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.

Friday, September 19, 2008

Study suggests urinary levels of BPA may be linked to cardiovascular disease, diabetes. In continuing coverage from yesterday, MedWire (9/17, Lyford) reported that "urinary levels of bisphenol A (BPA), a chemical found in plastic food and drink containers, are associated with cardiovascular (CV) disease, type 2 diabetes, and liver-enzyme abnormalities," according to a study published in the Sept. 17 issue of the Journal of the American Medical Association. David Melzer, M.B., Ph.D., of Peninsula Medical School, Exeter, U.K., and colleagues, "examined associations between urinary BPA levels and the health status of adults living in the USA.” Doc D: You may have seen this on TV in the last three days. Another example of scaring ourselves to death (SOTD). Bisphenol A has been around for a long time: I remember discussions many years ago about whether it was a health risk or not. It’s important to note (above) that they say these diseases are “associated” with urinary levels of BPA….not “caused by”. Remember the post hoc ergo propter hoc fallacy? Also, you should know that they took one blood sample from each subject: if you have BPA levels on one day, and you have diabetes, doesn’t mean you had levels in the past that led to diabetes. The authors admit this limitation. I can make up any number of hypotheses to explain this phenomenon that doesn’t involve Bisphenol A toxicity. Here’s one: there’s another unknown chemical that we find in cans and plastics along with BPA. It’s the toxic chemical. BPA is just an “innocent bystander.” Here’s another one: People who are genetically pre-disposed to heart disease and diabetes also have a disposition to absorb more BPA than other people. The problem is genetics, not BPA. Note: these are probably false hypotheses, but you get the point, I hope. BTW, alcohol consumption is associated with “liver-enzyme abnormalities.” Drink a couple of beers and your enzymes exceed normal levels for a day or so. We used to use liver enzyme tests as a screen to know whether recovering alcoholics were staying on the wagon. All that being said, this may eventually turn out to be a real cause-and-effect relationship. But, we’re not there yet: a lot of work needs to be done. For those of you who just can’t stand the anxiety, buy fresh instead of canned, and use glass jars. I won’t change yet: there are too many other more important things to worry about. Doc D Opinions are entirely my own. Quotations excerpted from AMA Morning Rounds (© U S News Custom Briefings)

Wednesday, September 17, 2008

Healthcare Platforms

Analyses question McCain, Obama health plans.

CQ (9/17, Jha) reports, "Twenty million people will lose coverage provided through their employers under Sen. John McCain's (R-Ariz.) healthcare plan, while Sen. Barack Obama's (D-Ill.) proposal will add $100 billion in new spending every year, according to two separate analyses published Tuesday in the journal Health Affairs." McCain proposes a shift away from employer-sponsored coverage, but that may result in the "same number of uninsured Americans," because approximately 20 million "would use the tax credits to buy cheaper, but less-generous, non-group coverage," according to researchers Thomas Buchmueller of the University of Michigan, Sherry Glied of Columbia University, Anne Royalty of Indiana University-Purdue University at Indianapolis, and Katherine Swartz of Harvard University. Obama's private/public plan would "reduce the number of uninsured by imposing a mandate for employers to offer health insurance to their workers, or else pay a payroll tax that would help fund a new public program." Joseph Antos, of the American Enterprise Institute, Gail Wilensky of Project Hope and Hanns Kuttner, formerly of the University of Michigan, said this employer mandate "conceals who actually pays for the required benefit," warning that the mandate could "undermine their chances for economic success."

Doc D: I’ve written about the candidates’ plans before, talking about these issues and others, so I’m feeling like a pretty smart guy today. Once again, though, the media goes for the conflict: I subscribe to Health Affairs and have read the articles…it’s actually about combining the good elements of both parties’ plans (note the title: “Blending Better Ingredients for Health Reform”). By the way, the media likes to refer to the candidates’ policies as “theirs,” but the plans are all written by policy wonks that work for the campaigns: I believe the candidates themselves have little understanding of the healthcare system. I don’t agree with some of the analysis in this article, but it would take 20 pages to say why, and bore you to tears.

I did a fun experiment. I went to the health plan comparison website at http://www.health08.org/sidebyside_results.cfm?c=5&c=16 and asked the computer to search for two words in the side-by-side comparison: “choice(s)” and “require(d)(ment)”. Here’s the result: the McCain plan uses “choice” twice; the Obama plan, not at all. The McCain plan uses “require” three times; the Obama plan, eleven times. This is not scientific and shouldn’t be given more than a moment’s consideration [for instance, in the Obama plan, most of the time, “require” is used toward the industry (insurance, employers, doctors, hospitals, and such), but saying “require all children to have health coverage” doesn’t tell you how that’s going to happen—it’s probable that the details are in the platform somewhere]. However, I do think that there is a fundamental ideological difference in the parties. If having a say in who, what, when, where, and how is most important to you, then you like “choice”. If ensuring that everybody gets a share by contributing according to ability, then you like “require”. Said differently, do we want to make sure people don’t obtain (choose) less coverage using their tax credit, or do we want to mandate (require) coverage and pay for the increased cost in government spending each year? The above article greatly oversimplifies things, admittedly. For you Poli Sci majors, this is old stuff between the Left and the Right.

It took me a long time to write that paragraph: it’s almost impossible to choose language that is balanced, and I probably didn’t succeed. The problem I have is that neither plan will solve the nation’s need for high quality, accessible, affordable coverage. The parties just want to pander to the public’s demand to get people into the “insured” column.

Doc D

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

Thursday, September 11, 2008

TERRORIST ATTACKS WITHIN THE US

I read a poll that said only 38% of Americans are worried about a terrorist act within the United States. I can understand that if we aren’t seeing any explosions, it’s hard to stay excited about a threat.

I ran across this list of attempts since 2001, so you decide. To be fair, some of these resulted in convictions, others are still in the legal process. Also, I have to say that this list does not include any classified attempts. I believe the real total is over 50 (as of last year when I had access to info).

•May 2003, Iyman Faris: American citizen charged with plotting to use blowtorches to collapse the Brooklyn Bridge.

• June 2003, Virginia Jihad Network: Eleven men from Alexandria, Va., trained for jihad against American soldiers, convicted of violating the Neutrality Act, conspiracy.

• August 2004, Dhiren Barot: Indian-born leader of terror cell plotted bombings on financial centers.

• August 2004, James Elshafay and Shahawar Matin Siraj: Sought to plant bomb at New York's Penn Station during the Republican National Convention.

• August 2004, Yassin Aref and Mohammed Hossain: Plotted to assassinate a Pakistani diplomat on American soil.

• June 2005, Father and son Umer Hayat and Hamid Hayat: Son convicted of attending terrorist training camp in Pakistan; father convicted of customs violation.

• August 2005, Kevin James, Levar Haley Washington, Gregory Vernon Patterson and Hammad Riaz Samana: Los Angeles homegrown terrorists who plotted to attack National Guard, LAX, two synagogues and Israeli consulate.

• December 2005, Michael Reynolds: Plotted to blow up natural gas refinery in Wyoming, the Transcontinental Pipeline, and a refinery in New Jersey. Reynolds was sentenced to 30 years in prison.

• February 2006, Mohammad Zaki Amawi, Marwan Othman El-Hindi and Zand Wassim Mazloum: Accused of providing material support to terrorists, making bombs for use in Iraq.

• April 2006, Syed Haris Ahmed and Ehsanul Islam Sadequee: Cased and videotaped the Capitol and World Bank for a terrorist organization.

• June 2006, Narseal Batiste, Patrick Abraham, Stanley Grant Phanor, Naudimar Herrera, Burson Augustin, Lyglenson Lemorin, and Rotschild Augstine: Accused of plotting to blow up the Sears Tower.

• July 2006, Assem Hammoud: Accused of plotting to bomb New York City train tunnels.

• August 2006, Liquid Explosives Plot: Thwarted plot to explode ten airliners over the United States.

• March 2007, Khalid Sheikh Mohammed: Mastermind of Sept. 11 and author of numerous plots confessed in court in March 2007 to planning to destroy skyscrapers in New York, Los Angeles and Chicago. Mohammed also plotted to assassinate Pope John Paul II and former President Bill Clinton.

• May 2007, Fort Dix Plot: Six men accused of plotting to attack Fort Dix Army base in New Jersey. The plan included attacking and killing soldiers using assault rifles and grenades.

• June 2007, JFK Plot: Four men are accused of plotting to blow up fuel arteries that run through residential neighborhoods at JFK Airport in New York.

• September 2007, German authorities disrupt a terrorist cell that was planning attacks on military installations and facilities used by Americans in Germany. The Germans arrested three suspected members of the Islamic Jihad Union, a group that has links to Al Qaeda and supports Al Qaeda's global jihadist agenda.

Doc D

Wednesday, September 10, 2008

Fire Hazards. Medical Costs

Study suggests children may have high levels of chemical fire retardants in their blood.

USA Today (9/5, Szabo) reports that "a study of 20 families [conducted] by the Environmental Working Group (EWG)" reveals that "young children have high levels of chemical fire retardants in their blood." According to the EWG, "toddlers and preschoolers had levels of" polybrominated diphenyl ethers, or PBDEs, in their blood "that were, on average, three times higher than their mothers.'" In 2007, Danish scientists also "found that boys whose mothers had high levels of fire retardants in their breast milk were more likely to have" testicles that did not descend properly.

Doc D: This may not be all bad: maybe fire retardants in the blood stream increases toddlers’ resistance to getting burned in a fire, or scalded in their bath water.

That was kinda heartless, but it was a joke. Seriously, I’m hard pressed to know whether I want to take fire retardants out of toddlers’ clothes based on this. Neither option sounds too good; I’m not aware of any retardant substitutes yet, other than asbestos (which is carcinogenic)… or going naked (your clothes won’t catch on fire if you’re not wearing any). And while I’m really committed to every testicle’s journey into descent, I don’t think we’ve got the full story yet—only 20 children in the study.

Medical pricing system seen as "inscrutable."

In the Los Angeles Times's (9/7, Lazarus) Consumer Confidential column, David Lazarus wrote about "the inscrutable way that healthcare providers and insurers put a dollar value on medical services." According to Jim Lott, executive vice president of the Hospital Association of Southern California, "patients are wrong to think that the charge on their bill reflects the actual cost of treatment." Lott explained the "cost-plus system" allows hospitals to include "both the cost of a service and a portion of general overhead, including treatment of uninsured people," to calculate charges. Meanwhile, insurance companies and "state and federal authorities...negotiate lower rates, in return for delivering thousands of patients to a particular clinic or hospital." Lott described the system as one "that both condones and perpetuates inflation, while all but eliminating transparency in the marketplace.

Doc D: It’s not inscrutable. As a doctor, if I know that the insurance will pay $40 for a routine visit, I charge $80…because I know that if I charge $40 (what I should get) the insurance company will re-average the “customary” charge and give me $20. So I’m forced to charge high in order to keep the reimbursement rate up. Is this a stupid system or what?

Doc D

Opinions are entirely my own. Quotations from Kaiser Daily Health Policy Report ( © Kaiser Family Foundation), PND News Briefs – Texas Edition ( © 2008, Physician's News Digest, Inc.), and AMA Morning Rounds (© U S News Custom Briefings). As always, you may share this column, with appropriate attribution (above) included

Saturday, September 6, 2008

How Doctors Think

Folks,

I saw this article http://www.aarpmagazine.org/health/why_doctors_make_mistakes.html in the current issue of AARP Magazine. (BTW, this mag has some good stuff in it). The author wrote a book last year called “How Doctors Think.” I read it and thought it was a good book, and recommend it, but it does oversimplify.

This article is great because there are three questions you should ask your doctor (in bold print below, if you don’t want to read the whole thing). The mistakes he discusses are real, and in learning the practice of medicine we got chastised any time we showed cognitive bias. I’ll never forget being close to tears after a 15 minute tongue lashing from one of my professors, or the several times Dr. DeBakey asked “Doctor, don’t you care?”

A couple of caveats. The rate of misdiagnosis may be 15%, but it aint that simple.

1. About 3% of people do not have a diagnosable disease. Despite the “wonders” of medicine, some people just don’t have a definable cause for their symptoms. (BTW, the rate of so-called Desert Storm Syndrome is also 3%). This doesn’t mean they won’t ever be diagnosable…just not now.

2. About 5% of people present to the doctor before a diagnosis can be made…too early in the illness. Sometimes the signs that make the diagnosis don’t appear until much later. Appendicitis is an example.

3. If the diagnosis is not certain, and the illness doesn’t seem serious, many doctors will try a course of therapy for what is the most likely. If you think that’s not right, just ask yourself how you would feel if your doctor said “we can’t diagnose this yet, you’ll have to wait.”

3. In another 5%, patients don’t tell their doctor everything…or the right stuff…or they intentionally withhold important information.

(All percentages are my personal observations, and not scientific)

And, see #2 below. The likelihood of having two things at once is vanishingly small. So, don’t bank on this being the problem…but, it can occur.

Lastly, if your doctor won’t talk to you, or answer these and any other questions, get a new doctor.

Doc D

1. “What else could it be?” This question helps to prevent an anchoring error or an availability error, where a diagnosis is formulated too quickly in the physician’s mind because it corresponds to the initial symptom or abnormality (anchoring) or because it is most familiar to the doctor (availability).

2. “Could two things be going on to explain my symptoms?” In medical school doctors are taught to be parsimonious in their thinking, meaning they are taught to identify a single cause to explain a variety of complaints and symptoms. But sometimes a patient can have two medical problems simultaneously. Physicians sometimes stop searching once they find an initial problem, even if the patient does not fully recover.

3. “Is there anything in my history, physical examination, laboratory findings, or other tests that seems not to fit with your working diagnosis?” All physicians tend to discount information that seems to contradict their hypothesis. This bias can lead a doctor down the wrong path; his or her anchor diagnosis may be so firmly fixed that this leads to ignoring contradictory data.

Jerome Groopman, M.D., is the author of the New York Times bestseller How Doctors Think (Mariner Books, 2008).

Friday, September 5, 2008

Where Do We Focus Out Attention in Healthcare?

I wrote this a few weeks back, and held on to it for awhile to see if anything changed. It didn’t.


CMS on Monday announced that it has granted Massachusetts a third extension on a Medicaid waiver that would allow the state to divert $385 million in federal funds for the program towards funding for the state's new health care law, the AP/Boston Globe reports. The current waiver would have expired on June 30, but the renewal extends it an additional two weeks to Aug. 11. According to the AP/Globe, the state Legislature is in the midst of developing legislation that would require employers to cover an additional $130 million in costs under the health care plan, and both chambers are expected to work out a resolution by on Thursday (AP/Boston Globe, 7/28).

 
Doc D: Some time ago I wrote about the candidates’ plans for healthcare reform, arguing that none of them account for the major elements necessary to success. Also, that Massachusetts had passed a law providing universal coverage and was already experiencing problems with not having addressed access, cost, and quality. The excerpt above highlights what I would have expected: funding problems. Also, note that MA is now passing along the increased cost to employers, who will then transfer the cost to employees through reduced hiring, increased layoffs, and no salary increases. Does this sound like a circular process to you? Note the excerpt below:

San Francisco Chronicle: "both candidates are mostly silent on the building tidal waves around Medicare and Social Security, which face rising bills, longer enrollment lists and gridlock politics," according to the editorial. Both Obama and McCain are "headed in the wrong direction," and their "appealing plans will add to the debt, piling up billions more that will prolong a downward slide," the editorial states, adding, "Voters shouldn't be fooled into thinking anything else" (San Francisco Chronicle, 7/30).



I think we deserve better than we’re being offered. The candidates programs just mollycoddle us with high minded sound bites.

Doc D

Politics has taught the healthcare community to be cowards

NYTimes says FDA should re-evaluate need for more definitive trials before approving drugs.

The New York Times (9/5, A26) editorializes, "The risks and benefits of" Vytorin (ezetimibe and simvastatin) "remain thoroughly muddled, despite a new analysis that purports to exonerate it from the worst safety concerns." Right "now, patients and doctors are best advised to use Vytorin only as a last resort." In a recently released analysis, "Vytorin did not seem to increase the risk of getting cancer, although there were hints that it might increase the risk of dying from cancer once you got it." Still, the editors of the New England Journal of Medicine "warn that the risk can't be dismissed until more data comes in." Although "experts...hope that the ongoing clinical trials will yield clearer results," those "trials may not be completed until 2012, at the earliest." The Food and Drug Administration (FDA) plans to "conduct its own analysis of the cancer risks." The Times argues that "the agency also needs to evaluate whether it should demand larger and more definitive clinical trials before approving certain drugs."

Doc D: Here’s the background story. The editor of the NEJM got his rear end kicked when he worked for the pharmaceutical companies. So, he wants to make sure that there’s no evidence of a problem with this medication. The problem is, he has no evidence for concern than his own professional scars. The data controverts another study of only 1000 people that there is an overall cancer increase.

We run across this issue repeatedly: risks of illness follow a pattern. A particular chemical or drug causes a particular reaction in humans that leads to a specific disease. There is no risk factor, or exposure that leads to cancer of all types in humans…none. Think about your knowledge of biology: are you aware of anything that causes problems in humans across the board? The study that related Vytorin to cancer included all types of cancer, and in fact was so small in number, that it has no value for real people like us. Also, a follow up study failed to substantiate even the “inclusive” increase in cancer that the Scandinavian study purported to demonstrate. Bottom line, if my doctor said Vytorin was the best drug for me, I would take it without hesitation.

Policy analyst says Republican focus shifting from healthcare to energy, defense policies.

Modern Healthcare (9/4, DoBias) reported, "The topic of healthcare reform has been crowded out of the Republican National Convention, replaced instead with a focus on energy and defense policies," according to Norman Ornstein, "a policy analyst with the American Enterprise Institute." Ornstein added that Sen. John McCain's (R-Ariz.) "marginal focus on healthcare" shows that he "may not fully be engaged in the topic." And, despite the "half dozen events this week [that] have courted advocates of free-market principles in the medical industry," Ornstein pointed out that "the Republican party's base is focused on many other things." And, while healthcare remains a top concern for Democrats, "the ground [Republicans] want to fight on is energy, not on health," Ornstein noted.

Doc D: According to the Census bureau, the number of uninsured Americans fell by 3 million in 2007. Remember when I said that 19th century Prime Minister Benjamin Disraeli said that the by the time an issue rises to the level of public concern the worst had already come and gone? The healthcare issue is an issue; it needs to be put into the mix with everything else…despite what Harry and Louise say in those commercials.

Doc D

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

Thursday, September 4, 2008

Is HIV a huge problem, or a REALLY Huge problem?

Data indicate HIV-related deaths may have dropped worldwide.

The Los Angeles Times (7/30, Maugh) reports that the United Nations has released its "biennial UNAIDS report...just days before the Sunday start of the International AIDS Conference in Mexico City." And, while the "numbers are little changed from a report issued in November in which the agency drastically revised estimates of HIV prevalence," the new data indicate that HIV-related deaths worldwide dropped in 2007.

According to the 2008 Report on the Global AIDS Epidemic, "Fewer people are dying of AIDS, more patients are on HIV medication, and the global AIDS epidemic is stable after peaking in the late 1990s," the AP (7/30, Cheng) adds. Furthermore, there are approximately 33 million cases of AIDS worldwide, which is somewhat lower than the agency's "previous estimate of 40 million." That figure "was revised last year because of changes to how it counts cases."

Doc D: Public health experts have been saying for years that the UN has been over-counting due to unreliable methods that vary from country to country, and have chosen to always take the highest estimate available. It finally got so un-credible that they had to publish a “drastically revised” estimate, along with a lot of excuses for why they chose politics over good data. AIDS is a major global problem…it doesn’t need falsification to convince us. But, there are only so many resources available to address global disease and poverty, and we need the truth to decide where to put them.

BUT:

Health Officials: CDC Understated Number of New HIV Infections in U.S.

ATLANTA — The number of Americans infected by the AIDS virus each year is much higher than the government has been estimating, U.S. health officials reported Sunday, acknowledging that their numbers have understated the level of the epidemic.

The country had roughly 56,300 new HIV infections in 2006 — a dramatic increase from the 40,000 annual estimate used for the last dozen years. The new figure is due to a better blood test and new statistical methods, …. it likely will refocus U.S. attention from the effect of AIDS overseas to what the disease is doing to this country, said public health researchers and officials.

"This is the biggest news for public health and HIV/AIDS that we've had in a while," said Julie Scofield, executive director of the National Alliance of State and Territorial AIDS Directors.

HOWEVER, the CDC’s actual statement said this, too: “It should be noted that the new incidence estimate does not represent an actual increase in the numbers of HIV infections. Rather, a separate CDC historical trend analysis published as part of this study suggests that the annual number of new infections was never as low as 40,000 and that it has been roughly stable since the late 1990s (with estimates ranging between 55,000 and 58,500 during the three most recent time periods analyzed).”

AND, the new numbers use “innovative testing technology to determine, at the population level, which positive HIV test results indicate new HIV infections (those that occurred within approximately the past 5 months). Before the widespread availability of this technology, HIV diagnosis data provided the best indication of recent trends in key populations. However, diagnosis data indicate when HIV infection is diagnosed, not when a person becomes infected (infection can occur many years before a diagnosis).”

Doc D: So, to decipher all this talk, there’s a new test that allowed them to now measure “infection” when they used to measure “disease” (two different things). When you define what you’re measuring differently, the numbers change…what a surprise. And, nothing has changed…the number of people showing up with disease symptoms is the same…we just can now know much earlier those people who will become ill. But, in the first report, it sounded like things were worse, didn’t it? If you’re interested, see http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/pdf/incidence.pdf

Wednesday, September 3, 2008

Regarding the campaigns, a couple of definitions and comparisons

Boy,

The last couple of weeks have been wild and exciting. This presidential campaign is the most interesting I’ve seen in over twenty years.

Like most of you, I have my own thoughts about how to choose a president. But I don’t want to get into that here.

However, I’ve noticed that there is some confusion about a couple of military things that have entered the discussion. I usually write just about medical stuff, but 27 years in the AF is also a credential.

The American people know so little about the organizations that provide for the national defense. I think I told you that a woman once thought I was an airline pilot.

1. First, being a commander is pure authority and responsibility. As a commander, I had the power to imprison, garnish wages, and even put people on bread and water (yes, technically you can still do that…but it’s never done)

Next, there’s been some discussion of the National Guard and how it’s commanded. We have two large groups of non-active duty forces in the country: the Reserves and the National Guard. The Reserves are federal; they belong to the US and are commanded (ultimately) by the President, whether they are here in the US training, or deployed to conduct combat operations.

The Guard is loosely overseen by a Director in the Pentagon, but command and control is exercised by the state. They are “owned” by the state, and their Commander-in-Chief is the governor. He or she exercises complete control and discretion over their use. The origin of the Guard is pre-Revolutionary War…the Minutemen.

Once a Guard unit is mobilized, or “federalized”, their status under the law changes and command passes to the President. But practically speaking, the Governor has to “go along” with the mobilization. The Governor resumes commander-in-chief role upon their return, or release from active military duty. Then, the governor can use them for any purpose he/she wants within the state again.

It gets more complicated that this. I won’t bore you with it much: there is COMCON (command control), OPCON (operational control), TACON (tactical control), and ADCON (administrative control).

If you want to impress your friends say the following: “Gov Palin normally exercises COMCON. She relinquishes OPCON and TACON for overseas military operations, but retains ADCON.” It sounds like you’re really smart.

2. Over the last few years, I’ve run across comparisons between now and Vietnam. Military personnel know the vast difference between the war on terrorism and Vietnam, but I ran across the following graph that gives a taste for the magnitude of the two. Considering that Vietnam is tiny and Iraq/Afghanistan is huge, the casualty comparison is striking. (by the way, what happened to the media reporting the casualty total all the time?) The total number of deaths, all a tragic loss, since 2003 is 4154. This is total, not all are combat (accidents happen). By comparison, the first day at Antietam was 23,000…June 6, 1944 was ~5000 (I think). The average is about 15/mo now, about 130/mo at the height of the counter-insurgency.

Doc D

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