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.

Monday, January 31, 2011

Breast Reduction Surgery For Men On The Rise

Largely ascribed to the collision between obesity and body scuplting, but there are other causes.

According to the BBC News (Jan 30), male breast reduction surgery rose by 28% last year in the UK.

There's a lot of discussion in the article about obesity as a cause.  Many of the men who request the surgery are advised to do diet and exercise instead.  But the pressure to give the appearance of a "male" chest, is clearly behind most of the requests.

And, while overweight and obesity are a large part of the problem, there are a couple of things you may not know about.

Some of the substances to which we expose our bodies contain compounds that have "estrogenic" activity.  That is, they act like estrogen, the hormone that is critical in women's reproductive and sex characteristic expression.

Men's bodies can be sensitive to those estrogen-like effects. 

Here are a couple of things that can contribute to Man Breasts:

1.  Saw Palmetto, the herbal product taken by some for "prostate health" (whatever that means) guessed it,

2.  Marijuana

There are probably a lot more herbals that have estrogen-like activity, and then there's the estrogen that's present in the environment --rom human use.  We don't have a clue yet just how pervasive this all is, or how influential, when it is absorbed internally.

Which is not an endorsement of free-range chickens and such.  I've raised chickens; their eggs are natural ,but they taste the same to me, and you have to wash off the fecal smears just like the commercial farms do.

Doc D

Sunday, January 30, 2011

Who's An MD And Who's Not...And Does It Matter.

A survey by the AMA shows that people are pretty confused.

The American Medical Assocation released a survey this week;  the survey asked people whether certain professionals were MD's or not.  It's amusing, really, but not that helpful.  The AMA was trying to use the survey to show that people really prefer MD's, but I don't think it's very persuasive about that.  Yes, some people do, but others have great trust and benefit from other healthcare providers.  I will concur, however, that some of the non-MD's have years of training that qualifies them, and some do not.  That should be the distinguishing feature:   skills and knowledge.

But, back to the funny part.  Here's my mini-version of the test.  Make your choices and don't cheat...answers below.  Which of these is an MD?
1. Podiatrist
2. Orthopedist
3. Chiropractor
4. Gynecologist

5. Anesthetist
6. Psychiatrist
7. Audiologist
8. Dermatologist
9. Nurse Practitioner
10. Otolaryngologist
11. Midwife
12. Ophthalmologist
13. Dentist

Answers:  All the even numbered are MD's.  The others aren't.  Some are pretty obvious to most of you, I'm sure.  But here's some amusing percentages:

Despite the title "nurse practitioner,"  1 out of 4 thought they were MD's.

70% thought that dentists were MD's.

88% were sure that orthopedists were MD's, but that's down from 94% two years ago.  Huh?

The AMA didn't ask about anesthetists, I just threw that in.  CRNA's (certified registered nurse anesthetists) are nurses with special training in anesthesia, and very capable at what they do (see my post here on whether they should always be supervised by an MD).  Anesthesiologists are MD's.

Don't get me wrong.  I'm not being derogatory of the critical role in health care all of these experts play--except chiropractry, which is quackery IMO.  However, they do not spend from 8-12 years training for the job.  Midwives just deliver babies, audiologists manage hearing, podiatrists deal with feet, etc....but they don't have to go 4 years to medical school first.

The other parts of the AMA survey are interesting, but phrased in ways to get the answer they want ("Do you think somebody that amputates a foot should be an MD?").  They could have asked more neutral questions IMO.

One last survey result:  People were evenly split on whether they could easily tell who was an MD and who was not from "services offered," "credentials displayed," and "marketing materials."  51% said "No."

The charts are entertaining.  See how you match up.  You can find the results here.

Doc D

Saturday, January 29, 2011

Medical Quote Of The Day - 29 Jan 11

This is a long quote.  And it's not a funny one.

I've struggled with a vision of health care reform throughout the three years I've been writing here.  I know the Big Four issues:  Coverage, Access, Cost, Quality.  I know they are inextricably linked such that attention to less than all at once will fail.  I don't want a slogan...maybe later.  I've used the phrase "Patient-Directed Care" to express my frustration with the "patient-centered" approach that's being touted by policy wonks.  I'll keep working on the vision.

But the following, by a practicing physician, published in the New England Journal of Medicine (Sep 10, 2009) captures the perspective that I see for doctors and the patients they serve.
It is a tired and cynical cadre of physicians who will implement health care reforms. Yet few published perspectives include the view from the factory floor. The usual platitudes about changing financial incentives, increasing efficiency, and delivering high-quality care sound naïve to clinicians who deal with the imperfections of human nature and the messy effects of illness on patients. Doctors are already, by training, sophisticated decision-making machines, capable of achieving extreme efficiency through the use of heuristics and experience.

The main problems that clinicians face in achieving efficiency and reducing costs are, first, a perceived need for certainty in diagnosis and treatment — a need driven by secular expectations and malpractice concerns; second, gross inefficiency created by obligatory documentation to satisfy billing requirements that have little value for clinical care; and third, restrictions on the use of clinical judgment that could avoid excessive testing. None of these problems, whose solutions would save money and time, have been incorporated into the national discussion about reform.

One change that would augment the role of clinical judgment would be for the health care system to resist the temptation to require adoption of often-elusive “best practices.” There has been an assumption by analysts that published clinical trials provide a sound guide for therapy, but all reputable studies report odds, hazard ratios, and effect sizes, almost all of which are small or modest. Absolutes are discordant with the realities of sickness and health. There may be guidelines and measurable outcomes for mundane problems, but for the vast majority of daily doctor's visits and hospital decisions, incremental or recursive approaches to diagnosis and treatment are more effective and efficient.
--Allan H. Ropper, MD

This is very Kantian.  Persons are ends in themselves...and unique.  Large-scale social planning in an area like health care  places other priorities in conflict with the interests of persons.
Doc D

Tone Down The Rhetoric On Reports Of Cancer In Breast Implants

The FDA is looking at a handful of reports of lymphoma around breast implants.  But it's in the scar tissue from surgery, and unrelated to silicone.

The reporting on this (Boston Herald, Jan 26) is surprisingly balanced...for the media.  Except for the linked article title:  "FDA sees possible cancer risk with breast implants."   We're talking 60 reports out of 10 million implants. 

The FDA doesn't "see" anything yet.  The reports of this are so rare that it reaches the limits of what can be studied with any assurance of a definitive answer.   Looking at how common implants are, and how few of these cases, and how mnay years it takes for problems to occur, I guess that it will take almost a million women to be followed for over 10 years...and even then there may not be a clear-cut result.

Before you think breast implants may be a risk, consider the following:
1.  Lymphomas can occur in scars of any type, like a cut on your arm...rarely.  It may be that--if it exists--the risk is the same as with any scar tissue, and has nothing to do with implants.
2.  The few cases don't show any predilection for one type of implant over another (silicone versus saline).  This is minor support for item #1 above.
3.  Even if some researchers were able to corral this many women with implants for long enough, the risk may turn out to be in the "one in a million range."  This is right at the limit of the abilities of the scientific method to discern differences under controlled circumstances.  In scientific slang this is called the "One In a Million" rule.

So, bottom line, in 20 years we may know that's not a problem, or at worst, a miniscule problem.

Our dietary habits are a thousand times more risky.

Doc D

Thursday, January 27, 2011

Study Undermines Assumption That Payment Reform Can Improve Quality

Another assumption of health care reform rebutted:  that quality of care will improve if doctors get paid for what they accomplish, rather than what they do.

This is the so called "outcomes-based" or "pay for performance" proposal.  The quality solution to the nefarious "fee for service" system we currently have.

Pay for Performance (PfP) carries the kind of simplistic logic that avoids getting into the details of the complex interactions in health care delivery.  The premise is that (1) doctors get paid to do stuff, (2) doctors want to get paid more, (3) doctors will do more stuff to get paid more.   This will result in unnecessary and potentially harmful tests, surgeries, and treatments.  So quality will suffer.

Despite refuting false claims about health care quality being poor in the US (see my posts here and here), the media and activists have been largely successful in portraying the US health care system as giving poorer results than abroad.  In fact, longevity and infant mortality, two of the most common comparisons, are better.

But given that most people now assume the critics are right, it makes things easier for them to propose changes that have the appearance of  being "a good idea," when they may not be.

Enter Pay for Performance (PfP):  to reverse the incentives to perform too much, and potentially harmful, care; to change the payment system--pay only for results, or "outcomes."

Take the example of high blood pressure (hypertension).  Pay for Performance would reward physicians if they met certain standards for whether a patient's blood pressure is checked regularly and is controlled, whether they follow standard protocols for what drugs are used to control the pressure, and whether they reduce the number of complications in the patients they are taking care of (strokes, heart attacks, etc). 

As I say, it all sounds very straightforward.  The incentives are shifted from income to outcome:  keeps doctors focused where they should be, eliminating care that's not needed.

There've been a few limited experiments that show quality improvement under such a scheme, but they've all been criticized on the basis of the Hawthorne effect, small study size, and other issues.

Now, there's a large scale research project out of the UK, looking at hypertension, where Pay for Performance resulted in no improvement in quality.  The authors conclude,
"Governments and private insurers throughout the world are likely wasting many billions on policies that assume that all you have to do is pay doctors to improve quality of medical care," says senior author Stephen Soumerai, professor in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute. "Based on our study of almost 500,000 patients over seven years, that assumption is questionable at best." (Science Daily, Jan 25)
Note the scale and duration of the study (available here, BMJ Jan 25).  They looked at over half a million patients from 2000 to 2007 not only to have a large denominator, but also to ensure a comparison to the non-PfP results prior to implementing the scheme in 2004.  The date range included data for three years prior to implementing PfP, and three years after, for comparison.  There was no change in blood pressure control or in complications from the disease.

For Onion Peelers,
After accounting for secular trends, no changes in blood pressure monitoring (level change 0.85, 95% confidence interval −3.04 to 4.74, P=0.669 and trend change −0.01, −0.24 to 0.21, P=0.615), control (−1.19, −2.06 to 1.09, P=0.109 and −0.01, −0.06 to 0.03, P=0.569), or treatment intensity (0.67, −1.27 to 2.81, P=0.412 and 0.02, −0.23 to 0.19, P=0.706) were attributable to pay for performance. Pay for performance had no effect on the cumulative incidence of stroke, myocardial infarction, renal failure, heart failure, or all cause mortality in both treatment experienced and newly treated subgroups.

The separate question, whether it saved money, is not addressed.  But even so, PfP is being sold as a correction to poor quality...which didn't occur.

As another author put it, in the same Science Daily piece,
"Doctor performance is based on many factors besides money that were not addressed in this program: patient behavior, continuing MD training, shared responsibility and teamwork with pharmacists, nurses and other health professionals. These are factors that reach far beyond simple monetary incentives."
Quality improvement is a critical effort.  Lobbyists, politicians, and advocates for PfP are diligently implementing expensive programs as we speak.

Wouldn't it be better to validate the concept first?  Maybe look at some of the other contributions to quality that interact with payment?

Doc D

UPDATE:  Omitted a duplicated paragraph.

Tuesday, January 25, 2011

BOOK: "Overdiagnosed" Generalizes Too Much--And Another Personal Story

A new book called "Overdiagnosed" got me to thinking about treating health issues when the patient feels well.

The authors make a point about looking for diagnoses when there are no symptoms, and someone feels healthy.  Most doctors would agree that if you do enough lab tests, you'll find an abnormal value that's a red herring.

But this is different.  The authors, of "Overdiagnosed," H. Gilbert Welch, Lisa Schwartz, and Steven Woloshin, make their point in this way:
"Overdiagnosis occurs when physicians make a diagnosis in an individual who would never go on to develop symptoms or die from the condition. It happens when we try to make diagnoses too early, in people who don’t have symptoms. I’m not saying we should never do that, but members of the general public have gotten the message that early diagnosis is always in your best interest, that it’s always good to look harder and find more. But the reality now is that we can find abnormalities in just about everyone and that can start a whole train of harmful events. So we all need to adopt a more balanced approach."  (WSJ Health Blog, Jan 20)
1.  Often people have no symptoms when a serious illness is in its early stages.  Breast cancer, borderline heart failure, diabetes, and the like.  There are standards for when people are most prone to develop certain serious problems, and screening tests are used to discover them.  There aint no such thing as "too early" a diagnosis here.

2.  There's some research that says better control of some borderline conditions improves the long-term prognosis.  Welch and his co-authors give the example of borderline high blood pressure (hypertension) as an overdiagnosis.  However, we have some data to show that if you control borderline hypertension, or get even better control of some one who already is under treatment for hypertension, you reduce the risk of heart attack and stroke further.

Here's a personal story  (my other personal stories are here and here).  I have hypertension.  It's not that bad.  At first, 6 years ago, I would have a borderline reading at the doctor's office; but not always.  So, I asked for a 24-hour blood pressure (BP) monitoring.  It showed that while my BP didn't often get high (while resting) during the day, at night there wasn't the normal fall in pressure that occurs with sleep.  This is a sign of developing hypertension.

For me, this was enough.  I was having trouble exercising to control BP and weight, due to back problems.  I knew that the damage from high BP comes from many years of being high, during which I would feel fine (no symptoms).  But after 20 years of this, there will be risks: heart attack, stroke, kidney damage, vascular trauma, circulation issues, etc. 

So, I went on medication.  It brought down the pressure, but not to what it was when I was 20 years old.  For example, if without treatment I averaged 145/92, under treatment I would be 135/80.  But back when I was younger and running every day, the average was about 118/68.  Initially, my doctor--and I--was happy to get below the 140/90 threshold.

But later, large-scale reviews began to show that if you could normalize the pressure even more, the risk would fall even further.   There's a counter-balancing risk, however; if you over correct, people can get syncopal--their blood pressure can be that low under normal circumstances, but when they stand up quickly, or get a little dehydrated, they can feel faint.

In any case, I asked for more aggressive treatment.  It brought down my BP.  In the meantime, I had back surgery (I posted that personal story, too), allowing more physical exercise.  Admittedly, there were a few times when, working out in the heat of the summer, I got a little woozy and had to sit down for a minute.  So, we re-adjusted the medications.

Having this condition--hypertension--is like having diabetes, you have to monitor things.  Not all the time, but every few months or so.  I lost weight exercising, and my need for medicine went down, so another adjustment was needed.  These days, I range about 128/75, which is safe and probably an improvement over my initial therapy.

But I'm still watching the research on this, because science is always being modified by new results.  Should the benefits of "optimizing" blood pressure, as opposed to "lowering" BP turn out to be minimal, then I'll re-look at the strategy.  That's the way it works.

The authors' example of borderline cholesterol results can be argued similarly.

But unlike my story about getting a spinal fusion, I've tried to avoid being Dr. Know-it-all, and work with my doctor to obtain the best solution.  When I try to run my own medical care, I'm just as stupid (if not more so--a little knowledge is dangerous) as anybody else.  None of the above should be undertaken on your own, and it may be that your condition is not amenable to this kind of management.  Or you may decide, with the authors, that living your life unburdened by early diagnosis is happier.  (BIG DISCLAIMER).

So back to the book "Overdiagnosed."  I can't agree with the underlying premise that accidental health issues, uncovered by routine exam or testing, which are asymptomatic--and the patient is feeling well--should be unexplored.

There are many health issues that benefit from being discovered early.  And, in particular, there are conditions where fully treated borderline, or partially corrected, problems can make a difference to long-term health.

We're all unique.  Generalizing about "over"-diagnosis makes the mistake of "over"-looking that fact.

Doc D

Semi-Vegetarian Tacos

Somebody figured out that Taco Bell's meat filling is not all beef, and they're suing.

But, take a lot at what is alleged to be added to your "beef" taco.
"water, ‘Isolated Oat Product,’ wheat oats, soy lecithin, maltodrextrin, anti-dusting agent, autolyzed yeast extract, modified corn starch and sodium phosphate.."
Sounds like to me they reduced the percentage of the "bad," unhealthy beef...and added in vegetable products that are more healthy.  See the OC Register, Jan 24, for more.

Not only that, they put in all that tasteless, healthy veggie stuff and kept the taste that people want.

Oats, soy, yeast, corn.   This could be a health food store supplement.  Water?  Sodium phosphate?  These are added to many foods.

So, what's your reward for stealthily reducing red meat in the American diet (and saving money, since it's cheaper)?

Sued for false advertising.  Only in America.

Considering the investment in four years of law school, you have to do something to support 25% of the world's lawyers.

Doc D

Monday, January 24, 2011

Jack LaLanne Mini-Euology

Mr. LaLanne was a daily feature of my early childhood.  His TV show was a breakthrough at a time when exercise was un-feminine and weightlifting was frowned upon.

You have to remember that when I watched his show, it was on a huge wooden box with a tiny black and white screen.  And if you didn't tweak the antenna "rabbit-ears" just right there was poor reception.

Amazing man.  Upbeat and energetic, he lived the life he encouraged every day.  I'm not sure many of us can say we walk the walk all the time.

He was first to show that you don't need any equipment to do a good workout, and the first to propose that inactivity is our own worst enemy.  His advice was always simple and never strayed from common sense.  He didn't care what you did to exercise as long as it was moving and using your body.

So different from all the extreme self-help gurus of today.

Clips from some of his 50's TV shows are available on YouTube.

The news reports (OC Register, Jan 24)say he died of pneumonia.  He'd had a heart valve replacement sometime in the last 2 years, I think.

But he put everything into his 96 years.

Doc D

HHS Collects Some Chump Change From Medicare Fraud

The Secretary of Health and Human Services (a political appointee with no experience in health care) announces that they recouped 4.0 billion dollars in Medicare fraud last year...about 4% of the total fraud.

Great job.  This puts us up from 1% in the past.  See here for the positive spin from USA Today (Jan 24).

Now if we could just get back the other 96% of the approximately $100 billion in Medicare fraud each year.

You've heard the stories about how easy it is for criminals to defraud the government's program.  Organized crime is finding it a lot safer than drugs or prostitution.  There was the pizza parlor in Florida that was getting paid for AIDS transfusions.   And the dentist in New York who was filing claims for almost 300 patient procedures a day.

And the answer to why all this money down the drain?  "We don't have the resources to investigate."  Well, if we had that 100 billion we wouldn't have needed any funds for Health Care Reform.  Can't you figure a way to get in the game?

But, thanks, Madame Secretary, for putting your heart and soul into this determined effort in the cause of justice...that gave us very little.

Doc D

Sunday, January 23, 2011

Study: Benefit From Electronic Health Care...Not So Much

This was a large scale review of over 50 studies, examining multiple aspects of electronic records, pharmacy, decision-making, adherence to standards.  They found benefits to be overrated.

This study was published in an online journal.  You can read the whole thing here (PLoS Medicine).  The Wall Street Journal also covered it in their Health Blog (Jan 21).

The interesting thing is, electronic health records, computer ordering, computer-driven practice guidelines, and the like are all being heavily promoted by advocates, commercial software vendors, politicians...and the President of the United States.

I'll give you some of the data below, but here's a quotation from the authors' conclusions:
"There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and “techno-enthusiasts” as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle."

So, why do they say this?   Here's the chart reviewing the benefits from computerized decision support systems (which help in the diagnostic process):

Note that "patient outcomes" on the right all showed no benefit (that's what '+/-' means).  If you take the time to look through the charts for other variables like electronic health records, order entry, e-prescribing, and data storage, you find the same.   Where it really matters, under "outcomes" (that is, doesn't the patient get better, or better care), the pattern is mostly the demonstrated benefit.  Shouldn't outcomes be our highest priority?

Another pattern on the charts is that (1) time required, and (2) costs both go up with eHealth systems--not a savings as the advocates promise.

Health Care Reform is already spending what will amount to many billions of dollars to implement these systems, in the authors words "as if it was a given" that health care will improve.

I'm not convinced.  And I'm not against electronic systems.  But before we throw tons of money at them, there needs to be standardization, proven benefit, and demonstrated cost-savings.

To be fair the data isn't all negative.  Pharmacy prescribing shows a solid benefit in "improving organizational efficiency".  There are several other small areas where some good was achieved.

But overall, we're assuming too much and spending too soon.

Doc D

Notice To Readers

There was a post yesterday.  For some reason, Amazon didn't pick it up from the feed and send it to your Kindles.  You'll probably get it along with this one.

Sorry about that.  It happens occasionally.  But, it takes 3 days to complain to Amazon and get a response.

I try to post almost every day.  If I'm going to be out ot town, or under the weather, I try to let you know.

Have a healthy day.

Doc D

Saturday, January 22, 2011

Article: Judging Risk Of Alternative Medicine

A quick plug for a great article on complementary and alternative medicines.  No shouting and name calling, just a discussion of the science.

If you have an extra 10-15 minutes, I highly recommend the article cited below at Science-Based Medicine.  The site publishes high quality articles that concentrate on the evidence--from sound research--into medical treatments, their benefits and potential harm.

If you have beliefs that can't be modified by controlled clinical trials and scientific plausibility, then this is not for you.

The comments section of the article is also worthwhile, as commenters discuss some of the issues raised in the article--without insulting each other.

This is the citation:  The risks of CAM: How much do we know? by Scott Gavura.

One last thing.  If you use supplements or other alternatives medicines please list them when your doctor asks you what you're taking.  Studies suggest that over half either don't consider them a "medicine" to put on the list, or they don't feel comfortable letting their doctor know they're taking them  (I don't judge my patients' decisions, we discuss them).

Not notifying your doctor is unwise.  There are interactions between pharmaceuticals and herbals/supplements that could be adverse.  Even simple things like Vitamin A.

Doc D

Friday, January 21, 2011

Surgery Entails Risk: Sixth Breast Implant Operation Proves It Once Again

The German TV star Cora Berger died in a coma after her sixth operation to increase her breast size.  The scapegoating has begun.

The authorities in Germany are investigating for negligent homicide, but barring some strange incompetence, my bet is that when people actively engage in risk-taking behavior, they are likely to encounter what makes that behavior risky in the first place.

You can see the details on the BBC News website (Jan 21).

[The BBC is my best source for scandalous screeds and ridiculous reporting.]

Apparently Ms Berger was attempting to increase her implant size from 34F to 34G.  This, in someone who weighed 106 pounds.

Despite all the body sculpting that goes on here and abroad, poor results and deaths do occur.  Surgery is something that ideally should be undertaken for demonstrated medical need.

What a tragedy, but you have to shake your head at the poor judgment.

Doc D

Physician Survey Portrays Pessimism About Health Care Future

You can criticize this survey of physicians on a couple of points.  But the overall picture is pretty gloomy.

The survey was conducted through the fall of 2010.  It included 3,000 respondents, who may, or may not, be representative.  Also, the company doing the survey is a commercial outfit that provides management products to physicians.

You can get an overview of the survey from the Wall Street Journal Health blog (Jan 19), or go to the survey directly and make your own judgment of how well it was conducted.

Here are the results of a couple of the questions:

During the next five years the quality of health care in this country will:

Overall, the impact of the Health Care Reform Act of 2010 for patients:

This is pretty much what I hear in talking to doctors.  In some cases there's a lot of anger.  Surprisingly, the most common complaint I hear is about administrative requirements, new regulations, wasted time and effort, frustration with getting patients what they need.   Another gripe is falling reimbursement rates, and the rising cost of running a practice.

My opinion of the future is similar.  I think the reform law and all its new regulations (and panels, study groups, committees, task forces, etc) will just levy more reporting and forms and authorizations with no demonstrable improvement in access to care or quality.  Rising costs won't skip a beat.

As I've said before, HCR was a missed opportunity to "turn the Titanic."  Attempts at cost, quality, and access reform were pitiful.  We just increased the rate at which the whole system will sink beneath the waves.

In fact, there's little effective "reform" in the law.  It extends coverage and pays subsidies to obtain it.  That's called an "entitlement."

Doc D

Thursday, January 20, 2011

Bill Introduced In CO To "Presume Consent" To Organ Donation

Colorado is already a donation-friendly state.  If this bill becomes law, a person would have to make a positive declaration that they don't want to donate; otherwise it's a done deal.

According to the Associated Press (Jan 19), this form of legislation has not been successful in other states.  Advocates for the bill think Colorado could be their break-through effort, since the state has among the highest percentages of people willing to donate their organs when they die.  The advocates AP talked to tend to be organ recipients and their families, or those who are still waiting.  The number of donations required each year continues to grow rapidly.

Some European countries have similar laws.  This has increased organ availability for recipients where it's been enacted.  But, then again, Europeans have a different culture than ours, one more amenable to government intervention.

I'm surprised to find that some bioethicists think it's OK to circumvent active consent, as noted in the article above.  These days a surgeon can't do anything unless she/he advises the patient about everything that could go right or wrong in a surgical procedure.  Lawsuits for millions of dollars are commonplace when people don't think they gave permission properly.

Yes, this surgical procedure (to take an organ) would be on a deceased person--or at least near the moment of death.

And what do we do if a person would have consented but changed their mind, and never got around to going down to the DMV to stand in line all day and accomplish the paperwork?

I haven't studied why some ethicists think presumed consent is OK, so I'll have to look into it.  But, my gut reaction is that persons own their bodies, and control does not revert to the government or any other person in the absence of "intent" to transfer that ownership.

"Presumed" consent contains no element of positive intent.

Can you imagine the scene in the hospital?  "I know you're grieving about your loss a few minutes ago, but we'd like you to understand that we can take eyes, kidneys, lungs, etc even though your loved one didn't say we could.  That's the law."

The first state that passes this law will face a big lawsuit when a bereaved family finds that not all of Grandma has gone to the funeral home.

Doc D

Wednesday, January 19, 2011

Another Study Of Cell Phone Use And Brain Cancer

A battle has been raging for years over whether wireless phone use is a risk for intracranial tumors.

I've written about this before (here and here).  The evidence is not compelling either way yet, and this study does nothing to settle the question.

Appearing in the Journal of Computer Assisted Tomography (Nov/Dec 2010), this study attempts to filter data from old studies by limiting analysis to long-term use, re-defining what can be called an "exposure," and modifying which tumors can be counted as occuring in the presence of a wireless phone exposure.  See Science Daily, Jan 19, for a journalistic view of the original publication.

This is a great example of fiddling with the data to support your conclusion.  Not that they don't have a rationale for modifying others research data, but there's an inherent danger to modifying end points of an experiment after the fact.  If you design an experiment to look at the occurrence of result A, then after the experiment is over you decide to look back at the data for a different result B (for which the experiment was not designed) bias and error can intrude.  Not always, though.

The whole question of whether wireless phones (expanding the definition to include both cellular and home wireless phones) are a risk for cancer is undecided because the dozens of studies can all be criticized.  If you go by raw numbers, there are just as many studies that conclude "yes there is a risk" as there are "no there's no risk."

The authors admit that their study is not definitive, but argue that the possibility of harm is sufficient to warrant economically feasible methods to reduce exposure while further studies are done.  I don't have a problem with the "precautionary principle" where concern is established, but I doubt that the recommendations the authors make will be implemented:  for instance, using "tube" type earpieces instead of wired ear plugs (the wired version radiates energy from the phone and can act as an antenna for other exposure.  I'm not sure that's been demonstrated to occur). 

This article does a couple of useful things.  It focuses more on long-term use, assuming a cumulative effect of exposure with phone use.  And, they point out that industry-funded studies have been more likely to show no hazard than independently funded studies.

This is important to know, but labeling industry evil is premature.  It's always the case that supporting funding would rather do studies that focus on safety of their product/policy.  You wouldn't expect the President to fund a study that shows Health Care Reform to have major problems, would you?  (as of today, the number of states suing the federal government over HCR is now at 28).

I don't use phones of any type very often, so this controversy won't cause me to make any changes.

But, if you're the kind of person who spends several hours on the phone every day, it's possible that you have other....uh...issues.  (Does phone addiction exist?)

Doc D

Tuesday, January 18, 2011

Control Booze And Only The Drunks Will Have Booze

The government in Britain is discussing raising alcohol prices to reduce the incidence of alcohol-related disease.

I don't think they understand the nature of addiction.

The study they did (BBC News Health, Jan 18) to show it would help to raise the price of alcohol did show a reduction in consumption: the higher the price, the more consumption fell.  You can read the study here.

But, stupidly, they didn't look at "who" would reduce their drinking with price increases.  [This is why we should never blindly accept numbers from "the experts."].  And the researchers recognize that any pricing program to reduce harmful consumption must "target" those most at risk, but they offer no concrete way to do that.

Given even a superficial understanding of human nature, my guess is that those persons who have problems with bingeing, abuse, or addiction would continue on as before, diverting more of their income to their problem.

And the people with disposable income who drank socially would decide (given the increased cost) that they could get more for their money elsewhere.

But it would give more revenue to the government...which most governments consider a benefit in itself.

Doc D

Monday, January 17, 2011

Drowning In Nonsensical Research

We live in the Information Age.  And almost all of it is worthless.

Nostrums was begun two years ago to provide an antidote to the hype and distortion that issues from the media, advocates, and researchers, all of whom are looking to push their own agendas.

Some days the quality of work is so bad, I can't choose what to write about.

So, I'm going to make up my own nonsensical research title to illustrate what they all sound like:

"Scientists Discover That Humans Have Ten Fingers, But Two Are Only Thumbs."  (p-value = 0.001, CI 9.0-11.0)

A startling breakthrough, that could lead to further insight into quantifying human feet and toes.

Doc D

Sunday, January 16, 2011

Scaring Ourselves: "Smoke One Cigarette And You Die."

A new study shows that damage from cancer-causing chemicals in cigarette smoking can be detected "immediately" after smoking your first cigarette.  And?

Am I the only one who has always thought that the cancer-causing chemicals were there from the beginning?  And it takes 30 years of damaging cells to result in cancer?

The research is being hyped as showing something startling.  "Smoking 'causes damage in minutes', US experts claim" is the news title (BBC News, Jan 15).
"Scientists involved in the small-scale study described the results as a stark warning to people considering smoking.  Anti-smoking charity Ash described the research as "chilling" and as a warning that it is never too early to quit."
Some background:  polycyclic aromatic hydrocarbons (PAH) in tobacco are thought to be among the agents that cause lung cancer.  PAH was added to cigarettes that the experimental subjects smoked.  This allowed them to trace the additive as it was metabolized to a chemical that damages DNA.  The altered carcinogen was measurable 15-30 minutes after smoking.

This result is being hyped as showing that damage occurs immediately.  OK, that's what I always thought.

Damage becomes cancer only when it can't be repaired or deleted.  Our bodies do a pretty decent job of this on a daily basis; our cells get damaged all the time.  But the health-restoring process of removing damaged cells can be overwhelmed, exhausted, or destroyed.  When that occurs the cancer cells can then go their own way, and develop into a tumor.

So, this research (Clinical Research in Toxicology, Dec 27) is interesting by virtue of documenting that the damage to cells begins immediately, confirming what was always expected.

But it's not a breakthrough that undermines the belief that you can smoke without harm for decades before, suddenly, it causes cancer.  Most of us were aware it's harmful to even start smoking.

If there are people who think that smoking is not harmful initially, I'm surprised.

I'm not sure that I'm being clear.  It just bothers me when the media and advocacy groups, well-intentioned though they may be, try to create a sense of previously unknown imminent danger that can't be inferred from the research.  It's scare tactics.

Just say it's harmful to smoke at all, or ever.  And don't start.

Doc D

Friday, January 14, 2011

So Breastfeeding For Six Months Is Harmful Now?

The issue is whether the World Health Organization's (WHO) to breast feed solely for six months, is the right guidance.

New evidence not available to the WHO in 2001, when the guidance was issued, suggests that the situation is more complex that originally thought.

Yes, breastfeeding protects against infection in the infant.  But, if you go six months, the risk of iron deficiency, food allergies, and celiac disease increase.

On the other hand, protection against infection is more important in developing countries, where sanitation is poor.

You can go to the UK's Guardian Life and Style blog (Jan 14) for a readable discussion of the issue.  The British Medical Journal (Jan 13) has the original commentary from the medical experts who are raising the questions.

Expect a flurry of controversy over the issue of reducing the six month time period, as breastfeeding advocates chime in. 

The good news is, even though the WHO guidance says six months of breast milk only, it's not common for mothers to make it to six months.  Infants commonly influence the process by needing more sustenance than can be provided, or express a desire for solid food.

I would tell mothers to use some common sense.  There's nothing magic about six months, and every infant is different.

Transition--gradually--as soon as the babies are ready, immunologically and nutritionally.

Doc D

26th State Joins Supreme Court Challenge To Health Care Reform (HCR)

According to legal experts, this is the first time in US history that a majority of states have sued the federal government over passage of a major piece of legislation.

Kansas has asked to join the suit.  Along with the 20-state suit, and suits by individual states, the total comes to 26.  Surveys continue to show that slightly less than 2/3's of citizens are unhappy with the law.

I'm bored with the health care reform debate at this point.  My view, which I've written about extensively--and don't care to repeat extensively--is that HCR  was a missed opportunity.  See here for the basics.

The summary of all that work: desperately needed reform, incompetently executed.  The politics drove the result, which gave us a massive entitlement that can't be sustained.  See my Poison Pill series for all the bad juju that was revealed after the bill was passed.

Longtime readers know that I see the health care system as principally composed of issues involving four elements:  coverage, cost, access, and quality.  They are interlinked and equally important to the overall functioning of the system.  The recently passed law focuses principally on the coverage part, adding everybody to the rolls.  Cost is not addressed except as a "price control" effort, which economists agree has never worked.  Access is addressed by promises of expanded numbers of some point in the future...and incentives to make care to the underserved more attractive that are re-hashed versions of efforts that have been tried...and have failed....several times over the last 40 years.  Lastly, quality improvement was seen as a regulatory imperative...more regulations to report and administer health care (raising costs..see the linkage?);  new data is showing that the expected reductions in medical error from efforts such as these are not emerging.

So, overall the law was a failure in three of the four basic elements.

Will the law be repealed?  Doubtful.  Will the Supreme Court rule parts of it unconstitutional?  My guess is, 50-50 chance.  But major changes will have to occur as costs continue to rise and access to care plummets. 

But Congress doesn't normally act until we reach the precipice from which only draconian measures will rescue us from their incompetence.

Doc D

Thursday, January 13, 2011

Research That We Can Forego

A new study correlates living in a high altitude county with increased suicide risk.

There are much better things to study than this.  You can see the whole article in the Journal of High Altidue Medicine and Biology (Winter 2010)  here.  I've never seen this journal before; it must be a special interest there might be a journal called Skateboarding Economics or Skiing Sociology.

The jist of this research is to find the 50 counties in the US with the highest suicide rates, and the 50 with the lowest rates.  This is available online.  Then you find the average altitude of these counties.  This is also available from the Geological Survey (nice research; no need to gather data or do an experiment).  Take the average altitudes and suicide rates and compare them.

Voila.  The average altitude is higher in the 50 high-suicide counties.  And they have p-values to prove it.

But what does it show?  Altitude in a county can vary from sea level to 15000 feet.  I once lived in a county where half the surface area was at sea level and the other half was at 9000 feet.  What can you make of that?  Yeah the average altitude will be 4500 feet.  I lived at sea level, not at altitude.  And?

Also, maybe all the suicides occurred in those people who lived at the lowest altitude in the county.  Just because I live in a high altitude county doesn't mean I'm actually living at altitude.

Plus, the authors found the reverse in "all-cause" mortality:  the death rate from all causes is actually lower in high alittude counties.

Let's assume there actually is a risk of suicide.  What are we going to do about it?  Restrict people from living above a certain altitude?  Lower the earth down to a level where suicides are less common?  Treat all high altitude residents with an anti-depressant?

I got it.  If you want to live longer, move to high ground:  you won't have to worry about depressed neighbors, they'll all kill themselves.

Much sarcasm on my part, but it's hard to see where this research could take us.

Doc D

Wednesday, January 12, 2011

New Book On How Fear Undermines Sensible Medical Decision-Making

Journalists manage to distort so many things.  It's a pleasure to see one that investigated his subject in depth, and can tell the difference between evidence and testimonials.

I've just begun The Panic Virus, by Seth Mnookin, an exploration of the impact of fear, distrust, and the media on how parents and others make decisions about life-threatening risks; fear that is motivated by the sense of loss and disorientation we experience in a culture that calmly announces we each create our own reality.  We accept without question that there is no reality other than that we intuit, and it is different for each of us.

The springboard for the book is the anti-vaccine nonsense, and how it came to exert influence over parents, the media, and public policy.  I've written about this multiple times (see category "vaccine" for a list)

You may have recently seen the news regarding the discredited British physician Andrew Wakefield, how he manipulated and distorted the clinical data from his 12 autistic subjects to publish a study that claimed to show a link to the MMR vaccine.  Investigation showed that he fraudulently changed dates and clinical histories, in some cases changing the date of diagnosis to after vaccination, when the records show onset prior

The second part of the story appeared yesterday (Science Daily, Jan 11), revealing that even as Wakefield was caring for the first of those 12 children, he was making business deals secretly to cash in on his own alternative vaccines and diagnostic kits, which would only be financially rewarding if he could discredit the current vaccine.

Mnookin's book came from his puzzlement over why people made decisions to not vaccinate when the evidence is clear and unambiguous.  If you've never heard of "cognitive dissonance," and the role it plays in sustaining belief in the face of contradiction, this is a good place to learn.

Outstanding book.  Entertaining while instructive.  A perfect compromise between rigorous analysis and the technical jargon of original research, along with vignettes from the history of contagion and vaccination (like George Washington's personal experience of smallpox, and subsequent dilemma as a general leading an army undergoing an outbreak he knew could be prevented by vaccination, but would be politically dangerous to do).

I subsequently read an interview with the author (Wall Street Journal Health blog, Jan 11).  I was struck by the quotation below.   The interviewer asked Mnookin how the media had contributed to the Wakefield-induced fear that led to declining vaccination in Britain and subsequent outbreaks (and child deaths).  His answer indicts his own profession for being uncritical of unsubstantiated claims.
"We would never have the type of reporting about business that we do about science. You wouldn’t see a story on the front page that Apple was going to declare bankruptcy based on the opinion of one person — even if he had a business degree. We have to take a greater responsibility to train reporters and editors in the topics they cover."
This reminds me of the "cold fusion" debacle some years back.  A pair of scientists claimed to have developed a method of nuclear power generation that was safe.  Unfortunately, no one could duplicate their results, and the underlying premise was implausible to begin with.  In a wave of uncritical journalism, the media hailed the potential breakthrough.  The whole thing unraveled fairly quickly, but not before comical news interviews appeared that provided "balance" by pairing the chairman of the Dept of Physics at the Univ of Md against a man who was trying to market a perpetual motion machine.

Doc D

Tuesday, January 11, 2011

Falling Abortion Rates Leveling Off...But Wide State Variation

The economic recession gets blamed for everything, and this is no exception.  More interesting is the state-by-state comparison.

There were 1.2 million abortions in 2008.  This works out to about 20 for every 1,000 women.  This is down from the high of about 30 per 1,000 back in 1981.  The rate has been falling since then, until 2008 (last year for which  there are data).

But take a look at where the abortions are occurring.  USA Today Your Life (Jan 11) has a map and table that compares all the states. 

In Wyoming the rate is 0.9 per 1,000, while in Delaware its 40 per 1,000.  Whoa, quite a difference.

Kentucky and Mississippi are on the low end.  The welfare states--New York, Maryland, New Jersey, California--are on the high end.

We all know this is a highly charged political issue, but speculation that the economy is at work is exactly that...speculation: no data to suggest cause and effect.  In fact, there's some suggestion from the data that the leveling off in the decline started several years ago.

I offer this link for info, since there are dozens of news stories about it today.

Doc D

If You Contracted Swine Flu, You May Be Ahead Of The Game

There's some lab data that suggests those who caught the H1N1 have broader immunity to other strains than those who took the vaccine and didn't contract the disease.

This study appeared in the Journal of Experimental Medicine (Jan 10).  This is from the abstract:
"we report a detailed analysis of plasmablast and monoclonal antibody responses induced by pandemic H1N1 infection in humans. Unlike antibodies elicited by annual influenza vaccinations, most neutralizing antibodies induced by pandemic H1N1 infection were broadly cross-reactive against epitopes in the hemagglutinin (HA) stalk and head domain of multiple influenza strains. The antibodies were from cells that had undergone extensive affinity maturation. Based on these observations, we postulate that the plasmablasts producing these broadly neutralizing antibodies were predominantly derived from activated memory B cells specific for epitopes conserved in several influenza strains."
For the hyped version, you can read the BBC News health blog (Jan 10). who reported the study as suggesting
"People who recover from swine flu may be left with an extraordinary natural ability to fight off flu viruses."
I hope you can see the difference.  The research is saying that there's a cellular and antibody response when you get the disease that can cross-react with strains of H1N1 itself that are slightly different from the original virus, and with H5N1.  It doesn't say that they tested all one thousand existing strains of influenza virus in people who had swine flu.  Probably, they won't get H1N1 or its variants again for some time.

While the news article says that "Doctors hope to harness this power to make a universal flu vaccine that would protect against any type of influenza,"  the researchers say that,  "This suggests that a pan-influenza vaccine may be possible, given the right immunogen."

They state the potential of their research in a more cautious way because (1) having antibodies doesn't mean they work well; they tested them only in mice, (2) getting from a positive lab result to an effect in human disease is a leap that most lab results never accomplish, and (3) they don't know if this cross-reactivity from H1N1 disease is something unique, or generalizable to all flu viruses.

Lastly, given that flu mutates almost every year, it would be challenging for a "universal" vaccine to keep up.

Scientists have been announcing the imminent development of a malaria vaccine for about one hundred years now, and we don't have it.  [BTW, know the difference between eminent, imminent, and immanent?]

So, let's all breath into a paper bag...then, wait for more data to see if this project can go anywhere.

Doc D

Monday, January 10, 2011

Some Data On Doctors' Attitudes

I got these graphs from the state medical association (TX)  and offer them without comment, except for some clarification.

For reference, the survey was sent to about 29K physicians and 3,500 responded.  The percent isn't high, but it's enough for statistical significance probably.  Most doctors don't like to be bothered with stuff like this.

As far as bias, you have to ask yourself which ones would be more likely to send back the survey.  I'm not sure:  some people are more likely to respond if they're upset, others are more likely to ignore it.

Surveys are always suspect ("Are they telling the real story?")

And you have to ask whether Texas is typical or not.  I don't have any reliable data about that.

First, results on doctors' reactions to health care reform:

Second, what percent are accepting all new Medicaid/Medicare patients:

For any of you who have tried to find a new doctor through your insurer's network (including me):  sometimes they say they're accepting new patients, but when you call, they aren't.  It's a dishonest way of keeping your options open (the insurer can say you are available, but you can cherry pick who you accept).

On the other hand, providing coverage to 38 million more people under HCR will only make this worse.  Despite the optimism of HCR advocates, It's going to take decades to increase resources to match the workload.

[OK... so I commented]

Medicaid has always been the least desirable patient.  Reimbursement is lowest, and the patients are the least compliant and reliable.

Unfortunately, these are the poorest...and the very patients who need help the most.

Doc D


Sunday, January 9, 2011

Another Diet Book: Plant Foods...And Plant Foods Only (Yawn)

Interesting interview with a co-author of another diet book.  Clearly knows nutrition, but not so much about disease.

The China Study is a book based on 20 years of nutritional research in rural China and Taiwan.  The data purports to show that the population eating a plant-based diet were the healthiest.  You can read an interview with a co-author here (NY Times Well blog, Jan 7).

Based on that interview, I think the author, in advocating only plant food sources, violates his own principles, which I discuss below.  But for now, see this quotation from the interview:
"The problem is that we study one nutrient out of context. That’s the way we did research — one vitamin at a time, one mineral, one fat. It was always in a reductionist, narrowly focused way. But I learned that protein is not quite what we thought it was...What loomed large for me was that we shouldn’t be thinking in a linear way that A causes B. We should be thinking about how things work together. It’s a very complex biological system."
Well, yeah...but that applies to isolating plant food sources in the same way, doesn't it?

I haven't read the book, so I can't judge the overall claim.  For a critique of the book's conclusions go here

It's common sense that a balanced diet containing fruits and vegetables is healthier, and that Americans don't consume enough of this group of foods.  It's a much stronger statement to say that we should avoid all non-plant food sources.  The 500K people who bought the book are willing to consider it.

The anthropological evidence is that humans are omnivores, and have been from the beginning.  Not scavengers, really, but rather "un-picky" as a species.  It's speculated that this is why our appendix is vestigial, a word meaning "degenerate, persisting, but of no further use."  Many herbivores have GI tracts that process food in stages through serial digestion in multiple "stomachs" or pouches.  The appendix might be one of those (very speculative), and is now more of a problem (appendicitis), and not a benefit.

Even ignoring this, there's still no evidence that our bodies were designed to eat only plants.

But there is evidence that societies with a history of plant-based diets became so originally through necessity, not choice.  They ate animal foods when they could get it.

Plant-only nutrition requires some attention to diversity of source.  Single plant foods may be deficient in some building blocks for proteins and lipids required by the body.  The classic story for this diversity is the combination of corn and beans into menu items of Hispanic cooking.  Both corn and beans provide the amino acids missing from the other.  Maybe this story is apocryphal.

Some very restrictive plant food diets are deficient in protein.  You will hear vegetarians (often an ideological group) talk about needing protein supplements.

Trying to put all these books and diets into a reasonable course of action is a challenge.  I'm convinced that the more extreme the diet is, the less likely it is to be healthy in the long run.  So, I shy away from nutritional proposals that exclude entire food sources.  My sense is that all food sources bring something to the table (sorry).  Where we go wrong is in consuming too much of one thing; an overabundance of selected food types overwhelms our bodies' ability to burn or store the amount consumed.

And while our bodies evolved to handle a wide variety of foodstuffs (as omnivores), there was no need to evolve a way to handle too much food.

Not many Pre-history human societies had a problem with too many Burger Kings.

Doc D

Saturday, January 8, 2011

Help! We're Overhwelmed With Health Advice

A plethora of studies over the last week:  environmental, nutritional, genetic, and traumatic influences...good and bad.  Do any of them matter?

The appearance of a news report (Science Daily, Jan 7) on the influence of tomatoes on vascular disease was the last straw.  As I read the article, I started wondering if there was anything on the planet that doesn't influence us in some subtle way, either harmfully or beneficially.  The researchers were enthused about their results:
"Tomatoes are already known to contain many compounds beneficial to health. In this study the team analyzed 9-oxo-octadecadienoic acid, to test its potential anti-dyslipidemia properties.  The compound was found to enhance fatty acid oxidation and contributed to the regulation of hepatic lipid metabolism. These findings suggest that 9-oxo-octadecadienoic acid has anti-dyslipidemia affects and can therefore help prevent vascular diseases."

Earlier this week there was a study suggesting that compounds in pomegranate juice could prevent cancers from spreading.  Juice producers love to point to this kind of research to market their products. 

Again, so?

Should we go stock up on tomatoes and pomegranates, while continuing to seek out or avoid all the other stuff we've been pummeled into pursuing or avoiding?

Think back over the years: how many studies have you seen like this that hail some product as a cure or preventative?   And the just-as-frequent number of studies of things to avoid.

Coffee reduces Parkinson's disease, breast feeding reduces cancer, cactus controls blood sugar, sodium leads to hypertension...the list is endless.

Then there are the (seemingly) contradictory studies.  Anti-oxidants reduce, they are a cancer risk (according to a study this week).  For every study that shows a benefit, there's another that shows harm.

There must be tens of thousands of these.  I imagine scientists saying, "What else is there in the grocery store we haven't injected into mice that might result in a publication?"

And say you spend thousands of dollars buying some health supplement that you take for decades in the hope that it makes a difference.  In the end, how will you know?  Maybe, amongst all the other stuff, it gets lost in the wash.

It's not that each of these reported effects are not true.  But they are studied in isolation.  What if we took all these studies and threw their data together.  Imagine a super computer that could add up all the good and bad effects, giving proper weight to how important each influence is (mostly minimal)....what would happen?

My guess is they would all cancel out.  Bottom line impact, null.

But don't let me discourage you from buying milk thistle and wrist magnets.  Ironically, I would be doing the same things these studies are doing.

If you think it helps, I guess that's something.

Doc D

Friday, January 7, 2011

Medical Quote Of The Day - 7 Jan 11

Did you spend $25 for a Power Balance bracelet?  2.5 million people did.

This bracelet wins my Human Gullibility Marketing Award for 2010.  The inventers of this device claim that it balances the body's energy flow, increasing energy, strength, and flexibility.  Despite the claim, they admit there's no scientific evidence to support it.

I mean, it's really bad when the charlatans admit the baselessness of their claim, and people still go for it. (Note:  that's over $62 million in revenue for an item that costs about 50 cents to make).

The Power Balance was a CNBC "Sports Product of the Year."  Endorsements by celebrities followed.

So, I thought this quote from the author of a review of the whole comedy was right on target, describing human folly in general:
"Products that seem to work via mysterious means inaccessible to scientific investigation are more than likely bullpucky and always have been. Their makers have always used sophistry and fuzzy explanations to sell them, and have always relied on the power of suggestion to propel the pucky as far as it'll go. The game never really changes; the shysters just develop craftier ways to circumnavigate our judgment and appeal to what we really want -- an easy way to feel better, look better, and be better." 
--Psychology Today, Jan 4: Power Balance Scam Shows Again That the Pseudoscience Song Remains the Same, by David Disalvo

Very nicely put, Mr. Disalvo. Recommended article.

Doc D

Thursday, January 6, 2011

Medical Quote Of The Day - 6 Jan 11

"Eat right, exercise regularly, die anyway."


There are those of us who pursue good health with such grim determination that well-being falls by the wayside.

Doc D

STUDY: Cocaine Vaccine For Stoned Mice

Making the world safe for mice.  Not that they need it; mice don’t have addictions unless we force them into it.

See the article (Science Daily, Jan 5) reporting on research into a vaccine against cocaine. The researchers took part of a virus, attached a cocaine analogue to it, then injected it into mice. The injection caused an immune reaction, just as would occur if the virus was an infection.  Except… the immune reaction in this case occurs to the attached cocaine analogue.  Hypothetically, the immune response would block any cocaine look-alike from having an effect on the mouse.  Researchers then gave addicted mice cocaine and observed their post-vaccinated behavior.

I’m not an expert on the behavior of addicted mice.  You might ask “What is the behavior of a stoned mouse, such that researchers could discern a change in that behavior?”

The criterion used was whether the mice exhibited signs of hyperactivity. I’m not sure whether this is an accepted measure of mouse cocaine-high-ness.  Ultimately, we have no idea what’s going on in a mouse’s head, stoned on cocaine (or even if they are stoned, in the human sense).

They found those mice who had been given the cocaine vaccine didn't appear to exhibit the hyperactive effect that cocaine-addicted, unvaccinated mice did when given cocaine.

Readers of Nostrums will look beyond the headline and question the claim that such a vaccine could be useful in treating cocaine-addicted humans. Subconsciously, we make the connection that a “vaccine” prevents a harmful disease.  So, a vaccine against cocaine would prevent the cocaine effect, and addicted persons would have no reason to abuse the substance. 

The analogy to other vaccines breaks down because addiction, while considered a disease, is not one that people get through no action of their own, like polio, say, which you get by chance exposure.   Substance abuse requires a behavior that seeks out the disease.  Clearly, people don’t want polio, and the vaccine prevents it. A cocaine vaccine may prevent the effect of something that is harmful, but not the motivation that led to the substance abuse.

My guess is that this vaccine, if effective, will prevent people from using cocaine to get high…and they'll find a substitute. It may be a new compound--synthesized from cocaine, maybe--that is different enough chemically that the vaccine-induced immunity won't recognize it as cocaine, but the brain will. Or, they will seek out some other substance that gives as close to a cocaine high as possible.

As we’ve seen in previous attempts to deal with human behaviors, methods that don't address the need, or the motivation, for that behavior are less effective. The vaccine (which should be pursued) is not an answer. Maybe it can help, but until we are able to address directly the “thing in us” that drives us to addictive behavior--whether it be drugs or food, or other destructive and harmful attitudes and actions--the problems will persist.

There’s always another way to get high.  Sarcastic smile

Doc D

Wednesday, January 5, 2011

Everything Is Coming Up Stem Cells...Even Baldness

The latest hook in promoting stem cell research is the suggestion that a defect in stem cells converting to hair follicle precursors leads to baldness.

You can read the whole study here, but it's technical.  To wit, this quote from the abstract:

"Cells expressing cytokeratin15 (KRT15), CD200, CD34, and integrin, α6 (ITGA6) were quantitated via flow cytometry. High levels of KRT15 expression correlated with stem cell properties of small cell size and quiescence. These KRT15hi stem cells were maintained in bald scalp samples. However, CD200hiITGA6hi and CD34hi cell populations — which both possessed a progenitor phenotype, in that they localized closely to the stem cell–rich bulge area but were larger and more proliferative than the KRT15hi stem cells — were markedly diminished."
Yada, yada, yada...

In common sense English, the problem with baldness is not a lack of hair; it's that new hair is too small to be seen.  If you were to look closely, hair follicles would appear shrunken and tiny hairs are present.  From the "macro" perspective, it looks like "no hair."

There are stem cells in the scalp that have to differentiate into cells that are precursors ("progenitors") for hair production.  If something interferes with the process of how these precursor cells mature, then the hair that grows is microscopic.

Soooo....if you could correct the defect in how stem cells become mature progenitor cells,  normal hair would grow (hypothetically).

The research, quoted above, documents that the stem cells are there, but normal progenitors are not.

Two comments:  (1) none of this implies that rubbing stem cells on your head will cure baldness, and...

(2) How about we concentrate our funds on stem cell research that cures cancer, then turn to baldness once we solve that?

Doc D

Tuesday, January 4, 2011

Medical Quote Of The Day - 4 Jan 11

Paul Tournier was a famous Swiss physician whose work had a great impact on the psychosocial aspects of patient care.

This saying attempts to explain how educated people can be bamboozled by charlatans.

"The more refined and subtle our minds, the more vulnerable they are."
--Paul Tournier, MD [1898-1986]

I interpret it to mean that refinement and subtlety can deter us from recognizing basic common sense and high priorities.

Doc D

Project To Develop A Blood Test To Identify Individual Cancer Cells

Interesting concept.  Uncertain utility.

There are several media articles today (here's one:  Bloomberg Businessweek, Jan 3) about an agreement between Massachusetts General Hospital and a company called Veridex to look at developing a blood test that can identify single cancer cells.  Note that we're not talking about a product, just an agreement to develop something along these lines.

It's not that no work has been done; an earlier attempt to develop a chip that could count wayward cancer cells was developed by Mass Gen, but it couldn't hang on to the abnormal cells as they were seen.  This partnership will attempt to develop the needed technology to gather the cancer cells that are floating in the bloodstream for analysis.

You can see the potential value here:  tumors, although they may initially exist as a single mass, lose cells that float away into the bloodstream.  A simple blood sample that could pick up on these stray lambs, that have lost their way, could show that a cancer was in development at an early stage, identify the type, and point to where the origin is.  Neato.

However, there's some evidence to show that most of us who don't have cancer still produce cancer cells on a regular basis.  Our bodies are just very good at finding cells that don't belong and destroying them before they get out of control.  This is not hard to imagine:  cells divide all the time and defects occur in the process, more as we get older.  Our immune system would have to be on guard throughout life to pick up these anomalies and eliminate them.

In fact, one hypothesis is that we get cancer as a disease--at least some types of cancer--because our ability to fight these cells--when they occur--breaks down.

So, going back to the blood test, you can see how a positive test for individual cancer cells might be misleading.  We're just picking up the usual strays that the body hasn't dealt with yet.  We might over-react to the result, or just be confused as to whether the finding of a cancer cell means anything.

But, this is worthy research, and I'm interested to see what they come up with.

Doc D

Monday, January 3, 2011

Great Vaccine Book

I've been out all day getting car repairs, but here's a quick notice about a new book I'm reading.

It's by a reputable physician, about what the heck is going on when a public health tool that has saved the lives of untold millions comes to be seen as a threat due to unsubstantiated claims by a vocal minority.  It's a work of history as much as science, tracing the growth of the panic, the disregard for controlled studies that undermine their claims, the psychology of fear, and how they threaten others who can't take the vaccines due to ill health or other vulnerability.

Deadly Choices:  How the Anti-Vaccine Movement Threatens Us All, by Paul A. Offitt, MD

Recommended.  (Unless you think invisible rays cause creeping jungle rot...then you're beyond help)

Doc D

Sunday, January 2, 2011

Wellness Exams For Seniors Not Welcomed

Very few want what they're offering.

I was reading an article in NPR's Shots health blog (Jan2) about the Wellness exam that's been offered to new Medicare recipients since 2005, and the beefed up version under Obamacare.  The new Exam v2.0 gives guidance on what should be included, pays doctors more, and is now free (co-pay of 20% under v1.0).  But not many cotton to it.
Fewer than 10 percent of seniors took advantage of the "Welcome to Medicare" physical exam paid for by Medicare, according to the government.  So what does that mean for how seniors will use the new, more comprehensive preventive health exam benefits that kick in by 2011?  “I don’t think people will be running to do this,” said Judith Stein, executive director of the Center for Medicare Advocacy. While she applauds the new benefit, she said seniors may not see the value without a strong recommendation from their doctor.
Prevention is a perennial problem.  Just getting patients to follow up on an illness is hard to do.  There's something in us that wants to "let sleeping dogs lie."  We don't see the benefit.  Maybe it's part of our "Live in the Moment" culture, or a fear of finding out something unpleasant or harmful, or distrust of the results.   Likely all of the above.  And, in a word, "human nature."  I doubt the law will change that.

The article goes on to talk about incentives to get people to do wellness exams, and encouraging doctors to push them.  All very well-intentioned.

But as I read, a Creepiness Factor emerged.  When do I reach the point where I get to live my life untrammeled by an endless parade of experts and government functionaries?  I'm already told what I can and can't say, what I should and shouldn't eat, who I can and can't associate with, where I can and can't go, what I have to buy and what I can't buy.

This must be what it feels like to be one of the cows in a well-managed herd.


Doc D

Saturday, January 1, 2011

First Steps At Stiffening Child Vaccination Laws...Finally

It's about time public health officials and politicians recognized that the anti-vaccination crowd doesn't have the right to kill your infant child.

From the Orange County Register, Dec 31, reporting that California wised up to the threat.
Beginning in the fall, all children in 7th through 12th grades planning to attend public or private school must submit proof they've received a booster shot to guard against whooping cough, also known as pertussis. Otherwise, they can't enroll.  The mandate came in a bill passed overwhelmingly in the Legislature and signed by Gov. Arnold Schwarzenegger in September, as a response to the worst outbreak of the preventable disease in generations. There were more than 7,800 reported cases of pertussis in the state in 2010, the most since 1947. Ten infants have died, all of them younger than 3 months, when babies haven't yet received their full round of inoculations.
To vaccine wacko's, please note that the Supreme Court decided the issue of whether the government can compel an individual to vaccinate over two hundred years ago.  In cases of contagion, the citizen does not have the right to be a Typhoid Mary.
For whooping cough, as with many infectious disease, the schools are the most fertile ground for disease spread:  thousands packed into a confined area.  Those exposed then bring the disease home to our most vulnerable:  the infirm, and infants.
Doc D

Medical Quote Of The Day - Jan 1

A thought for the new year.

Every day doctors have to deal with people who are worn out and unable to stand up to the life they lead. They generally assert that it is impossible to alter the way they live, and sincerely believe that their overwork is the product of circumstance, whereas it is bound up with their own intimate problems. It is ambition, fear of the future, love of money, jealousy, or social injustice that makes men strive and overwork, invent all sorts of unnecessary tasks, keep late hours, take too little sleep, take insufficient holidays, or use their holidays badly. Their minds are overtense, so that at night they cannot sleep and by day they doubly fatigue themselves at their work.

-- Paul Tournier, M.D. [1898-1986]


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