"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
Quackery: The BMJ equates disarming Iraq with quackery. Let them know what you think of their facile analysis by hitting the "Respond to this article" link, it's like a comment page on a blog, but it takes twenty-four hours to show up on the site. And it gets previewed for suitability . Be nice. Be polite.
I do wish, though, that this physician would give them a Rapid Response:
I write this to protest against all those people who oppose the war against Saddam Hussein, or as they call it, the "war against Iraq". I am an Iraqi doctor, I worked in the Iraqi army for six years during Iraq-Iran war and four months during Gulf war. All my family still live in Iraq. I am an Arab Sunni, not Kurdish or Shia. I am an ordinary Iraqi not involved with the Iraqi opposition outside Iraq.
I am so frustrated by the appalling views of most of the British people, media and politicians. I want to say to all these people who are against the possible war, that if you think by doing so you are serving the interests of Iraqi people or saving them, you are not. You are effectively saving Saddam. You are depriving the Iraqi people of probably their last real chance get rid of him and to get out of this dark era in their history.
My family and almost all Iraqi families will feel hurt and anger when Saddam's media shows on the TV, with great happiness, parts of Saturday's demonstration in London. But where were you when thousands of Iraqi people were killed by Saddam's forces at the end of the Gulf war to crush the uprising? Only now when the war is to reach Saddam has everybody become so concerned about the human life in Iraq.
Where were you while Saddam has been killing thousands of Iraqis since the early 70s? And where are you are now, given that every week he executes people through the "court of revolution", a summary secret court run by the secret security office. Most of its sentences are executions which Saddam himself signs.
I could argue one by one against your reasons for opposing this war. But just ask yourselves why, out of about 500,000 Iraqis in Britain, you will not find even 1,000 of them participating tomorrow? Your anti-war campaign has become mass hysteria and you are no longer able to see things properly.
Locum consultant neurologist, London
Oh, and another thing. The editorial posits that half a million Iraqis are likely to die in the war. I seem to remember similar predictions being bandied about before the Afghan war. They didn't come true then, and there's no reason to believe they'd be true now. Besides, as Josh Clayburn has pointed out, war (at least war with the United States) has its benefits. posted by Sydney on
2/15/2003 07:51:00 AM
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Bugs, Hearts, and Brains: Researchers at Duke University have linked cognitive malfunction after open heart surgery to the inability to fight bacterial toxins in the gut. The theory is that during the stress of open-heart surgery, the bacteria get loose and release endotoxins in the bloodstream that can then damage neurons in the brain:
Physicians can determine a patient's level of immunity to these bacteria by measuring the number of antibodies (EndoCAB) in the bloodstream that the body has created in response to the bacteria.
"In our study, we found that reduced preoperative levels of EndoCAB are a predictor of postoperative cognitive dysfunction in patients undergoing bypass surgery," said Joseph Mathew, M.D., Duke anesthesiologist and principal investigator of the study. "Among patients who undergo bypass surgery, low endotoxin immunity may exacerbate the inflammatory response typically associated with the heart-lung machine and cause greater cognitive dysfunction.
"This effect was particularly pronounced in patients over the age of 60," he said.
Thin Evidence: A new study suggests that taking ibuprofen, a popular arthritis drug, raises the risk of heart attack in daily aspirin users:
They found that the 187 taking both aspirin and ibuprofen had a doubled risk of dying from any cause and a 75% increased risk of dying from cardiovascular disease, compared to those just taking aspirin.
Those taking aspirin and another NSAID were also at no increased risk.
Percentage of those taking aspirin alone who died during the study: 32% (1983 out of 6285)
Percentage of those taking aspirin and ibuprofen who died during the study: 33% (62 out of 187)
Percentage of those taking aspirin alone who died of a cardiovascular event during the study: 21% (1350 out of 6285)
Percentage of those taking aspirin and ibuprofen who died of a cardiovascular event during the study: 21% (39 out of 187)
So how did the BBC come up with that doubled risk for any sort of death and 75% increased risk for cardiovascular death in those who take aspirin and ibuprofen together? Chances are they didn't look at the study, but relied on a press release which only focused on the author's overblown conclusions. The authors, you see, focused on hazard ratios which exaggerate the miniscule differences between the two groups. Don’t be in a hurry to throw out your ibuprofen if it’s helping your arthritis. In a few months another study will claim just the opposite, on just as tenuous data.
The larger question is, why do respectable journals allow that sort of hypberbole to flourish in their pages? It's become the norm rather than the rule, and it does nothing to enhance the credibility of the medical profession. posted by Sydney on
2/14/2003 06:22:00 AM
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Battle of the Studies: Last December, a study came out in JAMA that concluded that diuretics are superior to ACE inhibitors for the treatment of hypertension. Now comes a study in this week’s New England Journal of Medicine which claims that ACE inhibitors are superior to diuretics. Both studies are well-done and well-controlled. Which to believe?
A better question would be whichmedia spin to believe. As pointed out in these pages, the first study really didn’t show much difference in outcomes between the two types of drugs. The same can be said of the most recent study.
The study looked at blood pressure control in patients taking the diuretic hydrochlorothiazide and in those taking the ACE inhibitor enalapril. (Not the same drugs used in the earlier American study, by the way.) At the end of four years, here’s what they found for blood pressure readings in the two groups:
At year 1, blood pressure had decreased by 20/9 mm Hg in the ACE-inhibitor group and 22/9 mm Hg in the diuretic group; at year 2, it had decreased by 23/10 mm Hg in the ACE-inhibitor group and 24/10 mm Hg in the diuretic group; and at year 5, it had decreased by 26/12 mm Hg in both groups.
No difference there. But it isn’t superior blood pressure control that the authors claim for the ACE inhibitors, it’s a superiority in preventing death and heart attacks. Turns out there isn't much difference in that respect, either.
Among the ACE-inhibitor patients, 695 out of 3044 (23%) either died or had a cardiovascular illness (heart attacks, strokes, angina requiring treatment, or heart failure) during the study. For those treated with diuretics the figure was 736 out of 3039, or 24%. Separating deaths and cardiovascular illnesses doesn't improve the numbers. Six percent of those on an ACE inhibitor died during the study, compared to seven percent of those on a diuretic. Thirteen percent of those on ACE inhibitors had a first-time cardiovascular event; fourteen percent of those on diuretics.
That one percent difference might mean a lot to someone who deals with populations, but it doesn’t mean squat when you’re dealing with an individual patient. All things being equal, given the choice between a $5 a month pill whose users have a 24% incidence of death or cardiovascular illness, or a $34 a month pill whose users have a 23% incidence of the same, most people would choose the $5 a month prescription. (At least they would if they had to pay the bill themselves.)
The moral of the story is that diuretics and ACE inhibitors are equivalent when it comes to their effectiveness in lowering blood pressure as well as their influence on mortality and cardiovascular morbidity. Neither study has made a strong argument to favor one drug over the other, which means that physicians should still choose blood pressure therapy based on what's best for their individual patient, not on the latest media spin of the latest study.
UPDATE: DB has some things to say about this, too.
Homeland Tort Reform: Word has it that the final omnibus spending bill does, indeed, repeal the vaccine protection clause of the Homeland Security Bill, as promised by Senator Frist last month:
Senate Majority Leader Bill Frist, R-Tenn., who supported the original vaccine provision and said he still hopes to take up the issue later this year in more comprehensive legislation, said he would include the special interest eliminations in a fiscal 2003 spending bill the Senate will take up this month.
The provision was placed to eliminate the many ill-founded thimerosal lawsuits. At least the issue will be revisited. It deserves to be.
Hey: I just realized that January has come and gone without any birth announcements from renegade Italian embryologist Severino Antinori. A quick Google search reveals he's still on a hunger strike. Perhaps to deflect attention from the lack of any developments?
Antinori, an embryologist has succeeded in helping several post-menopausal women -- including one aged 62 -- give birth to healthy children in recent years. But according to many, his real talent lies in the field of self-promotion.
Antinori, who can be seen driving the streets of Rome in a cherry-red Ferrari and on television talk shows that usually focus on Milan runway models, stunned observers when he announced last April that he had helped three women become pregnant with the cloned offspring of a childless Arab sheik.
If he knew in April that the women were pregnant, there should have been some births by now. posted by Sydney on
2/14/2003 06:10:00 AM
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By asking three simple questions, most people can diagnose stroke and act quickly to get the victim to a hospital for treatment, researchers reported Thursday
..The bystanders were able to accurately diagnose 96 percent of speech deficits and 97 percent of one-side arm weakness. They were less accurate with diagnosing facial weakness -- spotting it only 72 percent of the time -- but Amy Hurwitz, a medical student who co-authored the study, said this was expected because it is more difficult for a stranger to "know if there is something unusual about a smile.
..In the study, Brice and her fellow researchers played the part of 911-dispatchers while 100 visitors to the UNC Medical Center were recruited as bystanders and stroke survivors played the part of stroke victims. The bystanders were asked to place a phone call to the dispatcher who then walked the bystander through the three-part test.
The bystander asks the victim to "show us your teeth," which is a smile test to detect facial weakness. The victims are also asked to close their eyes and raise their arms to detect one-sided arm weakness. And finally, the bystander asks the victim to repeat a simple sentence like "The sky is blue in Cincinnati." Slurred speech and one-sided facial or arm weakness are all classic signs of stroke, said Brice. posted by Sydney on
2/14/2003 06:07:00 AM
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Smallpox Vaccine Update: The military has so far had three serious complications and no deaths from smallpox vaccine:
While much of the U.S. public has balked at starting a smallpox vaccination program, the military said on Thursday it has vaccinated more than 100,000 troops with just three serious "adverse events."
Two soldiers developed encephalitis, a potentially life-threatening brain inflammation, but both recovered fully, Col. John Grabenstein of the U.S. Army Surgeon-General's office said.
An airman developed an even rarer side effect called myocarditis, an inflammation of the heart that can sometimes lead to heart failure, but also recovered, Grabenstein told a meeting of the Institute of Medicine.
And it should be noted, no one has given the cowpox to anyone else, either. posted by Sydney on
2/14/2003 06:06:00 AM
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Thursday, February 13, 2003
Preparedness Update: Florida vaccinated 500 people against smallpox yesterday. CNN reports that a woman had a reaction. But it was a very minor reaction. The kind you could have to any immunization, in fact:
One woman suffered a mild allergic reaction during Monday's vaccinations. It was believed to be the first adverse reaction since the voluntary program started nationwide last month. The woman, who was not identified, was treated and released. posted by Sydney on
2/13/2003 07:22:00 AM
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Public Service Announcement: I had to admit someone last night who inhaled too much Liquid Plumber. It's very corosive, and damaged his lungs so much that he had to be placed on a ventilator. Be careful when using liquid drain cleaners. Make sure you have plenty of ventilation, and don't lean over the drain inhaling the fumes while trying to unclog it.
UPDATE: A reader emailed a warning about corosive solvents in spray form:
I recently discovered another type of product which poses the same dangers. There are multiple products out there, mainly of interest to woodworkers, that remove gum and pitch from table saw blades, router bits, and other high-speed cutting implements that are prone to accumulation of these deposits. Essentially they are Dran-O in a spray can. They are very caustic and should be used outside ONLY and kept under lock and key.
Chinese Mystery Illness: A respiratory illness has been sweeping southern China:
Chemists and stores have been swamped by people in parts of southern China fearing a mystery lung virus.
Some people were wearing surgical mask in the streets, despite doctors insisting that rumours were unnecessarily fanning public fears.
About 300 people were in hospital with pneumonia caused by the virus, one-third of them doctors, nurses and other health workers, an official of the provincial Disease Prevention and Control Centre said.
But doctors said that so far only five people had died and not the hundreds suggested by residents in Guangdong Province near Hong Kong.
Not sure what the source of the infection is. They’re speculating that it could be a new strain of the flu. It has, however, had an effect on the Chinese stock market:
Shoppers cleared stores of antibiotics and queued to pay inflated prices for vinegar, which many Chinese use as a disinfectant.
The panic also affected regional stock exchanges, with shares of drug companies rising, outdone only by a few vinegar-makers. posted by Sydney on
2/13/2003 07:05:00 AM
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Tests on the white particles found in more than 100 bags of quarantined blood in Georgia and Tennessee showed that they contained little more than platelets, white cells and other "normal blood components," the American Red Cross said today.
But officials with the organization, which supplies about half the donated blood in the country, said they did not know what was causing the particles to appear in the bags.
"We're starting to discover what this stuff is, but we don't know why it is happening," said Candice Gulden, a spokeswoman for the Red Cross in Atlanta. "Our investigations are continuing."
They're still keeping them quarantined, though, even as shortages of blood continue. posted by Sydney on
2/13/2003 07:05:00 AM
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Other Vaccine News: Some states have enacted legal requirements for the immunization of college students against meningitis:
Last year, Pennsylvania joined 13 other states that have passed laws concerning the immunization of college students against the disease, a deadly disorder that strikes mostly infants and college students.
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This year, similar bills are expected to be introduced in at least seven more states.
But some legislators and college administrators are reluctant to require a vaccine that does not completely protect against a disease that is rare to begin with.
It is a rare occurrence, although when it happens, it can be quick, deadly, and devastating. Still, requiring the vaccine by law raises some sticky issues. It isn’t a very efficacious vaccine. It's only 80-90% effective in preventing the types of meningitis it's designed to combat, and it doesn't protect at all against one serotype that accounts for 46% of cases. Once it becomes required by law, insurance companies may be compelled to pay for it. That means that cost shifts from the individual to all of us, and that, in turn, means that millions of dollars are diverted from some other aspect of healthcare. posted by Sydney on
2/13/2003 07:00:00 AM
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Behaving Badly: Michael Fumento had an article in last week’s New Republic about attention deficit disorder which I wanted to link to last week, but couldn’t because it wasn’t online. Well, it’s available here. Fumento argues that conservatives have unjustly maligned the disorder. There’s some truth to that, but there’s also some truth to the criticisms made by conservatives - that’s it’s often overdiagnosed and too often used as an umbrella diagnosis for what are really behavioral disorders.
Attention deficit disorder is a true disorder, and when properly diagnosed, the treatment can make all the difference in the world to a child. However, it’s also easily misdiagnosed, and I have seen it used as a convenient excuse by both parents and teachers to deal with children who need disciplining more than anything else. The difference, of course, is that the kids who are truly discipline problems don’t get better with the medication - they get worse. posted by Sydney on
2/12/2003 07:26:00 AM
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Food for Thought:JAMA had a thought-provoking essay about a man who was left in a vegetative state for a year by an illness whose diagnosis forever eluded his physicians. Many would have stepped back and let him die “a good death,” but his wife insisted that he be given full medical care at all times. He recovered to the surprise of all, and describes himself as back to normal.
His case is a rare one, to be sure, but the dilemma is a common one. Where do you draw the line of hopelessness? It’s easy when the patient has a terminal illness like cancer, or a heart so damaged that it barely pumps the blood. But it’s much more difficult in the elderly person with a chronic illness. How can you tell when the emphysema exacerbation or pneumonia in an 85 year old is the final illness or one from which she’ll rebound? It’s a tough call, and it makes the interpretation of do not resuscitate orders difficult, both for the physician and for the patient. posted by Sydney on
2/12/2003 07:18:00 AM
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Drug Trade: One of my patients clued me into a new twist on the practice of Canadian drug importation. Up until now, I’ve only been aware of individuals sending away to Canada for their drugs, but her employer is actively encouraging their employees to get their drugs from Canada. If they import them the company picks up the entire tab. If they get them in the US, they have to pay a co-pay. If this catches on, you can bet more pharmaceutical companies will follow Glaxo's lead and stop doing business with Canada.
UPDATE: This is interesting. Page A25 of today's New York Times is a full-page ad for a coalition of Canadian mail-order pharmacies and US senior citizens groups that says "Glaxo is taking away your right to affordable prescription drugs!" It's accompanied by a large picture of an angry little old lady. Is there such a "right"? More to the point, bringing drugs in from other countries is specifically illegal. The FDA has just been looking the other way when it comes to drugs for personal use that are brought across the border in quantities of 90 or less. posted by Sydney on
2/12/2003 07:16:00 AM
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National Medical Defense: Via Virginia Postrel, a column that makes all the right arguments for smallpox vaccination by Jonathon Rauch. He hones in on what has become the exaggerated risk of the vaccine to the unvaccinated:
"The real problem is that nonvolunteers can also be infected by the vaccine virus and can be crippled or killed."_ This is the reservation that thoughtful public health officials voice most often. As The Post reports, "Physicians said their main concern is for patients and family members who might inadvertently be infected by the live-virus vaccine."
The site of the smallpox inoculation on the body can shed vaccinia virus, which, if it infects someone who has a compromised immune system -- say, an HIV or cancer patient -- can kill in a horrible way. In an interview, John Neff, a pediatrician and infectious-disease specialist at the University of Washington School of Medicine, told me, "If I were to go out and get vaccinated for myself, and I inadvertently infect my spouse or someone I didn't even know had an immune problem, and that person died, I've done a terrible thing." Moreover, even one such case in the national headlines could cause a backlash against not only smallpox vaccination but against vaccines generally.
It is proper to be concerned about this problem. But it is not proper to be paralyzed by it. Working from data that Neff and three of his colleagues recently published in the Journal of the American Medical Association, I figure the odds of dying from "contact vaccinia," as it's called, at two to four per 10 million inoculations. In 2001, by way of comparison, every 10 million licensed drivers caused the deaths of about 300 pedestrians and other nonriders -- people who had not voluntarily assumed the risk of getting into an automobile.
Notice, please, that driving a car is on the order of 100 times more likely to kill a bystander than is getting a smallpox inoculation. Yet we do not prohibit driving. Nor do we even discourage it. Nor do we run a national compensation program for pedestrians injured by automobiles. Rather, we recognize that a sensible society puts up with certain small risks in the pursuit of larger goals.
So the people who are foot-dragging on smallpox vaccination are really people who are asking this: "Should Americans be expected to assume a mild inconvenience or a minuscule risk in order to help secure their nation against a fearsome attack?" A country, or a government, that fails to answer that question very clearly in the affirmative is either neurotic about risk or unserious about terrorism.
Or both.
Our public health system is definitely both. Their statements to the media have managed to make the vaccine seem as dangerous as the disease. When the head of the CDC says that obesity is a bigger threat to our nation than terrorism, when public health officials publicly accuse the smallpox vaccination program of being a political ploy, and when some equate vaccination with supporting war, then you know they aren’t taking the threat of terrorism seriously. And you have to ask, should we be trusting the public health system with our defense?
Prof. Michael Osterholm says he's not surprised that some hospitals and health workers are getting cold feet about the smallpox vaccine.
But as one of the architects of the national smallpox plan, he thinks the critics are a bit shortsighted -- especially hospitals that want to wait until there's an outbreak to vaccinate their employees.
"I can guarantee you that if smallpox were to hit anywhere in the world today, there would be a mad rush for smallpox vaccine," said Osterholm, a University of Minnesota professor who is now a leading bioterrorism adviser to the Bush administration.
..."I don't care if the only smallpox case in the country is in New York City," says Osterholm, the former Minnesota state epidemiologist. "Tens of thousands of people will rush into emergency rooms . . . thinking they have it."
If no one there is vaccinated, he warns, hospitals could be overwhelmed. "It will be the perfect storm," he said
OK, so he indulges in that overused storm metaphor, but he makes a point that’s being lost on a lot of these people who are opting out - that it isn’t going to be an easy task to vaccinate everyone in the aftermath of an attack:
Osterholm says that's easier said than done. "I believe in a situation where you have many people coming in with possible smallpox, there will be people who are literally running from the facility," he said. That will include some unvaccinated employees, he predicts.
"That's human nature," he said. During that first 48 hours, he said, every hospital in Minnesota will have its hands full even if the closest case of smallpox is 1,000 miles away.
"We're going to need everyone we can who's willing to stay on the front lines," Osterholm said. "Make no mistake, even if we vaccinate all these health care workers . . . we are still going to have a catastrophic event. But it's an event we now can manage [better] than if we had no preparedness at all."
Yeah, and if you wait until after an attack to vaccinate everyone, you can’t thoroughly screen out all the people at high risk for complications.
This is the one terrorist threat that keeps me awake at night. Sure, it’s only one of many possibilites. They could attack with a dirty bomb, with cyanide, sarin, or VX gas. They could poison us with botulin, or try to infect us with the plague or anthrax. But of all the threats, smallpox not only has the most potential to spread far beyond its initial introduction point and affect us all, it’s also the only one from which we have the means to protect ourselves.
It keeps me awake at night to know that my children will go unprotected from this threat because the American Academy of Pediatrics and the CDC deny them the vaccine, despite the fact that it was used in children for generations before us. It keeps me awake at night to know that nurses across the country are opting out of it, not because they’ve weighed the risks for themselves, but because the nurse’s unions are encouraging them not to take it. (I know this to be true, because I’ve seen the letters being circulated by our local nurse’s unions.)
It’s hubris, pure and simple, to think that the same organizations who complain that this pro-active vaccine campaign is going forward too fast to be administered safely could adequately vaccinate large numbers of people within the two day window to prevent the dissemination of smallpox. It's cock-eyed optimism to think that everyone exposed to smallpox is going to realize that in time for a post-exposure vaccination to be effective. Unfortunately, since our most vulnerable citizens are also our youngest, it’s a hubris and optimism that very well could cost us our future. posted by Sydney on
2/12/2003 07:02:00 AM
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Our Inglorious Past: The New York Times points out that the medical profession has a rather good track record for cowardice:
Doctors who declined to risk their skins for their profession include some of the famous physicians of history. Galen, the eminent Greek doctor, fled Rome in A.D. 166 at the onset of an epidemic that might have been smallpox.
Thomas Sydenham, the pre-eminent cardiologist of 17th century London, left town as soon as plague broke out there in 1665. When yellow fever struck Philadelphia in 1793, three of the best known doctors immediately headed for the Poconos (but the indomitable Benjamin Rush stayed behind).
These men were hardly the exceptions. Medieval records repeatedly bemoan the cowardice of doctors who left infected towns during the great bubonic plague epidemic of the 14th century (and also note the outrageous consultation fees demanded by those who stayed).
In an outbreak of plague in Venice, most of the doctors who did not actually leave the city locked themselves in their houses and refused to come out.
Ultimately many European cities resorted to hiring "plague doctors" ? usually young graduates paid generous salaries to treat plague patients and relieve other doctors of that duty.
But even plague doctors had their limits sometimes. "If you are asked to treat a patient with no chance of recovery," wrote the author of a late-14th-century medical textbook, "say that you will be leaving town shortly and cannot take the case." posted by Sydney on
2/12/2003 06:40:00 AM
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The scientists found 17 genes that make yeast slow or stop growing when exposed to gentamicin. This cheap and powerful antibiotic is used to treat skin, eye, and ear infections and bacterial meningitis. In 5- 10% of patients it can damage the kidneys and inner ear.
"Understanding how gentamicin does its damage would be very important in figuring out how to avoid this toxicity," says Timothy Hain, a neurologist at Northwestern University in Evanston, Illinois.
The screen also identified four genes that make yeast sensitive to tetracycline and oxytetracycline, which are antibiotics used to treat Lyme disease, pneumonia, acne, bladder infections and ulcers. Figuring out how to prevent antibiotic toxicity in patients based on the molecules identified here will be a much more daunting task, however.
They haven't been able to find any analogous yeast genes for commonly used antibiotics, however:
The sift did not reveal any deletions that make cells susceptible to amoxicillin, penicillin, rifampin or vancomycin, which are used to treat bacterial infections of the airways, stomach and skin. This could be due to differences in the way in which human and yeast cells take up antibiotics, says Avery. He admits that the screen probably missed some gene functions that are specific to humans.
Media Bias: A reader sent this story from the Scranton Times Tribune that has an interesting spin on the malpractice issue:
For the 14th consecutive time, a Lackawanna County Court jury this week refused to award any money after hearing testimony in a medical malpractice trial.
In the latest case, jurors rejected the claim of Bernadette and Craig Westbrook, Scranton, that Dr. Bharat Patel did not properly inform her of the risks of a diagnostic test.
Mrs. Westbrook went to Dr. Patel, a gastroenterologist, in 1993. On Oct. 26 of that year, he suggested she undergo a procedure to see if she had stones in her gallbladder or common bile duct.
After the test, the complaint said, she developed pancreatitis, together with a cyst on the organ. She eventually underwent corrective surgery at a Philadelphia hospital.
Mrs. Westbrook, represented by attorney Michael Roth, contended she would have refused the test had she been told of the dangers that could result in death.
Dr. Patel testified he told Mrs. Westbrook of the possible complications, but did not mention the risk of death associated with them because the percentage was so small.
As my email correspondent points out:
The only reason they mentioned that 14 out of the last 14 cases were found for the defendents was to reinforce an earlier article whose title ran "Jury Awards not Driving Malpractice Rates". They never make the point that with the average case going to trial costing over 100K then those 14 cases cost the insurance companies over 1.4 Million dollars to defend innocent doctors. Is it any wonder Scranton PA is in a malpractice crisis? posted by Sydney on
2/11/2003 07:38:00 AM
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Big Fat Lies:Michael Fumento takes apart that New York Times Sunday Magazine article on the Atkins diet from several months ago, What if It's All Been a Big Fat Lie?. He does a good job, too. Turns out a lot of the metabolic experts were inaccurately portrayed as supporters of Atkins. Most of them agree - it's the calories that count, regardless of where they come from. posted by Sydney on
2/11/2003 06:22:00 AM
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Abusing Prescriptions: Justin Katz points out that it isn't just methadone that's a problem:
The most recent survey by the federal Substance Abuse and Mental Health Services Administration says 11.1 million people used prescription drugs for fun in 2000, nearly half of whom were under 25.
In New York City, the number of people showing up in emergency rooms after taking too many legal narcotics jumped 47.6% from 2000 to 2001, the most recent year for which numbers are available.
"In 2001, for the first time, we had more emergency room mentions of prescription narcotic analgesics nationally than for heroin," said Dr. Westley Clark, director of the administration's Center for Substance Abuse Treatment. posted by Sydney on
2/11/2003 06:03:00 AM
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Cost Analysis:Business Week on the high cost of medicine:
How much is a year of life worth? This may seem like a question that should never be asked--and in the U.S., it rarely is. But as ever more expensive medical treatments and tests are introduced, our society will have to face this issue head on. "In the current health-care environment, ignoring cost is no longer tenable," says Dr. David Atkins, science adviser to the U.S. Preventive Services Task Force, a panel of medical experts.
Bias: The Atlanta Journal Constitution ran a story a couple of weeks ago about the emotional aftermath of abortion. They covered both sides fairly - acknowledging that there have been no good studies to investigate the mental health effects of the procedure, and also giving voice to some women who have had abortions. Descriptions of how abortions are performed remain disturbing:
"I remember we had to pay with cash or credit card; they didn't take checks," said Matthews, now an abortion opponent. "It was $350. We were informed that if we decided to leave before having the abortion, we weren't going to get our money back."
After a pause, Matthews continued, "In a situation like that, you don't know how to get out of it. You panic. I had nine months to realize how to care for a baby, but I tried to figure it out in seven weeks."
It isn’t standard policy for most doctors to charge a patient for services not rendered, just as it isn’t standard policy to meet them for the first time when they’re draped and sedated.
But back to the issue of the emotional aftermath of abortion. The American Psychological Association says it’s launching a website to explore the issue. They aren't making any attempt to avoid bias, however:
The group is working with sociologist Eleanor Lee, who founded the Pro-Choice Forum Web site in 1998. The task force chose to collaborate with the site, based in the United Kingdom, because of its international audience, says Russo, adding that anti-abortion and other reproductive health misinformation is spread globally.
Privacy Matters: Chris Rangel addresses my concerns about the security of electronic medical records.
The issues he raises about paper records are certainly valid, but I'm not so sanguine about hackers or about the potential for theft. It's a lot easier to walk away with the back copies of a practices electronic medical records than it is to walk away with a roomful of patient charts. And, government regulations about patient privacy definitely make it difficult for small practices to adopt electronic records. It makes it almost impossible, for example, for an office to use wireless technology for electronic medical records. Without the ability to use wireless technology, the systems have to rely on expensive networks. Personally, I would love to have computerized medical records. I just haven’t found a system that’s affordable, secure, and faster than the paper charts we have now. posted by Sydney on
2/10/2003 08:09:00 AM
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Public Health Hyperbole: Well, this isn’t very reassuring. Tucked into a report on obesity was this quote from the head of the CDC:
"The biggest problem we face in America is not terrorism. The biggest health problem we're facing is obesity," Dr. Julie Gerberding, head of the Centers for Disease Control and Prevention, told The Associated Press last week.
Protecting us from our own weaknesses is a higher priority than protecting us from terrorists. Looks like it’s time to move bioterror preparedness away from the CDC and to Homeland Security. posted by Sydney on
2/10/2003 08:05:00 AM
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Beware the Playground: Playgrounds have evolved from the steel and concrete patios of my youth to soft rubber-and-wood cushions, but turns out that even those seemingly safe havens carry hidden dangers:
Scientists at the Consumer Products Safety Commission said Friday that children playing on millions of outdoor wood playground sets nationwide faced an increased risk of bladder and lung cancer from arsenic exposure.
The report recommends that children wash their hands after playing on wooden playground sets and also not eat in the vicinity of the wood.
As of this writing, the report isn’t up at the Consumer Products Safety Commission website, so I can’t say how significant a risk there is, but I’ve got to think it’s miniscule since I don’t remember hearing about any explosion in pediatric bladder and lung cancer rates.
And by the way, given the CDC and the HHS obsession with obesity, shouldn’t these government groups be careful about defaming playground equipment? posted by Sydney on
2/10/2003 08:00:00 AM
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Ouch: A group of doctors in Cleveland is taking flak for charging a surcharge to cover their malpractice expenses:
Sharon Forsch knows that a sharp rise in the cost of medical malpractice insurance last year hit doctors hard in their pocketbooks.
The retired preschool teacher just doesn't think that is any reason for doctors to dig deeper into her pocketbook.
Forsch, 59, is refusing to pay a $30 surcharge that she says Beachwood OB GYN Inc. in Lyndhurst added to her bill to help pay for costly malpractice insurance.
Her health insurance, like most, does not cover the add-on fee.
As doctors struggle to buy increasingly expensive malpractice coverage, a few are trying this revenue-enhancing tactic. So far, local and national medical societies have taken no position on whether it is ethical. But the head of a medical consumer rights group called the surcharges "extortion and fraud" that patients have no obligation to pay.
The patient in question has an HMO. When we contract with HMO’s we agree to accept a certain amount per month from the insurance company to provide care, plus the patient’s co-pay for each visit. This surcharge, also often called an “administrative fee” is growing more popular as overhead becomes more and more burdensome, but it would seem to violate the terms of an HMO contract. (And those surcharges aren't necessarily just to cover malpractice premiums. They're also to cover the added administrative burden of dealing with insurance companies.)
Consumer groups, predictably, aren’t happy about it, either:
No managed-care company is going to cover surcharges for malpractice insurance, said Charles Inlander, president of the People's Medical Society, a consumer-rights group in Pennsylvania. And he said consumers should not be left to pay.
Ah, but there’s the rub. If our healthcare system were truly a free-market and not the corporate-socialist system that it is, doctors would increase their fees as their overhead increased, and the high cost of malpractice insurance premiums would be passed on to the patients. In our system, though, we can’t increase the fees. The insurance companies and the government (via Medicare) determine how much we are paid for our efforts. And their reimbursements have been diminishing as overhead costs have continued to increase due to malpractice insurance and to administrative overhead devoted to extracting payments from those same insurance companies and government programs. That’s why doctors in so many states have been driven from practice. They have no other recourse.
The Plain Dealer isn't convinced that doctors can't cover their overhead, though:
But last September - one day after doctors told a special state legislative committee hearing in Cleveland that the high cost of malpractice insurance was forcing some out of business - Steven Klein signed a lease for a new Mercedes. The model he selected had a base sticker price of about $50,000. He drives home each evening to a $740,000 house in Moreland Hills.
Yet Forsch said an office assistant told her the doctors "just can't afford to practice without that fee."
One factor perhaps adding to the cost of Beachwood OB GYN's insurance is that Klein and the three other doctors whom state records list as shareholders are named in malpractice lawsuits pending in Cuyahoga County Common Pleas Court.
I don’t know about Dr. Klein’s spending habits. For all we know, his wife could be an heiress (or a successful trial attorney), but I do know that Cuyahoga County has one of the worse reputations for aggressive malpractice lawyers. Given that we’re talking about obstetricians, a group that’s particularly singled out by trial lawyers, it’s no reflection on the doctors that each of them has a suit pending. posted by Sydney on
2/10/2003 07:46:00 AM
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Just Want to be Sedated: Methadone is fast becoming a drug of choice among drug abusers, just as its popularity grows among physicians for control of pain and treatment of addiction:
In most states with increased methadone deaths, the methadone being abused appears to be tablets prescribed for pain. These are sold or sometimes given to addicts by people who have stolen them from patients or, in some cases, by the patients themselves. Addicts either swallow the tablets or grind them into powder that can be inhaled or turned into liquid and injected.
In Maine, however, and to a lesser degree in a few other states, the authorities say much of the methadone has been the liquid form used in drug clinics and spread, in some cases, by clinic patients. Many clinics across the country, following federal guidelines designed to make methadone treatment more accessible, have stopped requiring patients to take all their daily doses at the clinic, and instead are allowing them to take home doses of methadone once a week or more.
This does seem to be a growing problem:
There are no national figures for methadone deaths or overdoses. But the federal Drug Abuse Warning Network reported that in 2001, 10,725 people turned up in emergency rooms after having abused methadone. That is nearly double the number of such visits in 1999.
This sort of thing, along with the rise in abuse of Oxycontin, is the natural consequence of an overly liberal approach to the treatment of chronic benign pain. Have to wonder, too, how much groups like this have contributed to the methadone problem. posted by Sydney on
2/10/2003 07:14:00 AM
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UPDATE: Regarding the above contrasted with last week's post about a similar story in The Washington Post, a reader emails that I'm conflicted:
Today's post about a story to warm your heart and a "but I really could have done without seeing that photograph" posted on 1/31/03--actually I found the photo to be touching--it was not as if it was celebrating their bodies, just their spirit and desire for intimacy.
Ah, but the difference is that the story in no way forced a mental image on me of elderly couples having intercourse. The picture in the Post very explicitly did. (for those of you who missed it, it was a photo of a naked elderly couple embracing.) It elicited the same reaction that listening to Angelina Jolie and Billy Bob Thornton publicly describing their sex life used to give me. There are some mental images I'd just rather do without. posted by Sydney on
2/09/2003 04:51:00 PM
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Threaten Me, Threaten You: Ohio is thinking of limiting its Medicaid benefits. The response of at least one Medicaid recipient is to threaten the peace of others:
If the state takes his Medicaid benefits, Dazzle Joe Young wants to go back to ``the joint.'' At least there he would get his medication.
Young got out of prison in May after serving the better part of the last 10 years for assault and selling drugs. He knows exactly what he'd do to maintain his benefits: steal money and items, anything to get thrown back in. Anything to get the drugs that help his diseased heart, arthritic feet and high blood pressure.
``If they take Medicaid, y'all will be reading about me,'' he said recently. ``They might as well open the doors to the penitentiary and say I'm on the way back.''
Humph. You can also get three square meals a day in "the joint" and not have to worry about paying for rent, but that doesn't make harming others to obtain free food and shelter right. posted by Sydney on
2/09/2003 03:02:00 PM
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Eye of the Beholder: One of the more interesting things the New England Journal of Medicine does is publish photographs of purely artistic merit submitted by readers. Last November, they published one of bicycle racers. (Sorry, the images aren't available on-line). The picture elicited two letters to the editor of very different perspectives. One saw it as a symbol of hope:
On the right side of the image, it is possible to recognize, wearing the leader's yellow jersey, the American champion of cycling and cancer survivor, Lance Armstrong. This picture led me to reflect - first, how medicine is important in facilitating a recovery to full health in a person affected by cancer; second, how the example of such a full recovery has been important psychologically to many persons affected by neoplastic diseases; and third, how physical activity is important in determining many beneficial effects for health.
The other only saw gloom and doom:
Though pleasingly colorful to the eye and showing what appears to be an appealing, Old World setting, Dr. Curfman's photograph of cyclists racing in Luxembourg is unfortunate for its prominent portrayal (in the center foreground) of a helmetless racer. I will choose to believe that the editors' choice of this particular photograph does not mean that the Journal advocates careless neglect of such a simple and accessible preventive health and safety measure.
The journal went on record as being in favor of bicycle helmets, but stop short of forcing them on unwilling adults. posted by Sydney on
2/09/2003 02:54:00 PM
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Brave Heart: I've posted a review at Blogcritics of the latest biography of Dr. James Miranda Barry - 19th century British soldier, physician, and woman. This biography isn't worthy of its subject. A much better treatment of her life can be found in June Rose's The Perfect Gentleman, though it's out of print and only available through used book vendors.
UPDATE: Oh, what the heck. I realized that I inadvertently published the review here and at Blogcritics. I had removed it, but on second thought I'll keep it here as well:
Dr. James Barry stands out in the annals of medical history. A surgeon in the British army, with a career that spanned the Napoleonic Wars to the Crimean War, the doctor was a tireless champion of the common soldier, fighting for good food, clean shelter, and trustworthy medications before Florence Nightingale ever arrived on the scene. In a time when abdominal surgery was risky and fairly uncommon, Dr. Barry won over the hearts of civilians in Cape Town by performing successful Cesarean sections. All of that should be enough for a claim to fame, but Dr. Barry's fame rests not so much in medical glory as it does in the fact that she was a woman.
But, to assume that she lived as she did because of sexual orientation or her biology is to ignore the circumstances of her times and of her life. After all, she lived in a time when the education of women was limited to such niceties as painting, music, and needlework; when women without fortunes or respectable families were virtually unmarriageable, at least in Dr. Barry's social circle, and when unmarriageable women without fortunes were impoverished women. Given the circumstances, it isn’t too suprising that an uncommonly intelligent young girl of diminished means would be willing to live the life of a man for the chance to support herself doing something that she loved.
The particulars of Dr. Barry's early life are shrouded in mystery, and need a better historian than Rachel Holmes to unveil them. The author makes her first historical mistake with her subject's date of birth. Throwing out all evidence that Dr. Barry herself placed her birth around 1799, that boys in the 18th and early 19th century were sent to learn their chosen professions at early ages, and that those who knew James Barry early in her career often commented on her youth, she assigns her subject an age that is ten years older than most estimates. She also assigns to her the identity of Margaret Bulkley (who was most likely her older sister) on the basis of a handwriting comparison between a letter of Margaret's and the entry for James Barry in the ledger of St. Thomas Hospital. The problem is, the photograph of the ledger makes it clear that all its names are in the same handwriting. Either Margaret Bulkley/James Barry was able to assume several identities at once, or the entries in the ledger were made by a clerk, as was the custom for official records of the time.
But there are some things that are known about her early life. She's believed to have been the niece of the 18th century painter, James Barry. Her mother (his sister) had fallen on hard times, and found refuge of a sort with her brother in London, or perhaps with one of his many bohemian and free-thinking friends. Among those friends were Lord Buchan who espoused the rights of women, and General Francisco de Miranda, the Latin American revolutionary-in-exile who was known to have an extraordinary medical library. At least one biographer has speculated that it was under the influence of these two men, that the young and gifted girl was enrolled at Edinburgh as a medical student, disguised as a boy and under the name James Miranda Barry. After medical school, she joined the Army medical corps. She was thirteen. Many commented on her unusual appearance and she seemed to do her best to exaggerate her masculinity as a result. She was known as a loner and an eccentric, and something of a crank, but her medical skills were widely appreciated, and she made the usual career advancements. She died in London, age 65, having been forced into retirement. It was the woman who took care of her body after her death who revealed her secret.
Of course, the revelation was a bit of an embarassment for her personal physician, who attempted to cover himself by proclaiming that for all he knew Dr. Barry might have been an "imperfectly developed man." It's this statement that Rachel Holmes uses to launch her argument that Barry was, in fact, a hermaphrodite. It's even less convincing than her estimate of the doctor's age and identity.
Her most vigorous argument in favor of hermaphrodism is the choice of dissertation by the young medical student - female hernias. Before imaging techniques were widely available, undescended testicles were often mistaken for hernias, and in women they were sometimes the means by which hermaphrodism was discovered. Holmes speculates that James Barry chose that topic because she had a hernia herself, and therefore an undescended testicle, despite no evidence of any such ailment. The author mentions references by Barry to "cushions" that she needed to use for personal reasons. Most authors have understood those to be sanitary pads. Holmes understands them to have been trusses for the care of a hernia. Sanitary pads seem more likely. And as for the choice of a dissertation, it isn't unusual for a young woman to choose a subject that would allow her to learn as much as possible about the female anatomy.
There are other problems with the hermaphrodite theory. The woman who prepared Barry's body for burial also noted that she had stretch marks, as if she had once had a child. This is dismissed by Holmes as a misinterpretation of the ravages of yellow fever and other tropical diseases. But those diseases don't leave stretch marks like those of pregnancy. And there are some details in Dr. Barry's life that suggest that she was once in love and perhaps had a child.
In 1816, at the age of 17 she was stationed in Cape Town, South Africa and quickly became a favorite of the widower governor, Sir Charles Somerset. The two became very close, so close that there were rumors that they were having a homosexual affair. In fact, the only duel Barry actually fought was in the aftermath of a confrontation with the governor’s aide-de-camp when he told her that she couldn't see the governor because he was busy with a prostitute. That's a revelation that one soldier would casually make to another, but not one that a woman in love would accept with equanimity. Sir Charles left for England in 1819, his departure marked by the absence of his close friend, whose whearabouts are unaccounted for in that year. Some have speculated that in that year, Dr. Barry absented herself from Cape Town to conceal a pregnancy. Sir Charles returned to Cape Town two years later with a socially suitable wife. Dr. Barry was there to greet him, but their relationship was a distant one thereafter. and she eventually left the Cape to further pursue her career.
So, why the eagerness on the part of Ms. Holmes to paint James Barry as a hermaphrodite? Well, for one thing, it gives the book a different angle than previous biographies and piques the interests of publishers and readers alike. But Rachel Holmes also sees Barry as a modern hero of sexual ambiguity. Neither man nor woman, she chose her own sex. But in truth, Dr. James Barry's story transcends her sex and her sexuality. She was a bold and brave heart who used her brains and her luck to forge a life denied her by her times. The fact that she was a woman is central to her heroism. It's a pity that her most recent biographer denies her that distinction. posted by Sydney on
2/09/2003 10:41:00 AM
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