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.

Wednesday, December 17, 2008

AM I MY FACE? IS MORE THAN ONE DISEASE REALLY BAD? AND, GENDER...AGAIN.

Folks,

I’m slipping this issue in.  I can’t help it.  There are a few funny, puzzling, or infuriating things that have come along.  I’ll still be sending the silicone breast implant commentary…soon.

 

Surgeons perform first US face transplant.

ABC World News (12/16, story 10, 2:15, Gibson) reported, "The Cleveland Clinic announced" on Tuesday "that its surgeons have performed the nation's first near-total face transplant, only the fourth worldwide. The operation was performed on a woman earlier this month."

        The Washington Post (12/17, A4, Stein) reports, "The clinic refused to release any details other than to say that a team led by reconstructive surgeon Maria Siemionow, M.D., replaced about 80 percent of a disfigured woman's face with that of a deceased female donor within the last two weeks. Neither the recipient nor the donor" was identified. The Cleveland Clinic "plans a briefing today to release more information about the procedure, which was far more extensive than the three previous face transplants, which were performed in France and China."

 

Doc D:  This is a little spooky to me.  Never mind that there are ethical issues involved in putting someone on transplant rejection drugs for the rest of their life, with the risk of cancer that involves.  Proper patient selection processes will be able to balance the relative harm to operate versus not operating.  What’s spooky to me is how much our face is a representation of who we are:  I have a picture of how I look in my memory, and another picture of how I look that the mirror shows me.  They don’t match.  Now, with a face transplant, my “mirror” face gets moved to memory, and a new one replaces it.  But what happens to my original picture (“concept”) of myself?  Is it still me?  Am I different, or someone else?  Does the representation of myself, and all that entails, get modified by such an intimate change?  Philosophers love this stuff.

 

Court rules company is not obligated to provide experimental drug to patient with muscular dystrophy.

The AP (12/17) reports, "A pharmaceutical company does not have to provide an experimental drug to a Minnesota teen who is terminally ill with a rare form of muscular dystrophy, a federal appeals court ruled Tuesday." The ruling reversed a decision by a lower court, stating that although the court is "sympathetic to the plight of Jacob [Gunvalson] and his family," the lower court "'abused its discretion' in ordering" PTC Therapeutics "to supply the drug to Gunvalson." Jacob's family claims that "the company led them to believe that Jacob could participate in a clinical trial of the drug, which is being investigated as a possible treatment -- and that the company then went back on its word." For its part, the company said that "no promises were made, and that allowing Jacob to join the clinical trial would not be safe." PTC president and CEO Stuart Peltz released a statement calling "the ruling 'important...for the future of the clinical trial process for all experimental drugs for rare disease.'"

 

Doc D:  Between a rock and a hard place is no fun.  In this case, both the drug company and the patient are there.  The patient’s tragedy is evident, but the company’s is not:  do they risk legal action when they are not yet far enough along to call this drug a “treatment”?  when it’s unapproved?  The courts have sometimes not allowed a defense of impending death, or agreed that there were mitigating circumstances in the principle of “do no harm.”  The pharmaceutical industry has been whacked so many times recently for unsafe (approved) products, they’re punchy.

 

Investigators continue to look for new ways to ease vaccination pain.

AMNews (12/22, Elliot) reports that a paper appearing in the December issue of Family Practice reveals that "children experience less pain with a vaccination if the skin is pretreated with an anesthetic and they are taught about what to expect."

 

Doc D;  You know, if parents would just stop saying, “you’d better be good or the doctor will give you a shot,” a lot of the fear that magnifies the pain would go away.  It aint that painful.  I do something to myself just as painful almost every day…stub a toe, bang my head, etc  (it’s the stuff of family legend…ask the kids). 

 

Study suggests patients with both cancer and diabetes face increased mortality risk.

According to an article posted in the Health section of the CNN (12/16, Tamkins) website, "two of the most common diseases in the United States -- cancer and diabetes -- are not often linked together in the public mind." But a paper appearing in the Dec. 17 issue of the Journal of the American Medical Association reveals that "cancer patients who already have diabetes have a greater chance of dying of the disease than cancer patients who do not have the blood-sugar disorder."

 

Doc D:  Does anybody think this study should have been a high priority for funding?  That somebody with an illness is worse off if they get an additional one?

 

Survey shows greater number of female cardiologists, persistence of gender discrimination.

HealthDay (12/16, Preidt) reported, "The number of female cardiologists in the United States doubled in the last decade, but under-representation of women in the profession and discrimination continue to be problems," according to findings published in this week's issue of the Journal of the American College of Cardiology. Lead author Athena Poppas, M.D., of Brown University, noted that "women in cardiology continue to face the same institutional and personal roadblocks as those in other areas of medicine and science."

 

Doc D:  This is a touchy subject.  I’m for opportunity and against discrimination.  But things have improved, and I’m not sure we need to have parity at every level.   At my undergraduate university the percentage of women was “around” 30 when I was there,  and that was high for then.  It’s now approaching 60%, but there are still many fewer women going into math and physics.  What’s the right mix of opportunity and apportionment?  There are other medical specialties where there are more women than men, and medical student ratios in some schools have swung in favor of women.  I once had an indignant reporter how I could justify that there were fewer women colonels in the Air Force.  I asked her,  “Do you want us to commission them as colonels?  It takes 15-20 years for someone to get from lieutenant to colonel.”  So, these disparities take time to correct…and they are.  The authors above go on to say that men also suffer discrimination, so… when does a “put down”, or “harsh criticism” that singles you out transition from an unpleasant experience to discrimination?  Is it the environment; you’re the only women or man present?  Can every individual who perceives an experience as being discriminatory be the decider?  I’ve not experienced ethnic or gender discrimination, just religious, so I can’t talk about this from all perspectives.  I DO know this however:  when I was a military commander, there were just as many women dirtbags as there are men dirtbags, but to take disciplinary action against a woman was always a risk.  I had to have twice as much evidence as would satisfy disciplining a male, in order to be given permission to proceed by my superiors.  But I tried not to shirk my responsibilities, so pressed ahead.  This got me accused several times; none of them successful.  But anytime a colonel or higher is accused of discrimination, the case goes to the Secretary of the Air Force, and that’s scary:  nothing ruins your career more than getting relieved of command.  I know a few commanders who said “it’s not worth the threat” and let women get away with some things they shouldn’t have (the cowards).  Richard M. Weaver said that “Ideas Have Consequences”, the ones you want and the ones you don’t.   Despite the threat, I still think the system is good, if imperfectly implemented and burdensome.

 

Medical quote of the Day

“I was once requested to call on a lady suffering from nervous and other symptoms.  It came out in the preliminary conversational skirmish, half medical, half social, that I was the twenty-sixth member of the faculty into whose arms, professionally speaking, she had successively thrown herself.  Not being a believer in such a rapid rotation of scientific crops, I gently deposited the burden, commending it to the care of number twenty-seven, and, him, whoever he might be, to the care of Heaven.”--Oliver Wendell Holmes [1809-1894]

 

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), and other sources in the public domain.  As always, you may share this column, with appropriate attribution (above) included.

 

Monday, December 15, 2008

HOW DO THE HEALTHCARE SYSTEMS OF THE WORLD STACK UP IN PROVIDING UNIVERSAL CARE?

Sorry.  It’s been a while getting around to this second “One Issue” newsletter.  Recall the first Object Lesson on Ginkgo biloba (“untenable to recommend a drug or nutraceutical in the absence of efficacy evidence simply because it could possibly help and initially appears harmless.”)?  This is the second Object Lesson.

 

Also, a few folks have asked that I put them on the list to receive these … Columns? Newsletters? Commentaries? Rants?  I’m going to open it up for anyone who wants to receive it.  You can tell your friends to send me their email address (directly or through you) and I’ll add them to the distribution.  This will also help me get an idea how many are reading it. 

 

I guess I have to have a privacy policy, so please be assured that I will never distribute your address for any reason, and I will be sending the newsletter out with “blind” addresses, so none of you can see who else is getting it.

 

I publish this just to keep myself up-to-date.  Writing it down forces me to check my data and think things through.  And, hey…it’s free.

Doc D

 

 

Comparative Healthcare Systems

 

Frequently the American healthcare system is compared to those in other countries who have universal healthcare.  The comparison is intended to point the way to reforms for our current mess.  Arguments over which way to go, and uniformly glowing interpretations of foreign efforts, have been a staple of US health policy academia for decades.

 

Now there’s a very nicely done review and analysis of those universal systems, HEALTH CARE SYSTEMS AROUND THE WORLD by Alyssa Schabloski, of the Insure the Uninsured Project.  It covers 10 countries.  You can find the 38 page document here: http://www.itup.org/Reports/Fresh%20Thinking/Health_Care_Systems_Around_World.pdf.  Very readable, but a lot of numbers.

 

Great data, some of which shows that the rosy interpretations may not be telling the whole story.  Some comments:

  1. The data doesn’t talk about Quality of medical care.
  2. The report includes subjective discussion about Access (but includes no data), which remains a problem in some of these countries.  Waiting times are a source of dissatisfaction, while overall there is widespread support for the idea of universal coverage.
  3. Where and how doctors practice medicine is controlled nationally in some cases, and in most countries decisions about what is a benefit and how much is covered is also controlled by the central or regional government.
  4. Several of the most successful countries are re-vamping their entire system because steadily rising Costs are making them unsustainable.  This is the same issue we have here; getting everybody covered is not going to solve the underlying problems, particularly those of cost.  Rising costs appears to be a global problem…and independent of whether you have universal coverage with cost controls.

 

I like this report because the organization that publishes it is an advocate for insuring the uninsured, but lets the data take you wherever it’s going, successes AND failures. How refreshing is that?

 

You have the reference to keep me honest, but here are some observations (my comments are in italics and emphasis in bold is also mine).  I’ve limited the review to only 5 of the countries to keep the verbiage down to a manageable level:

 

It should be recognized up front that all 10 countries deserve acclaim for succeeding at achieving (or attempting to achieve) primary care access for all.

Canada

“provinces and territories set much of their own health care policy and manage their own health services delivery”

“Six of the provinces…go so far as to outlaw insurance that attempts to provide alternative or faster access to health care already covered by Medicare.” (but the supreme court recently ruled that the law is unconstitutional if waiting times could compromise needed healthcare which could have been addressed by alternative insurance. Quebec has a year to comply)

“Canada(‘s) …essentially single-payor system has created a bottleneck for timely access to services.” (I read that over 50% of their physicians have referred patients to the US:  this may help to keep their system from collapsing, see next item)

Waiting lists are a point of dissatisfaction with care and erode public confidence in the system. The country as a whole also must address the rising costs of health care to ensure the sustainability of its programs”

 

Denmark (major reforms implemented in 2007, a system undergoing change)

“Financing for Denmark’s health care system has become more centralized through taxation only at the national level.”

“The distribution of general practitioners is regulated …to ensure an even distribution across the country. Entry is tightly restricted—…they can only enter practice by purchasing the goodwill of a retiring physician or obtaining permission from the regional authorities.”  (Imagine our physician workforce complying with this…whew!)

“About one-third of Danish residents purchase complementary insurance to cover (drug, dental, medical equipment) services.”

A small number of Danes—approximately 5% of the population—purchase supplementary insurance to move to the head of queues.

“reforms have yet to perfect some systemic issues

Denmark…must make sure that it can sustain universal coverage while satisfying increasing demand due to the aging population.”

 

France

“To cover the cost of “copayments”… 86% of the population purchased voluntary health insurance in 2000.”

“The number of general practitioners and specialists in France is almost evenly split—of the 194,000 physicians in France in 2000, 51% were specialists and 49% provided primary care

“private general practitioners in France still make home visits, which account for about 25% of their care activities.”  (I’m sure US doctors would do this…NOT)

“French residents may consume as much health care as they like; however, to increase their price sensitivity, they pay for their care upon receipt and do not receive full reimbursement.”  (This is pure genius:  how do you inhibit people from seeing a doctor unnecessarily, and driving up the government’s costs?  Make them pay cash upfront, then reimburse only a part of the total.  Wow.)

“The WHO has ranked France as the best health care system in the world.” (FINALLY, France is good at something.  Clearly they excluded French intellectuals from the decision-making process.)

France must address challenges relating to sustainable financing and meeting growing demand due to aging populations.”

 

Germany

Germany enacted another significant reform to its healthcare system in 2007.”

“The Ministry of Health introduces and executes health policy for the country.”

Germany offers residents coverage through the statutory system with the option to purchase supplemental private insurance.

“physicians receive payment based on an invoice of total services provided and calculated according to a relative value scale.”

“Individuals who have made more than US$60,000 per year for three consecutive years or the self-employed may opt-out of social insurance and purchase private insurance instead.”

“the Organization of Economic Cooperation and Development has criticized the plan for not doing enough to alleviate the rising costs of health care in Germany to the detriment of the population.”

 

United Kingdom

“The central government sets health priorities for NHS (National Health Service) as a whole and controls the overall pool of funds.”

“NHS is the largest publicly funded health system in the world.”

“Sustainability and improved quality are two of the major challenges facing the NHS.”

delays in receiving specialist care decrease consumer confidence in the system.”

 

 

 

Here are single blurbs on the last 5:

Israel:  biggest challenge is violence.

Japan:  fastest rising healthcare costs for the elderly in the world (one-third of all health costs).  30% co-pay to population.

The Netherlands:  inability to control costs in their former system led to reforms in 2006.

Sweden:  One of the best universal systems, but problems with shortage of primary care providers, quality, and patient safety.

Switzerland: extremely de-centralized system makes reform very difficult in the face of rising costs.

 

 

There’s a pattern here.  The most common challenge faced by these systems is Cost, followed by Access.  An affordable and accessible healthcare system requires attention to underlying forces in the delivery of medical care.  Universal coverage cannot be sustained without it.  (Object Lesson #2)

 

 

When the new administration rolls out their plan, look for how they deal with these issues.  Surely we can do better than France.

 

Doc D

Opinions are entirely my own.

 

 

Monday, December 1, 2008

FIRST IN A SERIES OF SPECIAL ISSUES: GINKGO BILOBA

There were several studies published in the last two weeks that are fascinating, for the results… and the Object Lessons they contain about science and health policy.  I decided to alter the format and write these up as a series of single topic newsletters.  The subjects are Ginkgo biloba, universal healthcare world-wide, and silicone breast implants.  You’ll be surprised by what I found.

Today’s subject is Ginkgo biloba and dementia.  Note that “dementia” is a general term, and Alzheimer’s accounts for over 90% of all dementias of the elderly.

“How much unlike art thou to Dementia
How much unlike my hopes and my deservings!” …(The Merchant of Venice, medical edition)

Talk to people about Ginkgo biloba and you find that most people think it improves thinking and memory.  A smaller percentage isn’t sure and wouldn’t take it, but think it’s OK to try…what could it hurt?  Few are wary of it.  Biochemical studies have shown promise that it reduces neuronal cell death and other beneficial effects --in the lab, not in humans.  Worldwide sales of Ginkgo biloba products, out of the US alone, exceed $249 million annually, despite analyses that show that these products contain variable amounts of the active ingredients, and sometimes contain adulterated material (lead, in one case).

A large randomized controlled trial of over 3000 people 75 years old or older was recently published.  The subjects were followed for over 6 years, while they took a standard dose of G biloba versus placebo.  The people were interesting because there were about the same number of men as women, from all over the country, but were 95% ethnically white.  Although most performed normally on a dozen cognitive tests initially, 15% had mild cognitive impairment (MCI).  All the tests and diagnostic criteria were ones that are considered standard.  They got re-tested about every six months, while taking placebo or a formulation of G biloba that is used in many commercial products, and at the maximum dose used clinically.  This was a very well-designed study and the largest ever.  (Reference: Ginkgo biloba for Prevention of Dementia, A Randomized Controlled Trial by Steven T. DeKosky, MD. et al, JAMA. 2008;300(19):2253-2262)

 

All that is very dull stuff, but what did they find?

1.       During the study 523 people developed dementia.

2.       More people developed dementia, including Alzheimer’s, after taking G biloba, than those people taking placebo, but the results were not statistically significant. (277 v 246, p = 0.21)

3.       There was no influence of age, gender, genetic susceptibility, or MCI on the results.

4.       Those individuals who had cardiovascular disease (CVD) from the beginning were more likely to become demented after taking G biloba, and this was statistically significant, if small in number (p = 0.006).

5.       Twice as many people taking G biloba experienced hemorrhagic strokes than those taking placebo, but this was not statistically significant.  An even larger study is needed to decide this.

Caveats:  Dementia is not the same as mental alertness in normal people; taking G biloba may make you feel like it’s helping your alertness and recall, but it’s clear that it doesn’t slow down the development of dementia.  Also, it’s possible that if you took G biloba for 20 years, or all your life, it might be different.  However, the trend after six years is, if anything, in the opposite direction.  AND, don’t forget those pesky strokes…

So, the bottom line is not surprising:  a product containing many different, and uninvestigated, compounds may be harmful.  This includes most herbals and alternative medicines.  We’re finding out new things every day about their constituents.

As the editor wrote,

“The potential adverse effects of G biloba extract illustrate why it is untenable to recommend a drug or nutraceutical in the absence of efficacy evidence simply because it could possibly help and initially appears harmless.”  (Object Lesson No. 1)

By the way, you may know about another herbal, Saw Palmetto—some men take it for “prostate health,” whatever that means.  I read a study showing that it contains a compound with estrogenic activity…and, you guessed it, some men experience breast enlargement.  Not something every male looks forward to.

I don’t take any herbals, and don’t recommend any of them.  If you want something that’s organic and healthy, eat oatmeal.

As I’ve said to some of you, being “natural” is no assurance of being beneficial, or even harmless:  digitalis is natural, but so is hemlock.

Doc D

Opinions are entirely my own.

 

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