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.

Tuesday, August 31, 2010

Medical Quote Of The Day - 31 Aug 10

 
I haven't done a medical quote for a while, but I ran across this.  It doesn't sound medical, but the author was referring to why it's so hard to make the right medical decision.  Any attempt to analyze the problem with data and science overlooks that underneath all the planning and analysis, we are dealing with real people, who are unique and our real concern.  Reform, whether in healthcare or finance or welfare or whatever, always comes up against this.

Such is the problem with ethical dilemmas; often the complexity of reality ends up confounding a perfectly good analysis.
--Stephen Workman, MD, MSc
 
 


Monday, August 30, 2010

Another Supplement Scam. It Has To Be This Bad Before Gov't Can Act

 
It amazes me that people get so bent out of shape about medicines that have undergone an extensive approval process, but are accepting of alternative therapy scams.

From the Federal Trade Commission website (Aug 16), in re Central Coast Nutraceuticals, Inc,
At the request of the Federal Trade Commission, a U.S. district court has ordered the marketers of acai berry supplements, “colon cleansers,” and other products to temporarily halt an Internet sales scheme that allegedly scammed consumers out of $30 million or more in 2009 alone through deceptive advertising and unfair billing practices. The FTC will seek a permanent prohibition. Since 2007, victimized consumers have flooded law enforcement agencies and the Better Business Bureau with more than 2,800 complaints about the company.
I see one of these legal actions about every week.  But the crimes go on....  There's a video on the FTC website from this company that is classic for deceptive techniques.  Imagine yourself not knowing about the above allegations; would you be influenced by it?

Go here to view the commercial:  http://www.ftc.gov/opa/videos/acai/index.shtm

Most of these naturopathy companies are smart enough to fly under the radar, so they continue to market nonsense to gullible consumers...often at great expense.

They stay under the radar through "weasel" words:  our product "may", "could", "in some cases", "according to testimonials," etc., that always fall short of claiming a definitive verifiable effect that could be tested.

As I've said here before, first ask yourself if what someone advertises sounds "too good to be true."  If it does, then it usually is.  Then just apply some common sense:  does it sound plausible that there's an invisible force that surrounds all our being and determines our health?  Any claims for unproven mechanisms of action should be viewed as fraud until proven otherwise.

To make it easier, I'm going to list physicist Robert L. Park's Seven Warning Signs of Bogus Science, in abbreviated form.  For a complete explanation go here.  Everyone who's exposed to claims of miracle cures and "new" alternative therapy breakthroughs should know these signs:
1. The discoverer [or company] pitches the claim directly to the media.
2. The discoverer says that a powerful establishment is trying to suppress his or her work.
3. The scientific effect involved is always at the very limit of detection.
4. Evidence for a discovery is anecdotal.
5. The discoverer says a belief is credible because it has endured for centuries.
6. The discoverer has worked in isolation.
7. The discoverer must propose new laws of nature to explain an observation.

I would add that the "real" cure is only available from the one who's proposing it.  Everybody else lacks the key ingredient or technique.  And it costs a lot, preying on our delusion that what costs more is more valuable.

Doc D
 
 

Sunday, August 29, 2010

The Great Egg Recall: Media Says It's Blaming The Victim To Recommend Fully Cooked Food

 
We're not talking about rape here.  The media is over-the-top to label caution from the industry about cooking eggs as "blaming the victim."

Yes, you should be able to prepare your Eggs Benedict, or eggs "over easy,"  and be safe...but it should be remembered that, in general, it's safest to ALWAYS fully cook or thoroughly wash foods.  This is just common sense.

If you want to read the media hype (and contribute to their sensationalized view that sells newspapers), you can go here (USA Today, Aug 29).  It appears the egg producers need to look at ALL of their procedures and have quality control systems in place that work.  The FDA will take action.  But,...

Remember the outbreak of contaminated tomatoes some time back?  The producers were at fault for poor processes that allowed contamination to enter the processing of the tomatoes.  But, if people had still washed their tomatoes at home nobody would have gotten sick.  Despite current regulatory requirements for food safety (which could be improved) you should always wash the produce before chopping it up for your salad.

And you can always eat steak tartare, which is ground up raw steak, but you accept some risk in doing so.  I don't recommend it.  Same thing with sushi.

The egg producers need to clean up their act, and inspectors need to ensure they do so.   But don't become complacent if you want to avoid everybody getting sick at your annual Thanksgiving dinner.

And if you like your eggs "over easy," understand that the yolk is not cooked...and you're betting that somebody else is going to keep you healthy.

The larger problem is the decline of small farms and the rise of huge food conglomerates.  In the past, an outbreak of foodborne illness would have been limited to the small area supplied by your Mom-and-Pop egg farm.  Nowadays, vast amounts of food that supply whole regions of the country are processed through single-point preparers and distributors.  This magnifiies the exposure when something goes wrong.

Small is beautiful, sometimes.

Doc D
 

Saturday, August 28, 2010

Medical Cartoonville - 28 Aug 10

 
Pickin's are slim today.

I've read or scanned about thirty medical articles and studies this morning.  Yawn...

If you have to have something...then...OK, we destroyed about a half a billion eggs to track down two farms that had a problem.  Look on the bright side:  nobody will be eating all that cholesterol.

Instead of the usual, here's some medical gallows humor.





Have a healthy, low-cholesterol day.

Doc D
  
 

Friday, August 27, 2010

Non-Religious Doctors More Likely To Provide Life-Ending Care...And?

 
Admonitions by British ethicists that doctors who aren't religious should make this known to their patients sound off-target to me.

A Brtish study published in the Journal of Medical Ethics (Aug 25), surveryed about 3000 doctors in the UK about their last patient who died.  As described by Assoc Press (Aug 26)
"Doctors who described themselves as "extremely" or "very nonreligious" were nearly twice as likely to report having made decisions like providing continuous deep sedation, which could accelerate a patient's death....Seale [lead author] also found that doctors who were religious were much less likely to have talked about end of life treatment decisions with their patients."
Does this sound like a meaningful addition to our knowledge of end-of-life care?  My experience of world religion is not extensive, but those western religions to which I have been exposed make it an article of faith that God's children are here for a purpose and that He will determine when it is time for them to depart this vale of tears.

So, is it real surprising that atheist doctors don't buy into the "He will determine" part?

This research didn't twang my guitar string.  It certainly didn't lead me to think that
To ensure doctors are acting in accordance with their patients' wishes, Seale [the lead author]wrote that "nonreligious doctors should confess their predilections to their patients."
Nothing in this study said that non-religious doctors pushed end-of-life decisions more frequently, or advised patients to lean toward early termination criteria.  If they did that it would be something to worry about.  But, just acceding to patients wishes more frequently doesn't sound very important...unless you're in the market for someone who will help you end it all.

If you want a Nature Note to remember from this research (also fairly worthless) try this (from the abstract),
Specialists in care of the elderly were somewhat more likely to be Hindu or Muslim than other doctors; palliative care specialists were somewhat more likely to be Christian, religious and ‘white’ than others. Ethnicity was largely unrelated to rates of reporting ethically controversial decisions.
Here are the skimpy data, for Onion Peelers,
A postal survey of 3733 UK medical practitioners, of whom 2923 reported on the care of their last patient who died. Independently of speciality, doctors who described themselves as non-religious were more likely than others to report having given continuous deep sedation until death, having taken decisions they expected or partly intended to end life, and to have discussed these decisions with patients judged to have the capacity to participate in discussions.

Under the US House HCR bill, doctors must discuss end-of-life plans with their patients over 65...unless this got removed from the original 2700 page bill...who knows?  We had to "pass it to know what's in it", right?

Doc D
 
 

Thursday, August 26, 2010

Doctors Opting Out Of Medicare. Some Data

 
Progressive bloggers have been saying that doctors won't leave Medicare.  Here's some data in one state.

Reassurance that HCR won't adversely affect people's health care plan or doctor have been sounding hollow for some time, but that doesn't keep some activists from insisting that "all is well."

This is from the Houston Chronicle, Aug 19:
"Forty-four Texas doctors opted out of Medicare in the second quarter of this year, continuing the state's erosion of government-funded health care for seniors.  The opt-outs bring the 2010 half-year total to 94 and keep the state on a pace to lose an all-time high number of Medicare-accepting doctors in a single year, no small feat considering the recent trajectory."
And here's the graph.  Note that the 2010 figure is only the first half of the year.





Trivial numbers until the mid-2000's.  The increase started back in '07 as the projected cuts to Medicare reimbursement loomed larger and larger (21% this year), but Congress was unable to do more than brinksmanship to forestall the disaster.  In 2009, the numbers were still high but not accelerating.  However, as you can see from the first half of 2010, the annual total may reach a new high.

I don't think the situation is strikingly different in several other states.  With Congress out of money, and planning to take $500 billion out of Medicare to spend on the new entitlements under HCR, it's unlikely that a breakthrough in falling payment rates will get a permanent fix. 

So, if you're a senior--or will become one soon--reconsider buying that Medicare supplement.  And if you're a member of AARP, who makes most of their money through selling insurance supplements to seniors, you now know why they supported Obamacare.

Doc D
 
 

Wednesday, August 25, 2010

Gov't Healthcare At Work In The UK: How Cost Distorts Decisions

 
Controversy over Britain's decision not to fund the drug Avastin for bowel cancer.  Does extending a life for a couple of months on average justify the cost?

Go here for a video from the BBC on the topic.  The cancer treatment with this drug costs over $30,000.

The government makes the claim that the drug doesn't significantly benefit the patient who requires it.  They are a little "dodgey" (appropriate British slang?) on why they think it's not a benefit.

But the National Health Service in the UK is very above-board about their process of approving government funding for medical treatment:  they look at length of life, quality of life, and ....cost

This is why I think this is unethical:
1.  Quality of life is subjective, and personal...not a government assessment to make.
2.  The "high" cost of this drug is high relative to what?  A car?  Which is of more value:  a life or a car?

And most important of all:

3.  Average life extension due to a drug is ...well...average.  This means that if 1,000 patients get the drug, some are near death's door and will survive only a few days, while others may live for one or two years.  But the average comes out to be two months.

So, we condemn those who might have benefited greatly to an earlier death. [Note that I have exaggerated the statistical range of benefit for effect.  BUT, in some diseases the range is even longer than up to two years.  It depends on the disease, the treatment, and other things.  But you get the idea:  average life extension unfairly dooms some patients.]

The British healthcare system is broke, and other Euro systems are heading in the same direction.  They are cutting cost by cutting lives. 

The smartest countries, like the Netherlands and Switzerland, are introducing the market back into their system...but I still think they're just postponing the collapse.

This is what you get when the government makes healthcare decisions.  It becomes a budgeting problem.

Doc D
 

Tuesday, August 24, 2010

A Couple Of Health Care Myths

 
I hear these things so often it's driving me crazy.

Myth #1:  Preventive health care will lower cost.

Ask yourself, which costs more:  the person who dies young, or the person who gets great preventive care and lives to be 85, needing health care for multiple chronic diseases for the last 30 years of their life?

With all intended sarcasm, if you want to lower health care costs to the minimum, let people die immediately after birth.

Now, it's true that for specific disease care, like breast cancer, it's cheaper to prevent the disease than go through all the expensive surgery, radiation, and chemotherapy.  (duh...not having to treat a disease is cheaper than treating a disease.  What an insight!)  But that person's total lifetime healthcare cost could still be over the top, treating the arthritis, osteoporosis, type 2 diabetes, hardening of the arteries, and high blood pressure that so many people suffer from when they live longer (and don't get breast cancer).

And this is where the money is.  The money you save by not having to treat breast cancer is peanuts next to the money spent to maintain a person who lives longer and needs chronic care.  Even if you add up all the treatment for specific disease care it doesn't add up to what it costs for the chronic disease care you created by saving lives.

Prevention is good medicine; that's why we should do it.

But, "Prevention Lowers Cost" is BS.

Myth #2:  People in countries with government health care live longer than in the US.

This one is infuriating, because the people who publish this tripe cook the data.  The implication, of course, is that they live longer because they have better health care under their system.

But it's not true.  The way you lie with these statistics is to include deaths that occur unrelated to health care.  Specifically, you include data on homicide and auto accidents.  Those two causes of death have nothing to do with how good your health is.  In fact, if you look at those two types of death alone, the survival rate per event is much higher in the US.

But, when you take homicide and auto accidents OUT of the data from all countries, guess which country lives the longest.  Yep....the US.

[That doesn't mean we don't a have a big problem with violence and auto accidents, but we need other solutions to those]

So, "People With Universal Gov't Health Care Live Longer," is also BS.

The funny thing about myths like these?  The real answer is in the data, but unless you go look it up for yourself, you may be influenced by unreliable sources and political advocates.

For homework, figure out why government healthcare advocates claim that infant mortality is higher in the US.  Hint: In the US, every baby that's born with either a heartbeat or spontaneous movement is considered a live birth.   (for the answer, go here.)

Doc D
 
 

Why A Federal Judge Blocked Embryonic Stem Cell Research

 
You may have seen this in the news.  It's not clear to a lot of people why this occurred.  What follows is an everyday language explanation.

Sometimes the science jargon is baffling.  Sometimes the legal jargon doesn't make sense.  What's underneath all the scientific community's shock is a little-known law that Congress renews every year. 

Despite the fact that we all heard the Obama administration's announcement to "return science to its proper place" and that embryonic stem cell research could now be funded, it's not that simple.  The articles I read this morning (Wall Street Journal, Aug 24), emphasize the poltical blather rather than what's behind the decision.

The little-known law is referred to as Dickey-Wicker.  It just says that federal funds can't be used for research in which a human embryo is destroyed.  It sounds straight-forward, but...

What the Obama administration did is tell the National Institutes of Health (NIH) to come up with guidelines that would allow federal funding for stem cell research where the embroy's were not being created or used for the purpose of research.  But, rather, embryo's which were not used for In Vitro Fertilization (and would be lost anyway), could be used to develop cell lines in culture that could then be used for research.

Did I make that clear?  Looking back, I'm not sure.  One more try:  NIH developed guidelines that allowed  cell lines from unused embryo's to receive federal funding, because the embryo's weren't being produced for the purpose of stem cell research.  So, use of destroyed embryo's NO, use of cells from destroyed embryo's YES.

However....the federal judge said that doesn't meet the requirements of Dickey-Wicker, which says "no research in which a human embryo is destroyed."... It doesn't matter that the cell lines are later in time, they still came from a destroyed human embryo.  Also, the law doesn't make any distinction about why the embryo ended up being destroyed.  The government tried to limit D-W to direct use of the embryo, and that cell lines were distinct and different.

In the legal decision,
...the Dickey-Wicker Amendment does not contain any language to support such a limited definition of research. Rather, the language of the statute reflects the unambiguous intent of Congress to enact a broad prohibition of funding research in which a human embryo is destroyed. This prohibition encompasses all “research in which” an embryo is destroyed, not just the “piece of research” in which the embryo is destroyed.
I think the legal opinion is clear and correct.  The law can always be changed, but we know members of Congress don't like to be on the record as having voted on evenly split moral issues.  So, we'll see...

And there's another problem.  The Bush administration allowed 21 cell lines of long standing to be used for embryonic stem cell research (despite what you heard about Bush not allowing any).  The Obama administraiton increased the number to 75 under their (now-blocked) guidelines.  How come the older cell lines can keep going?  They came from embryo's originally, too?

This is typical for when science and politics get into a head-butting contest.

Doc D
 
 

Monday, August 23, 2010

How Health Care Reform Impedes Care - Video

 
Some major indignation over the health care reform law from a pre-existing conditions parent.

This parent who has private insurance and two kids with complicated medical issues rejects her Senator's excuses about health care reform:

1. Why do I pay for Medicaid patients who fraudulently receive care?
2. Your law forces businesses to reduce benefits in order to pay increased taxes due to HCR, including my husband's company.
3.  Why have you set up bureaucracies that are unresponsive to the electorate?
4.  I work for a non-profit that helps patients from other countries that have government health care who can't get life-saving treatments because it's too expensive.
5.  And, basically, I want you out of my life and personal business.

She was very...uh...articulate.

This parent later made her case on cable news TV.  Guess which networks didn't pick up the story.





The Senator basically gives up after using up all the platitudes we've heard so far, and having them refuted.


Doc D
 
 

My Article On The FDA Drug Review Process

 
Many people think the FDA is the Gang That Can't Shoot Straight. I wrote an article that shows how the drug review process really works.

The FDA takes a lot of heat:  it takes them too long to approve a drug, or they approve something that turns out unsafe;  they are influenced by special interest groups like the pharmaceutical industry and patient advocacy groups; etc...

The real story is much more complex.  The science they struggle to make sense of  is inextricably linked to public opinion, politics, and the legal system.

For a review and case study, please see my article published in Science-Based Medicine here.

Doc D
 
 

Saturday, August 21, 2010

So Much Bad News On HCR That Dem Strategists Say, "Stay Away From It"

 
The accumulated reports of HCR's increased costs, loopholes and contradictions, and suppression of economic growth have finally penetrated.

Remember when Nancy Pelosi said, in the Healthcare Summit that the bill would be a jobs program?  Well, election strategists are telling candidates in the mid-term elections to avoid any claims for HCR except that it "needs to be improved,"  unless they want to lose.

As Politico reported (Aug 19), campaign advisors gave a confidential presentation to political supporters that said,
"Straightforward ‘policy’ defenses fail to [move] voters’ opinions about the law," says one slide. "Women in particular are concerned that health care law will mean less provider availability — scarcity an issue."   The presentation also concedes that the fiscal and economic arguments that were the White House's first and most aggressive sales pitch have essentially failed.  "Many don’t believe health care reform will help the economy," says one slide.  The presentation's final page of "Don'ts" counsels against claiming "the law will reduce costs and [the] deficit."
Note, these are people who desperately want to be re-elected, but have run out of excuses to explain their voting record.  The presentation tried to be upbeat by recommending that candidates make some form of "it's a first step that needs work" kind of statement that will avoid them getting whacked by a furious public.  You can look at the whole powerpoint presentation here.

This is a huge collapse in the strategy that, "You'll love it after we pass it."  Even their own advisors recognize it now.

But the presentation doesn't mention all the incompetence issues in the legislation:  groups that were overlooked, deadlines that couldn't be met, unintended costs that dwarfed the expected ones.

And the assumption that people who saw taking $500B out of Medicare and using it elsewhere were too stupid to figure out how this couldn't "improve" Medicare and was a "savings".

In my view, this election will be a referendum, but not on the economy.  It'll be a referendum on contempt for the public and incompetence.

Doc D
 
 

Friday, August 20, 2010

My Congressional Testimony On The Anthrax Vaccine

 
Just for fun, I thought you might like to see my testimony to Congress about the anthrax vaccine back in 1999.

At the time I was the Surgeon for the Air National Guard, the Pentagon, DC.

Most of the discussion between Congressmembers and witnesses was informational.  Congressman Dan Burton entered the hearing, and things got a little more provocative.  Mr. Burton's granddaughter had some kind of severe event that was in close association with receiving a vaccine.  He clearly believed it was the vaccine and not his granddaughter that was the problem, but his description didn't match up with a known reaction.  So I'll never know what the deal was.

But his legendary temper and confrontational style were in full flower.

Oh...and by the way....when you get "invited" to testify, there's no RSVP "No."

Excerpt from Hearing of the Subcmtee on National Security on "The Impact of the Anthrax Vaccine Program on Reserve and National Guard Units,"  Sep 29, 1999.
___________________________

Mr. Burton. Did you hear the question I asked about the Fort Detrick experiment using guinea pigs showed 9 of 27 strains tested killed 50 percent of the vaccinated guinea pigs, and in a second study 26 of the 33 strains tested killed half of the animals? Are you familiar with that?

Colonel Dougherty. Mr. Chairman, I am aware of that study. Sir, I have read that study. I am not a vaccine expert but I have talked to vaccine experts about that study. I think there are some criticisms to be made of it. First of all, they don't follow the same protocol that we use. They don't challenge the experimental animal in the same way that humans get the disease. They didn't test for efficacy of the vaccine in the same way that we would with a better model for the human disease.  And, last, guinea pigs don't get anthrax in the same way that humans do. I think that those results are interesting but don't provide any conclusion about the coverage that the current vaccine provides.

Mr. Burton. I have two more questions, Mr. Chairman. How many strains of anthrax are there?

Colonel Dougherty. Sir, I am aware of at least 31.

Mr. Burton. Does this vaccine cover all of them?

Colonel Dougherty. This vaccine was designed in such a way that it provokes a response in the human body to a component of the organism that is required to produce disease. That is the logic for this vaccine.

Mr. Burton. So what you are saying is it will protect the person that gets the vaccination against all 31?

Colonel Dougherty. We believe that every isolate that you can come up with currently that has the so-called protective antigen as a part of the germ, it will provoke an antibody response to it. The protective antigen that is a part of that vaccine is a part of every strain that causes disease. If you don't have that antigen disease doesn't occur.

Mr. Burton. So you are saying it will protect you against every one of those strains?

Colonel Dougherty. Sir, it----

Mr. Burton. I just want a yes or no. Will it protect you against all 31 strains?

Colonel Dougherty. We believe it does.

Mr. Burton. You believe it does. Thank you. Now let me ask you this, Colonel. You have the Marberg virus which is an Ebola cousin, smallpox, biotoxins, resin I think is one of them, botulism, Japanese encephalitis, Venezuelan encephalitis and about 44 other viruses that could be used in biological warfare. Are we going to start inoculating people for every one of those? Because they can be used in a warlike situation, can they not?

Colonel Dougherty. We are not at this time. We don't have that capability. But the anthrax----

Mr. Burton. I know, but let us say that we inoculate the entire military for anthrax and let us say that your thesis is correct that it will work on all. I mean there are some scientists who don't agree with you. I think you know that. I think you know that.

Colonel Dougherty. Yes, sir.

Mr. Burton. But let us assume for the sake of argument that the anthrax vaccine is safe, which many people doubt, but let us assume it is safe and let us assume it will protect against every one of the strains of anthrax. If you were an enemy of the United States and you knew that everybody was inoculated against it, why wouldn't you use an Ebola virus because you know there is no protection for that and put that into some kind of a--into a military warlike missile and use it in a warlike situation.

Colonel Dougherty. Mr. Chairman, the reason we think that anthrax is the correct focus right now is because it is so easy to make, it is simple to make, you can make a ton of it and you can attack somebody without a lot of----

Mr. Burton. I understand, but you didn't answer my question. If an enemy of the United States knows that we are protected, our military, against anthrax, assuming it works like you say, why would they go ahead and produce a missile or a weapon that used anthrax when they could use the Ebola virus, smallpox or any of these other things?

Colonel Dougherty. Sir, a lot of those other things that you are mentioning I think have some real technical problems in producing an effective biological warfare agent.

Mr. Burton. Is it possible to do?

Colonel Dougherty. Anthrax is not.

Mr. Burton. Is it possible they could do it with the Ebola virus?

Colonel Dougherty. It is theoretically possible.

Mr. Burton. Thank you very much. Thank you, Mr. Chairman.
 
_____________________
 
Over the next several years and 6 million doses later, the anthrax vaccine is still safe and effective.  The suit filed by National Guard members was dismissed by the courts.
 
But the anti-vaccine forces are still with us.  California is experiencing an outbreak of whooping cough (pertussis) that is a direct consequence of vaccine resistance.  And pertussis can be fatal.
 
Doc D
 
 

Thursday, August 19, 2010

STUDY: Tai Chi and Fibromyalgia. GIGO

 
Touching openness by one of our premiere medical journals.  They want to prove it so bad.

In keeping with its new trend in exploring dubious therapies, the New England Journal (Aug 19) publishes a randomized, if single-blinded and poorly controlled, study of 60 people with fibromyalgia who underwent 12 weeks of Tai Chi versus education and stretching (approx 30 in each group).

The main outcomes were subjective assessments of pain reduction.

For Onion Peelers,
Mean (±SD) baseline and 12-week FIQ scores for the tai chi group were 62.9±15.5 and 35.1±18.8, respectively, versus 68.0±11 and 58.6±17.6, respectively, for the control group (change from baseline in the tai chi group vs. change from baseline in the control group, −18.4 points; P<0.001).
(FIQ is the Fibromyalgia Impact Questionnaire).

Statistically significant results.  Tai Chi works better to reduce pain.  And here's the title of the media article:  Tai chi eases fibromyalgia symptoms, study finds (Assoc Press, Aug 18).

Has the Holy Grail of alternative therapy been found?

No.  Despite the hype, despite a degree of openness on the part of the New England Journal that risks their brains falling out, despite the randomized design, and despite the statistical significance, this study represents almost every aspect of why benefit from alternative medicine therapies continues to be unproven.

The authors "dutifully" report (as the NEJM editorial says) that it would have been better if the study had a valid "sham" tai chi control.  (The subtitle of the editorial is "Are we there yet?"  Like it's assumed we will get there.)

At this point you're probably asking yourself, "What's the big deal?  They showed it helped, right?"

No they didn't.  Here are some of the reasons why not:
1.  As stated above, they didn't have a comparable control.  You can tell which subject group you're in.  This introduces a positive bias for the tai chi group.
2.  There was no equivalent group that "looked" like tai chi, but wash't .  You can't compare apples and oranges (tai chi v. stretching).  The researchers believe they met this requirement by just saying that it was a test of two different types of exercise regimen.  Right.  I wonder if ANY of the 60 people were fooled by that.  Maybe you haven't done tai chi, but can you tell the difference between it and a lecture with stretching?
3.  The study was only single-blinded.  Double blinded studies are best because neither the test subjects nor the investigators know which group they are dealing with.
4.  Measurement of pain is notoriously subject to external influences (like knowing which study group you're in).  My severe pain may be your mild pain, and tomorrow our positions may be reversed.  Also influencing subjective assessment of pain is:  how much sleep you got, your attitude, financial stress, personality type, etc.
5.  Thirty people in a test group is peanuts.  We not only need better controls, we need larger groups.  Small groups are subject to influence, and selection bias.
6.  The tai chi group were taught by a single teacher, who was a committed tai chi master.  Hundreds of studies have shown that if you have an instructor who clearly believes what he's doing, and exhibits great confidence in his ability, it influences the outcome...but it's still a placebo effect.  In the "stretching" group there were a number of different leaders of the sessions.
7.  Finally, fibromyalgia is a tough nut to crack.  Nobody can show what causes it, so patients are desperate for something that will help.  My guess is that tai chi's placebo effect will wear off over time (well beyond the 24 week follow-up that this study used).

There are other limitations, but it's clear we aren't there yet.  The first thing alternative therapies need to show is that they have some biological plausibility before we go spending a lot of money looking at them.  Then they need to meet the same requirements for benefit that all therapies do.

And before somebody starts claiming that my mind is closed, it aint.  I welcome well-designed and conducted research.  If tai chi and some other (even less plausible) therapies have one thing going for them, it's that there are few complications and side effects...unless a more serious disease is overlooked in the process.

This study doesn't hack it.   And shame on the NE Journal for failing to exhibit the same caution they would express for a new drug treatment of cancer.

Doc D
 
 

Wednesday, August 18, 2010

Pseudoscience: Acupuncture Just As Effective As Not Doing Acupuncture

 
This is classic for "proving" alternative therapies:  Insist it's "just as effective" as not doing anything.

Here's the title of the article in the NY Times Well Blog:  "Acupuncture, Real or Fake, Eases Pain"
Fake acupuncture appears to work just as well for pain relief as the real thing, according to a new study of patients with knee arthritis...
...both the real and sham acupuncture groups had statistically significant reductions in pain, averaging about a one point drop in pain on a scale of 1 to 7. The researchers also found that the enthusiasm of the person inserting the needles had a small but statistically significant effect. Patients reported slightly more pain relief when they were treated by someone who said “I’ve had a lot of success with treating knee pain,” compared with a practitioner who took a more neutral stance, saying “It may or may not work for you.”
I'm putting this one in my "Contra-rational research" file.  The title implies that there was some benefit, but at least the researchers acknowledged that what was occurring is consistent with placebo effect.  No matter what you do--give a sugar pill, fake an operation--some people will believe they are better for it.  To say that acupuncture equals placebo is just to say that it doesn't do anything...except for those people who are vulnerable to the impact of placebos.

My favorite acupuncture study is one that was done in Germany several years. ago.  They attempted to proved that acupuncture, accomplished in the traditional way along the body's meridians--through which harmonizing Qi flows--was superior to acupuncture that just placed the needles in random locations.

They found that it didn't make any difference where you put the needles.  Placing them on the meridians or not placing them on the meridians was equally effective (but still marginally so).

So what did they conclude?  Could it be that acupuncture theory (all that Qi stuff) makes no sense?

NO.  They concluded that there must be more meridians that had yet to be discovered.

It's enough to make you despair of human intelligence.  We are prisoners of our beliefs.

Doc D
 
 

Surveying The Media For Medical News: Mostly Rubbish.

 
A quick tour of articles that didn't need to be written. 

Feel free to click any of the link if you think there's something to learn from any of them.

Study: 1 in 5 US teenagers has slight hearing loss (Assoc Press, Aug 17).  Say what? I can't hear you...my son's stereo is too loud.

Report: Cancer is the world's costliest disease (Assoc Press, Aug 16).  Behind what?  Global warfare?

Boyfriend just can't get past tattoo of ex (Miami Herald, Aug 18).  Quick fix.  Have your boyfriend change his name to your ex.
 
U.S. Circumcision Rates on the Decline (NY Times, Aug 17).  Don't tell the pediatricians, it's the only time they get to do anything surgical.


Just think how much more useful the print media would be if they cut out all this stuff and filled us in on the important information.

Doc D
 

Tuesday, August 17, 2010

US: Free Care To The World's Uninsured

 
For those who think that healthcare provided to illegal immigrants is just a bunch of folks with the flu.

This is a state hearing in Florida.  When I ran a hospital, we came across similar cases on a regular basis.  The host countries were always unwilling to aid their citizens and were very happy to unload the care onto US hospitals.  I sympathize with the speaker's frustration:  the US government also won't assist.

Note that (1)  in this country nobody can be turned away by an emergency room, whether it's an emergency or not; the "emergency" is self-defined, and their presence in the ER establishes that it is an emergency under the law (even though it may be just an ingrown toenail).  There are severe legal penalties for denying care.  (2) The US government does not reimburse care delivered to those who are in the country illegally.






I've not seen cost estimates for illegal care nationwide, but I'm sure it's in the billions.  Fix this and we might have been able to fund care for our own uinsured, without needing a 1 trillion dollar reform package.

Doc D
 
 

Monday, August 16, 2010

A Natural Food Implicated In Cases Of Typhoid

 
Another caution about natural foods.  Not everything that's a fresh fruit is good for you.

An article in the Miami Herald Health AP blog (Aug 12) describes the problem:
"A rare U.S. outbreak of typhoid fever has been linked to a frozen tropical fruit product used to make smoothies, health officials reported Thursday.  Seven cases have been confirmed - three in California and four in Nevada. Two more California cases are being investigated. Five people were hospitalized, according to the Centers for Disease Control and Prevention said.  The CDC said five of the victims drank milkshakes or smoothies made with frozen mamey (ma-MAY') fruit pulp. Four of them used pulp sold by Goya Foods Inc. of Secaucus, N.J.  Mamey is a sweet, reddish tropical fruit grown mainly in Central and South America. It is also known as zapote or sapote. It is peeled and mashed to make pulp, the CDC said."
A very low incidence of disease, I'll grant you.  And probably due to contamination.  But, for those who think you can't go wrong by using only fresh natural fruits, it's a word of caution.

Wherever you buy produce, wash it.

Doc D
 
 

ER's Flooded With....Insured

 
Remember when advocates of our HCR law said we needed to do this because the uninsured would be flooding our ER's?  Not so fast.

A study in the Journal of the AMA showed the following:




It's not the uninsured, it's the insured...by the government.  (Thanks to WhiteCoat's Call Room for the tip and the link to the image).

With millions more added to the Medicaid roles in the future, many of whom will not be able to find a doctor, I expect this pattern to continue to grow and accelerate.

Doc D
 
 

Sunday, August 15, 2010

Medical Cartoonville - 15 Aug 10

 
 
 
 

Saturday, August 14, 2010

Serving A Cholesterol Pill With Your Burger

 
Researchers in Britain suggest that a low-dose statin be offered to people who buy high-fat fast foods.

The idea is to have little packets of cholesterol-lowering drugs (called "statins") available along with the salt and ketchup packets. (See the WSJ Health blog, Aug 13)

There are several flaws to this thinking.  First, statins work over a period of many weeks.  They are not drugs that act immediately.  To counteract a single fast-food purchase, you would have to be on the drug for a couple of months--daily--ahead of time.

Second, statins act variably on different types of cholesterol and fats in our bloodstream.  While one drug may lower your LDL-C (the bad cholesterol), it may have no effect on the high triglycerides you get from eating that Double Whopper or Pan-style pizza...after you've been on the drug for a while, of course.

Third, in the UK people can buy low-dose statins without a prescription.  But it's not clear that taking a low dose does very much to reduce risk.  The therapeutic dose for an individual with a lipid problem has to be individualized through monitoring and dose adjustment...by a physician or other trained medic.

Fourth, statins have side effects and adverse reactions.  Not everybody can take them.  To offer them in a restaurant without follow-up could lead to harmful consequences.

And Lastly, I've got a problem with treating behavioral health problems with drugs.  If we had a pill that could remove the cancer-causing effect from cigarettes, would we then say it's healthy to smoke?  What about the emphysema and bronchitis?

In my opinion, treating poor eating habits with drugs deals with unhealthy behavior by sweeping it under the rug.  It would only encourage people to buy two Double Whoppers...double the flavor, double the hazard.  But wait, then we could take TWO pills.

This is bad medical practice.

Doc D
 
 

Friday, August 13, 2010

Another Dopey Dietary Law. From California, Where Else?

 
Bribing kids to eat veggies by putting toys in their Nutritionally-approved Happy Meal.

According to the WSJ Health Blog (Aug 13), San Francisco (of course), is now proposing legislation that would impose
"a 600-calorie cap on the entire meal, with no one item containing more than 200 calories. There would be sodium and fat limits, too, and the meal would have to include fruits and veggies. Only a few types of Happy Meals would qualify, the paper says, and promotions from Burger King and Jack in the Box would also be affected."
This is kinda hilarious, actually.  The Food Police think that kids will be lured by the cartoon characters they know and love into wanting meals that have vegetables and fruit.  However,
"We couldn’t dig up any research on whether kids prefer the meals with free toys (parents probably have plenty of anecdotal data) or whether the kind of requirement included in the proposed legislation would increase purchases of more nutritious foods."
I'll make a prediction.  Kids know that fast foods taste good.  They're kids, but they're not stupid.  They'll get the good-for-you Happy Meal for the toy.  Then they won't eat the stuff that doesn't taste good, and pester their parents to stop at Taco Bell on the way home.

These SF legislators obviously underestimate kids' intelligence (maybe they never had any...I sure wouldn't have wanted to be their progeny).

This reminds me of the couple who raised their sons in an environment where the children wouldn't be exposed to proxy violence through the toys they played with.  The theory being that they would learn cooperation and socialization.  So, instead of buying them little plastic soldiers, they bought them cute little animals to play with.  They were disconcerted to find that the boys had painted the animals in two colors, divided them up into two groups by color and used the painted figures for war games.

The Food Police, the Violence Police, the Esteem Police.  No wonder kids are having trouble growing up when they go off to college.

Doc D
 
 

Thursday, August 12, 2010

Judging How Good A Doctor Is: Quality Measures, Best Doctor Lists, Or Trust?

 
If my report card as a doctor shows that only a third of my patients with high blood pressure are achieving a normal pressure, does that make me a bad doctor?

The assumption behind these report cards is that I am (a bad doctor).  A superb article in the New England Journal of Medicine talks about the danger of taking quality measures for the patient population as a whole and applying them to judgments about individual practitioners.

It's been common for public health officials to look at measurements of effectiveness at the national or state level.  It makes good sense to know that only 75% of children are getting the immunizations they should, and whether they are getting them on time.   It's almost as clear that when only a small percentage of diabetics are reaching a set of objectives that give them the best care--like nutritional counseling, foot care, hemoglobin A1C measurements, etc--then we need to look for better ways to care for them.

But when institutions take these same criteria for effectivenss and set standards for each of the doctors, it can be self-defeating, because most of the time it's the doctors are doing what they should.

I can tell my diabetic patients how important it is that I monitor their care with all the elements listed above, but that's as far as I can go.  If I still get a below-standard report card for my diabetic patients, what would you suggest?  As the author describes his practice,
"And although these quality measures focus on diabetes in pristine isolation, my patients inconveniently carry at least five other diagnoses and routinely have medication lists in the double digits. Practicing clinicians know from experience that micromanagement of one condition frequently leads to fallout in another."
The impact can become pernicious if plans to tie physician payment to meeting these goals is carried out:
"I appreciate the efforts and good intentions behind the report cards, and I'm certainly not saying that we shouldn't have any data at all. But I think we need good evidence that the data measure true quality and that providing data is actually helpful. For individual doctors — as opposed to institutions or countries or populations — the evidence is not convincing. The possible mandatory use of these quality measures for reimbursement raises a host of other concerns."
The progressive reformers all have a love affair with scientific methods of health care measurement.  Reading the grandiose plans of some of these folks gives you the impression that they think of people as objects or machines, without frailties or weaknesses...or if they have them, they should be disincentivized or forced to act against them.  But surely in their own lives they see themselves as human and acknowledge the power of "all too human" needs?
"I've always wanted to ask these analysts how they choose a physician for their sick child or ailing parent. Do they go online and look up doctors' glycated hemoglobin stats? Do they consult a magazine's Best Doctor listing? Or do they ask friends and family to recommend a doctor they trust? That trust relies on a host of variables — experience, judgment, thoughtfulness, ethics, intelligence, diligence, compassion, perspective — that are entirely lost in current quality measures. These difficult-to-measure traits generally turn out to be the critical components in patient care."
I'm a great believer in population-based analyses of health care quality.  But what works for a large group, rarely translates down to the individual, one-on-one interaction in medicine.

I want the latitude to decide--with my patient--what the best approach is, recognizing that people are not a collection of criteria and standards, but unique individuals.

Doc D
 
 

Wednesday, August 11, 2010

Medical Cartoonville - 11 Aug 10

 
 
 
 

Should Nurse Anesthetists Work Unsupervised By Doctors

 
The nurse anesthetists want to "get out from under" physician supervision, which is currently the requirement.

A study appeared in Health Affairs (Aug 3) that alleges that anesthesia provided by nurses results in the same quality and safety whether they are supervised or not.

While one camp (nurse anesthetists, officially called Certified Registered Nurse Anesthetists-CRNA's) wants to revoke the supervision requirement, the other (anesthiologists) wants to maintain tight control of anesthesia practice.

The study was poorly designed and claims more than it proves, but I'll get to that.

I suggest there may be a middle way.  There is a clear difference in depth of training and range of experience between the two groups.  In medicine, when that occurs, there is usually some method of oversight that ensures that the less experienced group doesn't exceed the scope of what they are trained to do.

But that doesn't mean that within that scope of practice there isn't room for increased independence.  As a matter of practice, many nurse anesthetists are only loosely supervised.  It depends upon the complexity of the case.  Nurses tend to do the simpler, shorter, and safer cases on healthier persons, where there is less likelihood of a complication, or at least a complication that involves many organ systems, balancing benefit and risk to optimize the response.

There are even some cases which are so complicated that more than one anesthesiologists is needed.  There are many procedures on the other hand, where the skillset is less demanding, and it should be possible to define those operations and criteria for which independent care is safe and high-quality.

So, rather than throw stones at each other, how about sitting down and defining those criteria?  I know it's a difficult thing to accomplish in our "post-partisan," virulently polarized society.  But, the bottom line is we need to maximize everyone's potential to care for 30 million more insured and do it in a way that puts the patients' needs and safety first.

As far as the Health Affairs study, here's for the Onion Peelers:
They analyzed 481,440 hospitalizations covered by Medicare. They found that the frequency of nurse anesthetists’ providing anesthesia without anesthesiologist supervision grew from 1999 to 2005. As of 2005, 21 percent of surgeries in opt-out states and 10 percent in non-opt-out states used nurse anesthetists without anesthesiologists, as opposed to 17.6 percent and 7.0 percent in 1999.  The researchers also found that although nurse anesthetists are trained to handle very complex cases, anesthesiologists, on average, work on more of these cases, which involve greater risk of death. The authors hypothesize that anesthesiologists, who can choose their cases more often than can certified registered nurse anesthetists, prefer more complex, better-paying, cases. Anesthesiologists also are more prevalent in teaching hospitals that perform more complex surgery.

The thing about doctors prefering the "better paying" cases, is the typical slam that advocacy groups try to use to vilify others.  So we can disregard that, we're interested in data.

Although the study looks at almost 500K hospitalizations, they don't emphasize enough that the rate of mortality from anesthesia is very low (about 1:200K in some studies) so they still don't have much statistical power  to claim a difference.  A less important limitation on the research is they used insurance claims rather than clinical outcomes as their data source.

Also, I doubt that CRNA's are trained for complex cases.  Note the authors contradicted themselves; the docs do the more complex cases, so how is it that the nurses are trained in them?  In fact they aren't, except from the textbook perspective.  In practice, they have little experience of complexity.  Ask yourself if you want your appendix taken out by a surgeon who went through specialty training, but never did one.

I've seen CRNA's holler for help many times.

There is also value in having a general medical degree that involves the whole body and its integrated systems.  Nursing schools don't train to that level or depth.

Finally one of the authors said “Nurse anesthetists get essentially the same training in anesthesia as anesthesiologists. So in this case, a nurse is just about a perfect substitute for the doctor.”

As John Turturro said in O Brother, Where Art Thou?, "That don't make no sense."

Doc D

PS:  I have more training in management, governing, and leadership than the President.  Maybe I'm a perfect substitute.
 
 

Tuesday, August 10, 2010

A Test That Can Predict The Development Of Alzheimer's Disease

 
A spinal fluid test that's very accurate in identifying memory-loss patients early on.

There have been some recent significant advances in our understanding of Alzheimer's disease (AD).  One of these appeared in the Archives of Neurology (Aug 2010).  It's one of a series of sudies that identify "biomarkers" for a disease.

A biomarker is a compound, usually a protein, that is present only when the person has the disease, or is developing the disease.  Knowing how to measure such a biomarker will give physicians a head-start on diagnosing a problem before it become severe or ireemediable.

In Alzheimers there's more than one suspected marker.  These researchers looked at identifying a mix of markers, in this instance called "β-amyloid protein 1-42 + phosphorylated tau181P."  We see amyloid and tau in the brains of people with AD.  Now it can be measured in the cerebospinal fluid, as a signature for the development of AD.

The sensitivity of the test seems pretty striking, but there is a caution.  See if you can pick what that caution is from looking at the data:

For Onion Peelers,
The AD signature was found in 90%, 72%, and 36% of patients in the AD, mild cognitive impairment, and cognitively normal groups, respectively. The cognitively normal group with the AD signature was enriched in apolipoprotein E 4 allele carriers. In 1 study consisting of 68 autopsy-confirmed AD cases, 64 of 68 patients (94% sensitivity) were correctly classified with the AD feature. In another data set with patients (n = 57) with mild cognitive impairment followed up for 5 years, the model showed a sensitivity of 100% in patients progressing to AD.

These are pretty high percentages for a screening test.

But, notice that the signature was positive in 36% of cognitively normal people.  The authors think that means that the biomarker is present even before symptoms begin.  But that's true only if these normal persons all go on to AD.  And it's not clear that they followed the cognitively normal group to see if they developed Alzheimers.  We'll have to wait for further clarification.

If not, then over a third of normal people will have an abnormal test result that may be spurious. 

Even so, this looks like a real step forward in diagnosing a disease that affects so many, but can't be diagnosed until the disease is fully developed.

Doc D
 
 

Monday, August 9, 2010

Health Care Costs And The Psychology Of Numbers

 
Billions, trillions.  Big numbers, but are they so big that we can't really grasp what they mean?

A lot of the debate and discussion on the effectiveness of the health care reform law has centered around what it does to the rising cost of healthcare.  I've written a number of times that the new law does nothing to reign in cost.  According to some analysts it actually increases the cost above what would have happend had we not passed the law.

What was originally billed as costing less than one trillion dollars, and reducing the deficit by over $100 billion over the next ten years, is now discredited.  As analysts dug into the fuzzy math,  estimates have risen to $2.4 trillion.

Psychologists say our eyes glaze over about big numbers.  At some magnitude any increase further isn't perceived as more.  When I was in Army airborne training as a parachutist, we were told that psychologists have measured a person's ability to assess height in terms of fear.  They found that anything above ~30 feet had the same psychological impact on us.  Jumping out into the open air from higher points added nothing to the fear.

That's why they built their training towers as they did.  This is where you jump from a platform attached to a cable that slants toward the ground.  The jumper is attached to the cable by parachute risers.  Once the short fall is arrested by the risers, the jumper then slides down the cable and strikes the ground in a simulation of how one would land under a parachute.

The towers are a little over 30 feet tall.  Just as the pyschologists suggested, this allows the parachutist to deal with the fear of heights, indistinguishably from jumping out at 5,000 feet.

So, back to health care costs.  What do millions of dollars, hundreds of billions of dollars, and trillions of dollars, mean?

Here's one way to think about it...in terms of time.  We know that 60 seconds make a minute, 60 minutes make an hour, 24 hours make a day, etc.

One million seconds is about 12 days.

One trillion seconds is about 31,000 years.

Mind-boggling...and why we should be concerned about costs.

Doc D
 
 

Sunday, August 8, 2010

A Survey Of Recent Medical Literature - 8 Aug

 
Trying something new:  Interesting articles from today.

1.  I've written before that if we just recouped half of what's lost to Medicare fraud we could have funded all the uninsured.  Here's more on why we actually recover only about 1%

Medicare's private eyes let fraud cases get cold

2.  Foreign-trained doctors are as good as US-trained.  Very true, because they pass the same licensing tests.  More interesting is that US doctors who trained abroad, particularly at low-quality schools in the Caribbean, are not as good.  (One caution:  depends on how you measure good)  We don't have enough US training to meet US needs.  Those who allege that it's a plot by the AMA, or government, or whatever, don't realize that the bottleneck is not the schools, it's the training programs.  There are only so many university-size institutions that can expose physicians in specialty training to all they need to know.  And Congress sets a limit on how many they will fund per year, based on how many institutions can show they have the size and capability.

Study: Foreign-trained doctors as good as those trained in USA

3.  Masschusetts, the forerunner of universal health care (sometimes called "ObamaCare Lite"), lost another round in tyring to cap their skyrocketing state health care costs.  The governor tried to deny premium hikes, but the state's own insurance says that increases are necessary due to accelertating costs.  The issue is now a major political football, and we can expect future information to be tainted by election-year posturing from both sides.

State loses on appeal in effort to cap Fallon health insurance rates

4.  Dietary cleanses are part of the New Age nonsense that people get swept up by.  But the First Lady apparently has her own approach, which is unbalanced and not healthy.  As they all are, some are just worse than others.

First lady down on beets, up on dietary 'cleanses'


Click the links for further details.

Doc D
 
 

Friday, August 6, 2010

HCR Cuts To Medicare Impacts Some Seniors More Than Others

 
If I was still doing the Poison Pill count, I don't know what number this would be.  30?

The health care reform law cuts about $500B from Medicare.  You know all the funny math stuff; it was touted as a "savings," but actually gets spent on new programs created by the law.  I wish my budget worked that way.

A good part of those cuts comes from reduction in the Medicare Advantage program,  About 11 million seniors have signed up.  Critics said the cuts would force insurers to decrease benefits or close down, which supporters denied.  Now Medicare is saying that the 11 million covered will probably drop to around 7 million.

But that's not the Poison Pill.  The bad medicine taste comes from the fact that seniors will be impacted differently, depending on where they live.
--Although Congress set the highest funding rate for those counties where the government spends the least on traditional Medicare in which doctors and hospitals charge specific fees for individual services, the trims in the new payment system could still cause plans in those areas to reduce benefits or shut down.


--At the same time, plans in higher-cost markets where the government spends the most on traditional Medicare, which will get the lowest rate of federal funding, might continue to operate as they do today.
It's a quirk in the way Medicare is funded.  (Kaiser Health News, Aug 6)

For a full explanation go here, but be ready for some complex reasoning and financial scoring of costs. 

It's arguable, but I follow the logic.  Bottom line, if you live in a low cost area, you are going to be gouged more by the cuts.
 
And this creates a disparate effect on different parts of the country.  Another Poison Pill.
 
Doc D
 
 

The Senate Decides To Regulate Your Kid's Food At School (Some More)

 
The idea is to offer healthy food in the cafeterias and vending machines at school.  A good way to go out of business.

According to the Miami Herald (Aug 5),
Pizzas and hamburgers in the school lunch line would be healthier under child nutrition legislation passed by the Senate Thursday, a key part of first lady Michelle Obama's campaign to end childhood obesity. 

The $4.5 billion legislation passed by voice vote would create new standards for all foods in schools, including vending machine items, to give students healthier meal options. It would also expand the number of low-income children eligible for free or reduced cost meals.
You probably read the scandal about teachers eating the subsidized free meals intended for the low-income students.  The whistle blower was fired, of course.

But any program can be corrupted.   That's not my concern here.   Apparently, they are planning to do things with the menu, like use whole wheat for the pizza crust and only low-fat mozzarella cheese. 

My kids are grown up.  When they were in high school, the school district tried something similar.  It didn't taste good, so all four kids skipped lunch and went by Taco Bell on the way home.

As I've written before, menu restrictions don't affect the motivation to eat poorly.  People just look elsewhere.

And I'm not aware of definitive data that shows menu restriction leads to less obesity.

Doc D
 
 

Thursday, August 5, 2010

Medical Cartoonville - 5 Aug 10

 
 

 
 

Did This Research Really Need To Be Done? Ovulating Women Buy Sexy Clothes

 
I hope this wasn't funded by taxpayers. 

According to a study in the Journal of Consumer Research (whatever that is), and reported the BBC News health blog (Aug 5),
Women at different stages of their menstrual cycle were shown images of attractive women living locally or far away.  People are only semi-conscious of the underlying reasons behind the choices they make in the context of buying sexy clothes.  They were then asked to choose clothes and accessories which they would like to buy.
Women who were ovulating and who had seen photos of attractive local women were most likely to buy "sexier" clothes compared with those shown photographs of unattractive local women or women who lived more than 1,000 miles (1,600km) away.
They went on to hypothesize that women at the point of greatest fertility are acting out a subconscious biological imperative to attract mates, blah, blah, blah...

I'm sure this will be important to clothes makers.  Maybe they could offer an Ovulation Day Sale;  "Bring in your temperature spike readings and get 10% off on tight designer jeans!"
If the point is that we've developed psychological mechanisms that promote attractiveness, well...duh.  Take a look at the next peacock you see.  It's, like, all through the animal kingdom, dude.

Doc D
 
 

Wednesday, August 4, 2010

Missouri Voters Say No (Decisively) To Health Care Mandate

 
Most of you have heard about the MO vote I won't belabor the point.  The media are spinning it several different ways.

However, I thought you might like to see this.  Congressman Kevin Brady, TX-8, put his staff to work to research all the elements in the 2700 page health care reform law and draw a diagram of all the parts.

This is way cool, because each element they define has a reference to the paragraph in the law that you can look up if you doubt the existence, or the task, the new agency, task force, committee, panel, or advisory group has the authority to perform.  I am impressed by how powerful this makes the Secretary of Health and Human Services.

I put a smaller version of it here, but if you want to see the poster-size blow-up, go here.  You can zoom in on specific parts of the overall chart.

It's really kinda mind-boggling.




Doc D
 

Medication Shortages On The Rise?

 
Shortages exist in three areas:  anesthetics, pain medicines, and emergency drugs...but only selected ones.

The Wall Street Journal Health Blog (Aug 4) has a post about an increase in drug shortages.
"Shortages occur for a host of reasons, including the unavailability of raw ingredients, FDA enforcement actions that halt production, voluntary recalls, poor inventory ordering, a change in product formulation and even rumors of an impending shortage, which can cause hoarding, the ISMP says. And the group [The Institute for Safe Medication Practices] says “there’s no relief in sight.”
Well, this is hyperventilating a bit.

But there are some concerns.  Epinephrine injectable, used in the ER for a number of emergencies, is one of them.  But if we're short of IV ibuprofen (Motrin)--and we are--then that's not as big a crisis.

My experience is that regulatory changes are the primary reason for drug shortages; this would include FDA actions and the necessity for re-approval if you change any component of a drug.  Second would be recalls.  Last would be hospitals and clinics not anticipating need; they usually are pretty good at tracking usage rates and scheduling re-orders.

You can go to the FDA website and check for what's in short supply at any given time. 

There are always some shortages.  I'm not sure we've seen a dramatic increase that could endanger health yet, but it's worth watching.

Doc D
 
 

A Life Constructed Through Psychotherapy. This Is Healing?

 
A life-long therapy patient asks whether treatment goals are being met, or has she just constructed a life in therapy.

The NY Times Magazine has an article written by a person who underwent various forms of psychotherapy over four decades (wow!).  At the end of it all, she questions the benefit:
"To this day, I’m not sure that I am in possession of substantially greater self-knowledge than someone who has never been inside a therapist’s office. What I do know, aside from the fact that the unconscious plays strange tricks and that the past stalks the present in ways we can’t begin to imagine, is a certain language, a certain style of thinking that, in its capacity for reframing your life story, becomes — how should I put this? — addictive. Projection. Repression. Acting out. Defenses. Secondary compensation. Transference. Even in these quick-fix, medicated times, when people are more likely to look to Wellbutrin and life coaches than to the mystique-surrounded, intangible promise of psychoanalysis, these words speak to me with all the charged power of poetry, scattering light into opaque depths, interpreting that which lies beneath awareness. Whether they do so rightly or wrongly is almost beside the point."
I've written about our tendency to medicalize everything: making a disease out of being shy (social phobia disorder), conferring the diagnosis of PTSD on someone who saw an auto accident.

This person's experience seems the psychological version of that.  To my mind, psychotherapy or analysis should be undertaken with a defined goal, and a projected duration.  It should be just like attempting treatment for high blood pressure; if you prescribe a medicine and measure the impact in reducing blood pressure to normal levels over a 3 month period, and there has been no improvement...then you move on to something else.  Too often psychotherapy has no endgame, no termination criteria short of decease.

I'm reminded of how we used to treat soldiers who became unable to cope due to the stress of combat.  Up to and into the Vietnam war, these were often permanent casualties who left the war, and were often crippled by guilt and recrimination for years afterward.  Also, the more of them there were, the greater impact on combat effectiveness.

It was realized that these were not "abnormal" people, but individuals who had been placed in situations for which they were unprepared.  Military psychiatrists focused on developing strategies that would restore their confidence and allow a normal impulse to heal.  In the end, these soldiers were taken out of the line and given intensive treatment for just a few days.  Key to the success was instill in them the fact that their reaction was not unexpected, and, most important of all, emphasizing to them from the beginning that they would be returning to the fight soon and that their buddies relied of them and needed them.

There were treatment failures, but it was surprising how many could heal and return to duty...and not come back.  Most were able to experience that same stress again and adapt.

Combat is an extreme example.  But, still, maybe there's a lesson for us here:  that humans can adapt and recover if the therapy is structured in such a way that they can soon succeed on their own.

Admittedly, for some disorders--schizophrenia, and the like--a life in therapy (including drugs) may be necessary and preferable to how patients with these disorders were handled in the past:  packed away in state mental hospitals for life.  But the number of patients with serious psychoses is very small compared to the total with chronic depression and anxiety, for which a defined goal  and duration could be set, supporting healing strategies rather than just deeper insight and buzzword correlations.

We have a saying among us non-psychological docs:  wounds will heal, if you don't pick at the scab.

Doc D
 
 

Tuesday, August 3, 2010

Rating Systems For Doctors...I'm For It, With Reservations

 
Patient Groups and Insurers are posting ratings of doctors.  But assessing quality of care is complex.

I agree with the Washington Post health blog (Aug 3) that insurer rating systems need to be viewed from the perspective of the insurer:
The systems provided by some health plans to rate doctors are typically based on two factors: cost and quality. Data that measure the quality of care -- whether a diabetic gets regular blood-sugar tests or foot exams, for example -- are not as easy to translate to the level of individual doctors but cost is, so cost tends to be the bigger factor.  "Often insurers will do a two-step process," says Ha Tu, a senior health researcher at the Center for Studying Health System Change, a nonpartisan research and policy organization based in Washington. First, they "make sure doctors meet a quality threshold, but not a very high one. Then they'll weed them out further based on cost."
Patient groups similarly may focus on the aspects of healthcare they identify as important to them.  The American Diabetes Association, for instance, would adopt a rating system that defines quality very differently than would the Autism Society of America.

A first step, then, for all these raters would be to ascertain their focus.  What are they most concerned about in health care? 

From there go on to what things they rate, and how they rate them.  Clearly a rating system that looks at the chairs in the waiting room is not superior to one that looks at surgical complication rates.

I am a great believer in patient-directed care (not "patient-centered" see my post here).  I'm certain that with total information transparency about value and cost anyone can make the best health care decision for themselves (and by themselves).

Doc D
 
 

Media: Adult Stem Cell Research Far Ahead Of Embryonic

 
Well, duh...embryonic stem cell research was restricted for 10 years.

Many authors, myself included, have made the case that we were doing just fine without much embryonic stem cell research.  I've modified my position--just a bit--based on a recent study that said adult stem cells retain the ability to revert to their adult tissue type (skin, liver,etc).  See my post here.  But I commented at the time that this may be a minor inconvenience rather than a big stumbling block to using adult stem cells.

For those of you who haven't been paying attention much to stem cell ethics, there has been a real reluctance by some to sanction the use of human embryonic tissue for research.  There are ethical arguments on both sides of the issue, and I won't adjudicate them.  My position was that if adult stem cells are doing a great job, why bother with the moral and political polarization that accompanies embryonic cell use?

So,  I'm not surprised that looking back, when researchers were forced to develop techniques to harvest and produce adult stem cells, they did so with a vengence.  There have been several news articles in the last few days documenting that adult stem cell treatment modalities have exploded.

And after 10 years, they certainly should be in a dominant position as far as stem cell therapies are concerned.

But, give the newly unleashed (to some extent) scientists who would prefer embryonic cells a few years and let's see what happens.

However, there have been a rash of stem cell con artists that prey on the vulnerable who have incurable problems.  Always consult your physician.

If it sounds too good to be true, it usually is.

Doc D
 
 

Botox For Chronic Migraine? FDA Hints...Maybe

 
The manufacturer is completing Phase III trials.  The FDA will hold a hearing in about 3 months.  It's already been approved in the UK.

For chronic migraine sufferers any day without a headache is a good day.  Why?  Because qualifying for the diagnosis of "chronic" migraine requires 15 or more headache days a month.

So it's important to realize that we're talking about a subset of the worst migraine sufferers only.  If approved, Botox will only be for that group, because that's the group that was studied.

At this point, I'm at a loss to give a biologically plausible mechanism that could account for how this works.  I'm sure folks have a theoretical mechanism, but it strikes me that Botox operates locally and migraines are commonly due to a diffuse vascular spasm.

Maybe looking at some of the Phase trial data would help.  For the original studies try here, here, and here.

For Onion Peelers,
A total of 1384 adults were randomized to onabotulinumtoxinA (n = 688) or placebo (n = 696). Pooled analyses demonstrated a large mean decrease from baseline in frequency of headache days, with statistically significant between-group differences favoring onabotulinumtoxinA over placebo at week 24 (-8.4 vs -6.6; P < .001) and at all other time points. Significant differences favoring onabotulinumtoxinA were also observed for all secondary efficacy variables at all time points, with the exception of frequency of acute headache pain medication intakes.

Note that there was a strong placebo effect.  Even with placebo there was a decrease of 6.6 headache days per month, compared to the treatment group which had a decrease of 8.4 days.  I'll bet that even if the results weren't statistically significant, for 6 less days of headache alone, they would greatly desire any form of subcutaneous injection, placebo or otherwise.

One other caution:  I can't tell if the placebo control group could ascertain whether they were getting the placebo or not.  For example, whether Botox causes a stinging sensation when injected versus a sterile saline injection.  That would bias the results.  As I say, I just don't know.

But it is worth noting that the difference between placebo and Botox was 1.8 days of headache.  Not earth-shattering.

Unless you have chronic migraine.

Doc D
 
 

Monday, August 2, 2010

STUDY: Using Herpes To Treat Cancer

 
Interesting twist on cancer therapy:  use modified herpes virus to attack tumor cells.

I saw this note in the BBC News health blog (Aug 1) about some researchers who treat head and neck cancer.  So, I went to the original research  in the August issue of Clinical Cancer Research to see what the science was all about.

First, this is a work in progress.  More work needs to be done, but the idea is one that's rarely been tried:  take a infectious disease agent--one that normally causes a wide-spread infection in humans--modify the genetic code of the organism (in this case, a virus) so that it can no longer infect normal human cells, but can infect tumor cells.  Viruses infect cells by penetrating the cell membrane; the process requires that the virus have an intact mechanism to attach itself and open a gap into the cell to insert its genetic code.

If you damage or modify the virus's genes in such a way that the mechanism for infecting cells doesn't work any more, no infection can occur.  Why?  Because viruses can only reproduce from the interior of the cell they infect; viruses don't have all the resources to synthesize the components to reproduce themselves.  They have to steal from the cell they infect.  As they reproduce in the cell, they kill the cell.

So, unable to penetrate -> unable to multiply -> no infection.

In this study, they changed the herpes virus's ability to enter a cell so that it retained the ability to enter tumor cells only.  A neat trick.

This way the herpes virus kills the tumor cells they infect.  If you add standard chemotherapy to the treatment, theoretically it would improve the results...and maybe obtain more cures.

Caveat:  head and neck cancer are not common types.  So we're not going to see very large scale research.  In this study, it was only 17 patients.  But the results were encouraging:  82% survived more than 2yrs on average.  Normally, this type of cancer will be fatal for about 35%, because it is often detected late.

For Onion Peelers,
Fourteen patients (82.3%) showed tumor response ..., and pathologic complete remission was confirmed in 93% of patients at neck dissection. Herpes virus was detected in injected and adjacent uninjected tumors at levels higher than the input dose, indicating viral replication....disease-specific survival was 82.4% at a median follow-up of 29 months (range, 19-40 months).

I like the idea of turning the tables on a virus that has been such a scourge to humanity, enlisting it's abilities in treating cancer.

Doc D
 
 

Sunday, August 1, 2010

STUDY: In CPR You Only Need To Do The Chest Compressions

 
No rescue breathing?  Just chest compressions for CPR?

My issue of the New England Journal of Medicine this week contains a research study that is causing a stir. 

What's called "bystander CPR" can be effective in saving lives, but the prospect of performing it generates reluctance in some people.  From the start, some don't want to get involved, but those who do face the prospect of putting their mouth over the victim's and breathing into it.

Faced with the necessity to perform rescue breathing, we immediately remember our Mom's adage, "Don't touch that, you don't know where it's been."

Under these circumstances, some victims who might have survived don't because bystanders are not willing to perform the procedure.

A group from Washington State and London decided to make sure that the breathing part was really necessary.  That is, did doing the rescue breathing along with the chest compressions (1) improve survival (as measured by leaving the hospital alive), and (2) reduce neurologic damage (that is, brain damage from the period when it was getting no oxygen)?  The patients were randomized to one technique or the other by the instructions of the dispatcher (the person you talk to when you call 911).

They found no significant difference for either result between doing compression + breathing and compression along.  That's a shocker, but we shouldn't get excited yet; we need to look at the experimental design, and the statistics.

For Onion Peelers,
Using 1941 patients randomized to two groups.  They observed no significant difference between the two groups in the proportion of patients who survived to hospital discharge (12.5% with chest compression alone and 11.0% with chest compression plus rescue breathing, P=0.31) or in the proportion who survived with a favorable neurologic outcome ...(14.4% and 11.5%, respectively; P=0.13). Prespecified subgroup analyses showed a trend toward a higher proportion of patients surviving to hospital discharge with chest compression alone as compared with chest compression plus rescue breathing for patients with a cardiac cause of arrest (15.5% vs. 12.3%, P=0.09) and for those with shockable rhythms (31.9% vs. 25.7%, P=0.09).

The primary goal of the study seems straightforward.  P-values failed to reach a significant level (<0.05).  What's interesting is when they split the patients up into two sub-groups--one with those patients who arrested because of a primary heart problem and those who had heart rhythm that could be shocked to normal--the data came very close to significantly better results with compression alone (last sentence above where the P=0.09).

Should these results be verified by repeat studies, and further work done to make sure there isn't some unknown confounding variable, it would rrrreeaalllly help in bystander CPR.  No need to touch your mouth to somebody else's.

In summary, interesting and straightforward study results.  Let's wait for more.

Doc D
 
 

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