nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Saturday, July 26, 2008

Some Doom-and-Gloom...But Light-hearted

Physician recommends limited use of cell phones to minimize cancer risk, other health problems.

The AP (7/27, Yates, Borenstein) reports that Ronald Herberman, M.D., director of the University of Pittsburgh Cancer Institute, "issued an unprecedented warning to his faculty and staff Wednesday: Limit cell phone use because of the possible risk of cancer." This warning "is contrary to numerous studies that don't find a link between cancer and cell phone use, and a public lack of worry by the U.S. Food and Drug Administration."

Still, the UPI (7/24) quotes Dr. Herberman as saying, "Recently, I have become aware of the growing body of literature linking long-term cell phone use to possible adverse health effects, including cancer. ... Although the evidence is still controversial, I am convinced that there are sufficient data to warrant issuing an advisory to share some precautionary advice on cell phone use."

Doc D: This comes up about once every three years. I’m not aware of any “literature linking …cell phone use” to health problems. There are anecdotal reports: when summarized, they mostly say “I (he/she) got cancer and the only thing I can think of as a cause is the cell phone.” Make up your own mind, but consider the biology—what could be the mechanism involved? We’ve done tissue studies with frequencies, and at power levels, used by cell phones and it appears that there’s no measureable penetration of the skin. No matter how often you hold it up to your head, nothing gets in.

I admit that it’s a little scary to be surrounded by so much radiative energy, from radio, tv, phones, wifi, microwaves, satellites. I feel like a pincushion. But it’s trivial next to the amount of natural radiation that zips through our bodies all day, every day. If this bothers you, wear a hat: it won’t do any good, but you’ll feel like you did something.

House passes resolution allowing lawmakers to avoid considering President's Medicare proposals.

The AP (7/25, Freking) reports, "Congressional efforts to deal with growing Medicare spending will be set aside for another year under a rule change approved by the House on Thursday." President Bush previously "proposed having wealthier beneficiaries pay higher monthly premiums for the program's prescription-drug benefit, as well as limiting punitive damages awarded in medical malpractice cases." The proposed changes aimed "to keep general revenues from covering more than 45 percent of overall Medicare costs through at least 2013." But, the "resolution that the House passed on Thursday suspends" the requirement for the House "to consider the President's recommendations on an expedited basis."

Doc D: The “Do-Nothing” Congress continues on the same path. The problem is that the present rate of spending on federally funded programs cannot be sustained. The three major entitlement programs now account for over 50% of the federal budget, about double what the percentage was in 1965 (27%). Turn that around: we have less than half the budget to deal with everything else: energy, labor, justice, commerce, foreign affairs, defense, environment, education, community development, agriculture, transportation, etc.

This is not a budget deficit issue: The deficit has been falling for the last four years (413B to 162B) and we’re on a course that it will reach zero in ~4yrs. The war ain’t the problem: defense spending as a part of GDP has increased by only ~0.5% since ‘03. (This is all Budget Office data. You can see it http://www.cbo.gov/ if you’ve got the time to dig through it.)

I’m willing to bet any of you that, no matter who gets elected President, there will be no fundamental reform. The thousands of competing interests will make it impossible. Oh, sure, whoever is in office will accomplish something small that sounds really high-minded, and will then declare victory. The people who voted for him will buy into it, those who didn’t won’t. The Talking Heads on TV will make millions off our consternation.

AMA to investigate feasibility of offering incentives for organs.

On its website, MSNBC (6/25, Aleccia) reported that "[m]ost people who donate organs after death need no reward beyond altruism, but others could use a little nudge, according to the nation's doctors." But, according to the AMA, it is unclear "what kind of incentives -- and in what amounts -- might encourage potential organ donors and their family members to follow through…. During a recent meeting, the AMA "voted to move forward with plans to amend the law to allow pilot studies to settle the incentive issue." ….’studying incentives for donation after death should be acceptable in a nation where nearly 100,000 people remain on a waiting list for organs, and nearly 10 percent die before a transplant becomes available."

Doc D: If it’s my organs that are being donated, I don’t think I’m going to be enticed by an incentive….Clearly I won’t need them (the organs, that is) as I will have left the Corporate Plane (or This Vale of Tears, if you prefer). So, what could be a good incentive for me to donate? A new car? A Timeshare? A toaster?

Opinions are entirely my own. Quotations from AMA Morning Rounds (© U S News Custom Briefings)

Doc D

Thursday, July 24, 2008

Pulling my hair out...Wait, I don't have any

Heightened autism awareness may lead to wariness of vaccines, pediatricians say.

In continuing coverage from previous editions of Morning Rounds, New Jersey's Star-Ledger (7/20, O'Brien) reported, "With autism spectrum disorders now diagnosed in one out of 150 children nationally, and one in 94 in New Jersey, rare is the parent who isn't aware of autism." But, with heightened awareness "come[s] a new wariness of vaccines, which a vocal minority of autism activists blame for the jump in cases. Pediatricians report seeing more parents question, delay, or even shun altogether the traditional round of childhood immunizations." Further complicating the situation "are celebrities who either blame or suspect vaccines, such as actress Jenny McCarthy, and radio talk show host Don Imus. Doctors complain they get an unquestioning ride in the media." While the prevalence of autism "has soared in recent years, experts are unsure whether more cases are occurring, or simply more cases are being diagnosed."


Doc D: I’ve written about this before: there’s no evidence to support a link between vaccines and autism. I can’t say that there won’t ever be, but the studies we have are pretty solid. The problem is, vaccination is one of the unique interventions in an infant/toddler’s life, and there is little else that parents can look back on as a cause. However, as you all know, this is the “post hoc ergo propter hoc” fallacy. Translated it says “after this, therefore because of this”. Bertrand Russell gave a great example of this defect in how humans think: “Every morning the rooster crows and then the sun comes up. Therefore, the rooster makes the sun come up.” See here: http://en.wikipedia.org/wiki/Post_hoc_ergo_propter_hoc


Number of e-consults growing gradually in several states.

Florida's Sun-Sentinel (7/21, LaMendola) reports that "[a]fter more than four years in the mainstream in Florida and a few states, online doctor consultations are catching on, although not like many had hoped. Only a fraction of doctors offer the service, and a small number of their patients take advantage." Still, "[p]roponents of e-consults said the number has jumped since Aetna, Cigna, and other insurers began paying for them nationwide in January. They predict the practice will one day become a prime option for patients dealing with simple health issues." Insurers are beginning to offer "online physician contacts...as a way to improve patient satisfaction, ease office burdens on doctors, and save a little money." In addition, polls have shown that "patients like the idea of contacting doctors by email."


Doc D: So much of diagnosis is seeing, hearing, and touching. I expect to see the first e-consult malpractice case any day now (if it hasn’t occurred already). Then we can have an e-court case, with e-lawyers and an e-judge.


U.S. lags in quality of healthcare despite having costliest system, report indicates.

The AFP (7/17) reported, "The United States lags behind other industrialized nations in the quality of its healthcare, despite having the costliest system in the world, according to a report released on Thursday" by the Commonwealth Fund. The foundation said in the report that the "U.S. healthcare system is plagued by inefficiency, inequality, and an incoherent national policy." Utilizing a 100-point scorecard, the fund rated healthcare systems of various countries "based on 37 categories, including access to healthcare, quality of care, and efficiency." The U.S. "ranked last among 19 industrialized [nations] when it [came] to preventing premature deaths from conditions, such as heart attacks, that can be treated with timely, effective care."

The report also indicated that "U.S. healthcare has failed to improve since 2006, while access has [been] worse, and the country should expect 'a far better return' on its massive investment in health," according to the Financial Times (7/18, Timmins). "A more efficient health insurance system could save at least $50 billion a year, and 100,000 fewer people a year would die if the U.S. achieved death rates comparable to those in leading countries," the report stated.


Doc D: I think you would find it interesting, if you have the time, to read the report. If you do, note how there are many areas of improvement not mentioned in this article. Where the US compares poorly to other nations, this is specifically noted. Where we do well, no mention is made. There are some goods points made in the details, such that focused efforts could result in improvement in our healthcare, but the activists have to make their report sound like a disaster in order to be heard above the shouts of thousands of other activists for other causes. What a shame. Here is the overview: http://www.commonwealthfund.org/usr_doc/1150_WhyNottheBest_EXEC_SUMM_METHODOLOGY_ONLY.pdf?section=4039


I think you would be surprised if you looked up other data. For instance, we hear again and again about the “47 million uninsured.” I’m surprised to find this includes all the people who make enough to not need insurance, and that 20% of the 47M are people in poverty (they are eligible…why are they uninsured?). In the report they also admit that they changed the way they calculate the total, so some of the years are not strictly comparable. So… I want to fix the problem, but how big a problem is it? Another example is global warming. I’m very worried about that subject, but I can’t validate the garbage data that both sides toss around. The main model for warming said 10 years ago that we would experience a 2 degree rise by now, but the change has only been 0.2 degrees…a whole order of magnitude off. The IPCC, the UN panel that issued the analysis and call to action on global warming, used data on tree ring thickness to measure temperatures over the last several hundred years, despite the fact that those data have been shown to be unreliable (trees grow, or they don’t, due to a lot more factors than temperature), and more reliable data tell a different story. Finally, the IPCC was billed as a panel of 2000 scientists, but wasn’t…most of the minority who were scientists didn’t have degrees in climate science. Actually only about 10 climate scientists were involved in the writing. By contrast over 31,000 scientists, researchers, engineers, and physicians have signed a petition saying global warming due to human greenhouse gas production is unproven. Who’s right?


I don’t know about you, but I’m getting overwhelmed with the junk I have to sift through to find the right answer and there’s nobody you can rely on to do that work other than yourself.



Frustrated Doc D


Opinions are entirely my own. Quotations from AMA Morning Rounds (© U S News Custom Briefings)

Monday, July 21, 2008

THE VIOXX PANIC, AND "WHO'S GETTING FREE DRUGS?"

 

Almost one-third of patients who suffer cardiac arrests in hospitals may not receive timely defibrillator shocks, study suggests.


In a front-page article, the New York Times (1/3, A1, Grady) reports that approximately three out of ten hospitalized patients who go into cardiac arrest are not given an electrical shock from a defibrillator within two minutes, the time recommended by experts, according to a study published in the New England Journal of Medicine. Lead author Paul S. Chan, M.D., of Saint Luke's Mid-America Heart Institute in Kansas City, Mo., and colleagues, examined the "records of 6,789 patients at 369 hospitals whose hearts stopped because of conditions that could be reversed with" a shock from a defibrillator. The researchers found that when defibrillation did not occur within two minutes of cardiac arrest, just "22.2 percent of the patients survived long enough to be discharged from the hospital, as opposed to 39.3 percent when the shock was given on time."


Doc D: This is an observational study and has several problems. First, the health record is notoriously unreliable (even “code sheets” are not perfect): in all my years in emergency medicine, I’m not sure I ever got the times exactly right when I sat down later to record the event, mainly because I wasn’t watching the clock when I got called, or when I gave the shock. I was usually too engrossed in the patient…duh. Second, these are hospitalized patients: unless you want a cardiac team and resuscitation cart in every room, it’s going to take time to bring this all together. Lastly, the study didn’t say much about what happens after you shock somebody. Many times I’ve shocked a patient successfully (and rapidly), only to have them arrest again, and again, and again…or later in the ICU, and while it says that 22 percent survived to leave the hospital it doesn’t say much about what kind of shape they were in (paralyzed? couldn’t talk?). Studies like this are bothersome because it sounds like “three out of ten” got substandard care, and maybe that’s not true. In any case, hospitals should be good at reacting to arrests: I recommend practice, practice, practice.


Wall Street Journal cautions against panic in the face of medical risk.
The Wall Street Journal (1/2, A10) reported that the "Vioxx panic seems to have subsided, but the same kind of alarmism is beginning to wash over healthcare fields other than pharmaceuticals," such as "medical technology." One of the most pressing issues before Congress "is Medtronic, a major medical-device maker, and the controversy surrounding a component of its heart defibrillators." Last October, "in the face of escalating criticism over safety concerns, Medtronic voluntarily withdrew from the market a type of the complex wires -- called leads -- that connect a defibrillator to the heart muscle, and tell it when to deliver therapy." The Journal noted that "Medtronic's withdrawal may also have been driven by legal and political calculations." Since Vioxx was pulled from the market, "companies are under pressure to get out in front of even modest health risks." Treatments typically have some risk, and medical devices generally "undergo extensive laboratory 'bench tests' to simulate how they'll behave under the stresses of the human body." Still, the Journal concluded, "the real danger to public health is overreaction to medical risk."




Doc D: I agree with this. Frankly, I don’t think there is such a thing as a completely harmless medicine, especially when we get down to the “one-in-a-million” level of risk. Consider the case of polio vaccine: the “sugar cube” we all took is not as harmless as it sounds. Five to eight out of every million kids who took it…got polio from the vaccine. This is not something we learned just recently, we knew it all along. But, at the time there were 50-100,000 cases of polio a year that was the alternative. Now that polio is rare, we don’t give the oral vaccine at the earliest doses, to reduce the risk of vaccine-induced polio. It’s a matter of balancing risk, something we should always do…with every form of treatment. The media reports don’t discuss this. So, every time you read something about the risk of a drug or treatment, remember that somebody is trying to “scare you” into watching their show, or reading their article…and ask yourself, (1) how does this risk compare to other risks, and (2) what are the alternatives, if not this drug. If I had arthritis so bad that I could hardly walk, and Vioxx was the only thing available, I would take it and accept the very small risk of heart problems.




Survey finds that wealthier, insured patients receive most free medication samples.
USA Today (1/3, 7D, Szabo) reports that according to a survey published in the February issue of the American Journal of Public Health, the majority of "free medications...actually go to wealthier patients who have insurance." Study author Sarah Cutrona, M.D., a physician with Cambridge Health Alliance in the Boston area, and an instructor at Harvard Medical School, and colleagues, surveyed "nearly 33,000 Americans" in 2003, and found that just "28 percent of those who got samples were poor, whether insured or not." But, Ken Johnson of Pharmaceutical Research and Manufacturers of America argues that studies have "show[n] 75 percent of physicians frequently or sometimes give out samples to help patients with out-of-pocket costs." Still, "Cutrona says many poor and uninsured people never get to see a doctor, and more often visit public health clinics or emergency rooms, where samples may not be available, or go without care."




Doc D: Just so you know, when I worked at the county hospital, we tried to give away all we could to our poor patients. The problem is, as it was explained to me, there are some legal issues with trying to do this systematically. Also, most free samples are one-to-several days worth of medicine, and even if you had a handful of samples, this only postpones the cost, and risks discontinuity with those medicines where you don’t want the patient to stop it suddenly (you could even argue that giving samples is a “risky” thing to do, as above). And, if you were a pharmaceutical company, would you want a wealthy, or a poor, population to be trying out your latest whiz-bang, 3-dollars-a-pill drug? Related to that, we tried to use cost-effective drugs in public institutions, since this gave us more care for our dollars, which were limited. This study makes it sound like wealthy doctors are doing favors for wealthy patients. That happens, I guess, but it aint the only thing going on here.








Doc D


Opinions are entirely my own. Quotations from AMA Morning Rounds (© U S News Custom Briefings)






Tuesday, July 15, 2008

WHO WANTS A BIG BRAIN IF I STILL CAN'T THINK STRAIGHT?

Researchers explore role of physical fitness in slowing mental decline.

The CBS Evening News (7/14, story 8, 0:20, Couric) reported that "a powerful weapon to fight Alzheimer's could actually be the treadmill."

A new study published in the July 15 issue of the journal Neurology found that "[p]hysically fit patients with mild cognitive impairment had less brain shrinkage than those who weren't so well conditioned," Bloomberg (7/15, Alesci) reports.

According to the AP (7/15, Ritter), lead author Jeffrey Burns, M.D., of the Alzheimer and Memory Program at the University of Kansas School of Medicine in Kansas City, and colleagues, examined "57 people with early Alzheimer's" whose "physical fitness was assessed by measuring their peak oxygen demand while on a treadmill." Using magnetic resonance imaging scans, the researchers measured participants' "brain shrinkage." But, even though analysis revealed "participants who were more physically fit had less brain shrinkage than less-fit participants," they still did not do "significantly better on tests for mental performance."

Doc D: The key phrase is the last one. Exercise gives you a bigger brain…that still doesn’t work. Why this got national attention, I don’t know. The first sentence is misleading. Classic case of misrepresentation by the media.

Home caregiver abuse involving the elderly increasing.

On the front of its Personal Journal section, the Wall Street Journal (7/15, D1, Shishkin) reports that abuse, neglect, fraud, and even killings by home caregivers are growing "as more Americans age, and try to avoid nursing homes," according to law enforcement officials and "advocates for the elderly." Both groups are calling "for better oversight of an industry" that provides the "two kinds of jobs [that] are the second- and third-fastest growing occupations in America," those of caregivers who provide "basic health services, and those who provide housekeeping, cooking, and non-medical help."

Doc D: I don’t deny that this occurs. The problem with the story is that there’s no data. I think it was the 19th century British Prime Minister Benjamin Disraeli who said that by the time a problem becomes widely accepted by the general population, it’s already going away. We saw this with crime in the 90’s: by the time the administration and Congress had poured resources into fighting crime, the data showed that the crime rate had already been falling for a couple of years. In any case, we don’t need another panic, like MRSA or west nile virus. We just need hiring and performance monitoring for home caregivers…something we’re not doing now.

Study suggests easy access to cigarettes may increase risk of addiction.

In the New York Times's (7/15, F6) Vital Signs column, Eric Nagourney writes that easy access to cigarettes makes it more likely that sixth graders will "become smokers by the time they are in high school," according to a study published in the Annals of Family Medicine.

Doc D: Oh, no! You mean if there were free heroin dispensers in every convenience store, more kids might become addicted? Who would have thought!

This kind of dopey study probably represents the clash between those who want limit children’s exposure to bad things (sex, drugs) and those who say we can’t stop them, so why not make it safer for them to do bad things.

Standardized care may prevent clinicians from addressing patients' individual needs, op-ed says.

In an op-ed published by the Boston Globe (7/14), Victoria Rogers McEvoy, M.D., of Harvard Medical School, wrote that black patients "with diabetes fare worse than" patients who are predominantly of European descent, "even when they see the same doctor who orders the same tests, visits, and referrals to specialists," according to findings published in the Annals of Internal Medicine. While "[s]ome will surely assume that the doctors were -- perhaps unconsciously -- racist," the study's lead investigator, Thomas Sequist, M.D., M.P.H., surmises that physicians may "have failed to consider cultural differences when they, for example, assigned the same low-carbohydrate diet to all their patients, regardless of their traditional foods." Dr. McEvoy pointed out that "[i]n today's medical climate, we doctors are expected to standardize our care," which can "encourage doctors to check boxes on a form, rather than tune in to the needs of" patients.

Doc D: This is my token serious entry. For those who are concerned about quality and errors in medical care, the answer is to regulate and standardize. If we had a standardized patient that needed the same things and always reacted the same way—like a car—this would make sense. In our efforts to improve healthcare, we must not forget that everyone is different.

Doc D

Opinions are entirely my own. Quotations from AMA Morning Rounds (© U S News Custom Briefings)

JAMES J DOUGHERTY, Brig Gen, USAF (Ret)

Tuesday, July 8, 2008

Healthcare reform plan comparisons

For those of you who are interested, the webpage below has a candidate comparison on healthcare reform. It’s a fairly good, neutral explanation of the elements of each candidate’s proposal. Having run a healthcare system for a population, I find it fascinating to see what policy makers think will work: some good ideas here, some bad.

I have an opinion on the relative merits, but I’m not giving it here, except to say that I look for a workable solution to all the major elements of a good system: quality, cost, access, coverage…in descending order of importance. Here’s why: (1) I don’t want crappy care at any price (quality), (2) if underlying cost increases are not controlled, access and coverage can’t be sustained, (3) if nobody’s there to see you (access), it doesn’t matter whether you’re covered, and (4) I believe everyone should have a coverage avenue, public or private.

http://www.webmd.com/election2008/comparecandidates

One last thing. When the discussion turns to how we pay for all the things we want, I sometimes hear that we should cut defense spending. For the record, I’ve included a graph of defense spending since 1965. Back in 1950, it was about 30% of GDP. At the height of the Vietnam War it was 9.5%. It’s now 3.9%, and will be going to 3.5% in the out years. The interesting thing is how we’re going to deal with the “Acquisition Holiday” that occurred in the 90’s (a large part of the “Peace Dividend”). About $160B of the $200B budget deficit reduction came out of defense, mainly by cancelling future development and purchases.

Planes and tanks wear out, so get ready for some big bills to replace or repair them…and there’s little in the pipeline, which needs a 10-15 year lead time. Let’s hope we don’t go back to the late 70’s: when I entered active duty in 1980 we had blocks of wood we used as simulated surgical sets because we had no money to buy the real thing. Cheery thoughts.

Opinions are solely my own.

Doc D

Monday, July 7, 2008

Life's Beginning and Ending...and Vitamin D

Study suggests serotonin imbalance may be linked to SIDS.

The Los Angeles Times (7/5, Hansen) reported that "[m]ice genetically engineered to overproduce the brain chemical serotonin died at an early age after developing symptoms similar to those of sudden infant death syndrome (SIDS), suggesting improper regulation of serotonin may cause SIDS in humans," according to a study published in the July 4 issue of Science.

Doc D: This may be an important clue, but it’s WAAAAY too early to be thinking there is a simple cause-and-effect relationship here. SIDS is an incredible tragedy, but, even though we know SIDS babies lack one type of serotonin receptor, serotonin has many, and complex, functions in humans. It’s not time to start putting serotonin syrup in baby formula.

Controversial end-of-life bill heads to California Senate.

Medscape (7/4, Gandey) reported that the "California State Legislature...has amended an end-of-life care bill, known as the Right to Know Act." The legislation, known as bill 2747, "is designed to improve information and counseling for patients and, on Thursday, was amended after passing a senate committee." While the "amended bill no longer includes references to euthanasia," it "encourages the use of palliative sedation and voluntary patient starvation and dehydration." As a result, several groups, including the Association of Northern California Oncologists, oppose the bill. For the most part, "physicians are concerned that end-of-life discussions will distress terminally ill patients, and offer no benefit." But, a recent study conducted by researchers at the Dana-Farber Cancer Institute in Boston showed that "end-of-life care discussions between doctors and patients were not associated with psychological distress."

Doc D: The issue is not whether it’s a good thing to offer patients end-of-life counseling. It’s about intrusion into the doctor-patient relationship. I think doctors need to be taught and encouraged to offer and conduct these discussions. Patients who want counseling need to ask. BUT, it’s the patient and the doctor who need to decide what, when, if, and how…not the government. I understand this bill requires doctors who don’t think it’s in the best interest of their patient to proceed as the government directs to refer their patient to another doctor, and if they don’t they are subject to medical board discipline. This kind of legislation comes from those people who think they know better than you what you need.

Recent studies fuel debate over vitamin D dosage.

In a front-page article, the Washington Post (7/4, A1, Stein) reported that a "flurry of recent research indicating that vitamin D may have a dizzying array of health benefits has reignited an intense debate over whether federal guidelines for the 'sunshine vitamin' are outdated, leaving millions unnecessarily vulnerable to cancer, heart disease, diabetes, and other ailments."

Doc D: the rest of the story: Vitamin D in high doses is toxic…and there’s also some research to suggest that Vit D increases risk for some health problems. Bottom line: Situation normal, all confused up (SNACU), take no action yet.

Doc D

Opinions are entirely my own. Quotations from AMA Morning Rounds (© U S News Custom Briefings)

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