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    Saturday, February 22, 2003

    First Annual: Visit Blogcritics for the first ever Critiquees - like the Grammy's, only better.
     

    posted by sydney on 2/22/2003 06:26:00 PM 0 comments

    The Suck-It-Up Gene: There might be a genetic explanation for different levels of pain tolerance:

    The gene makes catechol-O-methyl transferase (COMT), an enzyme vital for mopping up the dopamine brain chemical linked with sensing pain.

    Tough guys and wimps carry different forms of the gene, showed Jon-Kar Zubieta and his team at the University of Michigan and The National Institute of Alcohol and Alcoholism, Rocksville, Maryland.

    People with a particularly active form of COMT were hardier, whereas people with a lazier form felt pain more acutely. Those with both forms of the gene, one from each parent, experienced intermediate pain, the researchers found.


     
    posted by sydney on 2/22/2003 11:24:00 AM 0 comments

    They Almost Had Spines: Professional baseball physicians almost banned ephedra, but backed down in response to the players' union:

    According to the doctors and an executive with a major league team, who was also present, one doctor asked Gene Orza, the union's general counsel, why there was not more extensive testing of amphetamines provided for in the new labor pact.

    Orza's response, according to three of the doctors and the team executive, was, "In every labor agreement, there are dark corners, and I would suggest this is a dark corner you shouldn't look into."


    The players have a point, though. The stuff’s legally available over the counter, so why should it be banned? The problem is, it shouldn’t be available over the counter. It's a drug, no matter how "natural" it may be.
     
    posted by sydney on 2/22/2003 11:23:00 AM 0 comments

    In Another Nutshell: Jane Galt explains the economic consequences of too much government intervention in medical care:

    Nursing homes are almost entirely government funded, largely because middle class people feel it's the duty of the state to pay for their care, so they hollow out their assets to qualify for Medicaid. This is disgusting, yet entirely predictable, and completely unstoppable as long as the government pays for care. Yet the government is not willing to impose the taxes on the children to pay for their parents care, so instead they cut funding. This makes it very hard to operate a nursing home profitably, resulting in said children suing the nursing homes because Mom is tied to a wheelchair 23 hours a day. The resulting verdicts raise costs, which the nursing homes can't recover because most of their rates are set by fiat. Instead they turn to fraudulent billing to recover the money they lose on patient care. And they're still losing money. And people wonder why I'm a libertarian?

    A hearty “amen” to that.
     
    posted by sydney on 2/22/2003 11:21:00 AM 0 comments

    Medical Blog Alert: Yet another physician joins the blogosphere. Check out The Minor Groove.
     
    posted by sydney on 2/22/2003 11:20:00 AM 0 comments

    Litigation Epidemic? A reader sent this account of the jury selection for his malpractice trial, which took place in a city that has a reputation for both aggressive attorneys (aggressive in that they sue indiscriminately and advertise liberally) and high jury awards:

    One of the questions the judge asked these twenty five people is, "How many of you have filed or are in the process of filing a medical malpractice suit, personal liability claim, or disability claim?" 12/25 jurors raised their hands. Just about 50%. I was stunned. At this point the judge individually polled each of those people who had raised their hands. There was a total of 17 various claims amongst these 12. These included:

    -asbestos class action. When the judge asked this guy if he was ill and receiving medical care, the guy looked back at the judge like he'd just grown two heads, and said no, just class action.

    -pending suit against a local hospital for death of a daughter, from injuries sustained in a car crash

    -case pending against the another local hospital for damage to an arm, I don't recall the specific circumstances

    -multiple car accidents

    -at least, 4 cases of breast cancer related difficulties

    -financial scam victims


    That's a whole lot of suing going on.
     
    posted by sydney on 2/22/2003 08:41:00 AM 0 comments

    Mail Bag: Comments from readers on last week’s posts:

    On British Heart Disease:

    A number of my English friends (middle-aged men) have had the beginning signs of heart problems. All now have private health insurance, which luckily is laughably cheap there by American standards. Last time I was visiting, I asked my friends if they were getting regular screenings. Apparently the NHS does not go for regular cholesterol or even blood pressure tests, nor for regular physicals (nor are there similar privately-run programs such as found in many American cities and workplaces).


    On Iraq and Snakes:

    There is no "snakier" place than Southeast Asia. One briefing I went to began with the briefer stating "There are 100 deadly species of snake in Southeast Asia: 98 are deadly poisonous, and the othertwo just swallow you whole." We survived that...

    On Sex, AIDS, and Africans:

    I was a Special Forces medic in the 1960's, and I not only vivdly recall the practice of local clinics re-using needles, I can remember some cases in which small operators did not even WASH them between patients. This was in SouthEast Asia, but I know people who worked in Africa, and the situation is the same. Compounding the problem is the fact that a lot of the patients do not believe that they have REALLY been treated unless they have received a "shot" (or even an IV infusion), often for very commonplace and self-limited problems.

    Not to be too hard on the "Third World", I also remember when we (in the Army, at least) were still re-using needles. I can still clean the blood from an infusion needle with a wire stylet, sharpen it on an Arkansas stone, check for barbs using a cotton ball, and re-sterilize it. In a true "mass casualty" situation, skills like this are going to be invaluable. We may not always have an endless supply of disposable equipment- but that is another subject. Regarding African AIDS, I have long suspected that this was the case (ie, dirty needles). The relentless politicization of this disease has ill-served many millions of people worldwide, I think.


    If I were bleeding to death, or had meningitis and need IV antibiotics, and the only thing standing between me and life-saving therapy was a dirty needle, I’d take the needle. But, if someone came knocking at my door and wanted to immunize my children with a dirty needle, I’d pass. Which makes me wonder - is it still common practice in Africa and Southeast Asia to reuse needles? If so, then that casts the refusal of parents in those places to immunize their children in a whole new light.
     
    posted by sydney on 2/22/2003 08:34:00 AM 0 comments

    Friday, February 21, 2003

    Sex, AIDS, and Africans: A new study suggests that the African AIDS epidemic is from poor medical hygiene (i.e. reusing needles for injections) more than sexual promiscuity:

    Research published by US experts indicates that the spread of HIV infections in Africa may be more closely linked to unsafe medical care than previously thought.

    The report challenges widely held scientific views on the spread of the virus that can cause Aids.

    It estimates that two-thirds of the people with HIV in Africa become infected mainly through contaminated needles rather than through sexual contact.

    The UNAids organisation disputes the findings, and says there have not been adequate studies to support the conclusions that are drawn.


    My very first thought when I read this was, “My God! Medical professionals reuse needles in Africa?” My second thought was, “Why would any organization object to the findings?” It’s much easier to provide clean needles than to change people’s sexual behavior.

    Then, I read the study. It turns out that the crux of its argument is that before 1988, when the public health community adopted a consensus opinion that AIDS was transmitted in Africa mostly through heterosexual sex, there was plenty of statistical evidence that the HIV epidemic in Africa was caused by dirty medical needles. That evidence, according to the authors, was not only ignored, but suppressed by the world public health community:

    First, it was in the interests of AIDS researchers in developed countries—where HIV seemed stubbornly confined to MSMs [homosexuals - ed], IDUs [IV drug users -ed], and their partners—to present AIDS in Africa as a heterosexual epidemic; ‘nothing captured the attention of editors and news directors like the talk of widespread heterosexual transmission of AIDS’ ... In a prominent 1988 article in Science, Piot and colleagues generalize with arguably more public relations savvy than evidence that ‘Studies in Africa have demonstrated that HIV-1 is primarily a heterosexually transmitted disease and that the main risk factor for acquisition is the degree of sexual activity with multiple partners, not sexual orientation’. Second, there may have been an inclination to emphasize sexual transmission as an argument for condom promotion, coinciding with pre-existing programmes and efforts to curb Africa’s rapid population growth. Third, ‘the role of sexual promiscuity in the spread of AIDs in Africa appears to have evolved in part out of prior assumptions about the sexuality of Africans’, as Packard and Epstein document in a regrettably ignored 1991 article. Fourth, health professionals in WHO and elsewhere worried that public discussion of HIV risks during health care might lead people to avoid immunizations. A 1990 letter to the Lancet, for example, speculated that ‘a health message—eg, to avoid contaminated injection materials—will be misunderstood and that immunization programmes will be adversely affected’ . In short, tangential, opportunistic, and irrational considerations may have contributed to ignoring and misinterpreting epidemiologic evidence.

    That’s pretty strong stuff. The authors are charging that WHO and other public health groups ignored the evidence of an easy solution to stemming HIV spread because of their preconceived notions about Africans - that is, their prejudices.

    Some of the highlights of the study:

    HIV and STDs: According to the authors' data, African HIV did not follow the pattern of sexually transmitted disease (STD). In Zimbabwe in the 1990s HIV increased by 12% a year, while overall STDs declined by 25% and condom use actually increased among high-risk groups.


    Infection rate: HIV spread very fast in many countries in Africa. For the increase to have been all via heterosexual sex, the study claims, it would have to be as easy to get HIV from sex as from a blood transfusion. In fact, HIV is much more difficult than most STDs to transmit via penile-vaginal sex.


    Risky sex? Several general behaviour surveys suggest that sexual activity in Africa is not much different from that in North America and Europe. In fact, places with the highest level of risky sexual behaviour, such as Yaounde in Cameroon, have low and stable rates of HIV infection. "Information…from the general population shows most HIV in sexually less active adults" .

    Children and injections: Many studies report young children infected with HIV with mothers who are not infected. One study in Kinshasa kept track of the injections given to infants under two. In one study, nearly 40% of HIV+ infants had mothers who tested negative. These children averaged 44 injections in their lifetimes compared with only 23 for uninfected children.


    Good access to medical care: Countries like Zimbabwe, with the best access to medical care, have the highest rates of HIV transmission. "High rates [of HIV] in South Africa have paralleled aggressive efforts to deliver health care to rural populations".


    Riskier to be rich: Most STDs are associated with being poor and uneducated. HIV in Africa is associated with urban living, having a good education, and having a higher income. In one hospital in 1984, the rate of HIV in the senior administrators was 9.2%, compared with the average employee rate of 6.4%.


    The authors conclude:

    At issue in a reevaluation of the heterosexual hypothesis are the profound implications for our interventive approach, and for the kinds of social and financial commitments that must be made. Finally, Africans deserve scientifically sound information on the epidemiologic determinants of their calamitous AIDS epidemic.

    At the very least Africans deserve what even Western junkies are provided - clean needles. Maybe someone should set up a needle exchange program for African healthcare providers.

    UPDATE: A reader who once practiced medicine in Africa sends the following:

    I worked four years in two African countries twenty years ago. Let me tell you the facts.

    One, many untrained or minimally trained people set themselves up in practice, including traditonal healers. In our area, the N'gangas and the local anti government guerllas would give penicillin shots, and vitamin B shots. This was before HIV waas recognized, of course. I suspect even today a lot of people get shots from these folks, or other treatments (see below) instead of going to a clinic. Needless to say, they don't sterilize needles.

    Second, our clinics "sterilized" needles over a coleman type stove, boiling water, not a autoclave. Our clinics were run by people with 7-10 years of school and four years medical assistant training. They tried hard, but I don't guarantee they sterilized everything properly.

    Third, although we were rich enough to use sterile needles each time, we often reused the same syringe over and over. Glass syringe, of course, and took the needle from a metal autoclaved box where they were lined up one by one.

    We rewashed dressings: If they were very dirty, we burned them, but the parts that weren't touching skin we redressed. But a wound from the outside would often come in dressed with a rag. And we were rich: I usually had gloves, (read the first chapter of When the band played on, where the doctor did not have gloves)

    Finally, traditional medicine treated pain with "muti cuts". We could always tell where it hurt, because there were shallow cuts where herbs had been rubbed in. It's similar to moxification, i.e. counterirrtant therapy for pain. The local women often had scarification for cosmetic reasons. They made shallow cuts, used some herb, and had lovely decorations of keloid tissue on their abdomens. I doubt any of these knives were sterilized.

    We DID see syphillis and other STD's back then. But not at the rate that one sees HIV nowadays. Genital sores increase transmission, of course, but most cases came from the cities, so I suspect some cases are indeed due to partially trained people giving shots.

    In other words, don't blame the hospitals and clinics. Blame poverty.


    She brings up a point that I didn't make clear enough in the post, and which the researchers also mention in their paper - a lot of healthcare in Africa is done by people with little training. Of course poverty is the reason they reuse needles, but you would think that providing disposable needles and educating the people who use them would be a priority of the same international aid organizations that provide the medications and the immunizations.

     

    posted by sydney on 2/21/2003 05:57:00 AM 0 comments

    Preparedness Update: The Reading Room at The Medical Letter has posted information about how to respond to chemical agents and the proper use of potassium iodide. Or, for the more visually-oriented, there’s this.
     
    posted by sydney on 2/21/2003 05:56:00 AM 0 comments

    In a Nutshell: Iain Murray sums up the relationship between science and the courtroom:

    Scientists come up with a tentative set of research results. The subsequent press release spins the results so as to grab public attention, which presumably will help gain more funds for further research.

    In the meantime, the resulting headlines are seized on by litigators, who take the issue out of the realm of scientific research and into courtrooms. The scientific process is pre-empted and the search for truth suffers while people go after a quick buck. And, doubtless, some people will grow fat on the proceeds.
     
    posted by sydney on 2/21/2003 05:55:00 AM 0 comments

    The Wonderful World of Government Run Medicine: From
    Numbers Watch, a British web site:

    Everyone (except the Chancer) knows someone who works in the NHS and is well aware of the demoralisation and despair that afflicts these dedicated people. In the NHS there are now eight managers for every ten nurses. No need to ask what they all do. They collect statistics and develop new and more creatively fraudulent ways of trying to demonstrate that Government targets are being met. [emphasis mine]

    It’s been my experience that, at least in medicine, the more managers (or administrators) there are, the higher the cost of doing business, and the less efficient the practice. Ask any doctor who’s had his practice bought by a hospital. Most describe their new practice as "hospital ruined".

    But governments interfere even more, at least in Britain. It seems that Welsh and English patients are treated differently, even when they attend the same hospital:

    Different waiting list targets set in London and Cardiff mean that the maximum waiting times for English and Welsh patients are different. In Wales, the target is that no one should wait more than 18 months for an orthopaedic operation. In England the target is currently 15 months and will drop to 12 months in March.

    In true bureaucratic form, those maximum waiting times are taken as the standard, rather than the limit:

    "The consequence is that routine Welsh patients are less likely to get their operation within a year than are patients in England. It is a big problem for us and we are desperately trying to get things resolved so the target times are the same. There is lot of goodwill and we are hopeful."

    Not surprisingly, the Welsh patients are none too happy:

    "We pay as much as our English counterparts towards the health service so we deserve parity. I think it is a disgrace I have to wait 18 months in pain for an operation while people in England attending the same hospital as me only have to wait about 12 months. I’m being discriminated against."
     
    posted by sydney on 2/21/2003 05:50:00 AM 0 comments

    Thursday, February 20, 2003

    Good News: Jesica Santillan is getting a second chance.
     

    posted by sydney on 2/20/2003 08:25:00 AM 0 comments

    Comic Strip Medicine: My Tech Central Station column is up.
     
    posted by sydney on 2/20/2003 08:24:00 AM 0 comments

    Rule Britannia: Britain leads Europe in deaths from heart disease:

    Britain has one of the highest death rates from heart disease in Western Europe but offers less treatment to sufferers than its neighbours, specialists said yesterday.

    Experts speculate on the reason for the difference:

    Professor John Martin, consultant cardiologist at University College London and spokesman for the ESC, said it was likely that genetic differences made Northern Europeans more susceptible to heart disease than those from further south which, when combined with differences in lifestyle, accounted for the difference in death rates. "Having high cholesterol levels might have helped us survive the winter in the past but now it is working against us," he said.

    Or maybe it's just because the British eat stuff like this.

    And then, there's this interesting statement:

    ESC research showed that only a fifth of doctors in France and Poland adhered to guidelines compared to a third in Germany, and Italy and three quarters of doctors in Spain and the UK. Professor Martin said: "We make an objective assessment of the risk based on measures including cholesterol level, blood pressure and smoking while doctors from most other countries do it by the seat of their pants.

    So, the doctors who practice "by the seat of their pants" achieve lower mortality rates than the ones who follow guidelines stringently? So much for guidelines.
     
    posted by sydney on 2/20/2003 08:18:00 AM 0 comments

    Natural Dangers: ABC points out that Iraq is full of snakes, and not just human ones. It's kind of a strange piece. If the weapons of mass destruction don't destroy the army, the snakes will. But, as an Army scientist points out, the U.S. Army already has a pretty comprehensive snake-avoidance policy. In addition to wearing combat boots, they do this:

    "Our policy is don't mess with any snake. Just assume it's dangerous," he said. "Don't play with them and don't try and show off with one. That's when you get hurt."

     
    posted by sydney on 2/20/2003 08:16:00 AM 0 comments

    Overcoming Adversity: This story about Iranian girls who dress like boys reminded me of women in other centuries who did the same. Like women in other centuries, Iranian girls resort to the masquerade when they have no other choice to survive:

    It is not an act of rebellion by Westernized feminists determined to buck the system and cast off the headscarf. Rather, it is a growing phenomenon mainly among lower-class runaways who believe that the disguise gives them a degree of freedom and protection they could not enjoy as girls. Posing as boys on the streets makes it easier to avoid rape and falling victim to prostitution rings.

    And sometimes, doing so gives them a chance to excel in careers denied them:

    Dressing and acting like a boy can bring other benefits, like jobs. One runaway who dressed as a boy easily got a job as an apprentice at a car repair shop in Tehran, something that would never happen if she were a girl.

    "When I asked her why she cross-dressed she said she was able to be successful in the workplace as a boy," Ms. Shirazi said. "This is the way our society thinks about boys."


    They aren’t homosexuals, who are illegal. They aren’t transsexuals, who are encouraged to have sex-change operations. (Or so the article claims. More about that later.) They’re women through and through. One girl explained to her psychiatrist:

    "Why did you dress like a boy?"

    "I was more comfortable like this," she said. "No one bothered me. I wouldn't have been able to survive in women's dress. I would have been finished by now."

    The doctor explained that she would have to undergo some blood tests, a standard procedure in such cases to rule out transsexuality.


    Only one problem. Transsexuality can’t be ruled out by blood tests. Only hermaphrodism can.
     
    posted by sydney on 2/20/2003 08:13:00 AM 0 comments

    Wednesday, February 19, 2003

    JAMA's weekly art history lesson.
     

    posted by sydney on 2/19/2003 09:07:00 PM 0 comments

    Dosage Counts: Derek Lowe has an excellent post about recent work suggesting that small doses of toxic substances aren’t, well, toxic.
     
    posted by sydney on 2/19/2003 09:06:00 PM 0 comments

    Soothing an Irritation of the Nerves: Most people with seizure disorders can control the random firing of neurons in their brains with medication. When that fails, they can try surgery. Brain surgery for epilepsy gets the most press, but there’s also the vagus nerve stimulator:

    A battery-powered stimulator -- about the size of a silver dollar -- is implanted in the upper left chest, sometimes under the collar bone. Every few minutes, the stimulator sends 30-second pulses of electricity through thin wires that run under the skin to the left vagus nerve, which carries the electrical signal into the brain.

    If patients feel a seizure coming on, they can wave a magnet over the battery to stimulate the nerve and stop the seizure.


    The procedure involves wrapping an electrode around the vagal nerve as it passes through the neck. The electrode sends electrical signals backwards along the vagus nerve to the brain. The vagus nerve’s site of origin in the brain is close to a lot of other areas that are responsible for seizure activity. The incoming electrical impulse from the stimulator confuses those adjacent brain areas and aborts their seizure signals somehow.

    It isn’t a panacea. It doesn’t take away seizures completely:

    Dr. Henry Bartkowski, a neurosurgeon at Children's Hospital Medical Center of Akron, says doctors want people to understand that vagus nerve stimulation is not a cure. Rather, it is a way to have fewer, less severe seizures and to take fewer medications, at least in most cases.

    Unfortunately, one in three patients sees no improvement at all with the stimulator.


    It also isn’t without side effects:

    Since the vagus nerve controls heart rate, breathing, stomach secretions, the windpipe and the voice, stimulation of the nerve can have an effect on any of those areas. Most common is a raspy voice if the stimulator turns on while the patient is talking. Some people can have trouble sleeping. Few people have heart rhythm problems.

    Still, if you’re having twenty seizures a day, and it can decrease that to three, I suppose it would be worth the try.
     
    posted by sydney on 2/19/2003 09:03:00 PM 0 comments

    Keeping an Open Mind: Andrew Sullivan read this story about brain activity during problem solving and came to the conclusion that all intelligence is innate and fixed:

    We're beginning to be able to measure such intelligence not simply from the results of written or practical tests but from live imaging of actual brain activity. Egalitarian ideologues have long resisted the notion that there is such a thing as general intelligence and that it is at least partly hard-wired and inherited. But as science advances, and our understanding of working memory and intelligence deepens, the evidence for such intelligence could become irrefutable. Imagine at some distant date going into an exam room and getting hooked up to brain monitors. No need for grad students grading papers. No need for SAT results. Just a brain scan to check how smart you are. Fantasy now. But you can already see the implications of current research. Blank slaters, be afraid. Your time is running out.

    Whoa, cowboy. The research doesn’t even support the fantasy, let alone the reality. What it did was find areas of the brain that are put into use during complex problem solving and reasoning - what’s called “fluid intelligence.”:

    The Washington University study included 48 participants, all healthy, right-handed, native English speakers between the ages of 18 and 37, about half men and half women. Each participant was administered a standard test of fluid intelligence, known as Raven's Advanced Progressive Matrices. Each participant was then asked to perform the word and face "mental juggling" tasks while lying inside an fMRI scanner. Each task tested a kind of short-term memory known as "working memory."

    The intelligence test was done to see if standard measures of intelligence corresponded with the ability to perform the challenging mental gymnastics of the study well. Here’s a description of the gymnastics:

    To get a sense of how the task works, ask a friend to read the following words to you at a rate of about one word every 2.5 seconds: dog, cat, chair, table, cat, door, chair, dog.

    For each word that you hear, make a mental note of whether it is the same word as you heard three words previously. That is, compare the fourth word you hear to the first, the fifth word to the second, and so on. (For the first three words, there is nothing to compare them to, so just remember them for later.)

    The participants in the study had to do a similar task, except that it involved viewing a series of either unrelated words or unfamiliar faces on a computer screen, one word or face every few seconds. Participants had to press a button to indicate whether or not the word or face on the screen matched one shown exactly three previously.

    The task is challenging, but the researchers included some especially tricky "lure" items that were even more difficult. These were words or faces that had been shown two, four, or five previously in the sequence, but not three previously.

    For example, the second time the word "chair" appears in the list above is a lure. The lure items are easily confusable for an item seen three previously. The mere fact that the word or face was seen recently is salient and hard to ignore.


    The people who did that task the best also happened to score higher on the intelligence test .Their scans also showed increased activity in certain regions of the brain while they were performing the task.

    You could say the study maps concentration. It doesn’t demonstrate that brain scans can predict or record intelligence. The mind has to be engaged in a problem for the scan to see the difference between good problem solvers and poor problem solvers. It’s no different than a written test in that respect.

    Nor does it prove that intelligence is innate and predetermined. One of the most amazing things about the mind is its ability to adapt and learn new things. Pathways in the brain are constantly changing and reshaping in response to our learning. That’s how stroke victims learn to talk and walk again, and how amputees learn to use their remaining arm as well as they once used the lost one. There’s nothing in the research to suggest that people can’t learn to recruit those regions of the brain that the good problem solvers used. Blank slaters still have hope.
     
    posted by sydney on 2/19/2003 08:57:00 PM 0 comments

    Errors: This is just sad beyond words sad beyond words. The Times story doesn’t mention it, but CNN's account suggests that a clerical error may have listed the teenager on the wrong transplant list.

    Some will see this case as a reason not to cap punitive damages. But what would be gained by giving her family millions of dollars? The money won’t give them their daughter back. It won’t regain the chance of a cure. On the other hand, a multi-million dollar punitive damage award could deprive many other people of the chance of a cure at that transplant program or that hospital.

    The money for those kinds of awards has to come from somewhere. Most insurance companies limit the amount of liability they’ll cover. Anything beyond that has to be paid by the hospital or doctor. An excessively large award could force a hospital into bankruptcy, or could result in across the board budget cuts that hurt the quality of care or the accessibilty of programs for other patients. Either way, thousands of others suffer because of one large award.

    This is the first time in thousands of transplants that the hospital has had this kind of error happen. Would it really be just to ruin it financially as punishment?
     
    posted by sydney on 2/19/2003 08:55:00 PM 0 comments

    Ephedra Strikes Again: The recent death of Baltimore Orioles pitcher Steve Bechler from heat stroke may have been caused by ephedra:

    Broward County Medical Examiner Joshua Perper said on Tuesday his investigation found that Bechler was taking three pills each morning of Xenadrine, a supplement that contains ephedrine, a stimulant that has been linked to other deaths.

    Ephedra, in addition to increasing metabolism, interferes with the body’s ability to regulate heat. It’s about time the FDA took action against it. Better yet, it’s time Congress revisits the issue of herbal “supplements” and treat them like the drugs they are.
     
    posted by sydney on 2/19/2003 08:52:00 PM 0 comments

    Med News Service: Steve Hoffman of Medscape, announces a new program from the internet medicine news source. They now have a news crawler service that will bring breaking medical news to your desktop.
     
    posted by sydney on 2/19/2003 08:50:00 PM 0 comments

    Apologies: Sorry about the lack of blogging. Couldn't access Blogger for most of the day. Can't help but wonder if it has anything to do with that Google buy-out.
     
    posted by sydney on 2/19/2003 08:40:00 PM 0 comments

    Tuesday, February 18, 2003

    Equal Treatment: OK, women of the world, no more complaining that men never have to suffer anything as humiliating and uncomfortable as a pap smear:

    Some doctors and researchers at major medical centers have started to recommend that gay men undergo regular anal Pap smears to screen for cell changes that could lead to anal cancer.

    Ouch.
     

    posted by sydney on 2/18/2003 05:46:00 AM 0 comments

    Broken Hearts: Like DB, this new test for diagnosing heart attacks took me by surprise. It’s a blood test based on an easily measured protein in the blood, albumin. In a healthy person, cobalt binds easily to albumin taken from the blood, but for some reason, when the heart muscle has been damaged, it doesn’t. The new test measures the ability of a sample of serum albumin to bind cobalt, supposedly improving the diagnosis of heart attacks, when combined with EKG’s and troponin levels:

    In a study of 200 patients, doctors were 50 percent accurate in ruling out a heart attack using just an EKG and troponin test. But when they added the new test, doctors accurately ruled out a heart attack 70 percent of the time, FDA said.

    Hmmm. Here’s what I’m saying to myself. I’ve got a thirty-percent chance of sending this patient home with a heart attack, even though all of his tests are OK. A thirty percent chance that I’ll be reading his obituary in a couple of days or leaving him a cardiac cripple. Or getting sued. Am I going to send him home? Nope. Sorry. Odds just aren’t good enough in a life or death situation. I’m going to admit him and do all the usual tests to be certain I’m not missing the one in three.

    Now, if I have a patient with a normal EKG and normal troponin, but an abnormal albumin cobalt binding test, I might be more inclined to put him in the cardiac intensive care unit and to get a cardiology consult. But then, according to one study, the albumin cobalt binding test may be abnormal in the presence of any tissue hypoxia:

    A third issue is that unlike troponin, ACB [albumin cobalt binding] Test measurements do not indicate necrosis; rather, ACB measurements reflect modifications in the NH2 terminus of albumin produced by extracellular hypoxia, acidosis, free radical injury, and sodium and calcium pump disruptions. Therefore, ischemia in the absence of necrosis may cause bias toward apparent false-positive ACB data by yielding a positive ACB Test result associated with a negative cTnI.[troponin]

    Sigh. Nothing’s ever straightforward, is it?
     
    posted by sydney on 2/18/2003 05:44:00 AM 0 comments

    Dulce Vita: A derivative of the vitamin thiamine may slow down complications of diabetes.....at least in rats:

    Diabetic rats were treated with benfotiamine and compared to animals left untreated and a diabetes-free group. The rats receiving no treatment developed diabetic retinopathy within nine months, a condition in which the blood vessels of the eye deteriorate, leading to blindness. The eye tissue in the treated rats remained as healthy as in rats that did not have diabetes.

    ..Researchers also reported benfotiamine produced a similar protective effect in the kidneys of the diabetic rats. Kidney failure is one of the top leading causes of death among diabetics.


    But don’t worry. It’s pretty harmless if you want to give it a try. As one of the researchers put it:

    "Thiamine is water soluble and you pee it out if you get too much of it."

    Not sure if the same holds true for its derivative, though.
     
    posted by sydney on 2/18/2003 05:42:00 AM 0 comments

    Choices: DB and Doc Notes had a brief dialogue about our healthcare insurance system this past weekend. This from Doc Notes, who favors a single-payer government-run healthcare system:

    Our system requires me to reach right into my own pocket and provide services, medications, etc .. for our patients without the means to pay for it themselves. Sure .. I can do this once in a while .. But I can't do it too often . or I won't be able to pay the nurses or the rent or pay for my kids braces.

    No .. I dont' drive a Mercedes. I drive a 1993 Saturn.


    I, too drive a Saturn. But here’s a sad truth. Some of my patients without insurance drive Mercedes. Not all, but some. And they whine the loudest about paying for their healthcare. I feel no more obligated to give them free healthcare than I would to pay for their food or their house. I don’t mind providing subsidized care or even discounted care to the truly impoverished, but I don’t want to provide free care for everyone, or submit to complete government control of medicine.

    We have an insurance program for the poor - Medicaid (and sometimes Medicare, but that covers the wealthy, too.) The majority of the uninsured are employed. They just either can't get it through their employer or they're self-employed and unable to purchase insurance. A better solution would be to make health insurance affordable for those who aren't able to obtain it from their employer. A better solution would be a plan like this.
     
    posted by sydney on 2/18/2003 05:34:00 AM 0 comments

    Monday, February 17, 2003

    Happy President's Day
     

    posted by sydney on 2/17/2003 07:26:00 AM 0 comments

    The Power of the Mind: The mind's ability to control the body never ceases to amaze. Researchers say that people who believe they've been abducted by aliens show all the hallmarks of genuine post traumatic stress disorder. In fact, they get just as physically distressed by recreating their abduction as combat veterans are by recreating battle scenes. The alien abductees share some common characteristics that may make them vulnerable to believing in their abductions:

    Professor McNally has found that many of them share personality traits and sleep disorders.

    "Most of them had pre-existing new-age beliefs - they were into bio-energetic therapies, past lives, astral projection, tarot cards, and so on," he said.

    "Second, they have episodes of apparent sleep paralysis accompanied by hallucinations."

    These frightening experiences usually prompted the individuals to visit therapists, who would frequently suggest alien abduction as a cause - an explanation which the abductees readily accepted, he said.


    Or maybe they really were abducted.......
     
    posted by sydney on 2/17/2003 07:23:00 AM 0 comments

    Recall Alert: For those with peanut allergies, Canada has recalled certain chocolates that may have peanuts in them. None of the names sound familiar to me, but for Canadian readers, there you are.
     
    posted by sydney on 2/17/2003 07:09:00 AM 0 comments

    Point of View: An excellent piece on what it means to be disabled:

    I used to try to explain that in fact I enjoy my life, that it's a great sensual pleasure to zoom by power chair on these delicious muggy streets, that I have no more reason to kill myself than most people. But it gets tedious.

    ....But they don't want to know. They think they know everything there is to know, just by looking at me. That's how stereotypes work. They don't know that they're confused, that they're really expressing the discombobulation that comes in my wake.

    ..Are we ''worse off''? I don't think so. Not in any meaningful sense. There are too many variables. For those of us with congenital conditions, disability shapes all we are. Those disabled later in life adapt. We take constraints that no one would choose and build rich and satisfying lives within them. We enjoy pleasures other people enjoy, and pleasures peculiarly our own. We have something the world needs.


    This particular person is a lawyer and an activist for the rights of the disabled, including their right not to be put to death. Not at the end of life. Not at the beginning. She describes what it’s like to meet Peter Singer, animal rights, euthanasia, and infanticide enthusiast. Her end-analysis of the man - nice but flawed:

    But like the protagonist in a classical drama, Singer has his flaw. It is his unexamined assumption that disabled people are inherently ''worse off,'' that we ''suffer,'' that we have lesser ''prospects of a happy life.'' Because of this all-too-common prejudice, and his rare courage in taking it to its logical conclusion, catastrophe looms.

    The fact that he’s nice and that his prejudice is common should not exonerate the man from taking responsibility for the consequences of his ideas. As the author’s sister points out, lots of Nazis were nice people, too. In fact, so was Hitler. He just didn’t think Jews, or disabled Aryans for that matter, were people. He shared Peter Singer's all-too-common prejudice.
     
    posted by sydney on 2/17/2003 07:00:00 AM 0 comments

    Why Patients Aren’t Consumers: And doctors aren’t merchants. This is a rant I’ve been meaning to put down for a long time, especially after listening to a plastic surgeon on ABC analyze Michael Jackson’s face. She used phrases such as “end-stage nose” and “nasal cripple,” in ways that indicated they’re in standard use among plastic surgeons. But when the reporter asked why a surgeon would do that much surgery on someone, she refrained from criticism. Instead, she made excuses, saying the plastic surgeon’s job is to give the patient, his customer, what he wants. If he wants an ever-narrower nose, then it’s the doctor’s duty to give it to him. Even, apparently, if it’s likely to be to his detriment.

    Then, comes this story about the use of an unapproved wrinkle treatment by plastic surgeons. It’s illegal to use it in the US, but plastic surgeons use it anyway, because their patients demand it. (And because, at $750 to $1,500 per treatment, it’s lucrative.)

    This sort of consumerist attitude isn’t unique to plastic surgery, unfortunately. Too often, we give in to the temptation to “give the patient what they want.” From the prescription for unneeded antibiotics, to the overuse of sedatives and narcotic analgesics, to treating ailments over the phone without ever examining the patient, most of us have been guilty of it at some time or other.

    But our motto shouldn’t be “the customer is always right,” because the customer often isn’t right. What the patient thinks is indigestion may really be a heart attack; the stomach flu an appendicitis; or the chest cold a pneumonia. It’s our duty to make sure those symptoms are properly diagnosed once they’re brought to our attention. To do otherwise is to betray our patients' trust.

    As one woman who uses the illegal wrinkle injection put it:

    "I trust my doctor. And after all the work and money we have put into my face, she is not going to put anything in it that is going to make it fall apart."

    Might Michael Jackson have said the same thing?
     
    posted by sydney on 2/17/2003 06:56:00 AM 0 comments

    What Remains is the Truth: The New York Times Sunday Magazine had an interesting column on diagnostic uncertainty, an all too common reality of daily medical practice. Is it a virus causing that cough, that sinus congestion, that fluid behind the ear drum? Or is it a bacteria that warrants antibiotic therapy? Most of the time, it’s an educated guess.

    The column, however, dealt with a much more serious uncertainty, the diagnosis of rheumatic fever. Rheumatic fever is difficult to diagnosis. There isn’t a blood test for it. It isn’t marked by one distinct symptom or physical sign. Instead, the diagnosis relies on a constellation of symptoms and signs that are backed up by evidence of a recent streptococcal infection. We don’t see it much these days, as the article points out. But, if it’s missed, the consequences can be devastating. In this case, the patient had a lot of risk factors that suggested other causes of inflammed and tender joints, such as gonorrhea. But, nothing panned out, and all that was left was the improbable.

    Medical diagnosis works this way more than most people realize. There are a few illnesses that announce themselves immediately, but there are many more that require much detective work. As Sherlock Holmes put it, “When you have eliminated the impossible, whatever remains, however improbable, must be the truth.” No coincidence that the author of those words was a physician.

    Sometimes patients grow impatient with the process, and give up before it’s completed. I’ve seen people who have left their doctors in mid-workup with exasperation, not realizing how close they were to having a final answer. All that remains for me in those cases, is to perform the final step. It makes me look unjustly good, but I know that there are an equal number of my own patients who have left me under similar circumstances, and who are singing the praises of someone else for “finally” properly diagnosing them.
     
    posted by sydney on 2/17/2003 06:48:00 AM 0 comments

    Sunday, February 16, 2003

    Privacy Protection: Hospitals are bracing themselves for the onset of the HIPAA rules, which can include criminal penalties for breaches of patient confidentiality. No more releases to the media of the condition of injured celebrities, no more release to family members of the condition of relatives, no more information to clergy:

    ''If you call about Aunt Sally, they're not going to be able to tell you anything. It will be a big change,'' said Wilda Stanfield, spokeswoman for Centre Community Hospital in State College, Pa.

    The rules will have a particular impact on news organizations that routinely call hospitals to learn the condition of people injured in crimes, car accidents and other noteworthy events. Information will be available only if a patient agrees. If the patient is not available to say yes or no--say, in emergency surgery--most hospitals plan to keep information confidential.

    The rules also will affect members of the clergy, who often check hospital directories for members of their congregations.

    A delay, some warn, could make it harder for patients who receive daily communion and may depend on a visit from a priest or pastor.

    ''It will certainly reduce the amount of visitation that's done in the hospital,'' said Lerrill White, the chaplain at St. Luke's Episcopal Hospital in Houston and liaison to the Health and Human Services Department for the Association of Professional Chaplains. In most hospitals the rules should be workable, he said, but patients may need to adjust their expectations.

    ''Patients basically expect their minister, priest or rabbi is going to show up to pay their respects, offer help and prayers,'' he said.


    That isn't necessarily a bad thing. Patients really should be the ones who decide who should know about them. But, it could be a problem with older, demented patients, or those who are unconscious.
     

    posted by sydney on 2/16/2003 08:48:00 AM 0 comments

    Fight Fire With Fire: I don't know how much merit this suit has, but one West Virginia obstetrician is suing the Trial Lawyer's Association:

    The complaint alleges the lawyers association and president William L. Frame have "engaged in the institution of frivolous, nonmeritorious and malicious lawsuits against physicians in the State of West Virginia resulting in the unwarranted and stifling increase in the cost of professional liability."
    McCammon, an obstetrician/gynecologist, said Friday that since she started her practice in West Virginia in 1988, her insurance premiums have increased from $22,000 to $95,000 per year.


    She's representing herself. Not a good omen, although it does show courage. Does anyone who represents themselves ever win cases? Even if they're lawyers?
     
    posted by sydney on 2/16/2003 08:36:00 AM 0 comments

    Computerized Medicine Malfunction: Doctors at one California hospital have rebelled against their computerized ordering system. It slowed them down:

    The CPOE system also was cumbersome and didn't follow physician workflow, said Dr. Uman, who helped organize physician opposition. To order an antibiotic, for example, doctors had to go through three or four different screens and wait six to eight seconds between screens. "For somebody ... who has 15 to 20 patients in the hospital, when you add three or four minutes per order or five to 10 minutes per patient, that comes up to two or three hours of extra time a day," Dr. Uman said.

    Yikes. If only computer systems worked as reliably and as quickly in real life as they do on TV.
     
    posted by sydney on 2/16/2003 08:34:00 AM 0 comments

    Condoms Are Our Mantra: The Weekly Standard has a piece this week on the sexploitation of young girls, and the response of the public health to it - give out condoms:

    In January, the Mexican paper El Universal published a three-part series on the trafficking of Mexican girls to brothels--rape camps, really--near San Diego. Over a 10-year period, hundreds of girls, 12 to 18 years old, from southern Mexico were either kidnapped or tricked by three brothers into coming to the United States. The girls were sold to farm workers--between 100 and 300 at a time--in small "caves" made of reeds in the fields. Many of the girls had babies, who were used as hostages with death threats against them, so their mothers would not try to escape.

    An anonymous American doctor who worked for a community health clinic that provided health care to migrant workers said, "The first time I went to the camps I didn't vomit only because I had nothing in my stomach. It was truly grotesque and unimaginable." Over time, the girls got younger; a number were 9 and 10 years old. One time, the doctor counted 35 men using a girl in one hour. When the police raided the brothels, they found dozens of empty boxes of condoms, each box having held a thousand condoms. Calculate how many rapes that represents.

    Yet for five years, under instruction from her supervisor, the doctor worked with the pimps "to prevent HIV/AIDS and other venereal diseases in the exploited minor girls." When she reported the horrific activities, she was told prostitution was not a migrant health concern. She said, "I fought a lot with the U.S. government and they told me that I shouldn't do anything, that I had signed a federal agreement of confidentiality." She said, "If I wanted to help these girls I had to develop a relationship with the pimps. . . . I had to convert myself into someone who doesn't judge, who doesn't express opinions."


    Heaven forbid we make any moral judgements. Especially when it involves other cultures. And it should be noted, reporting sexual abuse of this sort is mandatory when it happens to a child who also happens to be a US citizen. But the policy of the community health clinic was to give out condoms for protection instead. Condoms may protect against sexually transmitted diseases, but they sure won't protect against the emotional trauma of being a child sex slave.
     
    posted by sydney on 2/16/2003 08:31:00 AM 0 comments

    In The Critics Corner: Lots of stuff at Blogcritics worth checking out, including ways to support democracy in Iraq, an anti-war celebrity speaking sensibly, and my own review of some recently aquired CD’s, including Cowboy Nation: We Do as We Please, and Jane's Hand: The Jane Austen Songbook, among others.
     
    posted by sydney on 2/16/2003 08:11:00 AM 0 comments

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