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.
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Tuesday, November 25, 2008

IS A SYNDROME AN ILLNESS? GENE THERAPY THAT KILLS YOU. AND RIGHT-TO-DIE, JUST NOT BY ME

IRRELEVANT NOTE:  Did you notice a rise in some banks’ ATM fees recently?  --$3.00 is higher than I remember seeing here in Texas--  Recall that we had no ATM fees until the Savings and Loan debacle.  My conspiracy paranoia makes me wonder if this is how we pay for financial crises:  nobody raises your taxes, they just bump up the fees and hope you don’t make the connection.

 

Scientific panel concludes Gulf War syndrome is a legitimate illness.

NBC Nightly News (11/17, story 11, 0:40, Williams) reported, "A major federal study released" Monday "puts to rest the question of whether Gulf War Syndrome...is real or not." The "450-page report concludes that exposure to toxic chemicals, including a drug meant to protect troops from nerve gas, sickened one in four of the almost 700,000 veterans in the 1990 to '91 conflict. Veterans' groups said today's report vindicates them after years of denial on the part of their government."

 

Doc D:  There are a lot of problems with this report, from a scientific standpoint.  A peripheral concern is that the report was politically motivated, but that’s a separate question.  Allegations of “years of denial on the part of their government” are just BS.  I was a part of the investigation:  we studied every one of these people up one side and down the other; accepted into the investigation anybody who thought they “might” have an illness related to the war; and tracked and monitored them with repeated annual and other periodic testing and evaluation.  They got more tests and exams than you would ever order for a real patient with an illness (even more than House, MD), repeated over many years, in order to cast a wide net over something we weren’t sure “was” something.  The problem is, people alleged that Gulf War Syndrome (GWS) caused everything from baldness, to chronic lung problems, rashes, and brain cancer.  How do you define an etiology when every symptom known to man is possible?  I observed one patient testify to Congress that GWS made his vomit fluorescent. 

 

So, I’ve read through the report, and it still lumps people together in this way.  For example, it compares GWS to other “symptom-defined” illness, like chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivity.  Unfortunately the existence of these three as “illnesses” is still controversial.  For something to be a “disease”, it has to have an origin, cause, process, and defined effects.  To just throw together a bunch of symptoms that tend to occur after a common event (the war), is to commit the post hoc ergo propter hoc fallacy:  A precedes B, therefore A caused B.  Calling such bundles of symptoms a disease has occurred frequently throughout history (“railroad heart” for instance).  It may be that they are “socially constructed” syndromes, a phenomenon of a particular culture and place in time.  It could be a coincidence, but the rate of undiagnosable patients in this country is about the same as the rate of GWS---3%.  Or, with more knowledge of the symptoms, we may tease out a real illness in the future…admittedly our knowledge of many diseases started out this way.  Or finally, it may be just chronic effects of nerve agent exposure, which is not a war syndrome:  it’s a real complication of exposure to a toxic chemical.  I don’t know.  But for now, I don’t know of a single disease that can cause symptoms across every organ system.

 

Researchers hope gene therapy strategy will lead to AIDS treatment.

The Wall Street Journal (11/7, A13, Schoofs) reports that a new therapy preformed in Germany, in which a physician "deliberately replaced the patient's bone marrow cells with those from a donor who has a naturally occurring genetic mutation that renders his cells immune to almost all strains of HIV," has renewed hope that a gene therapy strategy against HIV could prove successful. "The mutation prevents a molecule called CCR5 from appearing on the surface of cells. CCR5 acts as a kind of door for the virus. Since most HIV strains must bind to CCR5 to enter cells, the mutation bars the virus from entering." The Journal notes, however, that "caveats are legion." For instance, "the transplant treatment itself, given only to late-stage cancer patients, kills up to 30 percent of patients. While scientists are drawing up research protocols to try this approach on other leukemia and lymphoma patients, they know it will never be widely used to treat AIDS because of the mortality risk."

 

Doc D:  if you just read the title of this news extract, go back and read the whole thing. Did you notice that this transplant “kills up to 30 percent of patients?” Not “hastens death,” not “causes fatal complications,” but “kills.”  That's three out of every 10 people. By contrast, Vioxx causes harm to one in ~20,000 people. You may be asking yourself, what is the utility of continuing to do research into something that “will never be widely used to treat AIDS?"  And, how likely is it that other immuno-compromised patients, with leukemia or lymphoma, will react differently?  The idea behind gene therapy is good, maybe eventually this will turn up something worthwhile.

 

The take-home lesson, however, is that the article didn’t really say what the title implied, did it?  I read somewhere that about a third of the people just read the headline.  Thanks again, American media…

 

Washington state voters approve measure allowing medically assisted suicide for terminally ill patients.

The AP (11/5, Woodward) reports, "Voters have approved a ballot measure making Washington the nation's second state to allow terminally ill people the option of medically assisted suicide." Under the measure, "a terminally ill person" can "be prescribed lethal medication, which would be self-administered."

 …The measure "protects doctors from being prosecuted under a state law forbidding anyone from aiding in a suicide attempt," and "specifies the patient's death certificate should list the underlying terminal disease as the cause of death," the Seattle Times (11/4, Tu) added. Still, "the Washington State Medical Association, which represents nearly 7,000 doctors, said it was opposed to" the initiative. Among the measure's backers were "national right-to-die organizations Compassion & Choices and Death with Dignity, along with former Washington Gov. Booth Gardner." Supporters stressed that "the measure includes many safeguards," and they contended that "terminally ill patients who are suffering great pain should have the choice to hasten their deaths in a 'humane and dignified' manner." Meanwhile, critics argued that "end-of-life care has advanced to the point where pain can be controlled."

 

Doc D:  I don’t have a problem with people controlling their own lives, and the ending of it.  There are other things that bother me about this:  Falsifying the death certificate is number one; I’ll bet that creates some legal wrangles.  Also, I suspect that a significant number of the ~350 cases in Oregon (the other state with such a law) had a treatable depression that they successfully concealed.  I also agree that our ability to control or eliminate pain in “end-of-life” care is now very good.  But the biggest thing for me is that I didn’t become a doctor to be the agent of death.  It’s possible that I’m out of touch…

 

 

Medical quote of the Day:

All doctors up to the present century seem to me to have failed, because in the cure of diseases they have given little thought, or none at all, to the specific nature of each disease, and considered only the external symptoms, which are no more concerned with their specific nature than the type and richness of the soil are with species of plants which may grow in it.—John Locke [1632-1704]

 

 

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.), AMA Morning Rounds (© U S News Custom Briefings), and other sources in the public domain.  As always, you may share this column, with appropriate attribution (here and in the text) included:  I just ask that you not forward my email address.  I don't care to argue with wacky strangers.

 

 

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