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    Saturday, October 02, 2004

    Medical Movie Trivia: The doctor who separates the Tenor twins in the movie Stuck On You, really is a surgeon. He's pediatric neurosurgeon Dr. Benjamin Carson who has separated conjoined twins in real life. Funny, he doesn't mention the movie in his President's Council on Bioethics bio.
     

    posted by sydney on 10/02/2004 09:44:00 PM 1 comments

    Hearts and Bones: Two widely used blood pressure medications may also protect bones:

    The team looked at data on 30,601 patients aged 30 to 79 from the UK General Practice Research Database who had been diagnosed with a fracture between 1993 and 1999.

    Researchers then compared each of them with four people of the same age and sex who had not had a fracture - a total of 12,837 - to see who had been prescribed beta-blockers prior to that date.

    They found that taking beta-blockers together with thiazide diuretics, which protect against bone loss, was linked to a reduced risk of fracture of 29%.

    Using beta-blockers alone for around six months was linked to a 23% reduced risk. Taking thiazides alone was associated with a 20% risk.


    What the study says is that more people who did not have fractures were taking beta-blockers and thiazide diuretics than those who had fractures. However, it's quite possible that the people who were taking beta-blockers and thiazide diuretics were in poorer health than those who took no medication - and thus were less physically active. A person who takes no medication and perceives himself as healthy may be more likely to do risky things like windsurfing or snowboarding than someone who has a heart condition and takes beta-blockers. The jury's still out on this one.

     
    posted by sydney on 10/02/2004 09:30:00 PM 0 comments

    All Powerful: One person's ethics committee experience.
     
    posted by sydney on 10/02/2004 08:59:00 PM 0 comments

    Housekeeping: I've updated the blog list to the left, adding EchoJournal, Shrinkette, Doctor Mental, and Facts and Fears. I also updated the address for The Bloviator's new home - Public Health Press.
     
    posted by sydney on 10/02/2004 08:32:00 PM 0 comments

    Swing State Notes: President Bush was in town today, and thanks to one of my very kind patients, I got a ticket to the event. The campaign stop was in the parking lot of a new community fitness center in Cuyahoga Falls, Ohio. Perhaps you've heard of Cuyahoga Falls, it gets a mention in Chrissie Hynde's song My City Was Gone. Muzak doesn't really fill the air there, and it isn't a paved parking lot, but it does have a shopping mall.

    The afternoon was rainy and cold, but there was still a sizable crowd



    The crowd was a diverse one, too. There were young families, college kids, service men, senior citizens, Firefighters for Bush, Policmen for Bush, Sportsmen for Bush, Veterans for Bush, and the sighting of one of my patients made me wonder if somewhere there wasn't drug dealers for Bush. Not everyone was a Bush fan. The little girl in front of me in the refreshment line said if she was old enough she'd be voting for Kerry. He's going to tax gasoline so no one can drive cars and kids will be free to ride their bikes in the streets, don't you know?

    The hour before the President's appearance was filled with the usual local and state politicians. The best speaker by far was the mayor of Youngstown, a Democrat who has endorsed Bush. He gave a fiery sermon-like speech a la Zell Miller, about how far the Democratic party has strayed from the days of FDR and JFK, with many allusions to the unholy alliance of the Democratic party and the Hollywood elite. Best soundbite (I'm paraphrasing, didn't have a pen and paper with me): "Some in the Democratic party embrace film maker Michael Moore with so much enthusiasm you would think they want to make him the next Secretary of State. FDR and JFK would have wasted no time showing him the door, with the imprint of their shoe on his backside."

    By the time Bush arrived, just a few minutes behind schedule, the rain was gone and the sun shone. My ticket was the wrong color to get a good view,



    and I couldn't always hear because I was in the Toddlers for Bush section,




    but it was a much better performance than last week's debate. The biggest applause lines, from where I was standing:

    And, yet, the most fundamental of our systems -- the tax code, health coverage, pension plans and worker training -- were created for yesterday, not tomorrow. I am running to change those systems so all citizens are equipped, prepared and, thus, truly free to make your own choices, so you can pursue your own dreams.

    ..First of all, you can't raise enough money by taxing the rich to pay for $2.2 trillion. You raise about $680 billion -- therefore, there is a tax gap. Guess who always gets to fill the tax gap? Yes, you do. "Tax the rich," yes, we've heard it. The rich hire lawyers and accountants for a reason, because they want to stick you with the bill.

    ..I'll tell you another thing we need to do to make sure health care is available and affordable. We've got to do something about these junk lawsuits that are running up the cost of medicine and running good doctors out of practice... I made my choice: I'm standing with the docs and patients; I'm for medical liability reform now. (Applause.) In all we do, we'll make sure the medical decisions are made by doctors and patients, not by bureaucrats in Washington, D.C.

    But because there's a lot of baby boomers getting ready to retire, we need to worry about our children and our grandchildren when it comes to Social Security. I believe younger workers ought to be allowed to take some of their own tax money and set up a personal savings account that they can call their own that the government cannot take away. (Applause.)

    We believe in a culture of life in which every person matters and every being counts. (Applause.) We stand for marriage and family, which are the foundations of our society. (Applause.) We stand for the appointment of federal judges who know the difference between personal opinion and the strict interpretation of the law. (Applause.)

    ...Our strategy is clear. We're defending the homeland. We're reforming and strengthening our intelligence services. We're strengthening our all-volunteer army -- which will remain an all-volunteer army. (Applause.) We are staying on the offensive. We are striking the terrorists abroad so we do not have to face them here at home. (Applause.)

    And my personal favorite:

    Wasn't all that long ago that our country was at war with Japan. My dad fought him, your dads and granddads fought him, as well. They were the sworn enemy. And after World War II, Harry Truman and other Americans believed that liberty can transform an enemy into an ally, and worked with Japan to promote democracy. Now, a lot of people then, I'm confident, were skeptical about that being able to happen. You understand why. We had just fought them. A lot of lives had been lost. But because Harry Truman stuck to those values, today I sit down at the table with the head of a former enemy, talking about the peace we all want, talking about how to work together to keep the peace. (Applause.)

    Liberty is powerful. It is powerful. I am confident that someday, an American President will be sitting down with a duly elected leader of Iraq talking about how to keep the peace in the greater Middle East, and our country will be better off for it, and our children and grandchildren will be able to grow up in a more peaceful world. (Applause.)

    I believe -- I believe that the women in the Middle East want to live in freedom. (Applause.) I believe that everybody wants their child to grow up in a free and peaceful society. I believe if given the chance, the people in that part of the world will embrace the most honorable form of government ever devised by man. And I'll tell you why I believe these things: Freedom is not America's gift to the world. Freedom is the Almighty God's gift to each man and woman in this world. (Applause.)


    I don't ever remember hearing or reading anything that positive in the Kerry campaign speeches. Nothing positive in the Kerry representatives, either. They had mostly anti-Bush signs, like "Get Out of My City," although one woman did have a sign that called Kerry a "towering tree of strength" compared to the tiny Bush.



    (Sorry for the long shot. The police wouldn't let us get very close.)

    And finally, as I was waiting to cross the street on my way back to the car, the President's campaign bus came around the corner. And there was the President, sitting next to the bus door with a microphone, waving to us all and thanking us for coming. Didn't get a picture, though. I had put the camera away.



     
    posted by sydney on 10/02/2004 05:32:00 PM 0 comments

    Friday, October 01, 2004

    Hurrican Victims: The CDC is looking out for you. They want you to be safe with those chain saws while clearing away debris.
     

    posted by sydney on 10/01/2004 07:18:00 PM 0 comments

    Wrapping Up: The special election debate on malpractice tort reform between Doctors for Kerry and Ted Frank at Point of Law has wrapped up. Just keep scrolling.
     
    posted by sydney on 10/01/2004 04:41:00 PM 0 comments

    Pulse of the People: The patient consensus on the debate, even among Bush supporters, is that Kerry won.
     
    posted by sydney on 10/01/2004 04:35:00 PM 0 comments

    Vioxx Recall Update: To their credit, Merck is offering to reimburse patients who have unused Vioxx. Details are here, and at Vioxx.com.
     
    posted by sydney on 10/01/2004 04:33:00 PM 0 comments

    Stem Cell Update: New advances in adult stem cell research:

    University of Toronto researchers say they are a step closer to a diabetes cure using adult stem cells. The team found pancreas cells from adult mice could be transformed into new islet cells - the cells that produce insulin. The scientists are hoping the same effect will be reproducible in humans.

    ....Meanwhile, scientists at Northwestern University in Chicago, using adult stem cells derived from a patient's sister's bone marrow, have successfully treated the woman for crippling rheumatoid arthritis. The researchers reported that her morning stiffness was alleviated before she left hospital, and now, one year later, she is no longer affected by the disease, and able to discontinue all medications.

    ...Finally, scientists in Germany have successfully re-grown a man's jaw bone, by using his own stem cells, and growing the bone within muscle tissues in his back. The man, whose jaw and half his tongue was removed due to mouth cancer, had his first real meal - a bratwurst sandwich - in nine years.


     
    posted by sydney on 10/01/2004 08:26:00 AM 0 comments

    Speaking of Doctor Supply: Was the care of an injured college athlete compromised in northeast Pennsylvania because he had to be transferred to southeast Pennsylvania for care?

    The Sabo case has revived the issue of the scope of General Hospital's neurological services over the past few months due, at least in part, to a conflict between Dr. William Host, chief executive officer of the Wyoming Valley Health Care System, which owns General Hospital, and Dr. David Sedor, a neurosurgeon at General Hospital for many years.

    A clash between Host and Sedor resulted in Sedor being terminated from the hospital's medical staff. His efforts to gain readmission have been unsuccessful.

    Following that event, General Hospital began to use neurology services from physicians associated with the Hershey Medical Center. General and Hershey have forged a cooperative agreement.


    Hershey is 90 to 120 minutes away from the Wyoming Valley area. It's also an area that's been hard-hit by the medical malpractice crisis, although in this case that appears not to have played much of a role in the access issue.
     
    posted by sydney on 10/01/2004 08:22:00 AM 0 comments

    Thursday, September 30, 2004

    Drug Withdrawl: Merck has decided to no longer sell Vioxx:

    Drug company Merck has removed its arthritis painkiller Vioxx because of data showing an increased risk of heart attack and stroke.

    ...A three-year trial showed an increased risk of cardiovascular events began after 18 months of Vioxx treatment.

    ...Merck's chairman Raymond Gilmartin said: "Although we believe it would have been possible to continue to market Vioxx with labelling that would incorporate these new data, given the availability of alternative therapies, and the questions raised by the data, we concluded that a voluntary withdrawal is the responsible course to take."


    There's not much available on the study that led to the decision to withdraw the drug from the market, but the FDA press release says it was a study comparing Vioxx to placebo in the prevention of colon polyps, and that the risk was small:

    The Agency was informed by Merck & Co., Inc. on September 27, 2004, that the Data Safety Monitoring Board for an ongoing long-term study of Vioxx (APPROVe) had recommended that the study be stopped early for safety reasons. The study was being conducted in patients at risk for developing recurrent colon polyps. The study showed an increased risk of cardiovascular events (including heart attack and stroke) in patients on Vioxx compared to placebo, particularly those who had been taking the drug for longer than 18 months. Based on this new safety information, Merck and FDA officials met the next day, September 28, 2004, and during that meeting FDA was informed that Merck was voluntarily withdrawing Vioxx from the market place.

    The risk that an individual patient taking Vioxx will suffer a heart attack or stroke related to the drug is very small. Patients who are currently taking Vioxx should contact their physician for guidance regarding discontinuation and alternative therapies.


    More details at Merck's website, although the actual data isn't available.

    It's difficult to say how serious the risk is, though previous studies that have suggested the same have shown very, very small increases in the absolute risk. (in the tenth of a percent range), which would suggest that there are probably other factors involved beyond purely the use of these anti-inflammatory drugs. Factors such as the absence of the use of prophylactic aspirin in Vioxx users.

    One of the previous studies that suggested Vioxx was a problem compared it to Naprosyn, an anti-inflammatory of an older class which has an effect on platelet metabolism not seen with the newer drugs such as Vioxx. Since platelets play a role in blood clotting, it was thought that Vioxx's disadvantage in the heart disease department could be explained by it's lack of platelet action. This was the same quality that supposedly made it more favorable in terms of bleeding complications.

    But the latest decision was based on a study that was comparing the drug to placebo. Again, the key to knowing how much to worry about it if you're a Vioxx user is in knowing the absolute risks involved, and whether or not aspirin use was controlled for in the placebo group. We don't have that data.

    In today's climate, though, it isn't surprising that Merck would pull the drug from the market. Any negative results, no matter how small, would surely be a death sentence for the drug in today's legal environment.




     

    posted by sydney on 9/30/2004 01:03:00 PM 0 comments

    Where Did All the Doctors Go? ABC notes that emergency room physicians are having problems getting specialists to come in for emergencies, but they blame the shortage on a "relaxation" of federal rules. I suspect there's another reason - malpractice insurance crisis.

    UPDATE: From a doctor in a non-medmal crisis state:

    While the malpractice crisis may be responsible for some specialists not responding to call from the ER, I don't think it explains all. Working here in a tort reform state where there is no malpractice crisis, we have the same problem. It is not limited to specialists coming in for call for patients from the ER, but has spread to specialists and GP's not coming in to to see their own patients. The ER and hospital are covered off hours, holidays, and weekends, by the ER docs, the radiologists, and the hospitalists. I will admit, we do see our surgeons, generally, when needed, since this is a big source of new patients. It has become quite clear that our practicing physicians, however, are not taking their own call and are utilizing the ER docs to screen thier own patients. I have even recommended to our ER staff tht they charge these docs for taking their call and present them with a contract. This is one of the reasons for excessive ER care. Many of the GP's and medical specialists don't even respond to phone calls on call, so all information on these patients is limited to their history, and hospital records, if any. These patients, including oncology patients, often have to be reevaluated from scratch if they come in off hours, because we are all at a loss as to what is going on and have no information. This includes not only, oncology patients, but cardiology patients, rheumatology patients, endocrinology patients and GP's. Most GP offices have off hours messages for their patients, that state the office is closed, and if you have a problem, go to the ER or call 911. There is no service option to talk to the doc covering your physician's practice on call. What are patients to do? And then the worst part for those of us in the hospital on call, is trying to get the responsible private doc on the phone to communicate with them serious information about their private patient who might require some form of urgent intervention, to find out what they want us to do and who they want their patient to see. Many times it takes hours to get a return phone call, and frequently no response at all.
     
    posted by sydney on 9/30/2004 08:31:00 AM 0 comments

    Rare Breed: A not-for-profit drug company. It will be interesting to see how it does.
     
    posted by sydney on 9/30/2004 08:25:00 AM 0 comments

    Shifting Blame: Doctor Mental says that the recent Supreme Court decision to protect managed care companies from malpractice suits puts more risk on the doctors.
     
    posted by sydney on 9/30/2004 08:19:00 AM 0 comments

    Pediatricians for Kerry: A "small but influential" (i.e. academic) group of pediatricians is working the ropes for Kerry:

    "'Our concerns about the condition of children -- millions in poverty, millions abused, millions without health care, and thousands killed each year in their own homes, their own streets, and the Bush administration's persistent indifference to these conditions -- prompted us to take action,' said Michael Petit, president and founder of Vote Kids.

    'We need to address the fact that it is simply unconscionable that the wealthiest, most powerful nation in the world under the Bush administration has millions of uninsured children. The words 'leave no child behind' ring hollow when so many children are left out,' said Dr. Joel Alpert, professor and chairman emeritus at Boston University School of Medicine and past president of the AAP.

    The letter, along with statements from various pediatricians at the news conference, bemoaned various aspects of White House policies, including cuts in state health programs.

    'In the president's home state of Texas alone, more than 150,000 children of working-class families have been dropped from the State Child Health Insurance Program, leaving them without any insurance,' said Dr. Stephen Berman, a professor of pediatrics at the University of Colorado School of Medicine and past president of the AAP.


    Reading this story made me think of a couple of older pediatricians I once knew. Once at a staff meeting they expressed some un-P.C. belief about some hot-button pediatric issue, (corporal punishment, infant formula, mandatory hepatitis B vaccines, I can't remember which), when one of the internists looked at them in disbelief and said, "But the AAP (Amercian Academy of Pediatrics) says just the opposite." One of the pediatricians said,"Oh, well, we don't listen to them. They're a socialist organization." And that was in Oberlin. Oberlin!

    But, getting back to the Pediatricians for Kerry, their criticisms are more than a little disingenous when it comes to the CHIP program that insures children who aren't poor enough to meet Medicaid standards but aren't covered by other insurance. It's true that in Texas this year there have been many disenrollments, largely due to the state increasing the premiums from $15 a year to $15 a month. (Is it fair to say that there may be people in Texas who don't think healthcare insurance is worth even a minimal premium?) That move was made by the Texas legislature and governor, who, by the way, is not Bush.

    CHIP is a good program, but it's a program run by each individual state using funds given to it by the federal government. The brouhaha about the program at the moment is that there's around $1 billion that have gone unused, partly because states haven't been able to round up enough enrollees, and partly because states have had trouble meeting their portion of the financial obligation for the program due to state, not federal budget cuts. Some people want to keep that $1 billion out there for the states to use anyway, Bush wants to let it revert back to the Treasury, as it's supposed to under the current program rules, but he wants to use the money then for national recruitment efforts for the program, rather than relying on the states who have had mixed success. Here's a non-partisan look at what's going on with CHIP.

    And "Vote Kids", which organized the pediatricians? It's the 527 arm of Every Child Matters, whose agenda and political strategy is outlined here, and whose founder is an early Kerry Supporter. Nothing wrong with that, but the media should have been forthcoming about that angle. And the pediatricians should be ashamed of themselves for manipulating the truth about CHIP the way they have.

    P.S. And here's a look at some of the reasons people give for not signing up for CHIP.

    P.P.S. Even the Associated Press gets the story straight.
     
    posted by sydney on 9/30/2004 06:42:00 AM 0 comments

    Wednesday, September 29, 2004

    Humor: Kerry's healthcare plan.
     

    posted by sydney on 9/29/2004 08:56:00 AM 0 comments

    To Sleep: A little bit of therapy is more effective than pills for treating insomnia:

    A handful of therapy sessions does more to help chronic insomniacs get to sleep than the top-selling sleeping pill, according to a new Harvard Medical School study, suggesting that doctors are relying too heavily on medications to treat Americans' increasingly restless nights.

    ...Therapists' advice typically includes such basics as going to bed only when drowsy and getting up at the same time every day, even after a poor night's sleep. The objective is to get insomniacs to unlearn bad habits such as paying bills in bed, worrying instead of sleeping, and keeping themselves awake at night with coffee and strenuous exercise.

    ...In the new study, published in today's edition of the Archives of Internal Medicine, Jacobs and his colleagues divided 63 chronic insomniacs into four groups receiving either Ambien, five therapy sessions, a combination of the two, or a placebo. The patients kept a sleep diary for eight weeks, recording such factors as how long it took to fall asleep and how long they were awake during the night. Researchers acknowledge that such diaries are subjective, but as long as the patient is consistent, they are useful for comparison purposes.

    The researchers found that therapy was most effective for shortening the time it took patients to fall asleep, from 67.9 minutes a night on average to a near-normal 34.1 minutes after eight weeks. The Ambien patients, by contrast, reduced sleep onset time only from 71.5 minutes to 58.7 minutes. Likewise, after therapy patients awoke much less frequently in the night, sleeping 83.5 percent of the time they were in bed compared with 67.2 percent for those taking Ambien.


    This is welcome news. Now, how do I get my patients to believe it? In my experience, people just want "something to help me sleep." I have a hand-out I give patients that describes the steps to improve sleep, which is basically an exercise in retraining bad habits. I go over it with them, but most of the time, they aren't listening. ( I can't tell you how many times I've found it in the trash after they've left.)

    Sometimes, when I'm going over it with them, I feel like the Jack Nicholson character in One Flew Over the Cuckoo's Nest trying to explain Black Jack to the Danny Devito character, who keeps saying over and over "hit me," "hit me," even though he's already at 20. I just keep hearing over and over "give me a pill," "give me a pill." This is one time, though, when I don't give in. In the long run, it does far more harm than good. (Sleeping pills are sedatives, and addictive, no matter what the drug reps say.)
     
    posted by sydney on 9/29/2004 08:35:00 AM 0 comments

    Born to Die: Who knew that living in the suburbs could be so dangerous?

    Scientists writing in the journal Public Health even found that the strain of life in suburbia could leave residents prematurely aged, compared with city dwellers.

    The study by the Rand Corporation, an American thinktank, discovered that the health profile of an adult with a home in the spacious suburbs of Atlanta was the same as someone who lived in inner-city Seattle but was four years older.


    Four years? From every stand-point, be it medical or social, a four year difference is insignificant. This suburban dweller won't be losing any sleep over it.
     
    posted by sydney on 9/29/2004 08:30:00 AM 0 comments

    Goodbye to All That: The group that accredits continuing medical education events for physicians is taking action against speaker with conflicts of interest:

    The nation's 750,000 physicians stay up to date on medical advances through mandatory participation in thousands of continuing education activities per year.

    In the past, a doctor teaching such a course would disclose his or her financial relationship with any drug company, say as a paid member of the company's speakers' bureau or a grant recipient. Once that was out in the open, the physician might then talk glowingly about anecdotal experience with that company's drug.

    Now, a third party with no ties to the drug company would have to tell the doctor what kind of recommendations he or she could make. Anecdotal observations would be replaced by results of systematic clinical trials. Any review of journal literature would have to include negative, as well as positive, studies.

    'So this whole thing about just saying 'I've got a conflict of interest. And I've got a relationship. And I've got a personal opinion. And I'm probably biased. But, I'm going to tell you anyways,' that's not allowed,' said Murray Kopelow, chief executive of the accreditation council.

    Doctors who balk at the new rules will be barred from presenting or teaching at continuing medical education conferences.


    This is a much needed move, although it will probably make it all that much harder to find speakers for continuing education events. It will also put a damper on the exchange of ideas that flows at these meetings. Most doctors view speakers who promote their drug sponsor throughout a lecture with suspicion, anyways, although not all. However, given the way so many of these early ideas make it into the mainstream press as if they were well-founded treatment recommendations, thanks to press releases and invitations to health reporters to attend the conference, it's a necessary change. The influence of the press on public perception of what is and isn't good medicine can't be ignored. Overall, the recommendations should improve the quality of physician - and public - medical education.
     
    posted by sydney on 9/29/2004 08:21:00 AM 0 comments

    Vaccine Shortages: There is a vaccine against the pneumococcus bacteria, a bacteria that causes pneumonia and occasionally meningitis, that has been in short supply for some time. Wyeth, the maker of the vaccine says that the shortage is over. Last week, I was at a conference on infectious disease in which one of the speakers arched his eyebrows at us and insinuated we'd better be vaccinating kids now or we might get sued. And the CDC has been busy notifying the media that children should start getting the shots again:

    There have been on- and off-again shortages of Prevnar, but the maker, Wyeth, has returned to full production, the CDC and other health groups said.

    That means small children can return to the recommended four-dose schedule, the Atlanta-based CDC said.

    'The manufacturer has assured CDC that PCV7 (Prevnar) supplies are now adequate and health-care providers should return to the full schedule,' Dr. Steve Cochi, acting director of the CDC's National Immunization Program, said in a statement.


    I've been trying to buy the vaccine since July when the company first announced that its supply problems were improving, but I've had no luck. My most recent attempt was three days ago. The medical supply companies I use can't seem to get their hands on it. I tried contacting Wyeth myself to order it without the middle man - still no luck. I was told the vaccine was on "allotment," and they couldn't tell me when it would be available. They haven't been forthcoming in explaining why I can't buy the vaccine, but according to this document, they aren't selling it to distributors - which is odd, since that's how most doctors get their medical supplies. Even the military can't get it. Once again, there's a vast disconnect between the CDC's public statements and reality. I hope they've got a better handle on the supply of vaccines against bioterror agents.

    UPDATE: A reader:

    Weird that you can't get any -- my son just got his 4th shot on the
    23rd. I hope you get some soon -- I don't hink my 18 month old needs
    it nearly as much as the newborns out there!


    Yes. Vaccine supply is oddly managed. I've been in touch with colleagues who say they haven't had trouble getting vaccine at all, even when it was in short supply. I was able to meet with a Wyeth rep today who's making arrangements for me to buy some vaccine. Turns out you can only buy the vaccine from the manufacturer, and you have to special account to do it. They've been supplying their established costumers with rationed amounts of vaccine, depending on their needs, and are just ramping up supply enough now to meet the needs of new customers. Unlike most vaccines, you can't buy it from medical supply distributors. (It would be nice if the medical supply companies would let their customers know that instead of just saying it's on "back order" for ever.)

    But what this means is that some young infants, who need the vaccine the most, are going without the vaccine because their doctors are waiting for supplies to catch up, while other (older) children, are getting less critical booster shots. It's enough to make one long for some sort coordinated oversight of vaccine distribution.
     
    posted by sydney on 9/29/2004 08:05:00 AM 0 comments

    Tuesday, September 28, 2004

    Hmmm Found this text book in a home schooling catalogue - Using the Media: Fact, Fiction, and Opinion. The print edition describes it like this:

    Enhance students' ability to distinguish between fact, fiction, and opinion in the media. Engaging activities sharpen students' critical thinking skills as they decide whether statements made in the context of various readings found in the media are factual or merely opinions. Media sources include newspapers, television, and the internet.

    Sounds like a primer for young bloggers.
     

    posted by sydney on 9/28/2004 06:49:00 PM 0 comments

    Pensions and Healthcare: The Manhattan Institute's Dr. David Gratzer has an excellent column on Kerry, Bush, and healthcare at NRO. He also believes that healthcare insurance should be divorced from employment, and likens it to pensions and 401(k)s:

    Ultimately, health insurance needs to be moved out of the office. Employer-based coverage doesn't make sense in an age of quick job turnover: The average employee in a small firm works there for just 15 months. Changing jobs today means changing health insurance — and, possibly, family doctors and health networks. Not long ago, pensions were equally archaic; but Washington created 401(k)s, which aren't tied to specific employers. That approach would work well with health insurance. Future reforms could allow employers to contribute to employees' HSAs, then let them purchase insurance.

    This truly is the root of our health insurance woes.
     
    posted by sydney on 9/28/2004 02:53:00 PM 0 comments

    Virtual Autopsy: The no-mess solution to solving a crime.
     
    posted by sydney on 9/28/2004 08:46:00 AM 0 comments

    Carnival of the Caregivers: It's the medical blogosphere's answer to Carnival of the Vanities, Carnival of the Liberated and Carnival of the Capitalists - only we call it Grand Rounds, a round-up of posts from our corner of the blogosphere. Medical blogs are an expanding niche. Check it out.
     
    posted by sydney on 9/28/2004 07:24:00 AM 0 comments

    Obsession: The former smoker who sued his smoking neighbor for $300,000 in damages, even though she moved away, lost his case. The newspaper reported last week that the jurors looked "irritated and bored" when Mr. Zangrando, the plaintiff, went through pages and pages of pictures of his front porch from different angles in different seasons. He was a man obsessed who didn't realize that few people share his obsession. Not to mention the major inconvenience he was causing the jury. The defense attorney thought it was a waste of his, and his client's time, too:

    He mocked the case brought to court, claiming the six-day trial could have been completed in mere hours. He blamed the protracted trial on Gilbert's insistence on reading Zangrando's entire 24-page log detailing Kuder's smoking and the dozens of photos the man took of the porch where she smoked.

    Adgate said Zangrando's claims would be better addressed by lawmakers -- rather than in a lawsuit brought by an attorney -- ``so long as the rights of homeowners are protected.''

    "It was a horrible trial, a mockery of justice,'' he said after the verdict. "It wasn't only a frivolous trial, but a long and frivolous trial.

    "My heart goes out to Mr. Zangrando for the legal raping he just took. But it was his choice. Believe me, this wasn't a win for smokers, it was a win for those opposed to frivolous lawsuits.''
     
    posted by sydney on 9/28/2004 07:02:00 AM 0 comments

    Monday, September 27, 2004

    Conflicts of Interest: In the wake of the Florida Supreme Court's recent decision in the Schiavo case, the New York Times has an excellent feature story on the conflicts of interest that gather round a death bed, or near-death bed. It's worth reading, if for no other reason than to scare you into making a living will and sharing it with your family members so they don't beat each other up over difficult medical decisions.

    The Schiavo case could have been avoided if Mrs. Schiavo had left a written record of her wishes - or at least shared those wishes with all of her family. She was young, yes, but even young people can have catastrophic accidents.

    CodeBlueBlog has more thoughts on the Schiavo case and euthanasia. My own view is here.

    P.S. And The New York Times > National >this story about a brain-damaged man who not only survived the discontinuation of treatment but began to make remarkable improvement is also worth reading:

    The family conflict became so pitched that a court appointed a guardian, Herbert A. Pickford 3rd, who decided last September that the respirator would be removed. Mr. Pickford said doctors had given different estimates of how long Mr. Childress, 27, would live after the respirator's removal: days, weeks or longer.

    They never predicted that Mr. Childress would come out of his coma and start responding. But he has.

    'I can't believe it,' said Dr. David L. Chesler, the medical director at Mr. Childress's nursing home. 'He's actually saying a few things. He can follow commands. He recognizes people. He's doing things I would have never guessed.'

    Dr. Chesler said Mr. Childress had 'significant permanent brain damage' and would reach a point where he would not improve. But doctors do not know how much more progress he will make and are considering sending him to a rehabilitation hospital for more intense therapy.

    ...."He can write his name, he can play tick-tack-toe, he can put his shirt on," Jerry Childress said. "I've talked to him on the phone. I asked if he was ready to go to work and he said no. I asked him if he was ready to go fishing and he said, 'Say what?'


    We know so little about the injured brain and its capacity to heal. Acting as if we do is just plain hubris.
     

    posted by sydney on 9/27/2004 10:52:00 PM 0 comments

    Liar,Liar: Shrinkette has some interesting observations on patients who lie.
     
    posted by sydney on 9/27/2004 10:32:00 PM 0 comments

    From the Heart: Duane Freese has a heart-felt column about his late sister's medical experience and its lessons about our healthcare system.

    He also points to this study (it's a CBS report, but not by Dan Rather, so maybe it's reliable), that shows that healthcare costs may be increasing because we're spending more per patient per disease, with better outcomes:

    Fifteen conditions accounted for more than half the overall growth in health-care spending from 1987 to 2000, according to a new report that examined 260 medical conditions and was published in the journal Health Affairs. U.S. health-care spending rose an inflation-adjusted $200 billion, or about 3 percent per year, in that 13-year span.

    ...Heart disease, mental disorders, lung conditions, cancer and trauma -- the five most expensive conditions -- accounted for 31 percent of the overall rise, the study said. High blood pressure, cerebrovascular disease like strokes, arthritis, back problems, diabetes, pneumonia, skin disorders, infectious disease, endocrine and kidney diseases rounded out the 15 most costly medical conditions driving spending growth.

    ...In eight of the 15 conditions seeing the biggest rise in spending, a rise in the cost per treated case -- and not a rising volume of cases treated -- contributed most to the spending boost. Growth in the cost per treated heart disease case, for example, accounted for about 70 percent of the rise in spending while the number of heart disease patients remained stable in that time.



     
    posted by sydney on 9/27/2004 10:26:00 PM 0 comments

    StatinGate? It's not quite as riveting or significant, but a group of doctors is telling the American Heart Association and the NIH that they no longer take their word for it when it comes to cholesterol guidelines:

    'There is strong evidence to suggest that an objective, independent reevaluation of the scientific evidence from the five new studies of statin therapy would lead to different conclusions than those presented by the current NCEP,' reads the CSPI letter, signed by 35 cardiologists, nutritionists and other health professionals.

    'The studies cited do not demonstrate that statins benefit women of any age or men over 70 who do not already have heart disease,' said John Abramson, a clinical instructor in primary care at Harvard Medical School, who signed the letter.

    'Furthermore, we are concerned about the findings from one of the five cited studies showing that statin therapy significantly increases the risk of cancer in the elderly.'


    The Center for Science in the Public Interest is a nutritional advocacy group, which is, unlike the AHA, open about their funding. Here's their letter, which actually makes a good case against the new cholesterol-lowering guidelines.

    Like Rathergate, this is long overdue. Like Rathergate, for too long we've been handed down guidelines by people who have personal and financial interest in presenting them - from prostate cancer screening to mammograms in young women, to the use of anti-depressants for such ills as "social anxiety," with very little scrutiny. But, like Rathergate, it probably won't make much difference in how things are done.

    UPDATE: Meanwhile, there's a movement afoot to make statins over the counter in the U.S., as they are in Britain.
     
    posted by sydney on 9/27/2004 07:53:00 AM 0 comments

    Trendiness: A town in Kentucky is plagued with an abundance of scooters:

    Stricken with arthritis, Connie Haller gave up strolling the streets of this mountain town. But when the 78-year-old woman learned that the government would buy her a motorized scooter, she gladly accepted. And so did her elderly friends. And their friends. And their friends.

    Now, this town of 4,000 in Kentucky's coalfields is seemingly overrun with scooter riders.

    Scores of scooters and motorized wheelchairs plod along busy streets to the Wal-Mart, restaurants and beauty salons.

    Motorists complain that they snarl traffic, and the gray-haired riders fret about the dangers of sharing the asphalt with cars and trucks.


    Is this a wave of the future for towns everywhere as the baby boomers age?
     
    posted by sydney on 9/27/2004 07:51:00 AM 0 comments

    Space of Milk and Honey: Did the building blocks of life come from the Milky Way?

    A cotton candy-like cloud of simple sugar drifts in the unspeakably cold center of the Milky Way about 26,000 light years away, offering a remote, yet tantalizing, hint of how the building blocks of life may have reached Earth billions of years ago.

    This frigid cloud is composed of molecular glycolaldehyde, a sugar that, when it reacts with other sugars or carbon molecules, can form a more complex sugar called ribose, the starting point for DNA and RNA, which carry the genetic code for all living things.

    Astronomers have known about sugar in space for some time, but new research reported last week in the Astrophysical Journal Letters showed that gaseous sugar could exist at extremely low temperatures, as are found in regions on the fringes of the solar system where comets are born.


     
    posted by sydney on 9/27/2004 07:48:00 AM 0 comments

    This Just In: Hormonal birth control has risks.
     
    posted by sydney on 9/27/2004 07:47:00 AM 0 comments

    Good-bye to Bikini Medicine: Gender-based medicine continues to gain traction:

    The gender-based medicine movement isn't an effort to diminish the importance of breast cancer, but is meant to emphasize that ''we have more than one body part, folks. Up until now . . . that awareness just hasn't been there,'' said Sherry Marts of the Society for Women's Health Research.

    The group seeks to expand the definition of women's health beyond breast and reproductive health, what some call ''bikini medicine.''


    That is a welcome change. Far more women suffer from diseases that affect their non-reproductive organs and systems. But in fairness, it's the activists and the media attention they get that have skewed the public perception that the major health problems for women are limited to their sex organs.

    And it's not unreasonable to break research results down by gender. Women's bodies do operate in a different hormonal milieu than men's. Controlling for those differences is just good science.
     
    posted by sydney on 9/27/2004 07:41:00 AM 0 comments

    Sunday, September 26, 2004

    Another Success Story: Mississippi, like Texas, begins to reap the benefits of tort reform.
     

    posted by sydney on 9/26/2004 10:12:00 PM 0 comments

    Flu Shot Season Approaches: The CDC and infectious disease experts are urging just about everyone to get flu shots this year:

    A record 100 million doses of flu vaccine will be available this year, the vast majority of it shipped to doctors' offices by the end of October, said Dr. Keiji Fukuda of the Centers for Disease Control and Prevention.

    That assurance comes several months after one major supplier, Chiron Corp., delayed its shipments because a small amount of vaccine failed sterility testing, suggesting contamination. That was "a precautionary move," and close monitoring so far suggests the rest of Chiron's supply is fine, Fukuda said.

    ..."When you are vaccinated, you not only protect yourself, you protect your loved ones," stressed Dr. Walter Orenstein, the associate director of Emory Vaccine Center.

    That's especially important advice for parents, who should double-check that day care providers, baby sitters and grandparents anyone in close contact with their young children are vaccinated, said Dr. Carol Baker of the American Academy of Pediatrics.


    Meanwhile, here in the real world, there's no word from suppliers when the vaccine will be shipped. I pre-ordered about 150 doses this past winter, yet my inquiries about when it will be available have gone unanswered so far. Yet, my patients tell me that their employers ( large companies like Ford, GM, etc.) and drug stores are already announcing that they'll have their vaccines in the next couple of weeks. They, of course, buy much more than 150 doses.

    That means the vaccine will be distributed without regard to medical need. Young, healthy adults can line up at work or the local drug store and get the shot. So can the elderly and those with chronic illnesses, but when it's distributed on a first come, first serve basis like that, the supply doesn't get distribute to where it's needed the most. And that's a big deal because even if it were only given to those who need it the most, there wouldn't be enough to go around:

    CDC's list of those in most need of vaccination includes about 185 million Americans, far more than the vaccine supply.

    But supply depends on consumer demand and since so many Americans skip their shots, the 100 million doses on tap this year should be plenty, Fukuda said. Temporary shortages did occur last year when an early start to the flu season sparked a run to doctors' offices. But ultimately, a little of last year's 87 million doses went unused.


    Those who need the shot the most are:

    -Those who are 65 years and older. (The CDC has broadened that to include those 50 years or older, but many private insurance companies won't cover the shot for those age groups unless they have a chronic lung condition.)

    -Anyone with a chronic disease such as diabetes, heart disease, asthma, emphysema, or a suppressed immune system, or who takes medication that suppresses the immune system

    -Children ages 6 to 23 months old. (Again, insurance companies often won't cover this unless the child has some respiratory disease. Also, most of the vaccines contain thimerosal. Studies have found it to be safe, but there are still websites out there devoted to litigating it. As a result, few physicians are eager to use it. And the supply of the thimerosal-free version of the vaccine is limited.)

    -Healthcare workers or those who work or live closely with someone in a high risk category.

    As much as I believe in free markets, vaccines like this is one area where it just doesn't work. If the CDC is going to urge everyone to get the vaccine, then they should make sure that 1) there's enough of it and 2) that it gets sent to where it's needed. The CDC doesn't have that power, but maybe they should be given it. Either that, or stop being so complacent about supply and demand.

     
    posted by sydney on 9/26/2004 10:27:00 AM 0 comments

    Charitable Servitude: What do you do when a charitable impulse leads to more than you bargained? Once, when we lived in a very cold and snowy northern climate with very long winters, I promised the little boy next door that he could shovel our walk for $5 every time it snowed. But, instead of waiting for a snow shower to end, the kid would shovel the walk every thirty minutes and come up to the door asking for his five bucks. I didn't have any trouble telling him to either wait until the snow ended or our deal was off. But now, I've gotten myself into a similar situation in the office that isn't so easy to end.

    I was asked if I would be willing to take on a new patient who was deaf and needed to have a sign language interpreter with her at each visit. I accepted, knowing that I would end up breaking even at each visit once I paid for the interpreter. The patient had traditional insurance, which would pay me about $50 for a fifteen minute office visit, and the interpreter services charged $25/hour with a two hour minimum. But now, my patient has switched to Medicaid, which pays I don't know how much for a fifteen minute visit, because I've yet to be paid. But you can bet it will be less than traditional insurance. In an added blow, the interpreter services have raised their rates to $30/hour with a two hour minimum. I'm no longer breaking even. I'm paying for the privilege of caring for my patient.

    I know that the charitable and kind thing to do is to ante up and not complain. Even as I write this, I feel miserly and mean. But my patient has turned out to be a somatisizer. She's also started recommending me to her friends in the deaf community. This has the potential to turn into some very serious giving. And I can't put a halt to any of it without breaking the law.

    Now, my patient is not illiterate. She could communicate with me through writing, but she prefers sign language. English isn't her first language, sign language is. And although the portion of the ADA relevant to the hearing impaired includes written materials as an appropriate aid, the reality is that written material may be considered inadequate. And, although the law also says that a business doesn't have to comply if doing so will be a financial hardship, the reality is otherwise. Physicians can not plead poverty. (A similar situtation exists for foreign language interpreters although the feds have cut small practices some slack in that regard. )

    The most frustrating aspect of it all is that I have no choice. I have to give and give again, even if the giving exceeds my capacity. Charity given freely is at least attended by some warm and fuzzy feelings. But forced charity feels more like being robbed.

    UPDATE: Another physician had a similar experience:

    I, too, became a "victim" of the ADA , and I was forced to stop accepting Medicaid because of this. When I suggested that the patient might be better served by going to one of the two local family practice residency programs where there were full-time institutional supported American Sign Language interpreters, I received a letter from an attorney from a local disability advocacy group threatening to sue me if I did not treat this patient. After consulting with two attorneys, I was basically told to "suck it up and see the patient" because I had no defense against an ADA suit.

    The patient turned out to be a nice enough person, but I realized that a couple of dozen patients for whom I would have to pay for an interpreter could financially destroy my practice. Even though there are institutional practices in the community with employed interpreters, the ADA states that I am obligated to take any patient like this one unless my practice is closed to all patients. Therefore, my only recourse was to terminate my contract with Medicaid. About 100 patients were forced to find a new doctor so that I could protect my practice from financial ruin.


    Sadly, this is one of the alternatives I'm considering. It means that some of my patients will have to find a new doctor, and it isn't easy to find doctors who accept Medicaid. It's one of those government mandates that's meant to improve care but only ends up making things worse.

    UPDATE II: In a related vein, Dr. Mental notes that doctors in Tennessee had to drop Medicaid when the state expanded its program to include all the uninsured. Which, by the way, is Senator Kerry's plan for the whole country - to expand Medicaid to include families making 200% of the poverty level. We'd have fewer uninsured, but they'd have a heck of a time finding a doctor.
     
    posted by sydney on 9/26/2004 09:59:00 AM 0 comments

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