cover me required me to take the expensive test again -- to prove that the marginal "condition" that was confirmed by my first taking of the test, and that might have never become an issue had I not taken the test. Needless to say, I am now very careful about which medical tests I submit to.

    Too many physicians, in my experience, are unconcerned about the costs borne by customers like me who have high deductibles and pay for most tests out-of-pocket. Physicians also tend not to be thoughtful about the costly and misleading paper trails they may be creating via excessive testing. I understand why American physicians order so many tests, but if I as a layman can understand the institutional dynamics of medicine, then perhaps they as physicians can learn to understand better the concerns of atypical patients.

    My auto mechanic has the sense to know that if I drive an old car he probably shouldn't recommend expensive cosmetic repairs. Is it too much to ask physicians to inquire, before recommending marginal tests, how their patients are paying? At the least, physicians should do a better job of discussing the benefits and costs (including money, privacy, and paper-trail costs in our brave new world of bureaucratized, insurance-driven medicine) of an array of alternatives when they suggest optional tests or treatments. In this regard, I think the frequently encountered "I'm a doctor not a businessman" attitude among physicians does patients a great disservice.


    Yes, it does do a disservice to our patients. And it's done a disservice to our profession.

    CORRECTION: One sentence in the above quoted email should read: " At least one insurance company subsequently wouldn't cover me, and the one that would cover me required me to take the expensive test again -- to prove that the marginal "condition" that was confirmed by my first taking of the test, and that might have never become an issue had I not taken the test, hadn't progressed." I inadvertently left out the "hadn't progressed" part.
     
    posted by sydney on 10/18/2002 07:03:00 AM 0 comments

    Thursday, October 17, 2002

    Something’s Rotten in the State of Oregon: Just a few weeks ago, the state’s medicaid program was reported to be taking a financial beating. But now it’s been expanded to include 60,000 more lives. What changed? They successfully begged the federal government for more money:


    Oregon received long-awaited federal approval Tuesday to extend Medicaid coverage to 60,000 more low-income residents at no additional cost to the state.

    The Bush administration's approval was required because the federal government pays more than half the cost of the Oregon Health Plan, the state's Medicaid program for low-income people.
    [emphasis mine]

    This is the same state that has a state-sponsored universal healthcare plan on the ballot for November. How on earth do they think they’ll be able to pay for healthcare for all when they can’t even pay for healthcare for the poor and disenfranchised?
     

    posted by sydney on 10/17/2002 07:21:00 AM 0 comments



    Pinked: CharlesMurtaugh gives much needed scrutiny to that LA Times travesty of an op/ed about breast cancer. His analysis includes this astute observation:

    I wonder if Orenstein's refusal to engage with death underpins her (and many others') crusade against "pollution" and other supposed ills. If we start with the assumption that continued life is the supreme moral good, then death must be the supreme moral evil. And absent a belief in original sin, or in a spiteful deity, we need to locate the cause of that evil in something, or else surrender to an existentialism that most people can't abide. Aha, evil corporations...
     
    posted by sydney on 10/17/2002 07:20:00 AM 0 comments

    Smallpox Preparedness Update: The Bloviator had all the news fit to print about smallpox yesterday. Including this piece about the change of course at the CDC's Advisory Panel on Immunization Practices:

    A federal committee voted Wednesday to recommend vaccinating about 510,000 hospital workers against smallpox, bringing its earlier proposal closer to the Bush administration's suggestion.

    The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices voted 8-1 for the plan, which amounts to vaccinating about 100 workers at all hospitals in the nation that could handle smallpox patients.


    At least they're beginning to see the light. Now, how long will it take the Academies Pediatrics and Family Physicians to pronounce that their policy is exactly the same?
     
    posted by sydney on 10/17/2002 07:18:00 AM 0 comments

    Smoking and Fascism: Fairhaven, the River pointed out that the New York City smoker who commented on fascism being dressed in a white coat and stethoscope may be more correct than he knows. To prove it he sent along a fascinating article on Hitler and tobacco. The author of the article felt obliged to add this little politically correct qualifier at the end:

    That does not mean, however, that antismoking movements are inherently fascist; it means simply that scientific memories are often clouded by the celebrations of victors and that the political history of science is occasionally less pleasant than we would wish.
     
    posted by sydney on 10/17/2002 07:15:00 AM 0 comments

    Wednesday, October 16, 2002

    Not Exactly Holmesian Logic: Sherlock Holmes has been given a "posthumous" honorary fellowship from the Royal Society of Chemistry. What would Holmes think? He would scoff, of course. He never suffered foolishness gladly. Surely the offering of a "posthumous" award to an immortal fictional character would have made him sneer. Still, it's a nice gesture in that it recognizes Sir Arthur Conan Doyle's contribution to fostering an interest in science through his fiction.
     

    posted by sydney on 10/16/2002 09:05:00 AM 0 comments

    JAMA's weekly art history lesson. (Those Napoleonic soldiers sure knew how to dress, and how to flatter Napoleon)
     
    posted by sydney on 10/16/2002 07:59:00 AM 0 comments

    On Free Will: Some neuroscientists are claiming there is no free will. They see the electrical impulses between neurons and their timing before volitional actions as an argument against man's command of himself:

    What Libet did was to measure electrical changes in people's brains as they flicked their wrists. And what he found was that a subject's ''readiness potential'' - the brain signal that precedes voluntary actions - showed up about one-third of a second before the subject felt the conscious urge to act.

    The result was so surprising that it still had the power to elicit an exclamation point from him in a 1999 paper: ''The initiation of the freely voluntary act appears to begin in the brain unconsciously, well before the person consciously knows he wants to act!''


    And then there’s this:

    A subject, he said, would be repeatedly prompted to choose to move either his right or his left hand. Normally, right-handed people would move their right hands about 60 percent of the time.

    Then the experimenters would use magnetic stimulation in certain parts of the brain just at the moment when the subject was prompted to make the choice. They found that the magnets, which influence electrical activity in the brain, had an enormous effect: On average, subjects whose brains were stimulated on their right-hand side started choosing their left hands 80 percent of the time.

    And, in the spookiest aspect of the experiment, the subjects still felt as if they were choosing freely.

    ''What is clear is that our brain has the interpretive capacity to call free will things that weren't,'' he said.


    The brain is well known for its ability to trick the body - phantom pain in amputees, for example, or seizures that manifest themselves as visual or audio hallucinations; but that doesn’t mean that the essence of who we are is defined by our neurocircuits:

    And just because some processes in the brain are automatic does not mean they all are, he said. ''My take,'' Gazzaniga said, ''is that brains are automatic and people are free.''

    Exactly.
     
    posted by sydney on 10/16/2002 07:35:00 AM 0 comments

    Pharma Influence: The Washington Post nicely laid out the Congressional influence of the pharmaceutical industry:

    Over the last decade, PhRMA and its member drug companies have spent more than $1 billion -- far more than any other industry -- to influence the legislative process. In that time, they have hired more than 600 Washington lobbyists. They include several former senators and congressmen, such as Bob Livingston (R-La.), Vin Weber (R-Minn.), Dan Coats (R-Ind.), Dennis DeConcini (D-Ariz.) and Robert S. Walker (R-Pa.).

    In 2001, a nonelection year, the industry spent $76 million on lobbying, according to the Web site PoliticalMoneyLine.com. PhRMA officials, including president Alan F. Holmer, declined to be interviewed for this article. By comparison, the defense industry spent less than $59 million.


    No wonder the head of the drug lobby can say:

    "We will not be out-thought, we will not be outworked," PhRMA president Holmer declared at the organization's annual meeting in March. "Our mantra at PhRMA is this: We will never allow for failure whenever the political circumstances are at all manageable."

    Then there’s this eye-opener about the proportion of healthcare dollars spent on drugs:

    In 2000, for every dollar consumers paid for health care, 7 cents went to hospitals, 17 cents to physicians and other clinical caregivers, and 20 cents to prescription medicines.

    This we can’t blame exclusively on drug company lobbyists and politicians. Physicians and patients share a large chunk of the blame. If doctors were more discriminating in the drug therapy we recommend and if patients were more discriminating in their acceptance of drug advertising claims, the money spent on drugs by third party payers could be much lower. This is what comes from generous prescription benefit plans, and if Congress passes a drug coverage for Medicare it will only get worse.
     
    posted by sydney on 10/16/2002 07:26:00 AM 0 comments

    West Nile Mutants? It appears that in some cases, the West Nile virus can cause a polio-like illness:

    Biopsies of Lewis' patients suggest that the virus had attacked the grey matter in the spinal cord, which contains nerve fibres running to and from the muscles. Why this sometimes affects only one side of the body is unknown.

    This is new, and some speculate that it might be caused by a mutation in the virus, but the virus is also new to us, so it could just represent another piece of understanding of its natural history. Although the West Nile virus has been present in the Third World for a long time, it’s never been subject to as much scrutiny and testing as it has since it gained our shores.

    ADDENDUM: The case reports from The New England Journal of Medicine documenting this, can be found here. (No registration needed as of 10/16/02 12:48AM EST)
     
    posted by sydney on 10/16/2002 07:23:00 AM 0 comments

    Tuesday, October 15, 2002

    Dubious Inventions: Baby cry translator.

    UPDATE: Dr. Weevil has the scoop on the true inventor of this.
     

    posted by sydney on 10/15/2002 07:55:00 AM 0 comments

    MedMal Crisis Continues... Although Mississippi has seen the light and come to an agreement on tort reform, other states are still struggling. Here's how one Ohio town is losing its obstetricians to increased malpractice premiums.
     
    posted by sydney on 10/15/2002 07:39:00 AM 0 comments

    Pink Ribbons On Parade: Orrin Judd sent along this diatribe against the “pink ribbon” breast cancer campaign. After reading the first paragraph, I was with the writer all the way. I’m no fan of any of the beribboned disease movements, but the pink ribbon campaign is especially odious; partly because it’s little more than a marketing gimmick, but mostly because it’s so closely associated with the breast-cancer-as-women’s-rights-issue, as if disease discriminated on the basis of sex. Unfortunately, the author endorses this idea:

    The pink ribbon once represented the effort to transform breast cancer from a source of silent shame into a public health crisis.

    When was breast cancer a “source of silent shame?” When Fanny Burney wrote in great detail about her mastectomy? It never had the same stigma as AIDS or syphillis or even leprosy for crying out loud. And turning it into a “public health crisis” is equally ridiculous. Substantially fewer women die of breast cancer than of lung or colon cancer. (If any cancer could be called a “source of silent shame” it would be colon cancer whose victims often have to carry their feces around in a little bag under their clothing.) Yet no one wears ribbons for those.

    The writer, however, lost my support much earlier than that fatal sentence, when she condemned the pink ribbon movement not for its shallow feminist politics, but for its reliance on corporate donors:

    Consider Breast Cancer Awareness month, which is every October. Its founder, the drug maker AstraZeneca, manufactures the breast cancer drug tamoxifen and other chemotherapies, but until recently it made agrochemicals as well.

    I am not one to underestimate the profit motive of pharmaceutical companies, but they are not run by gods who sit in a boardroam on high manipulating the environment to give us cancer so they can turn around and sell us the drugs to cure it. The author sees the high rate of cancers without known risk factors as evidence that the environmental pollutants are the cause:

    So this month, we are likely to hear a great deal about "prevention" in the form of behavior modification and diet but will not hear that as many as half of all cancers are not associated with known risk factors. The "e word"--environment--if it comes up at all, will be quickly dismissed.

    Breast cancer is not a monolithic disease. It can not be reduced to one single cause or one single type. Something, somehow, goes wrong at the genetic level of a cell. That’s all it takes. One gene. One cell. After that, the cell runs amok and turns itself into an army of cellular Huns invading the body. That something could be that the wrong amino acid got spliced into its DNA at its genesis. Or it could have gone wrong sometime during the life of the cell, either during normal cell maintenance, or under the influence of a virus or some biochemical insult. The incidence of breast cancer increases with age, suggesting that the “something” that goes wrong happens, in most cases, as a consequence of cellular aging. We don’t know enough about breast cancer, or most cancers for that matter, to say exactly what happens, but we know that it's most likely caused by a host of factors, most of them beyond the control of anyone.

    The column ends by calling for better detection techniques and better treatment, but those will only come from the work being done by the very companies she lambasts - made possible, in part, by the profits from those "agrochemicals."
     
    posted by sydney on 10/15/2002 07:09:00 AM 0 comments

    Duct Tape Miracle Cure: There's an old book about doctoring in rural Maine called "Bag Balm and Duct Tape" that took its title from the many medical uses those downeasters made of duct tape. Now it's official, it cures warts:

    In the study, patients wore duct tape over their warts for six days. Then they removed the tape, soaked the area in water and used an emery board or pumice stone to scrape the spot. The tape was reapplied the next morning. The treatment continued for a maximum of two months or until the wart went away.

    To tell you the truth, you can do the same thing with Compound W and Duofilm over the same amount of time and with a Bandaid, although you have to repeat the process nightly instead of weekly. I know, I've used it on my kids with good success (100%), and they didn't have to walk around bound by unsightly duct tape.
     
    posted by sydney on 10/15/2002 07:04:00 AM 0 comments

    Book Review: I posted a review of Pox Americana: The Great Smallpox Epidemic of 1775-82 at Blogcritics.
     
    posted by sydney on 10/15/2002 07:03:00 AM 0 comments

    Herbal Maladies: Iain Murray dissects the financing of alternative medicine research in his TechCentralStation column.
     
    posted by sydney on 10/15/2002 07:02:00 AM 0 comments

    Monday, October 14, 2002

    McSweeney's List: Scientific Journals Available Electronically at the Mt. Sinai School of Medicine
     

    posted by sydney on 10/14/2002 08:29:00 AM 0 comments

    No Thanks, I'll Wait: An Alzheimer's vaccine is believed to be safer than previously thought. The problem is, how do you decide who to immunize against Alzheimer's? The diagnosis of Alzheimer's as it stands now, is really nothing more than what used to be called senile dementia. (Back in the days when "Alzheimer's" was reserved for presenile dementia.) Not everyone with dementia in old age has those tangled fibers the vaccine works against. There's no way to tell if they have them without opening up their brain (i.e. autopsy.) There's no good way to predict who is likely to develop them, either. Then, there's the fact that the fibers the vaccine is directed against also occur in normal brains:

    They said the antibodies recognized AB in tangles, diffuse AB deposits and AB in blood vessels of the brain and were able to cross the blood-brain barrier, which suggests they might have the capacity to directly destroy plaques in the brain.

    The antibodies did not, however, attack the longer form of AB that occurs in the nerve cells of healthy people as well as Alzheimer's patients.

    The function of that type of AB is unknown, but healthy nerve cells can contain a lot of it. This selectivity is good news, because an attack on the longer form of AB could potentially result in complications.


    If healthy nerve cells contain a lot of it, then I'll keep mine, thank you, and not risk it to a vaccine.
     
    posted by sydney on 10/14/2002 08:02:00 AM 0 comments

    A True Epidemic: An idea of what the 1918 flu epidemic was like for one city:

    If the gates of hell had creaked open, it couldn't have been much worse.

    Death roamed the streets of Akron. It was found in a lover's caress, a child's kiss, a stranger's handshake.

    There was no place to escape.

    The Spanish Influenza, a gauze-wrapped nightmare of death and delirium, brought the city to its knees in October 1918. Few families were spared its withering touch.

    If you ever visit an old cemetery, you'll notice 1918 engraved on a lot of headstones. The killer flu claimed about 40 million lives worldwide, including an estimated 675,000 Americans.

    In less than eight weeks, the epidemic sickened more than 5,000 Akron residents. Of that number, 630 died of influenza and 278 died of pneumonia.

    In comparison, Akron lost 304 soldiers in World War I. And many of them were flu victims, too.


    The story goes on to describe how difficult it was to enforce quarantine, and how the sick overwhelmed the hospitals, forcing the city to use an armory as a make-shift hospital. The article's intention is to impress readers with the importance of influenza immunization, but it could also be read as a cautionary tale in our smallpox preparedness plans.
     
    posted by sydney on 10/14/2002 07:36:00 AM 0 comments

    Angell on Healthcare: The Times was just a wealth of medical issues yesterday. They also carried this op/ed by Marcia Angell, former editor of The New England Journal of Medicine on the current state of healthcare in the United States. She gets all the problems right:

    Private health insurance premiums are rising at an unsustainable average of about 13 percent per year — and as much as 25 percent in some areas of the country. Coverage is shrinking, as more employers decide to cap their contributions to health insurance plans and workers find they cannot pay their rapidly expanding share. And with the rise in unemployment, more people are losing what limited coverage they had. Last month, the Census Bureau reported that nearly 1.5 million Americans lost their insurance in 2001.

    ....Private insurers regularly skim off the top 10 percent to 25 percent of premiums for administrative costs, marketing and profits. The remainder is passed along a gantlet of satellite businesses — insurance brokers, disease-management and utilization-review companies, lawyers, consultants, billing agencies, information management firms and so on. Their function is often to limit services in one way or another. They, too, take a cut, including enough for their own administrative costs, marketing and profits. As much as half the health-care dollar never reaches doctors and hospitals — who themselves face high overhead costs in dealing with multiple insurers.

    One more absurdity of our market-based system: the pressure is to increase total health-care expenditures, not reduce them. Presumably, as a nation we want to constrain the growth of health costs. But that's simply not what health-care businesses do. Like all businesses, they want more, not fewer, customers — but only if they can pay.


    Her solution, however - a single payer system - is all wrong. Only a doctor who’s never had to deal with government-run programs could say this:

    Medicare is not perfect, but it's the most popular part of the American health-care system.

    The problem with the “third party pays” system, whether it’s composed of one or a thousand payers, is that it prevents the patient from acknowledging that every healthcare decision comes with a price. Direct-to-consumer advertising for expensive new drugs never would have been so successful if people had to pay for those drugs out of their pockets. The proliferation of drugs to reduce risks by even the smallest of percentages would never have happened, either.

    There are, of course, some medical illnesses and conditions for which people have no choice - emergency surgery, or trauma care, for example, but catastrophic health insurance could cover those sorts of expenses. The current system that provides insurance for every little doctor’s visit is just too expensive. Making it a single, government-run program won’t make it any less expensive, but it could make it cost a lot more. Congress can’t restrain itself now from holding hearings on diseases-of-the-week or cancer screening policies. Imagine how much more intrusive they would be if they were footing the bill for everyone.

    P.S. DB agrees.

    For Example: Consider how single-payer healthcare systems around the world are doing -

    Australia: "Medicare is meant to be a system of health care for everybody and everybody at the moment is unable to get timely medical care."

    England: Pat Adams has chronic arthritis. Earlier this year, the 62-year-old from King's Lynne was told she would need one of her hips replaced.

    Faced with a 15-month wait on the NHS and struggling to cope with excruciating pain, she re-mortgaged her house to pay the 8,000 pound cost of traveling to South Africa to have the operation.

    She is one of an estimated 250,000 people who, disillusioned with the NHS, have dug into their own pockets this year to pay for essential medical treatment in the private sector.

    ... "The NHS was once the best in the world. When I was in South Africa they called it the Third World NHS. I don't think the situation is going to change. It is very sad."


    Canada: "Quite apart from the issue of an aging population, Canada has had difficulty retaining and recruiting human resources in the health sector for at least a decade."

    New Zealand:: But sadly, he feels that everything he has worked for is being destroyed by a Government which has turned the health system into business run by health planners, politicians and accountants. (Read it all. A mere excerpt doesn’t do it justice.)

     
    posted by sydney on 10/14/2002 07:11:00 AM 0 comments

    Saint in the City: The story of one inner-city physician. He sounds almost too good to be true, and he probably is. There are some signs in the story of the strains his chosen path has placed on his personal life:

    ”I wouldn't want to be in his shoes for a single day. It's overwhelming. I'd get so frustrated," Perez later confides. "He hasn't had a real vacation in years."

    ...They're joined by Robson's wife, Senait Shiferaw, an Ethiopian-born nurse who, by necessity, not choice, spends her evenings cooking at their restaurant.

    This is Robson's second family, following his separation in 1989 and subsequent divorce; and in a sense, an indirect outcome of a passion he developed for Ethiopia after joining his mother on a visit there in 1982.


    I wonder how much longer the second wife will put up with it.
     
    posted by sydney on 10/14/2002 07:10:00 AM 0 comments

    Preparedness Update: The New York Times had a balanced treatment of the smallpox vaccine debate yesterday that's well-worth the read. In a related editorial the Times came out squarely in favor of voluntary pre-attack vaccination:

    As long as informed individuals can decide for themselves whether to take the risk, and as long as precautions are in place to minimize secondary transmission, mass vaccination seems a prudent way to protect against a smallpox attack, and possibly even deter it.
     
    posted by sydney on 10/14/2002 07:09:00 AM 0 comments

    Sunday, October 13, 2002

    Hazards of the Euro: What happens when the Euro coin touches sweat.
     

    posted by sydney on 10/13/2002 08:31:00 AM 0 comments

    Patients as Teachers: It’s certainly true that doctors continually learn from their patients, but there are a specific brand of patients who formally assume teaching roles - serving as living models for musculoskeletal exams, genital and rectal exams, or basic history and physical taking skills. My medical school relied heavily on these sorts of professional patients, and I think it was much to our advantage. The history and physical patients were from the VA hospital. (One of them told me they were paid in cigarette vouchers, but that was about fifteen years ago. I’m sure they’ve changed their policy by now.) It takes a very special person to be a model for genital and rectal exams, though. Ours inevitably came from the small liberal arts college town not far from our school. They had special training, and they were quite good. I’ve often had patients thank me for not hurting them during their pelvic exams - an ocurrence that always leaves me a little surprised. There must be a lot of people out there who examine the pelvis with a significant degree of discomfort. I give full credit to the patient teachers my medical school used.
     
    posted by sydney on 10/13/2002 08:27:00 AM 0 comments

    Educational Site of the Week: The on-line Dermatology Image Atlas. Best feature: they have a "homunculus" you can click on to find rashes that are most likely to appear on that particular body part.(via BMJ's Netlines.)
     
    posted by sydney on 10/13/2002 08:24:00 AM 0 comments

    Flu Season: Here's some good advice on beating influenza. In a related vein, our office got the first installment of our influenza vaccine shipment two weeks ago, and we started immunizing our patients at highest risk (the elderly, those with severe lung disease). Word has gotten out, though, and this past week we had several irate calls from younger, healthier people wondering why their neighbor or co-worker got the shot and they didn't. After spending several minutes on the phone calming down one woman, the receptionist in our office turned to me and said, "Can you imagine what it would be like if there were an outbreak of smallpox?" I've never mentioned the smallpox vaccine or bioterrorism to my staff before, but she's right. It would be chaos, and that's one more reason we should be offering the vaccine before an attack rather than after, or at least publicly debating the issue.
     
    posted by sydney on 10/13/2002 07:48:00 AM 0 comments

    The Strike Goes On: Doctors in Newfoundland are in the third week of their strike, with no relief in sight.
     
    posted by sydney on 10/13/2002 07:27:00 AM 0 comments

    Forgive Us Our Trespasses: Receiving an apology for injuries received not only makes it easier to forgive and forget, it does a body good, too:

    For their study, 61 college undergraduates--32 men and 29 women--were told to imagine that they had been robbed, and that the robber had afterwards either apologized, restored to them the things he or she had stolen, apologized and made restitution, or did neither.

    Overall, the students had lower heart rates when they imagined that the robber had given them a strong, guilt-ridden apology and made restitution to compensate for the stolen items and trouble he or she had caused, study findings indicate. Further, the students also showed less muscle tension in their face--such as less wrinkling of the brow--and had less stress and lower blood pressures.

    In other findings, when the students imagined that they had received a strong apology and had been compensated, they experienced a reduction in their level of unforgiveness that was twice as great as when they imagined themselves to have just received a strong apology, according to Worthington.

    The students also said they felt more forgiveness, gratitude and empathy and less anger, fear and sadness, study findings indicate. Finally, the undergraduates also said they felt more in control.


    I'd say that's true. I've mentioned this before, but I notice that it takes a lot longer for my patients to feel better after an injury if someone else caused it than if it's a result of their own action or negligence. This is especially true in auto accidents. The rear-ended inevitably hurt longer than the rear-ender.
     
    posted by sydney on 10/13/2002 07:19:00 AM 0 comments

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