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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Sunday, March 22, 2009

APPRECIATION FOR MAGGOTS; I'M SICK, DO I SEE A PATHOLOGIST OR A RADIOLOGIST? AND, OLDER FATHERS MAKE STUPID KIDS?

I do my best to resist the temptation to talk about strictly political stuff.  All of it is so outrageous; the only therapeutic thing to do is just grind my teeth.  But, I ran across this quotation and thought it interesting.  So, I apologize in advance for my lack of discipline.

The excerpt is from a speech to Congressional Democrats by Henry Morgenthau, who was Treasury Secretary for FDR.  The time is 1939, ten years into the Great Depression:

We have tried spending money. We are spending more than we have ever spent before and it does not work. And I have just one interest, and if I am wrong ... somebody else can have my job. I want to see this country prosperous. I want to see people get a job. I want to see people get enough to eat. We have never made good on our promises ... I say after eight years of this Administration we have just as much unemployment as when we started ... And an enormous debt to boot!".”  (from Burton Folsom, Jr., New Deal or Raw Deal? (New York: Simon & Schuster, 2008), p2).

Maybe we’ve figured out how to spend in the interim, but …I don’t know.  And unfortunately, we don’t yet (sarcasm) have a Second World War to fix the debt problem.

 

Research suggests maggots may be no more effective than standard ulcer treatments.

A 14th century treatment, typically employed by military doctors, has made its way into modern laboratories, according to the AP (3/20, Cheng). Until the 1930s, "maggots were commonly used" to treat wounds, but the practice "fell out of favor when antibiotics and surgery became widely available after World War II." Still, those "in a remote place," or communities that "don't have access to a surgeon or good medical care" might still choose such an option today.

       …in theory, maggots can "'clean out' dead tissue -- a process called debridement -- stimulating healing and getting rid of bugs such as MRSA in the process."

        Aiming to validate or debunk those assertions, the Canadian Press (3/19, Ubelacker) reported that researchers at the University of York conducted a study, published Mar. 19 in the BMJ, in which … the "maggot therapy was significantly faster at debriding...from wounds than hydrogel, (but) there was no significant difference in the time for the ulcer to heal."

 

Doc D:  This may be a little too gross for you.  There’s more to the story.  Medicines don’t help remove the dead tissue from a wound.  When I was in training we would put moistened dressings onto the wound and allow them to dry.  Returning later in the day we would peel off the dressing, to which the dead tissue had adhered.  This worked “fairly” well, but when you looked at the patient it was clear from their pale and sweaty face that having a dried dressing yanked off an open wound was like ripping duct tape off a hairy chest.  Also, some of the dying tissue wouldn’t come free, so you had to keep doing this procedure daily until all the bad stuff was gone.  Maggots can only eat dead and dying tissue so they have the advantage of being selective, and it’s uncomfortable only in the beginning.   BUT, remember what I said above:  antibiotics don’t remove the non-viable tissue and that’s what keeps the infection going:  a culture medium for germs.  So you need both debridement and antibiotics.

 

 

Nine percent of family medicine slots went unfilled this Match Day.

 

 In the Wall Street Journal (3/19) Health Blog, Jacob Goldstein wrote that while Match Day "offers plenty of human drama," its "process also offers a window into the collective desires of the newest crop of doctors." For example, about "nine percent of the" family medicine "slots went unfilled." Family medicine, a specialty in which physicians often "work unpredictable hours," offers "median compensation" of "around $180,000 a year, according to a 2008 report from the Medical Group Management Association (MGMA)." By comparison, "anesthesiology, which often offers regular working hours," offers "median compensation of about $400,000." Notably, approximately "one percent of" anesthesiology "slots went unfilled," possibly indicating that "medical students, who often have more than $100,000 in debt, respond to market forces."

 

Doc D:  Another tidbit of evidence that suggests we are headed in the wrong direction with healthcare.  Dis-incentivizing primary care will lead to access problems.  If there are few doctors trained in primary care, who will take care of people?  There are only two answers:  non-doctors (with much less medical training) or doctors who didn’t train in primary care.  Good luck with being treated for your pneumonia by a dermatologist.

 

And by the way, I never made $180,000 in my life, despite being a general, and receiving flying pay and hazardous duty pay for parachuting in addition.  My military pay was about a third of what my old partners were making in the ER group I left to join the Air Force.  In fact, my pay went DOWN when I made general because the government thinks that your position and authority are compensation enough (they stopped my medical pay).  Not so for other types of federal employment.

 

Children born to older fathers may score lower on cognitive tests, study indicates.

The New York Times (3/10, A12, Rabin) reports that "the children of older fathers scored lower than the offspring of younger fathers on I.Q. tests and a range of other cognitive measures at eight months old, four years old and seven years old, according to a study " published in the online journal PLoS Medicine. For the study, researchers "reanalyzed data from the federally sponsored Collaborative Perinatal Project, which gathered information from more than 50,000 pregnant women seen at 12 university clinics in the United States from 1959 to 1965." The investigators "analyzed the scores of 33,437 children who, as part of the project, had been tested at regular intervals in a variety of cognitive skills, including thinking and reasoning, concentration, memory, understanding, speaking and reading, as well as motor skills. Fathers in the study were age 14 to 66, while mothers were 12 to 48."

        Bloomberg News (3/10, Lauerman) reports that, according to the researchers, "average IQ among children dropped steadily on a number of tests as their fathers' ages rose." For instance, "children born to fathers who were age 20 scored an average of two points higher on an IQ test than children born to 50-year- old fathers."

        HealthDay (3/9, Reinberg) reported that the researchers also "found that the older the mother, the higher the kids' scores on the cognitive tests. WebMD (3/9, Doheny) also covered the story.

 

Doc D:  What the…?  This is one of those useless studies that waste our money and tell us nothing.  No knowledge of basic science and nothing that makes life better.  Are we saying that young men and old women need to “get together” and procreate in order to get the most intelligent children?  And what causes this ambiguous result?  Decadent sperm? Decaying skills in parenting?  Gray hair and balding?  Andropause?  Lastly, how significant is two IQ points…unless it’s the final seconds of a basketball game?

 

I want my money back.

 

 

Medical quote of the Day:

Entry in The Devil’s Dictionary, by Ambrose Bierce [1842-1914?]:

MIND, n.  A mysterious form of matter secreted by the brain.  Its chief activity consists in the endeavor to ascertain its own nature, the futility of the attempt being due to the fact that it has nothing but itself to know itself with.

 

 

Nature Note:    Media Portrayals of Suicide.  You may have seen recent testimony to Congress on an increase in suicides among military personnel.  I was involved in a couple of these episodes:  there were several during my 28 years of service.  The suicide rate goes up and down over time, and interest peaks when there is a rise.  The DoD has published data on this for a long time.  The first thing to note is that suicides are always a grave concern, but the rate in the military has always been lower than that of the general population, even during war.  Each military service has an elaborate program to detect, prevent, and treat signs of stress and mental illness among military personnel.  They take it very seriously; as a commander I disciplined supervisors who were slow to recognize when someone’s life was going off the rails. 

 

An interesting issue, though, is what is the effect of the media’s portrayal of suicides?  Do they precipitate more suicides?  The available evidence, which some psychiatrists argue is epidemiologically weak suggests that media portrayals are more likely to be associated with suicidal behavior when they are prominent on the page (e.g., large headlines, photos of the body), appear in multiple places (e.g., several TV networks and newspapers), report celebrity deaths, and are based on real rather than fictional (e.g., TV soap opera) suicides.  Two particular studies are often cited as evidence for a copycat effect.  A series of highly publicized media reports of subway suicides in Vienna, Austria was linked to a rise in subway suicides, and the suicide of a famous Canadian journalist, Gaëtan Girouard, was also associated with a rise in the suicide rate.

The media have always claimed that the impact of bringing to light these events is of greater benefit than harm.  A family destroyed by the exposure of the media is less important than that the public hear innuendo or unsubstantiated attacks on a family member.  For those who don’t buy that argument it’s always been hard to quantify the harmful effect.  Now there is data to make that comparison, and this is encouraging for those like me who think the media attack dogs need to do their job from principle rather than profit.

 

Recommended Reading (yes,  I read them):

 

--The Myth of the Rational Voter:  Why Democracies Choose Bad Policies, by Bryan Caplan.  This book is a little more academic than most, but it rewards the effort.  H. L. Mencken, the early 20th Century journalist and satirist, said that “democracy is a pathetic belief in the collective wisdom of individual ignorance.”  When six times as many adults know the name of the current American Idol winner as know the name of the Speaker of the House, the informed citizenry necessary for democracy to perform well is…absent.  But, it’s always been that way, according to Caplan.  Taken all together, only a few percent of the population know platforms, candidate’s records, or have a formed opinion of public policy.  This is a problem for those who think that democracy works to make good policy.  However, says Caplan, democracies don’t operate out of ignorance, an evident state of affairs, rather they operate irrationally.  The greatest obstacle to sound economic policy is the popular misconceptions, irrational beliefs, and personal biases held by almost all ordinary voters.  Voters vote for what they want rather than for what they should.  There’s a lot in this book that brings you up short; it will test your belief in our system of governance, and provide an antidote to any belief that everybody should like us because we’re “special.”

--Kluge:  The Haphazard Construction of the Human Mind, by Gary Marcus.  Evolution is frequently given great credit for the marvelous machinery of nature, including the human body and mind.  But, the author argues, that’s not the way it works.  In fact, whatever gives the organism an edge wins out, whether it’s the best solution, or just enough better to make the difference.  “Adequacy” is the goal of natural selection, not the fittest or best.  Further, Marcus says, our minds are not a wonderful and complex web of infinite capacity and creativity.  The mechanisms by which our minds work are patched together with baling wire, spit, duct tape, and glue.  The result is extremely un-pretty, but gets the job done.  He goes on to offer ways to side-step the kluge in our thinking.  Fun reading, with lots of examples of cognitive folly.

 

Doc D

 

The above are my opinions, and they are entirely my own.  If you don’t like mine, form your 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 that are in the public domain.  As always, you may share this column, with appropriate attribution (here, and in the text) included.

 

 

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