"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
Limits: A prestigious Pittsburgh hospital stands accused of processing fraudulent pap smears. Well, not really. What they're really be accused of is rubber-stamping normal pap smears:
Filed this week by a former Magee pathologist and two women, the suits claim doctors' electronic signatures were used to mislead patients into thinking that their Pap smears were being reviewed by physicians when the doctors had never seen the tests.
They're going to have a tough time proving that any damage was done by using electronic signatures. How many women actually look at their pap smear results? They usually just get a call or a card from their doctor saying all was normal, or they get a call telling them something was wrong. Very few actually look at the printed page and say, "Whew. Signed by a pathologist. Must be accurate."
I've always taken it for granted that pap smears were reviewed by technicians and that pathologists only look at them if the techs find an abnormality. In fact, that is standard practice, and it isn't necessarily a matter of neglect, but of necessity. There aren't enough pathologists in the world to review every single pap smear slide done in the United States each day. The pathologistis are still accountable for the work of the technicians (they periodically review random paps for quality control.)
Sounds like this is mostly the acting out of a disgruntled employee (the pathologist filing the original suit was fired from the lab) who has managed to pull along a couple of patients with her into her mad lawsuit dance. posted by Sydney on
12/20/2003 04:23:00 PM
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Influenza Update: The flu this season seems to have been especially rough on children:
At least 42 children and teenagers have died of the flu so far this year, fueling concern that this outbreak may be unusually dangerous for young people, federal health officials said Friday.
Although it isn't clear if that number is any different than past flu seasons:
In a typical year the flu kills about 36,000 Americans. Although there are no national statistics, one estimate calculated that about 92 youngsters younger than 5 succumb in an average year.
"So the fact that we have identified a total of 42 children this year of a much broader age distribution . . . is certainly within the estimates of that mathematical model. But it's just too early in the year to really draw any conclusions," Gerberding said.
First, apparently the Spanish Flu actually first showed its ugly head in the USA while our troops were in training for WWI, at the time it was a mild flu. We took it to Europe, while there the strain did what flu viruses do so well, it mutated. When it came back to the USA, with those returning from the war, it was a deadly virus. It apparently needed no help from secondary bacterial infections to kill healthy young adults.
Second, while you mentioned the issue with trial lawyers and law suit impacting the vaccine industry, it is an issue that is as serious as the war on terror. Because of a slight risk, usually knowable, parents are opting out of having their children vaccinated at a time when, regardless of the war on terror, vaccines are as important as ever. Some childhood diseases that were quite rare in the past fifty years are on the resurgence, whooping cough is a good example. As the USSR collapsed outbreaks of various diseases thought under control begin occurring again at epidemic levels, typhoid, whooping cough, etc. Afghanistan had major outbreaks of whooping cough in the past two years. The number of cases are up in the USA and I would bet it is in those states that have the most lenient policy relative to vaccination.
Outside of basic sanitation, vaccinations were most probably the greatest medical breakthrough in human history far exceeding antibiotics. Now we risk losing vaccines because a few people, who wish to live in what the believe should be a risk free world, are driving the industry into extinction. Having worked in government, I would hate to turn over all vaccine production to government.
Third, we all have little memory of the horrors that a parent could face raising children as short a time ago as the first half of the 20th century. Without vaccines we will face that again. As it is with the increase in resistant bacteria, strep diseases easily could begin to devastate our children again. Our schools systems do not educate us even to wash our hands any more, so expecting them to teach the history of the impact of disease on human history is something I do not expect to happen, yet it is necessary.
Fourth, we have set aside tool used and taught because of so called human rights issues. When I had the Asiatic Flu in the 1950s they closed schools trying to curb the spread. Even seemingly little things like requiring people to wash their hands and teaching our kids to do so, seems not to be politically correct.
The Bane of Old Age: At least for men, is prostate problems. As they get older, their prostates get larger and obstruct the flow of urine from the bladder. There might be some hope for the problem in two drugs that have been around for a while, but one of which has fallen out of favor. New research claims that using a blood pressure drug called doxazosin that relaxes the smooth muscle surrounding the exit of the bladder with finasteride, a drug that shrinks the cells of the prostate, provides the maximum benefit. That would make sense intuitively, but previous studies have suggested that it didn't work, and men who took finasteride ended up with more aggressive forms of prostate cancer. Here's what the study found:
The federally funded Medical Therapy of Prostatic Symptoms study involved 3,047 men at 17 centers around the country. They received an inert placebo, the alpha blocker doxazosin alone, the testosterone blocker finasteride alone or the two drugs together.
Compared with the placebo, the two-drug combination reduced by 66 percent the risk that the condition would get worse. Progression of symptoms was cut by 39 percent by doxazosin and by 34 percent by finasteride...
....."To have a risk reduced by almost 70 percent is almost unheard of in a medical trial," said John McConnell, the study's lead author. "We think this study will have great impact on the field."
...The combination therapy also reduced by 81 percent the risk that men would develop extreme problems urinating, and by 67 percent the need for surgery.
Actually, this is an approach often used by urologists for men whose symptoms progress on doxazosin alone (or one of its close relatives), and who want to avoid surgery. However, the study(subscription required for full text), isn't as impressive as the newspaper article would lead us to believe.
The researchers looked at several measures of the prostate: the prostate volume, as measured by ultrasound, the flow rate of urine from the bladder, the amount of urine left in the bladder after voiding, the prostate specific antigen, and serum creatinine, which goes up if the flow of urine is seriously obstructed, and the response to a series of questions put together by the American Urological Association to assess the impact of prostate symptoms on a patient's life. At the beginning of the study, all of the subjects scored essentially the same on each of the measures.
At the end of four years, the combined therapy group had decreased their AUA symptom score by a median of seven points. They started out with a median score of 16, which means that even after four years, their symptoms would still be described as falling in the moderate category. And when you consider that there are only eight questions, even a modest improvement in most of the categories would result in a seven to eight point change in the score, without making much of a difference in the impact of the symptoms on someone's lifestyle.
The urinary flow rate improved by about 4ml/second in the combination group, which is better than the placebo group (1ml/second) or the monotherapy group (2ml/sec), but not by much. Levels of prostate specific antigen decreased by 50% in the combination group (which would be expected since finasteride shrinks the prostate), but the baseline value of PSA was only two. In terms of PSA, going from a level of two nanograms per milliliter to one nanogram per milliliter is pretty small potatoes.
Most importantly, the incidence of severe complications from continued prostatic enlargement - the complete blocking of the flow of urine - is fudged in the result section. The actual number of cases are divulged for placebo (18 out of 737 men) and finasteride alone (6 out of 768 men) and combination therapy (4 out of 786 men), but not given at all for the doxazosin group, and it's hard to tell from the line graph provided because it's only expressed in "relative risks."
So, the bottom line remains that combining finasteride with doxazosin is probably a reasonable approach to take with men who want to avoid surgical procedures and whose symptoms are moderate to severe, but until the questions about the risks of finasteride and aggressive prostate cancer are addressed, it shouldn't be the first line of approach.
SIDENOTE: Finasteride breathed new life once before after it fell out favor as therapy for prostate problems. It's other incarnation is Propecia. posted by Sydney on
12/19/2003 08:34:00 AM
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Thursday, December 18, 2003
Reader Mail: On Howard Dean's background:
My little sister did her internal medicine residency at the Univ of Vermont/Fletcher Allen Hospital complex, back in the mid 90s. She worked her ass off. Has continued to work her butt off in cardiology training, has finally settled down to a practice. If Dean started his residency in 1978, how the heck did he get elected in 1982 to the state legislature? It does not compute....
...In addition, I happened to teach in the physics department at Univ of Vermont for three years, so I know a little bit about that area.....The town of Shelburne is a snobbish place, full of rich bigshots from the IBM plant etc. If that is where he practiced, I am not buying that "country doctor" thing about Howard Dean.
Dean was elected to the legislature in 1983, but that's still only five years after completing medical school. Most internal medicine residency programs take three years to complete. He's spent more time in politics than medicine. Which is OK, since he's a politician. But he's not the country doctor he pretends to be.
Self-Management: Virginia Postrel wonders, as many others also have, why all birth control pills can't be over the counter if the higher dose morning after pills can. She's got a point. It makes no sense to keep regular, lower dose birth control pills on prescription-only status if the higher dose morning-after pills go over the counter. They have the same risks.
Ah, you say, but the morning after pill is only a one-time pill, to be used only infrequently, so it's side effects aren't as potentially harmful as a once-a-day birth control pill taken over a period of years. Except there's no reason to think that the morning-after pill will be used appropriately, especially by teen-agers and others who are less discriminating about their health. It doesn't take much imagination to conjure the scenario of a woman taking the morning after pill once or twice a week just to avoid the hassle of going to the doctor to get regular birth control pills. The problem is, doing so would put her at risk for developing such potentially serious side effects as blood clots or high blood pressure - the same risks that are inherent in taking long-term birth control pills.
Although it may seem paternalistic to require a doctor's visits to get a drug, there is a legitimate reason behind the requirement. Prescription drugs all share the same characteristic - they have side effects that must be screened for. Not everyone does well with oral contraceptives, and there are some who should never take them (such as those who have had blood clots, or a history of liver disease, or strokes, or coronary artery disease.) Making the morning after pill over the counter ignores all of these potential threats to the health of young women.
It is, in the end, more of a political decision than a medical one. (You notice no one's clamoring to make medication for enlarged prostates over the counter, even though they're just as safe as the morning after pill - maybe safer.) And that's unfortunate, because it opens the way for other medications that should also remain prescription based, to go over the counter.
UPDATE: Another view:
Despite the warning labels being virtually the same with plan B (levnorgestrel) and ordinary pills, the real risk of Plan B is much lower. The risk of thrombosis with progestin-only pills is really quite low, if there is any risk at all. Morning -after pills used to be off-label Ovral or Lo-ovral, which do contain estrogen, Preven, with estrogen, is the other FDA-approved morning after pill. Plan B turned out to be less nauseating and more effective, and it is the one being approved for OTC use.
Personally, I predict there will be a lot of irregular bleeding and first-trimester progestin exposure from Plan B and its improper use. I also think it will increase the number of unwanted pregnancies as women forgo the inconvenience and expense of a trip to the doctor's for an OC prescription which is more effective than Plan B. Not to mention an increase in STD's and cervical cancer as condom use falls by the wayside and diagnoses are delayed because of the aforementioned avoidance of a checkup. I could be a chicken little about all this, but many women will do just about anything to get out of an annual gyn checkup.
Influenza Update: The flu is on the wane in Colarado, but it's waxing in the East.
Flu vaccine continues to be in short supply, which leads many to wonder why new vaccine methods aren't being developed. (Reasons are: money, regulations, litigation.) You can see just how laborious and time consuming the current system is
on these videos.
Meanwhile, Senator John Edwards has announced that the flu isn't an act of God, but an act of President Bush. Others think the blame lies elsewhere:
One Republican source said it was "incredibly ironic" that Mr. Edwards would complain about vaccine manufacturers.
"There would be more companies available to manufacture vaccines if people like John Edwards and his trial lawyer friends weren't putting them out of business with frivolous lawsuits," the source said. posted by Sydney on
12/17/2003 08:38:00 AM
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Influenza Update: Two health insurance giants - Cigna and Aetna - have announced that they'll cover FluMist this year. posted by Sydney on
12/16/2003 08:31:00 PM
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Origins: The etymology of influenza: from the Italian "influentia", meaning "influence". As in, "Donya letta that badda boy influenza ya." posted by Sydney on
12/16/2003 03:58:00 PM
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Homeopathic Flu: As the supply of influenza vaccine continues to dwindle, some are turning to alternative measures:
That's the premise behind homeopathic remedies, including a homeopathic flu vaccine called Influenzinum. The flu vaccine is diluted to 1/100th of its original strength, then that process is repeated.
So, maybe, for all the people who have been turned away from doctors' offices and health departments because they're out of vaccine, there's an alternative.
``We've had very good experiences in giving it to people who come down with the flu, relieving their symptoms quite promptly,'' said Dr. Leonard Torok, who opened Ohio Holistic Medicine in Medina this year. ``We've given people the vaccine and instead of getting better in a week or two, in a day or two they're well.''
Maybe they had colds and not the flu. The diluted flu vaccine is given in a pill form, not a shot. The Quackwatch guy is skeptical:
``I really think it's absolutely nutty and unethical,'' said Dr. Stephen Barrett, founder of the watchdog group Quackwatch. ``Flu can kill people. I think it's extraordinary that someone would have the gall to give a worthless product that may result in people dying. That's very bad.''
I share his skepticism. Although, I hear that older doctors in days gone by used to stretch out their supplies of vaccine by administering it through a nebulized aerosol solution that their patients inhaled. I don't know if it was effective, either. And it's not something I would try.
Celebrity Medical Watch: Did Colin Powell's prostate cancer cloud his senses?
But I wonder if we went to war in part the way we did because Powell was too sick to mount a fight and did not have the courage to resign.
Doubtful. Powell had surgery to remove his cancerous prostate, but the reports say that it was in its early stages. In fact, he deferred the surgery for several months, opting for observation instead. This is an approach that many men with prostate cancer take with no effect on their mortality, let alone their daily functioning.
Prostate cancer is an asymptomatic cancer, unless it has spread to the rest of the body. And once it's spread, it's too late for surgery. Most of the time, the cancer is found during a routine rectal examination or by doing the controversial PSA test. Since Powell's cancer is described as early, we can be pretty sure it was asymptomatic. The chances that it clouded his judgement or influenced his decision making in anyway are slim to none. posted by Sydney on
12/16/2003 08:15:00 AM
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Monday, December 15, 2003
Gifts: The Department of Health and Human Services is giving a $5.4 million grant to Mexico to combat border crossings by infectious disease agents (both natural and otherwise):
The money will be aimed at improving methods of identifying both infectious diseases and potential bioterrorism threats, the department said in a news release distributed outside the meeting. It also will fund bioterrorism surveillance systems in Mexico that are compatible with those in the four U.S. border states, the department said. It did not elaborate.
....The grant money announced Friday will be distributed to Mexico's Health Department and the six Mexican border states: Baja California, Sonora, Chihuahua, Coahuila, Nuevo Leon and Tamaulipas.
Now, the question is will they use the money for those purposes or will they use it to beef up their own pet projects? posted by Sydney on
12/15/2003 08:38:00 AM
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Medicare: A cogent explanation of what's wrong with the Medicare system. Best quote:
Medicare has now become so large and so costly that it is literally destroying the social and economic structure that supports it.
Magic Potions: Using Viagra as a performance enhancer rather than a treatment for a dysfunction appears to be gaining in popularity. Maybe it's all that porn spam arriving hand-in-hand with Viagra spam that's driving the demand.
But, in Bulgaria, they say that their honey is a better way to go:
"It really works, thousands of Bulgarians cannot be wrong and we have not had a single complaint," Ananova quoted Georgi Georgiev, the head of the Bulgarian Beekeepers Association, as saying. posted by Sydney on
12/15/2003 08:13:00 AM
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Verification: About that DNA test, and the quickness with which it was accomplished:
In routine practice, a commercial lab that is handling thousands of DNA samples develops a DNA profile from a given sample in a month or so, said Mark Stolorow, executive director of Orchid Cellmark forensic DNA labs, in Germantown, Md., and elsewhere.
For an extra fee, that can be hurried up to five days, he said. Focusing on just a single sample, such a lab could probably do the job in something under 24 hours, and a lab that has long been preparing to identify a particular person like Saddam could probably do it even faster, he said.
'I don't know what the bare minimum is,' he said."
....American military officials said last April that they had DNA from Saddam.
Read the News Today, Oh Boy: Friday afternoon I heard news that put me in an extreme funk all weekend long. First, my Medicare payments were being held at the Medicare payer for our state because the postman sent one back saying it was "undeliverable." I had to fill out a multiple page form to certify that I am where I say I am, and mail it in (no fax, no phone call would suffice.) If I wrote a letter of hardship, maybe, just maybe, they would expedite things. They say I can expect a six week delay.
Then, a colleague of mine announced he was closing his practice because his malpractice insurer is pulling out of the market. So far, he's been unable to find a replacement. The news took him by surprise, and he can't practice without insurance. This is the closest to home the malpractice crisis has ever hit. It had the same effect that hearing about the sudden, unexpected death of an aquaintance has. You think, "If it could happen to him, it could happen to me."
Then, today, I heard this news, and the funk lifted. The problems in my little corner of the world paled with the thought that things just might get better in other corners of the world where everyday problems are so much greater. posted by Sydney on
12/14/2003 08:48:00 AM
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