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    Saturday, December 07, 2002

    Love's Dear Sake: Maternal mortality in Afghanistan is, not surprisingly, abysmal:

    According to a recent United Nations study, 1,600 women die in Afghanistan in every 100,000 live births. In comparison, only 12 deaths per 100,000 are recorded in the United States.

    But in the remote Afghan province of Badakshan, high in the northeast mountains of Afghanistan, the situation is even worse. The study found that more women of child-bearing age -- 64 percent -- die in pregnancy and childbirth there than has been recorded anywhere else in the world.


    For those who think that because pregnancy and childbirth are natural no medical help is required, look to Afghanistan and see what happens when nature is allowed to take its course. This is what it was like everywhere before modern obstetrics. Pregnancy was a cause for joy and a cause for trepidation. Just ask Anne Bradstreet.

    (Thanks to Cronaca for the link.)
     

    posted by sydney on 12/07/2002 05:04:00 PM 0 comments

    Preparedness Update: Looks like my state's doing something afterall.
     
    posted by sydney on 12/07/2002 12:47:00 PM 0 comments

    With Charity for All: DB had a link yesterday to an article about the decline of charity care given by American doctors. The blame is put on financial pressure:

    Physicians are under a lot of growing financial pressures," said Peter Cunningham, who wrote the report for the Center for Studying Health System Change, a health policy think tank that conducts the ongoing survey of doctors. "This may be making it more difficult to serve uninsured patients."

    Its survey found that in 2001, 71.5 percent of doctors provided free care. That's down from 76.3 percent in 1997.

    The results are similar to those found by the American Medical Association, which also saw a drop in charity care between 1994 and 1999 in a survey it conducted of doctors.

    The result is less care for people who can't afford it.


    But, there’s another reason doctors don’t offer charity care. A lot of them assume they’ll be charged with fraud by the Medicare enforcers if they do:

    Secondly, Medicare may review your practice and decide that your billing of "insurance only" violates the "most favored nation" regulation they have whereby the Medicare fees must be the lowest you charge any patients. If you routinely accept "insurance only", you are telling the government that there is a fee schedule below what they are offered. In this case, Medicare may ban you from participation in Medicare and Medicaid, and can possibly investigate you under the False Claims Act.

    Some private insurance contracts have those “most favored nation” clauses, too. Doctors, or at least the people who advise them on Medicare laws, have taken the "charging insurance only" restriction and applied it to all discounts. No one wants to be accused of fraud. (There are hefty financial penalties for fraud, and sometimes jail time, too.) There’s some disagreement about this assumption, but the perception is widespread, nonetheless. My practice is owned by a hospital, and they’re very paranoid about this. Everyone has to be charged the same, no exceptions. They simply can’t risk being accused of fraud. They can’t risk the bad publicity nor the high legal costs of defending themselves against the accusation. It’s a lose-lose situation for them.

    SECOND THOUGHT: Could it be that my employers are just practicing Dilbert management?
     
    posted by sydney on 12/07/2002 07:51:00 AM 0 comments

    Mad Doctor: The woman who is the supposed master-mind of Iraq's bioweapon program, Dr. Rihab Taha, is not only an evilly productive scientist (Iraq admits to having made 30 tons of bioweapons), but she's a gifted hysteric as well:

    “I first met her in New York in late 1992 or early 1993,” says Rolf Ekeus, who headed the U.N. inspection effort until 1997. Several Iraqi officials had been invited to explain their research efforts, and Taha was among them. “She was very, very smart,” Ekeus recalls. “She made a big show on a blackboard of how much she could have produced with what she had, and it was only a few grams.”

            So persuasive was Taha, in fact, and so thin was the available evidence, that Ekeus says he was “quite skeptical about the existence of a biological program.” Then the U.N. scientists crunched Taha’s numbers, and confronted her with their findings at the next meeting in Baghdad. “She made a big scene, crying and slamming down her fists and running out the door and slamming it,” the courtly Swedish diplomat recalls. “The other Iraqis looked at us like we were not gentlemen.”


    Then, when the inspectors returned with evidence that she was lying:

    “It was a strange feeling when she was admitting she did all the production,” recalled Kraatz-Wadsack. “She was smiling, a nice person. You had the sense she was proud that she had done what no one imagined she could do. She was just as pleasant telling us how she did all this, where things were stored, as she was when she was lying to us about the single-cell proteins.”

     
    posted by sydney on 12/07/2002 07:24:00 AM 0 comments

    Friday, December 06, 2002

    An Army of One: One man's campaign against drug prices. (Although for some reason that's not mentioned as a possible motive.)
     

    posted by sydney on 12/06/2002 08:28:00 AM 0 comments

    Metabolic Syndrome: Does it predict heart failure? Maybe, who knows? There isn’t even a consistent definition of the syndrome. The study had to use two classification systems, and the results varied based on which system they used. When it came to over-all survival, those with the widest bellies fared the worst. Men with a waist circumference of 102 cm or higher and the metabolic syndrome had a survival rate of 79% over 13 and a half years compared to 90% for men without the metabolic syndrome. That’s over all survival. When it comes to what the rest of the men died of, well, then we get obfuscation:

    The study of 1,209 men aged 42 to 60, over a 15-year period, found that those with metabolic syndrome were from 2.9 to 4.2 times more likely to die of a heart attack than those who did not have the condition.

    "To our knowledge, this is the first prospective population-based cohort study reporting the association of the metabolic syndrome using recently proposed definitions with cardiovascular and overall mortality," study author Dr. Hanna-Maaria Lakka of Louisiana State University wrote in the journal.


    Neither the article nor the paper say how many men with metabolic syndrome died of heart disease or how many men without the syndrome died of heart disease. Both only express the differences in relative risks. The paper, however, does say that overall, 27 men died of heart disease and 46 died of stroke. That’s for all the men in the study, regardless of their abdominal girth, regardless of whether or not they had the metabolic syndrome. If you think about it, that’s a remarkably low mortality rate out of 1,209 men over nearly fifteen years. So, the study is comparing very small numbers to begin with and inflating them by using relative risks. It’s hardly the ground-breaking work the authors and the media are making it out to be.
     
    posted by sydney on 12/06/2002 08:17:00 AM 0 comments

    Mammograms for Heart Disease? A Mayo Clinic radiologist is claiming that artery calcifications on mammograms can indicate an increased risk of heart disease:

    Doerger reviewed the records of more than 1,800 women who had undergone mammography for breast cancer screening and also had undergone angiography to assess condition of coronary arties within the same 12-month period. Then he devised a simple scoring method for the number of calcified breast arteries that could be seen on the mammogram.

    There are three main breast arteries, and if all three were visible in both breasts, the patient was given a rating of 3.

    Doerger found if a woman had a score of 1.5 or higher, she had a 20 percent increased risk of heart disease. Higher scores did not increase the risk further.


    Proceed with caution. The findings haven't been published. They haven't even been presented to a scientific meeting yet. The raw data aren't available. We don't even know what other sorts of variables were involved - did the women with calcifications also have diabetes or high blood pressure, which would put them at high risk anyway for heart disease? Who knows? The guy has gone to the press before he has gone to his colleagues - always a bad sign. It makes it all the harder to refute weak findings.
     
    posted by sydney on 12/06/2002 07:41:00 AM 0 comments

    Supplement Watch: Some of those “natural supplements” available over-the-counter turn out to be anabolic steroids:

    Congress banned all known steroids in 1990 after hearing testimony about their health effects and rampant abuse in sport. However, the two new steroids -- called 1-testosterone and 4-hydroxy-testosterone -- escaped mention in the legislation because they were virtually unknown. Because their manufacturers can claim they are natural substances, the steroids have been marketed as dietary supplements that increase strength and build muscle.

    Dozens of products containing these full-blown steroids, which have been dubbed "pro-steroids" by their manufacturers, have proliferated on nutrition store shelves and the Internet in recent months. They are sold in a variety of forms but not as injectable steroids (considered the most potent means of administering steroids).


    A drug’s a drug, no matter how “natural”, and these things have the same side effects that any prescription testosterone product would have - increased risk of prostate cancer, liver tumors, aggression (aka “mood swings”), tendon ruptures, decreased libido, stunted growth, and shrunken testicles. Is the buff look really worth it?
     
    posted by sydney on 12/06/2002 07:27:00 AM 0 comments

    Outbreak: The diarrhea and vomiting epidemic on cruise ships caused by the Norwalk virus, continues. This is the thing about that virus - it’s usually transmitted by contaminated food, or by contact with stool-contaminated surfaces. I can understand why illnesses like that spread through daycare centers or elementary schools. Little kids aren’t always so good about washing their hands, or so careful about where they put them. But, what’s with adults who don’t wash their hands after going to the bathroom?

    The article also mentions in passing how the virus has been studied. There should be a special award for these scientific martyr/volunteers:

    It takes only a small dose of the virus, 100 particles or even fewer, to make a person sick, according to studies of people who volunteered to become infected by drinking a stool filtrate.

    One final thought about the cruise ship outbreaks that keeps nagging me, but borders on the paranoid. What if this was some sort of test-run for bioterrorists? The ships left from Seattle and southern Florida, where there are suspected terrorist cells. And it’s strange that they haven’t been able to trace the outbreaks to contaminated food or water, the usual mode of transmission. I hope the CDC’s looking into that angle.
     
    posted by sydney on 12/06/2002 06:30:00 AM 0 comments

    Back to Our Regularly Scheduled Program: Making Vaccines.
     
    posted by sydney on 12/06/2002 06:29:00 AM 0 comments

    Wonderful Woman: Check out Wonder Woman of Arabia.
     
    posted by sydney on 12/06/2002 06:28:00 AM 0 comments

    Wonderful World: The blogosphere is a great place. You can find blogs on anything - medicine, biology, physics, politics. Add to that the archeology blogs: Cronaca, and Calling Doctor Jones.... Not to mention the “original war blogger", Bloggus Caesari. (via Out of Lascaux)

    And since I'm on the topic of archeology, I'll share this exhibit of Greek artifacts from southern Italy that we went to last weekend. Unfortunately, the website doesn't include the most striking exhibits - statues of Aphrodite and Eros that called to mind later images of Madonna and Child and a statue of Eos carrying away the body of her dead son that bore a striking resemblance to the Pieta. (Clarification: The above links aren't to the same works that were in the exhibit. The exhibit statues were much more primitive and had more similarities to early Christian statues than to Renaissance art. I just couldn't find examples of the more primitive work.)
     
    posted by sydney on 12/06/2002 06:25:00 AM 0 comments

    Thursday, December 05, 2002

    Riding Thimerosal: The Wall Street Journal's on-line Opinion Journal has a good editorial about thimerosal in vaccines. They have their facts right. The litigation of thimerosal truly is one of those abuses of the legal system that makes tort reform necessary. (Here's the article from the Lancet on mercury levels in vaccinated children the editorial mentions. Requires free registration.)

    UPDATE: Derek Lowe has a great series of posts on thimerosal, too, from the medicinal chemist perspective. And I'll just add a personal perspective on the thimerosal/autism controversy: I've been in practice now going on twelve years. In that time I've immunized countless children and none of them have developed autism. I know that's not sound science, just observation, but I think if thimerosal had something to do with autism, I'd have at least some autistic patients.
     

    posted by sydney on 12/05/2002 08:32:00 AM 0 comments

    Genomic Art: Gene(sis), a contemporary art exhibit inspired by human genomics. (via The Eyes Have It)
     
    posted by sydney on 12/05/2002 08:09:00 AM 0 comments

    Genomic Medicine: The second in the series from the New England Journal - Genetic testing.
     
    posted by sydney on 12/05/2002 07:56:00 AM 0 comments

    Be Still My Heart: Research published today in the New England Journal of Medicine could change the way cardiologists treat atrial fibrillation.

    Atrial fibrillation is a very common rhythm disturbance of the heart. Normally, the heart contracts synchronously - the top chambers contract, forcing blood into the bottom chambers, then the bottom chambers contract, forcing it out to the body. In atrial fib, that synchronicity is lost. The top chambers get mixed electrical signals that confuse their muscle fibers and make them contract rapidly, again and again, without regard for what’s happening in the lower chambers. (The “atrial fibrillation” link in the first sentence has a great animated illustration of this.) The problem is, that kind of confused and uncoordinated muscle contraction isn’t very effecient for pumping blood. People with atrial fib often feel their heart racing, they can get light-headed and dizzy, and the blood can pool in areas of the upper chambers of the heart and form clots that could find their way to the brain eventually, resulting in strokes.

    Current therapy often focuses on using drugs or electric shocks to try to fix the confused signal. Unfortunately, it’s rarely a permanent fix. After being shocked, the heart often reverts back to its confused rhythm, and the drugs we use have all sorts of potential side effects. The good news about today’s studies is that the more pharmacologically benign approach of just slowing the heart rate down is just as good for patients as trying to change the rhythm. The first study found that death rates from atrial fib were just about the same, but a little better for the people who just had their heart rates slowed down (21% vs. 24% mortality). The second, smaller study, looked at the incidence of death as well as strokes, medication side effects, and heart failure between the two approaches. Seventeen percent of the rate-control group had one of those events, compared to 23% in the conversion group. That’s not a huge difference, but it’s enough to demonstrate that the less noxious drugs are the better choice for atrial fib.

    That’s actually good news for patients. The most commonly used rhythm-converting drug in our area is amiodarone, which requires careful monitoring of liver enzymes, thyroid function, and blood counts. I hate it; especially since the cardiologists around here put the patients on it then expect the primary care physicians to monitor and handle the side effects. They’re then reluctant to take someone off of it when the side effects pop up, because they aren’t the ones dealing with them. (So he’s a little hypothyroid? Put him on some thyroid medication. Can’t have him going back into atrial fib, you know. So he’s having a little vision trouble. His heart’s more important than his eyes.) Now, hopefully they’ll change their approach.
     
    posted by sydney on 12/05/2002 06:45:00 AM 0 comments

    Believe it or Not: Investigators find repeated deception in ads for drugs. The article blames the Bush Administration for requiring the FDA's legal team to review their warning letters before sending them out. They say that by the time the companies get the letters, the ads have run through their life-cycle. But that doesn't explain this:

    Since 1997, the report said, the F.D.A. "has issued repeated regulatory letters to several pharmaceutical companies, including 14 to GlaxoSmithKline, 6 to Schering Corporation and 5 to Merck & Company." Some companies, it said, "have received multiple regulatory letters over time for new advertisements promoting the same drug."

    There must not be any teeth to those truth in advertising laws about drugs, or the companies wouldn't ignore the letters like that. The ads are certainly working:

    The study estimates that at least 8.5 million Americans each year request and receive prescriptions for specific drugs after seeing or hearing advertisements for those products.

    You might ask, "Well, why do those doctors prescribe the drugs in the first place?" Because it's very hard to dissuade a patient whose mind is made up about the superiority of a drug. Most of the time there's no good reason to deny them their first choice other than cost. People who don't pay for their own drugs don't care about that. In fact, if a doctor tries to sell them on a less expensive alternative, they're immediately suspicious that he cares about the insurance company more than he cares about them. It's a no-win situation for the insurance companies, and a win-win situation for the drug companies.
     
    posted by sydney on 12/05/2002 06:03:00 AM 0 comments

    Preparedness Update: One reader says that New Jersey is prepared:

    My dad is a physician in NJ and says that NJ is in fact prepared with pretty elaborate contingency plans and that he has been contact by state authorities and informed as to what his role will be. If a case is confirmed in NJ, an immediate state of emergency goes into effect, all schools, etc., are closed, and all "first responders" and medical personnel immediately vaccinated. Then all school children get vaccinated (he hadn't been informed about exceptions, etc.), then everyone else. Supposedly all medical personnel would be mobilized to vaccinate about 8 million people within 30 days. Apparently the key is that the state would go into an immediate "lockdown" mode for some number of days or hours (undisclosed) to try to keep the cases from spreading.

    That's good. And from the state's department of health website, it looks to be true. Some states have been busy implementing bioterror plans and communicating with the physicians in the community, others haven't. For example, here's my state's bioterrorism webpage for healthcare professionals. It was last updated November 2001.

    UPDATE: The union for healthcare workers says they won't oppose smallpox vaccination of same workers.
     
    posted by sydney on 12/05/2002 05:27:00 AM 0 comments

    Wednesday, December 04, 2002

    JAMA's weekly art history lesson.

    BONUS ART LINK: Along the same lines, Out of Lascaux is a blog devoted to history and art. Scroll down to Saturday, Nov. 30th, for an excellent analysis and graphics of Caravaggio's The Beheading of St. John the Baptist.
     

    posted by sydney on 12/04/2002 07:37:00 AM 0 comments

    A Midwife's Tale: NRO has the story of a “beautiful and beloved” Ohio midwife who is in jail for using medication she wasn't licensed to use. I don’t know if she’s beautiful, she may be beloved, but she certainly did practice medicine without a license when she administered Pitocin and Methergine to her patient at home. Both medications are used to stop bleeding after delivery, and the midwife used them when "traditional herbs" didn't help. The NRO article only mentions the Pitocin, and paints her as a martyr to the cause of midwifery at the hands of an arrogant, power-intoxicated judge:

    Freida Miller met not only an overzealous prosecutor, but an equally overzealous judge. Prosecuting Attorney Stephen Knowling and Holmes County Common Pleas Judge Thomas D. White have nailed her with felony charges of Unauthorized Practice of Medicine and Possession of Dangerous Drugs. When Miss Miller refused to name the source from whom she got the Petocin, Judge White sent her to jail, and he shows no sign that he is going to let her out — unless she'll squeal.

    .....It is very difficult not to be angry at a judge and prosecutor who are going after this sweet, holy, and harmless midwife as if she were guilty of peddling cocaine at the local playground. What drives the seemingly unbalanced fervor with which they have gone after this beautiful and beloved Mennonite midwife?


    Here, in his own words, is what’s driving the judge:

    "The reason you're being punished is not because of your profession, it's because you failed to obey an order of this court," White told Miller. "Bringing new life into this world is a wonderful profession ... a wonderful ministry."

    White noted three of the four types of drugs recovered from Miller's home were expired. In one case, he said, "the drugs you were possessing to save lives were almost two years beyond their expiration date. This makes (Miller's possession of the drugs) not only illegal, but bad medicine. What you did was not only a crime, but is a practice that may pose a serious health risk."

    White said, "You have the keys to your own jail cell," explaining she may be released at any time after identifying the source of the drugs.

    He asked her to consider to whom she owes her loyalty -- to the doctor, nurse, or physician who illegally provided her the drugs, or her patients who will be without her services while she's incarcerated.


    Doesn’t come across as such a monster now, does he? Turns out Midwife Miller wasn't in possession of just Pitocin, but three other drugs as well, drugs which she knows very little about. In fact, if Ms. Miller were a certified nurse midwife, trained to understand and use drugs properly, instead of an untrained lay midwife, she wouldn't be in trouble at all. By her own admission, she doesn't even know what dose should be used, relying instead on "single-dose vials." Although Ms. Miller’s intentions are good, her own description of her practice isn’t very reassuring:

    During her career she has had infants die, but the percentage is "no higher than in a hospital," she said, unwilling to give an exact count. Never has she lost a mother, she said.

    If she feels a patient or a delivery is high-risk, she said, she tries to properly advise parents.

    "I put a lot of stock into the parents' faith, and if they feel this is what God wants them to do, I try to help them," she said.

    In high-risk situations -- including breech presentation, high blood pressure, heart problems, pre-eclampsia, diabetes, twins and premature labor -- she said she advises parents to seek outside help from a physician. And, while she doesn't have her own backup physician, many doctors "back up the moms."


    Home births are risky. Very risky. Even in the best of situations, with a healthy mother and uneventful pregnancy, things can go bad in the blink of an eye. Add complications such as those above, and you’re just asking for trouble. A responsible midwife would recognize when the potential complications are beyond her skills, and insist that patients get the medical care they need for a safe delivery. She wouldn't facilitate the patient's bad choice by going ahead with a home delivery. A doctor who operated outside the scope of his practice would be just as guilty. In fact, it turns out that the mother in question was a high-risk patient and that Miller tried to stop the bleeding first by questionable means:

    ...Miller said she administered the antihemorrhagic drugs to the mother in question after more traditional herbal techniques were seemingly not working.

    ...Prior to delivery, Miller said, the woman knew she had a history of postpartum bleeding and the delivery might be one of high risk.


    But then, Miller isn’t being punished because she overstepped the bounds of her abilities. She isn't even being punished for practicing medicine without a license. She’s being punished for failure to obey a court order. This isn’t as noble as it’s made to sound in the NRO piece. For one thing, Pitocin and Methergine aren’t the benign drugs that the article makes them out to be. They carry very real risks of hypertensive crises, seizures, strokes, and uterine rupture. Although they can be life-saving, they are also very risky, and should be used in a setting that allows for careful monitoring of the mother. Then, there's the very real danger that those drugs she administers could interact with the herbal medicines she uses. Someone put these drugs into the hands of a woman who wasn’t qualified to use them , and in doing so, put those women who trust Miller with their lives at risk. She was lucky this time, her patient had no adverse effects from the drugs, but she may not be as lucky next time. It would be better for her and her patients if she were more selective in who she delivered at home.
     
    posted by sydney on 12/04/2002 07:08:00 AM 0 comments

    Bioterror Preparedness: Britain prepares for a possible smallpox attack. Meanwhile, there's evidence that a Russian scientist may have given a virulent strain of the virus to Iraq.

    UPDATE: And our own Department of Health and Human Services has opened their new Star Trek command center:

    Thompson said he hopes the center will help combat perceptions that HHS has not done enough to prepare for bioterrorism. ``I would just like to point out that the Department of Health and Human Services, as far as bioterrorism (is concerned), is very well prepared,'' he said.

    Glad they're prepared. Now the question is, are the states?

    UPDATE II: The Bloviator has more details on the CDC smallpox preparedness broadcast slated to begin tomorrow afternoon. Most of us will be unable to drop everything on such short notice to participate, but it will be available on CD-ROM and videotape for later consumption.
     
    posted by sydney on 12/04/2002 07:07:00 AM 0 comments

    Prostate Cancer Screening: Screening for prostate cancer still isn’t heartily recommended:

    The USPSTF found good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence that early detection improves health outcomes. Screening isassociated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cancers that may never have affected a patient?s health. The USPSTF concludes that evidence is insufficient to determine whether the benefits outweigh the harms for a screened population.

    A summary of the research on which the recommendation is based can be found here. All in all, it’s a sensible recommendation. Prostate cancer is, in most cases, a very slow growing cancer. So slow, that the majority of people who have it die of something else. The screening tests we have are imperfect. Digital rectal exam can miss a cancer, and the prostate specific antigen, or PSA, can’t distinguish aggressive cancer from the slow-growing version. For some men, fear of cancer is enough to justify the risks of this imperfect screen, for others it isn’t. It only makes sense to leave the decision up to them after weighing the pros and cons. Now, why can’t the USPSTF take the same approach to mammography and breast cancer? Oh, that’s right, men’s health hasn’t been politicized to the degree that women’s health has.
     
    posted by sydney on 12/04/2002 07:06:00 AM 0 comments

    Errors = Murder? Yesterday the Washington Post had a long article on the horrid state our health care system is in. They refer repeatedly throughout the piece to doctors and hospitals “killing” patients. Again, they repeat the lie that has been so oft repeated that it now has a life of its own:

    Instead, the report's conclusion that as many as 98,000 hospitalized Americans die every year and 1 million more are injured as a result of preventable medical errors that cost the nation an estimated $29 billion commanded attention in a way Leape and his co-authors never imagined.

    Click here, here, here, and here to learn all that is wrong with that statement, and why it grabbed the attention it did.

    Of course, reducing errors is an admirable goal, and it’s something we should do at all times. But, it’s impossible to reduce errors to zero. Even if everything were done by machine there would still be the potential for mistakes to occur. And, you have to consider at what price the measures the article calls for will come:

    The vast majority of hospitals still rely on paper charts that often can't be located and are difficult to decipher, rather than more accessible and legible computerized medical records. Fewer than 3 percent have fully implemented computerized drug ordering systems, which have consistently shown dramatic reductions in drug errors.

    Systems like that cost money, and hospitals are seeing shrinking reimbursements from Medicare and private insurers alike. If forced to convert to those sorts of systems, where do you suppose they’ll come up with the money? It won’t be from bake sales. They’ll cut staffing - that means fewer nurses, fewer housekeepers, and fewer residents. Which means more errors and more germs.

    One revelation that was tucked away in the WaPo article was that one of the authors of the IOM report is the CEO of a business (non-profit, but that doesn’t mean he doesn’t make money from the business) that specializes in helping doctors and hospitals reduce error rates:

    "I'd say patients are safer today in some hospitals, and certainly in the VA, but it's still a pretty small minority," said physician Don Berwick, a member of the IOM panel who is president of the Boston-based Institute for Healthcare Improvement, a nonprofit group dedicated to bettering the quality of health care. "Safety is a very hard thing to accomplish and it has to be pushed way up to the top of the list, and that still hasn't happened" in most places.

    The Institute for Healthcare Improvement is devoted to improving safety in hospitals. That’s their business. They hold conferences, sell books and videotapes, and all sorts of other safety-related services. Nothing wrong with that, everyone's got to make a buck, and improving patient safety is an admirable business to be in. But, there is something wrong when the man who heads that business helps author a misleading report for a federally funded institution that is supposed to be unbiased. I’m sure the publicity they’ve garnered from the IOM’s inflated numbers has been a boon to business, which explains why Mr. Berwick is prone to indulge in flights of hyperbole:

    Reformer Don Berwick said he remains hopeful that the awareness raised by the IOM report will translate into programs that demonstrably reducte errors. "I don't know why the public isn't more pissed off about this. Imagine what the reaction would be if we had a similar mortality in aviation."

    The problem is that: 1) we don’t have the kind of mortality from errors he claims we have, 2) people aren’t machines. We can’t predict how they’ll react to drugs and what complications they’ll have from procedures, and 3) pouring money into computer systems at the expense of staff doesn’t necessarily translate into better care. By all means reduce errors, but do it sensibly and not at the further cost of patient safety. And don’t accuse physicians and hospitals of murdering their patients.
     
    posted by sydney on 12/04/2002 06:45:00 AM 0 comments

    Tuesday, December 03, 2002

    Blogging Lite: Had a more complicated than usual patient in the hospital this morning, so I can't blog to my usual degree. There's a lot of good stuff out there in the press today, but it all requires more thought and time than I have this morning. I'm sure the medical blogs to the left will have some things to say about them.
     

    posted by sydney on 12/03/2002 08:29:00 AM 0 comments

    Points of View: Two reports on the recent prostate screening recommendations -More harm than good from prostate screening? and Government panel drops objection to prostate tests. I’ll have more to say later about this, when I have a chance to read the full reports. (i.e. tomorrow)
     
    posted by sydney on 12/03/2002 08:26:00 AM 0 comments

    Ultimate Diet: Here's a diet that lowers cholesterol and weight. Unfortunately, only four out of thirteen people who tried it had any desire to continue it beyond the trial period:

    The researchers studied 13 subjects, male and female, who ranged in age from 43 to 84.

    As with all this team's studies, subjects were provided with pre-measured quantities of foods and were told what to eat and when.

    A typical breakfast might include soy milk, oat bran cereal topped with chopped fruit and almonds and oatmeal bread with vegetable margarine and jam. Lunch might be soy cold cuts, oat bran bread, bean soup and fruit. Dinner might be stir-fried vegetables with tofu, fruit and almonds.

    Some of the participants took to the diet "like ducks into water," Jenkins said. Others found it bland and restrictive.

    All found the diet excessively filling and had a hard time maintaining their starting body weight.
     
    posted by sydney on 12/03/2002 08:25:00 AM 0 comments

    Mountain Bike Warning: Protect that seat or risk your fertility:

    On average, the study found, the bikers produced only a third the amount of sperm as those who were not bike riders. The researchers suggest that trauma to the testicles causes vascular damage affecting the sperm.

    In an interview, Dr. Frauscher, a mountain biker himself, said that much of the damage could be prevented if the bikers outfitted their bikes with wider, padded seats and shock absorbers.
     
    posted by sydney on 12/03/2002 08:20:00 AM 0 comments

    Elusive Colic: Researchers set out to find if there was any relationship to colic and breast vs. formula feeding. There wasn't. The only connection they did find was this:

    Alcohol use did appear related, but it may have been a result of colic, not a cause.
     
    posted by sydney on 12/03/2002 07:52:00 AM 0 comments

    Monday, December 02, 2002

    Alternative Medicine Watch: CNN is reporting on a California man who died after being injected by steroids and vitamins by a traditional healer. The story makes it sound as if immigrants have no other recourse than to turn to alternative medicine because they have no insurance, but that's hard to believe when you consider this:

    Chavarria charged Caceres $310 on his first visit and advised him to dig a hole "where nobody could see him" and bury himself for two hours a day, police said.

    I'm willing to bet that none of the doctors he saw charged him $310. In this man's case, it seems he went to the faith healer because no one was able to cure his rash. Some things in this world just aren't curable, by any means.
     

    posted by sydney on 12/02/2002 07:42:00 AM 0 comments

    Vertigo: Most people find rollercoasters vertigo inducing. Here's a guy who found the opposite. The author had benign paroxysmal positional vertigo, which makes you dizzy whenever you turn your head. He tried the usual treatments without success. Then, he went to the amusement park:

    Symptoms increased during the next week until I attended an amusement park. Since children had to be accompanied on the rollercoaster by their parents, I had to ride two rounds. Although maximum acceleration and speed was moderate (2·5 g and 48 km/h), the symptoms were relieved immediately and never came back. Annual visits to a rollercoaster at the Munich Oktoberfest have prevented further symptoms for the past 2 years.

    Benign positional vertigo is believed to be caused by debris within the labyrinthine passages of the inner ear. Theory has it that the debris gets jostled into a sensitive area with head movements and causes the dizzy sensation. One treatment is a series of head maneuvers designed to dislodge the debris. The man in this case tried that, but it wasn't as effective as the roller coaster.
     
    posted by sydney on 12/02/2002 07:31:00 AM 0 comments

    Misplaced Hopes: The letters to the editors to the New York Times in response to an article about obesity surgery were interesting in that they expressed an almost universal belief that somehow it’s the state’s responsibility to keep people from overeating:

    Obesity is a disease that demands the combined efforts of professionals and policy makers from a wide variety of disciplines. Decisions about children's lives, welfare, safety, schooling and opportunities for activities and sports, as well as the types of foods available to them, can be made and acted on only with a communitywide effort - an Albany pediatrician

    What's needed is not a search for "a new miracle pill," but a comprehensive education and behavior-modification effort. That is a job not for medical scientists, but for therapists, teachers, celebrities, journalists, family doctors, parents and government. - a Brooklyn Swede

    A legislative remedy is sorely needed. - a New York obesity surgeon who wants mandated insurance coverage for the procedure

    Though surgery is drastic, the less drastic solution to obesity isn't a "miracle pill." It should be educating the public, especially parents-to-be, about the proper daily consumption of the basic food groups and the importance of particular vitamins in one's diet. Such a program should also offer resources to the poor and homeless to purchase foods of good nutritional value. - a New Jersey reader

    Then, finally, a letter that puts the blame squarely where it belongs:

    Why not add failure to stop smoking, failure to prevent exposure to the sun, failure to wear seat belts, failure to wear helmets and so on to severe obesity as examples of what constitute a "sad commentary on the failure of medical science"? Maybe the failure lies elsewhere. - a doctor from White Plains.

    Have we really gotten to the place where four out of five people think the nanny state is the proper role of government? Or is it just that four out of five New York Times readers think that way?
     
    posted by sydney on 12/02/2002 07:27:00 AM 0 comments

    Watch Out for Those Leftovers: The US Armed Forces in Afghanistan had a little trouble with their turkey stuffing.
     
    posted by sydney on 12/02/2002 07:27:00 AM 0 comments

    Celebrity Medical Watch: How they influence funding.

    UPDATE: Here's an apt observation re:celebrity health causes from a reader:

    OK, so where are they on the stuff that's really important to me?

    I'm waiting for some down on their career actor/actress to take up the cause of hemorrhoids.
     
    posted by sydney on 12/02/2002 07:26:00 AM 0 comments

    Sunday, December 01, 2002

    Blog Round-Up: Another blog by a physician - Under a Blackened Sky. (via
     

    posted by sydney on 12/01/2002 07:22:00 PM 0 comments

    Welcome Back: RangelMD is back and blogging.
     
    posted by sydney on 12/01/2002 07:07:00 PM 0 comments

    Blogosphere Tour: Here's an Australian blog that I hadn't been aware of before. (The blogosphere is a big place.) It's by John Ray, and it's quite good. I don't say that just because he linked to me, either. He has some great posts on the International Red Cross, and on the political leanings of Napoleon, Hitler, and Mussolini.
     
    posted by sydney on 12/01/2002 07:35:00 AM 0 comments

    Broken Heart: The lawsuit filed by the widow of James Quinn, the artificial heart recipient, isn’t against the surgeon, it’s against the ethicist the company provided to facilitate the informed consent process:

    The Quinns' advocate, David Casarett, a bioethicist and geriatrics specialist at the University of Pennsylvania, is being sued by Irene Quinn. But notably absent from the lawsuit is Samuels, with whom the Quinns had grown close and who, ultimately, was the person responsible for ensuring they were fully informed and getting them to sign the consent document.

    The advocate, according to the article, has no financial ties to the company. His very existence was to try to avoid just the sort of misunderstanding about experimental procedures that seems to have happened here:

    In setting up the trial, Abiomed, the Danvers, Mass., firm that makes the AbioCor heart, took steps beyond those required to help families make informed choices about participating. The company set up a trust establishing an independent patient advocacy council to provide advocates not affiliated with any of the trial sponsors to help patients understand the informed-consent process. The advocates typically have medical training and are experienced in end-of-life issues and medical ethics.

    "What's new here is that a commercial organization has hired a person experienced in patient care and ethics to serve as an advocate for each patient," said Robert A. Levine, Yale University professor of medicine and bioethics.

    "We believe it's the most progressive practical model yet devised to protect patients in high-stakes clinical trials," said Abiomed Vice President Edward E. Berger. "We're very proud of the effort that was made by the clinical staff at Hahnemann Hospital and by the original patient advocate to assure well-informed decision making. We do intend to defend against this lawsuit very vigorously."


    This could be the first time that an “ethicist” was sued. What makes someone an “ethicist” anyway? Are they given some special key to the wisdom of the ages? Are they trained to know right from wrong any differently than the rest of us? Of course not. They’ve just been given a title to mark them as such, much like the Scarecrow in the Wizard of Oz gets his brains by being given a degree.

    Not that the advocate is necessarily guilty here. We don't know what sort of role he actually played in the consent process. Traditionally, it's the surgeon who is responsible for explaining the procedure and its risks. You have to wonder, though, if setting someone up as a secular authority on the manners of morality isn't setting him up for a fall.
     
    posted by sydney on 12/01/2002 07:01:00 AM 0 comments

    Mercurial Mercury: Two studies in the New England Journal of Medicine last week were reported to have come up with seemingly different results on the effects of mercury levels on the heart:

    Two studies in Thursday's New England Journal of Medicine on the long-term effects of mercury exposure on the hearts of middle-aged and elderly men had opposite findings.

    One found no clear link between mercury levels in the body and the risk of developing heart disease; the other found men who had suffered a heart attack had higher mercury levels than similar men who had not.


    Here’s the study that claims an association between mercury levels and heart disease, and the accurate synopsis of it given by the article:

    Researchers at the Johns Hopkins Bloomberg School of Public Health reviewed data and tissue samples from an earlier, nine-country European cardiac study. They compared 684 middle-aged men who had had one heart attack with 724 similar men who had not had a heart attack. They looked at the men's health history, use of tobacco and alcohol, and toenail clippings and fat withdrawn from their buttocks.

    Toenails hold accumulated mercury, and fatty tissue accumulates DHA; their levels in each subject were measured. Those with the highest mercury levels were nearly 2.2 times more likely than those with the lowest levels to have had a heart attack, said Dr. Eliseo Guallar, assistant professor of epidemiology at Hopkins.


    That sounds impressive, but they only got that figure by playing with the numbers, or as they put it, “adjusting for age and center.” The truth is that for each center they looked at, the levels of mercury in heart attack patients and healthy people were practically the same. The mean levels differed anywhere from zero to 0.05 micrograms/gram. In two testing centers, the mean levels were the same in both patients and controls - Russia and the Netherlands. At all of the centers, the range of mercury levels in patients and controls overlapped more than they differed. It’s a stretch to say, as the authors do, that mercury is playing a role here in these heart attacks. What is obvious from their data, is that high blood pressure (26% of patients vs. 17% of controls) and smoking (61% vs. 37%), are playing a role.

    The other study made more of an effort to control for such variables. They matched patients with controls based on smoking habits and age. Even more notable, they had patients and controls with higher levels of mercury than the other study. The highest quintile in the first study had a mean mercury level of 0.66 micrograms/g. The highest quintile in the second had a mean level of 1.34 micrograms/g. (They think the levels were so high because they had a large number of dentists participating.) Yet there was still no association between heart attacks and lead levels :

    Researchers at Harvard School of Public Health studied 470 men who had had heart surgery or a heart attack, comparing each with a similar man without heart disease. Dr. Walter C. Willett, a professor of epidemiology and nutrition, said mercury levels in the men's toenails corresponded well with the levels of fish they reported eating, but his team found no association between mercury exposure and risk of heart disease.

    I’d say it’s safe to say, based on both studies, there’s no association between mercury exposure and heart disease.
     
    posted by sydney on 12/01/2002 06:16:00 AM 0 comments

    Smallpox Preparedness: Looks like the states have been told to get their ducks in a row to begin voluntary vaccination of healthcare workers.
     
    posted by sydney on 12/01/2002 06:15:00 AM 0 comments

    Cigna Settles: Cigna settled the class-action suit it was facing from doctors over late payments:

    As part of the agreement, Connecticut-based CIGNA HealthCare will post on its Web site additional explanations of its claim coding and other payment policies; appoint a third-party administrator to review certain claims that were denied since Jan. 1, 1996; and establish a $10 million "prompt pay fund" for doctors whose payments were tardy.

    They also say they will be revising their procedures. I hope that means they’ll be changing the way the process claims so that payment is fair and timely.
     
    posted by sydney on 12/01/2002 06:14:00 AM 0 comments

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