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, January 31, 2009

WHAT DO MEDICAL BILLS, CAR ACCIDENTS, VAPORUB, AND PEANUT BUTTER HAVE IN COMMON? NOTHING.

Massachusetts governor asks hospital, health-insurance leaders to hold down costs.

The Boston Globe (1/13, Bombardieri) reports that on Jan. 12, Mass. Gov. Deval Patrick (D) asked the "most prominent hospital and health-insurance leaders" in the state "to take quick action to hold down rapidly rising healthcare costs, suggesting that if they did not take steps on their own, they might face new government regulation."

 

Doc D:  I can’t help repeatedly poking Massachusetts, the poster child on how not to do universal healthcare…formerly hailed as the forerunner in solving healthcare availability.  Combine runaway costs with only 3% of graduates going into primary care, and Ole Mass is heading for the bottom of the heap in healthcare delivery…but, hey, everybody’s covered.

 

Fatal car accidents involving older drivers appear to have declined markedly in past decade, researchers say.

The New York Times (1/13, D5, Parker-Pope) reports that, according to research from the Insurance Institute for Highway Safety (IIHS), "fatal car accidents involving older drivers have actually declined markedly in the past decade." In fact, "while fatal crashes are declining overall, the rates for older driving deaths are falling the fastest. …  Currently, IIHS "is conducting further research to determine why the risks appear to be going down for older drivers." Perhaps "today's older drivers are simply in better physical and mental shape than their counterparts a decade ago, so they are not only less likely to make a driving mistake, but also less frail and better able to survive injuries."

 

Doc D:  Maybe we’re just hiding their keys. 

 

Study suggests Vicks VapoRub may increase mucus production in children under two.

The Los Angeles Times (1/13, Maugh) reports, "Many parents slather Vicks VapoRub on their sniffling, coughing kids when they're sick," but "using the ointment to ease coughing and congestion in children" under two years of "age might lead to severe breathing problems by increasing mucus production and inflammation," according to a study published in the journal Chest. For the study, Bruce K. Rubin, M.D., professor of pediatrics at Wake Forest's Brenner Children's Hospital, and colleagues, "applied the ointment directly to cultured ferret tracheal cells, as well as under the noses of healthy ferrets and ferrets with tracheal inflammation similar to that of humans with a cold."

        The researchers also "applied K-Y jelly instead of VapoRub to a similar group of ferrets," which served as controls, USA Today (1/13, Rubin) adds. The investigators found that, "compared with the K-Y jelly groups, mucus secretion rose in the VapoRub groups by 14 percent in the healthy ferrets, and eight percent in those with inflamed windpipes, which itself increases mucus production."

 

Doc D:  For those of you who have small children, drop everything and check your kiddo’s for ferret tracheal cells.  Not there?  Whew, that’s a relief.  Seriously, these products are a waste of money.   My parents liked Ben-Gay.  I can still remember the first-degree burns on my chest.  Little boys learned very quickly not to get it on their fingers and scratch you-know-where (by nature, little girls don’t share the same proclivity, so needed no warning).

 

Nearly 70 weight-loss pills sold in the US as dietary supplements may harm consumers, FDA says.

The Los Angeles Times (1/11) reported, "Almost 70 weight-loss pills sold in the US as dietary supplements contain drugs that aren't disclosed on the labels and can harm consumers, regulators said, expanding an earlier list." According to the Food and Drug Administration (FDA), "products, sold under names including Imelda Fat Reducer, Powerful Slim, and 24 Hours Diet, may cause high blood pressure, seizures, heart attacks, or strokes." In addition, "the products contain drugs that are legally available by prescription only, and in some cases the pills contain medicines that haven't been approved in the US, the FDA said."

 

Doc D:  This, unfortunately, is not a joke.  Congress gave a “regulatory pass” to all complementary and alternative supplements.  While a standard drug has to undergo several phases of human testing and research, lasting up to 10-15 years, by law these products can be put on the market with no review at all.  I recommend highly that you do careful research before taking any unregulated herbal, supplement, additive, or alternative product.

 

 

Medical quote of the Day:

Ignorance and credulous hope make the market for most proprietary remedies.—Samuel Hopkins Adams [1871-1958]           

 

 

Nature Note:    If you’re worried about salmonella-tainted peanut butter, go here:  http://www.accessdata.fda.gov/scripts/peanutbutterrecall/index.cfm.  The problem is that the alleged source was a provider not only of peanut butter, but peanut paste, which is used in cookies, ice cream, nutrition bars, etc. This magnifies the complexity of tracking down any contaminated sources, because scores of companies use the paste in their own products, under hundreds of labels. 

The last salmonella peanut butter recall was in 2006.    

 

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.

 

 

Friday, January 30, 2009

WHO'S MY DOC? HOW MANY LIVES PER KIDNEY? AND "THE TOBACCO INDUSTRY MADE ME SMOKE" (HACK, HACK...)

Before talking about medicine and healthcare, I want to offer this anecdote, and debate, that’s worth pondering. For me it started with an email blurb that said the former Vice President, Al Gore, was testifying to Congress this week on global climate change. The blurb alleged that Al said the carbon dioxide (CO2) in Venus’ atmosphere magnifies the greenhouse effect, resulting in surface temperatures of about 870 degree. He alleged that it’s not Venus’ closeness to the Sun that makes the planet much warmer than the Earth, because Mercury, which is even closer to the Sun, is cooler than Venus. Based on this rationale, then, Al said we need to stop emitting CO2 into our own atmosphere.

Well, I was doubtful he said that. I’ve read parts of “Earth In the Balance” and found it unconvincing--other academics I’ve talked to consider it a joke. His arguments about ice cores and short term temperature records have already been attacked, successfully I think. But, fair is fair…I went to the Senate Foreign Relations Committee web site and watched the video. You can see it here http://www.senate.gov/fplayers/CommPlayer/commFlashPlayer.cfm?fn=foreign012809&st=435 …long and mostly boring.

But the Veep’s whole slide show is there. What makes this all so incredible is the series of false analogies in his argument. While it’s true that CO2 in the atmosphere contributes to warming a planet, the atmosphere of Venus is 97% CO2. The atmosphere of Earth is 0.038% CO2 (380 parts per million). From the models produced by the Climate Change advocates, the CO2 level on earth is increasing at about 2 parts per million per year (but according to scientists has been several times higher in the distant past). So, I’m not sure where the comparison is. Also, the comparison with Mercury is inappropriate, since Mercury has no greenhouse gases in its paltry atmosphere. Mercury gets as hot as Venus, but its “average” temperature is much lower because the temp varies so widely on Mercury (from 800 to -275). And guess why it varies so widely there, and not on Venus…yep, CO2. CO2 cushions the planet from wild swings in temp. You can read about this science stuff here http://en.wikipedia.org/wiki/Atmosphere_of_Venus and here http://en.wikipedia.org/wiki/Atmosphere_of_Mercury.

Am I missing something here in not being able to link these observations together into an argument for decreasing CO2 emissions?

I think I’m as concerned as the next person about global warming, but it’s garbage like this…from both sides…that makes it impossible to find the truth. Although the IPCC (Intergovernmental Panel on Climate Change) says that “global warming is now firmly established,” there are 30,000 scientists, physicians, engineers, and other researchers who have signed a petition saying that the evidence does not support it. The public has been inundated with so much opinion in favor of the hazard that they take it for granted, and the media is no help (“Global Warming Not True” doesn’t sell a lot of newspapers). And, there is a multibillion dollar industry out there lobbying for adoption of CO2 mitigation, which stands to profit Big Time. How do we, as concerned citizens, make sense of all this, and support the right choice? If you figure it out, let me know.

This YouTube video, by JunkScience.com publisher Steven Milloy, helped put the different arguments in perspective. I recommend it (only 9 min long). http://www.youtube.com/watch?v=XDI2NVTYRXU

According to the psychologist authors of a SUPERB book I just read, “Mistakes Were Made (but not by me),” you will hear and view this debate in accordance with your pre-determined position on the question, and will engage in self-justification. I challenge you to step outside the cycle of confirming everything you already believe and grant that the situation is complex, ambiguous, and rife with misdirection. (Read the book, highly recommended.)

Back to medical.

Study indicates 75 percent of hospital patients may be unable to identify their physicians.

The New York Times (1/30, Barrow) reports, "Hospital patients are rarely able to identify their doctors by name or to describe their roles in the patients' care," according to a study published Monday in the Archives of Internal Medicine. Researchers found that an estimated "75 percent of the patients were unable to name a single doctor assigned to their care." Furthermore, "of the 25 percent who responded with a name, only 40 percent were correct." Some experts, however, disagree on "whether patients need to be familiar with hospital staff." Dr. Ernest Moy, medical officer at the federal Agency for Healthcare Research and Quality, questioned whether knowing about "processes that will help" patients "get at the information [they] need" is "more important" than physicians' names.

Doc D: Maybe people have something else on their mind when they’re in the hospital.

Researchers say people who donate kidneys have normal life spans, few kidney problems.

The Los Angeles Times (1/29, Maugh II) reports that, according to a study published in

the New England Journal of Medicine, "people who give kidneys to others not only have a normal life span, they also have fewer kidney problems than the general population -- perhaps because they are healthier to begin with."

Doc D: I guess this doesn’t mean that since I have two kidneys I’ll live twice as long, hunh?

First of 8,000 lawsuits against tobacco industry to begin.

Christian Science Monitor (1/29, Luscombe) reports, "A civil case that begins Thursday...not only brands Florida as a hotbed of tobacco litigation, but also marks the advance of a huge stream of lawsuits against America's largest cigarette manufacturers." An estimated 8,000 plaintiffs have filed a "wave of lawsuits," stemming "from a 2006 ruling in the Florida Supreme Court that broke up a class action suit of more than 700,000 plaintiffs and quashed a $145 billion award against the tobacco industry." The justices gave "all plaintiffs one year to file an individual claim for damages against cigarette-makers," and under the ruling, "each case will start from the same premise: that cigarette-makers were aware their products were 'defective' yet misled the public over their health effects."

Doc D: I’m sensitive to the plight of patients with tobacco-related illness, but there’s a fact that’s been nagging at me for years. That fact is, that tobacco smoking has been known to be injurious, and yes, even cause death, for at least two hundred years. There are newspaper articles in Victorian England that talk about the lung disease that ensues. Couple this historical evidence with the average consumer’s skepticism about advertising--just because Ford says the Bronco is the best truck, doesn’t mean I believe them—and I wonder why smokers have decided that they were fooled. Finally, most smokers I know (and I used to be one) have some justification for why they keep smoking, and it’s never that “the tobacco companies said it’s safe.”

In the preventive medicine world, to even bring this up means I’m a traitor to the cause.

Medical quote of the Day:

As is your sort of mind,

So is your sort of search—you’ll find

What you desire.

--Robert Browning [1812-1889]

Nature Note: A senior executive of the world's largest autism charity has resigned in a dispute about whether vaccinations could be a cause of the developmental disorder that affects an estimated one in 100 children. Alison Singer says that numerous scientific studies have disproved the link first suggested more than a decade ago and that Autism Speaks, a US-based organization committed to funding further research, needs to "move on". "If you keep looking under the same rock, you're going to keep finding the same thing," said Singer. "Over and over, the science has shown there is no causal link between vaccines and autism. It's time to look for answers in new and different places." (The Observer, 25 Jan 2009)

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), The Observer (© Guardian News and Media Limited) and other sources in the public domain. As always, you may share this column, with appropriate attribution (here and in the text) included.

Sunday, January 25, 2009

DO STEM CELLS NEED EMBRYOS, OR VICE VERSA? DRUG-TAKING AND DISEASE-MAKING; AND THE "FIRE A SMOKER FOR FREEDOM" CAMPAIGN

FDA approves first human embryonic stem cell study.

On the front page of its Business Day section, the New York Times (1/23, B1, Pollack) reports, "In a research milestone, the federal government will allow the world's first test in people of a therapy derived from human embryonic stem cells." The approval is expected "to be announced Friday by Geron, the biotechnology company that first applied to the Food and Drug Administration (FDA) to conduct the trial last March." Agency officials stated that "political considerations had no role in the decision." Still, "others said they suspected it was more than a coincidence that approval was granted right after the new administration took office." In the past, "the Bush administration restricted federal financing for research on embryonic stem cells because creation of the cells entails the destruction of human embryos."

 

Doc D:  Misleading article.  These are human embryonic stem cells that come from adult differentiated cells (like skin cells) that have been stimulated to “un-differentiate” into embryonic-type cells.  The key thing is that they are not taken from human embryos…which was what the whole moral argument was about.  President Bush told researchers to find a way to get stem cells without using embryos, and they did.  Can’t tell that from the article, can you?

 

The magnitude of distortion we get exposed to in the name of “news” continues to shock me.

 

Survey finds more Americans do without prescriptions.

The New York Times (1/23, Rabin) reports, "One in seven Americans under age 65 went without prescribed medicines in 2007 as drug costs spiraled upward in the United States, a nonprofit research group said on Thursday." That figure "is up substantially since 2003, when one in 10 people under 65 went without a prescription drug because they couldn't afford it, according to the Center for Studying Health System Change in Washington, D.C." Laurie E. Felland, a senior health researcher at the center and lead author of the study, said the current figure "may be even higher because of the recent economic downturn." She added that the people "who were least able to afford medicine were often those who needed it most: uninsured, working-age adults suffering from at least one chronic medical condition." Almost two-thirds of them in the survey "said they had gone without filling a prescription." The study also "one in 10 working-age Americans with employer-sponsored coverage went without a prescription medication in 2007, up from 8.7 percent in 2003."

 

Doc D:  We need more information here.  I would say that at least 10 percent of the medicines we take, we don’t need (maybe 20 percent).  So, it makes a difference whether you are taking Zantac because you have heartburn from overeating in the evening, or taking digoxin for heart failure.  I’m OK with people not being able to afford a prescription in the first example:  their doctor should get them to stop eating six tacos a night.  In the second example, it’s critical that we make sure they can afford the drug.  How many people are in the “don’t need it” category, and how many are in the “have to have it” category?  Of course, both categories of patients think they need the drugs.

 


Obama team puts new ICD-10, other rules on hold.

Modern Healthcare (1/22, Lubell) reports that the Department of Health and Human Services' (HHS) "implementation of ICD-10 and several other rules issued last week could potentially be delayed, as the White House proceeds with a review of any new or pending regulations issued under the Bush administration." … White House Chief of Staff Rahm Emanuel released a memorandum that "put a hold on all regulations that have either not been published or those that have not yet taken legal effect." …including HHS' final rule for transitioning to the International Classification of Diseases, 10th Revision," he added.

Doc D:   So now the politicians are going to get into defining what is or isn’t a disease.   The International Classification of Diseases and Related Health Problems is commonly referred to as the ICD.  ICD-9 is the old version and will be superseded by version 10.  The document is used world-wide to code diagnoses, and is the basis for understanding between the sub-sectors of the healthcare industry—between doctors; between doctors and hospitals; among doctors hospitals, and insurance companies.  I can understand reviewing Medicare regulations of the previous administration, but this is a “dictionary” of disease.  Important document, and apparently it needs review for political correctness.

 

Researchers criticize policies prohibiting smokers from employment.

In the Los Angeles Times (1/21) Booster Shots blog, Shari Roan wrote that "becoming more common is the practice of barring smokers from employment." This practice, however, "is unfair and may have unintended consequences that do more harm than good," according to an essay published Jan. 21 in the journal Tobacco Control. Co-author Dr. Michael Siegel noted that although "policies prohibiting the hiring of smokers have become much more popular in the past year," the "widespread adoption of such policies may make smokers nearly unemployable." As a result, they may "lose their health insurance," which would "affect their health and that of their families." Dr. Siegel and co-author Brian Houle, of the University of Washington, also contend that "refusing to hire smokers is discriminatory and may lead to the adoption of other selective employment practices." Meanwhile, tobacco-control advocates remain "divided over the merits of barring smokers from the workplace." Dr. Siegel stated that some advocates fear being "branded as 'traitors to the cause'" for "speaking out against the employment bans."

 

Doc D:  It’s interesting that the anti-tobacco advocates are at odds with each other.  I read an article a few months ago that one environmental organization broke into another’s officers in protest of their activities, disrupting files and writing slogans.  In the past, wars have been fought over minor points of difference in religious dogma.  So it seems clear to me we are equally prone to “religious” conflict, whether spiritual or secular.   As humans, we have a tough time accommodating anybody’s opinion of how things should be but our own.

 

 

Medical quote of the Day:

Smoking … is a shocking thing, blowing smoke out of out mouths, into other people’s mouths, eyes and noses, and having the same thing done to us. –Samuel Johnson [1709-1784]

 

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.

 

 

Monday, January 19, 2009

MEDIA PSEUDO-ISSUES, MORAL OBLIGATION TO VACCINATE, AND SIN TAXES

Army relied on unlicensed mental-health counselors to evaluate soldiers.

 

The AP (1/15, Hefling) reports that the Army relied "on unlicensed counselors before" its "policy was changed to exclude them in 2006." During "the early years of the war, the Army rushed mental-health counselors to the combat zone even if some weren't certified or fully qualified," and allowed "unlicensed psychologists and other counselors...to examine soldiers provided they were supervised by licensed professionals."

 

Doc D: This is media hype.  ALL clinical psychologists in the United States, once they receive their degrees, must do a year of supervised care.  It’s just a requirement they have to fill before they can receive their certification.  Residency trained neurosurgeons have to do practice (unsupervised) for two years before they can take their board exams.  These psychologists aren’t “unlicensed”, they are in the process of earning it.  And they were supervised, just like they’re supposed to be:  this means that another doctor is looking over their shoulder to review their actions.  This is how patients get treated back home.  I’m not sure why the Army stopped sending them to the war zone; probably it’s a result of improved availability (or the Politics of Perception).

 

But notice the language the Associated Press used to report this…the scare words, trying to manufacture a controversy.

 

Rates of pneumococcal meningitis fell after introduction of vaccine, data indicate.

USA Today (1/15, Szabo) reports that data appearing in the Jan. 15 issue of the New England Journal of Medicine indicate that "meningitis cases have fallen sharply since the introduction of a vaccine for children in 2000." Specifically, "rates of pneumococcal meningitis, an inflammation of the membranes around the brain caused by bacteria, dropped 64 percent in children under age two from 1998-1999 to 2004-2005." But the vaccine's benefits are not just for infants, because "with fewer contagious babies to spread germs, fewer older kids and adults are getting sick," according to study co-author Nancy Bennett, M.D., of the University of Rochester School of Medicine and Dentistry.

        In fact, "incidence decreased...by 54 percent in those older than 65," HealthDay (1/14, Gardner) added.

 

Doc D:  Vaccines are the number two most important medical advance in human history (after sanitation).  The benefits accrue not only to the immunized individual, but also to everyone else, as these data show.  This is not new, and is a standard principle in epidemiology.  But, we have to keep demonstrating this to the upscale, college-educated, New Age parent, who thinks that only “natural” (a poorly defined term) is good.  That’s right, the folks who fight hardest against vaccination are not the poor and ignorant, but those who should know better.  For some reason, they are the ones who are most vulnerable to “nutritional” cures for cancer, pyramid power, bogus reports of vaccine “horrors”, and treatments with magnets.  They’re the ones most likely to credit the sound bite scare tactics (Remember Meryl Streep on the use of alar to preserve fruit?  “These are your children!”)  Back in the 1950’s there was free-floating anxiety about The Bomb and invisible radiation.  Now, there’s a similar worry, containing the same paranoid component, about the government, and synthetic products.  What the next generation will see as The Big Threat, I don’t know.  Cyberspace, maybe.

 

In my opinion, parents who don’t have their children vaccinated, on time and on schedule, should be prosecuted.  I recognize no legitimate religious exemption or civil liberty that allows them to harm their children, or the rest of us, through their inaction.  The only exception is demonstrated (not “fear of”) life-threatening allergy…something I’ve never seen, but admit may occur.

 

Child health bill would benefit, and cost, Texas

 

Texas stands to gain more than any other state from the plan quickly making its way through Congress to boost the number of children who have health insurance. But the measure would also hit thousands of Texans hard in the pocketbook because it's being paid for with one of the biggest cigarette tax increases in history.

 

Doc D:  This is the Democrats’ SCHIP legislation, endorsed by the President.  For non-smokers, taxing cigarettes is a no-brainer.  The complication is that the data show that the cigarette tax hike hits the poor much harder than anyone else, since they tend to be the ones more likely to smoke.  If that isn’t a problem for you, then consider that it’s not clear that smokers will make a rational choice between their cigarette habit and paying for food, clothing, shelter and healthcare for themselves and their families.  They don’t call these “addictions” because they’re choices.

 

I don’t object to so-called “sin” taxes, or Value-Added Taxes (VAT) that are used world-wide (except US).  We just need to think through WHO we are taxing.  Put a tax on yachts, if you want to.

 

 

Medical quote of the Day:

If he [my next-door neighbor] is to be allowed to let his children go unvaccinated, he might as well be allowed to leave strychnine lozenges about in the way of mine. –Thomas Huxley [1825-1895]

 

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.

 

 

 

 

Sunday, January 18, 2009

CORPORATE LARGESSE CONTINUES, PUBLIC QUAILS AT REFORM COSTS, AND MEDICINE AT THE BAR

Hospital lobby seen as early winner in Obama healthcare agenda.

 

In a Health Policy column in Forbes (1/15), David Whelan observed that "buried" in the State Children's Health Insurance Program (SCHIP) legislation passed by the House on Wednesday "is another gift, this one to a powerful health lobby -- the hospital industry." The SCHIP bill contains "a section that bans physicians from owning or investing in hospitals." Whelan pointed out that "hospital groups, including the American Hospital Association and the Federation of American Hospitals...have spent millions of dollars on lobbying to ban physicians from becoming competitors by starting surgical and heart hospitals that typically provide better care than their counterpart general hospitals."

 

Doc D:  It appears that big corporate influence will continue into the new administration.  As you know, this rider has nothing to do with healthcare for children, the goal of SCHIP.  These new small specialty hospitals are an innovation in healthcare delivery.  They focus their expertise on a specific type of treatment, creating a comprehensive approach to that care.  An example is the long-term critical care hospital, for those patients who have dire injuries or illnesses that require a long time to recover.  General hospitals don’t focus on this type of care and are not as good at preventing complications and sustaining intensive efforts.  There is need for caution about these organizations, however: oversight mechanisms must be in place to make sure that physicians don’t establish conflict-of-interest business relationships with the hospitals.  That aside, they are a good thing.  For the sake of high quality medical care, let’s hope the Senate throws out this corporate give-away.

 

Survey indicates Americans' support for health reform decreases when faced with trade-off

The AP (1/16, Freking) reports that, according to a national survey conducted by the Kaiser Family Foundation and the Harvard School of Public Health, the "prospects for health reform drop significantly when Americans hear potential financial trade-offs associated with expanding health-insurance coverage." The survey revealed that "nearly seven in 10 people say they favor the concept of" employer-sponsored health insurance, or "requiring employers...to contribute into a fund that pays to cover the uninsured." But, support fell "to about three in 10 people" when they "heard the mandate would cause some employers to lay off workers." Meanwhile, support for a mandate "requiring all Americans to have health insurance" fell from "two out of three people" to 19 percent when told "some people may be required to buy insurance that's too expensive."

Doc D:  I know I sound like a broken record about cost,  but ….duh!  the government doesn’t grow money on a tree, it all comes from us.  My fear is that the sentimental motivation of providing coverage for the uninsured, noble as it is, will override any scrutiny and debate over proposed healthcare reforms.  (for uninteresting details see the bottom of this page). 

Physician testifies quetiapine may substantially raise diabetes risk.

Bloomberg News (1/16, Pearson, Bloodsworth) reports that, according to the testimony of endocrinologist Jennifer Marks, M.D., "AstraZeneca Plc's antipsychotic" medication "Seroquel (Quetiapine) raised by almost 400 percent the risk of developing diabetes when compared with first-generation medications in its class." During a pretrial hearing yesterday, Dr. Marks "testified on behalf of former Seroquel user Linda Guinn," who "blames Seroquel for her Feb. 2006 diabetes diagnosis." Dr. Marks cited a "2004 article published in Psychiatric Services," which "reported the increased risk in males who were exposed to Seroquel for at least 60 days," as well as other "studies bolstering her opinion that Seroquel causes diabetes." Attorneys for AstraZeneca, however, "attribute Guinn's diabetes to obesity, a family history of the disease, and hypertension."

 

Doc D:  This is interesting in a couple of ways.  First, there are doctors who are professional “testifiers;” basically hired guns for lawyers who want a certain testimony.  I don’t know if this doc is one of them, but what she’s saying tends to support that she is.  I looked up the study in question:  while there were more males (note the plaintiff aint a male) who developed diabetes who took second-generation antipsychotics (seroquel is only one), the data were not statistically significant.  A follow on article in 2008 reviewed 14 studies on the same question and came to the same conclusion:  an interesting thing to look further at, but not established.  The REAL risk factors of the plaintiff are listed in the last sentence above:  “obesity, a family history of the disease, and hypertension.”  That’s a prescription for diabetes all by itself.

 

Second, our legal system is adversarial in nature.  Science is not…it’s incremental:  two steps forward, one step back.  Adversarial systems have a winner and a loser, and when the question is a scientific one, the outcome may depend on who tells the best story.  There’s something about deciding blame based on who is more charismatic that really disgusts me.

 

Physician says compassion cannot be quantified monetarily.

In the New York Times (1/16) Doctor and Patient column, Pauline Chen, M.D., wrote that the authors of an opinion piece published in the New England Journal of Medicine "argue that the current drive to fit healthcare into a business framework has resulted in a loss of medicine's communal and compassionate aspects." ….Dr. Chen acknowledged that "all of us, doctor and patient, have become more comfortable with money's role in medicine." Yet, "in order to restore medicine's compassion, doctors and patients need to reestablish the balance between cost containment and compassionate care, profit-and-loss tabulations, and patient-centered partnerships."

 

Doc D:  I fear we are way past being able to do this.  Corporate America, the government, unions, and trial lawyers are involved… and Big Bucks are the prize.  Say goodbye to the idyllic, early 20th century image of Dr. Marcus Welby:  overburdened with paperwork and frivolous lawsuits, he retired for good.

 

 

Medical quote of the Day:

Physical pain is easily forgotten, but a moral chagrin lasts indefinitely.—Santiago Ramon y Cajal [1852-1934]

 

 

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.

 

 

 

Supplemental material.  Ignore it.

 

---Most of the claims for cost savings in the administration’s plan are spurious.  They were pushing the cost savings from administrative efficiencies until most analysts pointed out that the payback from that is trivial compared to the increased cost.  Now they are saying that disease management is the key.  Here are some quotations from the Congressional Budget Office on elements of the plan aimed at reducing costs:

 

1.  “There is insufficient evidence to conclude that disease management programs can generally reduce overall health spending.' Douglas Holtz-Eakin, Director of the Congressional Budget Office, letter to Don Nickles, chairman of the Senate Committee on the Budget, October 13, 2004, at http://www.cbo.gov/ftpdocs/59xx/doc5909/10-13-DiseaseMngmnt.pdf (October 24, 2008).

2.  "It would probably be a decade or more before new research on comparative effectiveness had the potential to reduce health care spending in a substantial way.' Congressional Budget Office, Research on the Comparative Effectiveness of Medical Treatments, December 2007, at http://www.cbo.gov/ftpdocs/88xx/doc889
1/12-18-ComparativeEffectiveness.pdf
(October 24, 2008).

3.  "By itself, the adoption of more health IT is generally not sufficient to produce significant cost savings.' Congressional Budget Office, Evidence on the Costs and Benefits of Health Information Technology, May 2008, at https://www.cbo.gov/ftpdocs/91xx/doc9168/05-20-HealthIT.pdf (October 24, 2008).

4.  "The reduction in drug spending from importation would be small.' Colin Baker, "Would Prescription Drug Importation Reduce U.S. Drug Spending?' Congressional Budget Office, April 29, 2004, at http://www.cbo.gov/ftpdocs/54xx/doc5406/04-29-PrescriptionDrugs.pdf (October 24, 2008).

 

 

I can’t say that the CBO is a totally unbiased agency, but their use of hard data instead of vague promises is encouraging….and they’re continuing to criticize even in the face of a Democrat-dominated Congress.

Thursday, January 15, 2009

MEDIA CELEB FOR SURGEON GENERAL?

I still have my TV turned off, for all practical purposes (I watch 24, and sometimes watch a DVD…but no news, talk shows, sitcoms, or reality).  So, I can only report a rumor.

 

The incoming administration is reportedly considering Dr. Sanjay Gupta for the job of Surgeon General of the United States.  This can’t be true…a CNN reporter?  I find it credible that Dr. Gupta may be a competent surgeon, and an interesting media personality, but I haven’t heard of any expertise in the field of public health or preventive medicine.  But, more importantly, the office is a federal bureaucracy:  I would hope that the administration’s nominee would have some experience running a healthcare organization, with a foundational knowledge of healthcare management and resourcing.  Maybe just having supervised something more than an OR nurse would be a start.

 

I first saw Dr. Gupta on TV during the 2003 war:  he was waxing eloquent about the far-forward surgical teams that the Marines were using.   Having been involved in the development of those teams two years before for the Air Force, I wondered at the time where had he been the last few years?

 

More recently, I read that, in reporting on a bubonic plague outbreak he referred to the cause of plague as being due to “rat bites.”  Maybe we need a public health official who knows more about diseases and their causes (fleas, in this case).

 

I did an internet search, and found that he was listed by People magazine as one of the “sexiest men alive.”  Am I missing something here about the job of Surgeon General?  Maybe he plans to write a surgeon general reality show, where contestants compete to investigate disease outbreaks around the world.  While people are dying, the contest judges would be delivering very dramatic pauses, followed by “Doctor, you’re out.”

 

The Office of the Surgeon General has become one of lessening importance due to the political nature of recent appointees.  Remember Bill Clinton’s appointee, Joycelyn Elders?  She made so many faux pas, that she was fired…after recommending that masturbation be taught in the schools.  As the JunkScience.com author Steven Milloy said, “over the last 96 years, the Surgeon General has gone from working on genuine public health problems (infectious disease, clean water and sanitation) to advocating golf, Mickey Mouse-less food and beverage containers and video exercise games as public health measures.”

 

So maybe it’s appropriate that a media celebrity (his only qualification for the job) become the SG.  It continues the downward spiral in responsibility and competence.  Maybe we could get a physician felon for the next Surgeon General… to complete the process.

 

This is certainly not the Change I was looking for.

 

Doc D

 

Opinions are entirely my own.

Wednesday, January 14, 2009

IF SILICONE IS TOXIC, SHOULD I LAY ON THE BEACH?

OK, I finally got my lazy self to finish this series.  Recall that this is the third in a set of single issue newsletters on medical advances and healthcare policy.

 

To recap,

 

Object Lesson 1 on Ginkgo biloba was, 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 2 on healthcare systems around the world was, “an affordable and accessible healthcare system requires attention to underlying forces in the delivery of medical care.  Universal coverage cannot be sustained without it.”

 

Supplement:  1. The Obama administration has been doing a lot of work to publish roundtables and solicit input on policy issues that follows up on their promise of change and openness.  However, remember that the Clinton administration promised something similar, and then Hilary met in secret on healthcare reform and refused to release the deliberations of her working group.  This, along with the industry’s ad campaign undermined any chance for success.

  1. If you look at the details of the incoming administration’s healthcare reform package, it’s starting to look more like the McCain plan.  Healthcare policy experts criticized the plan proposed by the campaign as too much regulation and unsustainable spending.  It’s my belief that they are trying to meet in the middle somewhere.  However, nothing I’ve seen so far will, in my opinion, achieve the cost savings they anticipate.  You can review their public offerings here:  http://change.gov/agenda/health_care_agenda/
  2. Maybe you saw the NPR special on TV about the crisis in healthcare.  They made the case that in Massachusetts almost everybody is covered now, and were very upbeat about that achievement…however, they pointed out at only 3%  of medical students are going into primary care, and others are leaving that type of practice, that waiting times are increasing steadily, and that costs are climbing at an even greater rate.  No expert or public official offered any plan to address access and cost as a result of their universal coverage law.

 

So, for me the jury is still out on Change.

 

Enough of that.  This is the third of the issues I wanted to review with you.  Most of you know that a recurring theme of mine has been that we are Scaring Ourselves to Death (SOTD).  We are told daily of new risks to our health, in very dramatic media stories.   Usually there is no comparison to other risks, and no data to substantiate the claims.  In those few cases, when data are presented, it’s misleading (“Cancer Deaths Are Increasing”).  Most of you also know that I’ve said that the jury award for silicone-filled breast implants that led to Dupont’s bankruptcy in 1995, the largest settlement in history at $5B, was unsubstantiated by any science…and that the Institute of Medicine issued a subsequent review in 1999 that continued to confirm this fact.  There is no evidence that silicone breast implants cause chronic disease (including cancer) in humans.

 

Now a well-designed study was reported that appears to refute my claim:  Anaplastic Large-Cell Lymphoma in Women With Breast Implants http://jama.ama-assn.org/cgi/content/full/300/17/2030?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&andorexacttitle=and&andorexacttitleabs=and&fulltext=silcone+breast+implants&andorexactfulltext=or&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT.  This is a free article, so you can read the whole thing.

 

Here’s how the media reported it:  “Study indicates silicone breast implants may increase women's risk of ALCL.  HealthDay (11/4, Gardner) reported, "Women with silicone breast implants may have a higher risk of developing a rare form of lymphoma," according to a study published in the Nov. 5 issue of the Journal of the American Medical Association.”

 

So, am I wrong?  Let’s see.

 

A previous study did not support the association of anaplastic large-cell lymphoma (ALCL) in breast implants…only 3 cases were found.  The strength of this study is that the ENTIRE population in the Netherlands was reviewed for any breast disease over 17 years (1990-2006).  We’re talking ~17 million people.  They found breast lymphoma in 389 women and 40 men (Yes, men can get breast cancer, but it’s rare as hen’s teeth.)  Of the 389 women, 11 had ALCL, and five of these had previous implants.  As you can see, this is a very rare disease:  the incidence rate is about 1 in 1 million.

 

There’s a lot of cellular biology here:  lymphomas break down into Hodgkin and non-Hodgkin types.  Of non-Hodgkin, those in the breast are a small percentage.  Of the breast non-Hodgkin, most are B-cell in origin…rarely T-cell—which is what ALCL is.  You can sort all that out if you want to, but it makes my head spin.   Leave it that we’re talking “exceedingly rare.” 

 

There’s a bunch of math and case-control comparisons.  You can dig through that if you want, but the bottom line is that the analysis shows an increased risk for women with breast implants.

 

On the downside, the weaknesses of the study are that women who get breast implants have been shown to be different from other women in child-bearing age, residency patters, socioeconomic status, and access to care.  None of these factors were controlled in the study.   No comparison was made for other chemical (or sun) exposure, diet, or alcohol consumption (other common risk factors) .  Also if you look at the math, the confidence intervals (CI) for the experimental groups were HUGE (typical for very rare things).  This reduces the statistical power of the results.

 

So, forget the data:  does this association pass the common sense test?  Silicone is immunogenic (so are many compounds and medicines).  Could it cause a reaction that leads to a specific type of cancer over time?  In this study 3 of the five cases occurred 1, 3 and 4 years after implant.  Is that long enough?  Most would say, “doubtful” when you compare other chronic inflammatory processes.

 

As on reviewer said, “It is more likely that a compilation of infections, autoimmunity, genetic host susceptibility, and environmental and lifestyle factors will identify the most robust predictors of lymphoma risk.”

 

I don’t think I’m wrong. 

 

Things are always more complicated, aren’t they?  If you’re still with me, I’m finally getting to my point.  In science, we informally refer to the “One-In-A-Million (OIAM) Limitation”:  any event that occurs at the rate of one in a million or less, is practically impossible to prove because the number of potential confounding factors is usually huge, and the number of experimental subjects you need to have exceeds the number of humans currently living on the planet (some exaggeration for emphasis).  This leads to a corollary to the OIAM Limitation:  any risk at this level or below, even if provable, is so far down the list of measurable risks as to be unworthy of our attention (being struck by lightning, or a meteor, may be more likely).  To pay any attention to it is SOTD.

 

That’s Object Lesson 3:  For some exposures, actual risk to health and safety may be so low as to preclude consideration.  If you’re playing the odds, you need to pay attention to the thousands of influences in your life that are more of a risk.  If fact, I would recommend you come up with your Top Ten risk list.  If you succeed in modifying only those, you’re way ahead…and a lot less scared to death.

 

 

Medical quote of the Day:

One of the first duties of the physician is to educate the masses not to take medicine.—William Osler [1849-1919]

 

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.  A special thanks to John Stossel for coining the phrase “Scaring Ourselves to Death.”

 

 

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