"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
Medicaid Action: One reader pointed out that my earlier post about Colarado and Medicaid was nothing new. And that's true. The same problem with Medicaid reimbursement plays itself out in all states. But, in some states, activist lawyers are suing the states for failing to provide healthcare to the poor as mandated by the Medicaid laws. The latest is in Chicago:
The suit contends Illinois has violated federal law by failing to ensure poor children receive appropriate preventive medicine, from immunizations to tests for lead in their blood.
The reason, according to the suit: Doctors refuse to treat patients whose care is paid for by the government's Medicaid program, because reimbursement rates are low, and the state is often late in paying its bills.
The case is significant because it could compel Illinois to spend millions of additional dollars on Medicaid, the federal-state health program for poor people. But lawyers who filed the suit argue that the state could face much larger medical bills unless it improves children's Medicaid programs.
The same thing is happening in California, but the plaintiffs are doctors. Better be careful what they wish for. If access is the problem, the government might just turn around and legislate that everyone has to accept Medicaid, regardless of the reimbursement rate.
In reference to your "Medicaid Action "post. Same thing going on in Georgia. Some of the surgeons in town are no longer taking Medicaid. And to comment on your last paragraph, I think such a requirement would be a NHS type system in disguise. I don't believe that it could withstand a "restraint of trade" lawsuit, but I'm not a lawyer.
Maybe it wouldn't. But if there's one certainty in this world (besides death and taxes) it's that you can't predict what the courts will do. Get enough activist judges and maybe it would withstand a restraint of trade lawsuit. (People laughed to think tobacco companies would lose to smokers who chose to smoke of their own free will and to think that the food industry would ever be under the same assault. But, here we are.)
Targeted Therapy: The cancer drug, Iressa, which showed promise in the treatment of hard-to-treat cancers, has turned out to work in only ten percent of patients. The answer is in their genes:
Now scientists in Boston and Japan have discovered that patients whose tumors shrink substantially as a result of the pill-a-day therapy harbor mutations in a crucial gene.
That gene bears the recipe for production of a key protein known as an epithelial growth factor receptor, an EGFR, as it is known in scientific shorthand. The receptor is intimately involved in relaying signals through a family of enzymes called tyrosine kinase. In the mutated form, the gene causes tyrosine kinase to be overactive.
The drug seems to be more effective in those with mutated genes. Testing patients for the mutation before offering them treatment will improve the success of the drug, The original paper can be downloaded in pdf form here. (It includes very impressive before and after lung scans.) posted by Sydney on
5/01/2004 05:33:00 PM
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1633 Turkish sultan Murad IV forbids smoking with the threat of execution. He also demolishes coffee-houses in Constantinople and confiscates the assets of executed smokers.
1640's Tsar Michael of Russia declares smoking a deadly sin. Arrested smokers are flogged or have their lips slit. A 1643 visitor to Moscow says: 'Those convicted of taking snuff, both men and women, can expect to have their noses taken away.
Playing Their Hand: Orchestra musicians are a catty bunch. Those at the Metropolitan Opera have started a whispering campaign about the fitness of their conductor, who has essential tremors:
The conductor James Levine has been suffering from unexplained tremors in his left arm and leg that at times impair his ability to lead the orchestra effectively, said some musicians who play under him at the Metropolitan Opera.
...They said Mr. Levine's condition had made his leadership of the orchestra inconsistent and even at times ineffectual.
These musicians said Mr. Levine could be difficult to follow because he always conducted sitting down, rarely gave easily visible cues and slumped in his chair as a performance progressed, particularly during lengthy productions like Wagner's "Ring."
His posture is a barometer, some musicians said. As the night goes on, one said, "You cannot see his baton behind the podium."
Another said: "He drops down, and you wonder what in the world is going on, or `what do we do now?' That's when you could use cues. And we don't have them."
Another musician added: "It's been very, very difficult. The reason the orchestra even had any glory days and rose to prominence was because of Levine. So you don't want to kick a man when he's down. Yes, there's a problem; yes, something has to be done; yes, it's the big elephant in the room, but who am I to lead the charge? I owe a lot to the man.
Modern Puritanism: Our society is so very tolerant of so many vices. Drug use, drinking, sexual promiscuity are winked at by the popular culture. Gluttony, however, is another story:
Insidious attitudes about politics, sex, race or class are at the heart of the frenzy over obesity, these scholars say, a frenzy they see as comparable to the Salem witch trials, McCarthyism and even the eugenics movement.
"We are in a moral panic about obesity," said Sander L. Gilman, distinguished professor of liberal arts, sciences and medicine at the University of Illinois in Chicago and the author of "Fat Boys: A Slim Book," published last month by the University of Nebraska Press. "People are saying, `Fat is the doom of Western civilization.'
...."The current hysteria about body mass and supposedly devastating health effects is creating a stratification in the society of power and privilege based on a scientifically fallacious concept of health. What we are seeing with this moral panic over fat in many ways is comparable to what we saw with the eugenics movement in the 20's.
There is a very definite prejudice against the overweight and obese in our society. They are often yelled at by their doctors and ridiculed by their peers. But in true Times style, that prejudice gets translated into one that disproportionately affects women and minorites:
In a new book, "Revolting Bodies" (University of Massachusetts Press), Ms. LeBesco writes that African-American and Mexican-American women are particularly targeted as obese in contemporary culture. "All of the discourse about fatness is about pathologizing the individual," she said in an interview, also likening it to the eugenics movement.
She refers to a study by the Centers for Disease Control in which the highest proportions of overweight people are said to be African-American women and Mexican-American women. "Is it coincidence that representatives of these two stigmatized racial and ethnic groups, as well as women, are most likely to be obese?" Ms. LeBesco writes.
Yes, it's coincidence. The food police and health puritans know no racial or sexual bounds when it comes to obesity. They are equal opportunity demonizers.
But, at the very end of the article is this pearl of wisdom:
Mr. Stearns insists he is not promoting obesity but rather arguing that making people feel guilty for being fat is a useless form of weight control. In describing the contemporary ethos, he said: "If you fail to lose weight you are demonstrating you're a bad person. It's a big burden. Faced with this additional pressure you are even more likely to end up by saying: `The hell with it! I'm going to get ice cream. I am such a bad person I need to solace myself.'
Preventive Medicine: Last night, when I found it necessary to Google "how to unclog sink" I came across this advice:
Once every three months, fill every sink and tub in the house with water. With the help of friends or family members, simultaneously pull all of the drain stoppers up and flush all toilets in the house. This large volume of water will help flush out the larger-sized drain stacks and underground building drains.
SARS Update: One of the Chinese patients has died:
China today reported the first SARS death worldwide since the World Health Organization declared the disease under control globally nine months ago.
The Health Ministry said the death of a woman in the southern province of Anhui on April 19 was caused by SARS, according to a statement. She had cared for her daughter, who spread the disease after catching it while working in a virology laboratory in Beijing. The daughter is recovering.
Supply and Demand: Colarado has a problem. It's Medicaid reimbursement is so low, they can't get doctors to take it:
The Denver Post reported Thursday that a report by experts at Children's Hospital in Denver due out this summer shows that an influx of nearly 60,000 poor children into the Medicaid program since 2001 has overwhelmed a thinly stretched network of doctors.
.....Pediatricians are subsidizing the cost of caring for large numbers of children, but their willingness to continue to do so is decreasing, the study says.
The study's authors say the core of the problem is that the state chronically underpays doctors who treat poor children. The average office visit costs a pediatrician $60, but Medicaid pays only $40, said Dr. Stephen Berman, a professor of pediatrics at the University of Colorado Medical School and author of the hospital study.
.... In Colorado Springs, only one of the city's 13 pediatric offices accepts Medicaid children, said Dr. Bruce MacHaffie, president of the Colorado chapter of the American Academy of Pediatrics.
Since 2002, 60 pediatricians have been added to the Medicaid network, but that's not enough to meet the growing demand, doctors said.
....The study also found that the number of pediatricians willing to accept new Medicaid patients dropped to 23.9 percent last year from 41 percent in 2000. That's based on a statewide survey of American Academy of Pediatrics members."
Your Brain on Booze: Iain Murray finds the media exaggerates (surprise!) the effects of social drinking on cognitive function. posted by Sydney on
4/30/2004 08:32:00 AM
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Wednesday, April 28, 2004
Yikes: A nurse in England stands accused of killing patients to free up hospital beds:
'If she thought there was no hope of recovery, she didn't want to wait too long.
'If the patient could be made well enough to be discharged, she would aim for that, if not she would hasten death.
'One way or another, she wanted these patients off her ward.'
I've seen patients booted out of the ICU too soon and discharged too soon to free up beds, but this is just going to far. posted by Sydney on
4/28/2004 06:05:00 PM
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Medicare Drug Cards:Complexity is their middle name: "
We are struggling with how to spend less than an hour of a counselor's time helping someone make a decision,' said Robert M. Hayes, president of the Medicare Rights Center in New York. 'It may well be that there is no reasonable process to make an informed decision given the complexity of the market.'
If the counselors can't figure it out, how are the elderly going to fare?
How Much is Your Mother Worth? A lot if you if live in Texas:
A jury in a state court in Beaumont, Tex., ruled yesterday that the pharmaceutical company Wyeth should pay $1 billion to the family of a woman who died from lung disease that the plaintiff's lawyers said was caused by a diet drug the company made in the 1990's
The huge award has other lawyers salivating:
Plaintiffs' lawyers say Wyeth faces dozens of such lawsuits and assert that the company will now find resolving those cases much more difficult and expensive.
"There's no question that it will have an impact on what plaintiffs' lawyers are willing to take, and it's going to embolden more plaintiffs' lawyers to try more of those cases," said Peter Kraus, a lawyer at Waters & Kraus in Dallas. Mr. Kraus said he represents 11 fen-phen plaintiffs with heart valve damage. "It's a huge win," he said.
Other lawyers said there are many plaintiffs with lung disease that they say was caused by the diet drug. "My office has over 100 cases similar to this one, and we anticipate that many of these will be filed by the end of this year," George Fleming, a lawyer at Fleming & Associates in Houston, said in a statement from a group of lawyers representing people who say they were harmed by fen-phen.
No matter that the woman developed lung disease four years after she stopped taking the drug. They went after the deep pockets - and won.
posted by Sydney on
4/28/2004 08:22:00 AM
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The Knot You Can't Untie: I've been running short of time lately because of the demands of my hospitalized patients. All of them are either critically ill or newly diagnosed with a terminal illness. This is unusual for my practice. But sometimes, things just come in bunches like that. The hardest part of these sorts of cases is dealing with the family dynamics that come to the fore in times of extreme stress.
One of the patients who has taken up most of my time with a lot of hand holding and family conferencing has lung cancer. Yesterday, he decided to have chemotherapy. His wife did not approve. She has a very forceful personality, and throughout my encounters with her during the years I've known them, it's been my impression that she always gets her way. If she doesn't, there's hell to pay. Well, yesterday, she reacted to his decision by throwing a temper tantrum. She yelled at him. She yelled at the nurses. She yelled at the oncologist. He told me it made him sad to think that she wanted him to just "go away and die," but he cancelled his chemotherapy. Now, he's got to go home and live out his final days with her.
This morning, I found this jaw-dropping note on the front of the chart. "Wife concerned that patient is depressed." And I'm supposed to fix it? posted by Sydney on
4/28/2004 08:02:00 AM
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Tuesday, April 27, 2004
Good Point: A BMJ reader points out the irony of the medical profession's fear of miniscule risk:
I beg to remain sceptical of the claim that small exposures to other people's tobacco smoke cause large increases in the risk of cardiovascular diseases. If we are to espouse such fundamental theories of Homeopathy, surely we should go the whole hog and embrace this rogue discipline in its entirety. If like cures like, then small amounts of environmental tobacco smoke may in fact be good for you. posted by Sydney on
4/27/2004 06:25:00 PM
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At work, doctors now face a worsening shortage of time: that's time as in tincture of, one of the best drugs and diagnostic tools around. Time soothes pain, cures fevers, knits broken bones, and it can outperform the most expensive scanner on the planet. Combine a little time with some food, a bed and a set of good nurses, and wonderful medical care can result.
So true. At my hospital, as in most others, each floor has a "care manager" whose job it is to facilitate discharge as quickly as possible, to make sure we doctors don't overextend the billable period of hospital inpatient care for whatever insurance the patient has. The hospital is no longer a place for convalescence. Home is. Or a nursing home. For most patients and their families, this works out OK. They frankly get better convalescent care at either place than they would at an acute care hospital where the nursing routine is constantly interrupted by sick patients' acute needs. Mr. Jones with the stroke isn't going to get the routine care he needs to prevent bed sores if the nurse is busy addressing chest pain, shortness of breath, and drops in blood pressure in other patients. But, for others, like the example in the Times column, going home or to the nursing home is a stress that they don't need in their time of illness.
posted by Sydney on
4/27/2004 04:48:00 PM
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Doctors in the United States carried out tests on 517 healthy people over the course of a year.
They found that their cholesterol levels changed throughout the year, peaking in winter. They were at their lowest in summer.
...All of those who took part in the study were closely monitored by doctors to see if they changed their diet or lifestyle over the course of the year. None did so.
How large was the seasonal variation? Not much. Just 4 to 5 points, but twenty-two percent more people qualified as having high cholesterol in the winter compared to the summer. (See this table.)
The truth is, we know very little about cholesterol metabolism, let alone what qualifies as "normal." And yet, we make economically significant decisions about treating minimally abnormal values. Maybe it's about time we stepped back and considered how little we know.
Heal Thyself: There's at least one physician out there who probably isn't for tort reform. The urologist who sued Greenwich over a broken leg:
The urologist, Nicholas Stroumbakis, and his 4-year-old son were going for one last run after a day of sledding when their plastic sled crashed into a foot-deep drainage ditch at the base of the hill, said Dr. Stroumbakis's lawyer, Stewart M. Casper.
Father and son were thrown from the sled, and Dr. Stroumbakis broke his leg in two places, which kept him from work for five months, Mr. Casper said.
The doctor sued for negligence, claiming the town had created a public nuisance by failing to maintain the ditch, and on April 14, the jury agreed, awarding him $6.3 million. The town, which is challenging the award, would have to pay $500,000 of the verdict, said Mr. Crumbine, the selectman. The remainder would be covered by insurance.
So far, there is no formal proposal to ban sledding, and Mr. Crumbine said he did not know whether the issue would emerge at the next meeting of selectmen. "It's just been talk up to this point," he said.
Though $6 million or so may seem like a hefty sum, Mr. Casper said the town should be thankful that it was not a Fortune 500 chief executive who was laid up for five months.
"They're lucky he was only a highly skilled urologist," Mr. Casper said. "A surgeon doesn't make anywhere near what some of these Greenwich residents make."
Image is Everything: Estee Lauder died. Whatever you may think of her and her business, there's no question she succeeded in creating a product that to many is synonymous with quality. I'll never forget the patient I saw with a rash on her face that ended sharply at the edges, just where a make-up line would end. I suggested that perhaps she was allergic to her foundation. "Impossible! I use Estee Lauder." And away she went for another opinion. posted by Sydney on
4/26/2004 01:29:00 PM
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Smaller Not Always Better: One case in which laparoscopic surgery is inferior to standard surgery - hernia repairs:
Overall, 87 of the 862 patients who had laparoscopic surgery needed a second repair of the same hernia within two years, compared to 41 of the 834 who got open incision repairs. That works out to 10.1 percent and 4.9 percent.
Twenty of the 78 surgeons doing laparoscopic surgery had done more than 250 such operations for groin hernias, also called inguinal hernias, and their recurrence rate was less than 5 percent, said Neumayer, a staff surgeon at the VA hospital and associate professor of surgery at the University of Utah. posted by Sydney on
4/26/2004 08:29:00 AM
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Researchers looked at patient's 'ejection fraction' - a standard measure of heart performance, determined by the total amount of blood pumped out by the left ventricle.
A normal person has an ejection fraction of 55%.
When the trial began, all patients had ejection fractions of less than 35%.
All patients underwent heart by-pass surgery.
During the operation, selected patients were given two types of stem cells taken from their hip bones.
The cells were injected into 25 to 30 sites where the heart muscle was damaged.
After six months, the group receiving stem cell therapy had an average ejection fraction rate of 46.1%.
Those who had surgery alone had an average of only 37.2%.
The treatment did not appear to cause any serious side effects, such as abnormal heart rhythms.
Poetic Mortality:Jim Miller notes that poets die earlier than other writers. And he quotes a lovely Edna St. Vincent Millay poem to explain why, too. posted by Sydney on
4/25/2004 12:24:00 PM
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"The other thing we've learned is how important the erect penis is for a woman's sense of her own sexual appeal,' Morgentaler says. 'When a woman finds out a man has been using the pill secretly, there are two main reactions. One is fury about the dishonesty aspect and the other is, 'I thought it was me that was turning you on. Why do you need a pill to have sex with me?'' posted by Sydney on
4/25/2004 12:14:00 PM
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Curry Mice: A component of the spice used in curry may prove to be a cure for cystic fibrosis:
Curcumin, a major component of turmeric, allows a defective cell protein that results from the genetic mutation responsible for cystic fibrosis to do its job, at least in animal experiments.
As described in the journal Science, Dr. Michael J. Caplan, from Yale University in New Haven, Connecticut, and colleagues gave curcumin to mice bred with the genetic mutation that occurs in about 90 percent of cystic fibrosis patients.
This mutation, known as delta-F508, involves the cystic fibrosis transmembrane conductance regulator (CFTR) and leads to production of an incorrectly folded CFTR protein. Because it is misshapen, the protein is destroyed by the cell's housekeeping machinery and never gets to its intended location in the cell membrane.
The defect causes problems with mucus buildup in the lungs and respiratory difficulties. Cystic fibrosis is the most common life-threatening disease resulting from a genetic mutation among Caucasians.
In mice carrying the mutation, feeding them curcumin at doses well tolerated by humans corrected an electrical abnormality characteristic of the disease. This effect was only seen in animals with a mutated CFTR gene, not in mice completely lacking the gene. posted by Sydney on
4/25/2004 12:02:00 PM
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China is reporting four new suspected SARS cases, bringing the number of infections in the past several days to six suspected and two confirmed cases.
All the cases have been traced back to China's top SARS research laboratory, the Institute of Virology in Beijing. The government ordered the lab shut down on Saturday while the spread of the disease is investigated.
The Health Ministry says the outbreak began when a medical student was infected while working at the facility. The student returned to her home province of Anhui in eastern China, where she was care for by her 53-year-old mother. Chinese officials say the mother died earlier this week, and that they are conducting tests to confirm whether she died of Severe Acute Respiratory Syndrome.
