Wednesday, December 21, 2005

Research: Machinery of the 'marijuana munchies'

One of the primary hazards of marijuana use is well-documented: the uncontrollable urge to consume a bag of Skittles, half of a leftover pizza, a pound of chocolate chips, and the freezer-burned date logs that have been around since Aunt Sarah came for a visit last October. Finally, some serious research on the munchies from some pointy-headed tokers at Columbia Univerisity:
In their studies, the researchers concentrated on the lateral hypothalamus (LH) of the brain, known to be a center of control of food intake. Their studies involved detailed electrophysiological measurements of the effects of specific neurons that they had identified in previous studies as being important in endocannabinoid signaling. Their studies revealed that activation of CB1 receptors, as by endocannabinoid molecules, induced these neurons to be rendered more excitable by a mechanism called "depolarization-induced suppression of inhibition" (DSI).

What's more, they found that leptin inhibits DSI. However, they found that leptin did not interfere with the CB1 receptors themselves. Rather, leptin "short-circuits" the endocannabinoid effects by inhibiting pore-like channels in the neurons that regulate the flow of calcium into the neurons. Such calcium is necessary for the synthesis of endocannabinoids.

In further studies of mice genetically altered to be leptin deficient, the researchers found the DSI to be more prolonged than in normal mice. Thus, they said, the findings "implicate this mechanism for leptin receptor/endocannabinoid signaling in contributing to the maintenance of weight balance…." The researchers also included that "upregulation of endocannabinoid signaling in the LH may explain, at least in part, the increased body weight consistent with a prior report of elevated endocannabinoids" in such leptin-deficient mice.

The researchers concluded that their findings "are consistent with the hypothesis that the integration of endocannabinoid and leptin signaling regulates the excitability of neurons on appetite-related circuits."

Link to press release (via Boing Boing)

Tonight, let's all burn a spliff to Young-Hwan Jo, Ying-Jiun J. Chen, Streamson C. Chua, Jr., David A. Talmage, and Lorna W. Role!

Monday, December 19, 2005

Health policy: $130 billion in regressive health coverage subsidies

In the NYT, Eduardo Porter points out that the federal government hands out a hefty subsidy for private insurance, much of it going to people who don't need help getting health coverage. I get it, and you probably do, too. It's the deal where you and I get to pay our share of our employer-provided health coverage from pre-tax earnings. It adds up to $130 billion or so-- enough, Porter points out, to turn Medicaid into something very close to universal coverage.

It's another maddening example of tax policy that seems to turn good social policy on its head: let's say I make $40,000 a year and you're my boss you make $140,000 a year. We're both on the company health insurance plan, which costs each of us $2,000 a year. If I can pay my share from pre-tax earnings, my marginal tax rate is maybe 20%, so I save $400 in taxes I would otherwise paid on that $2,000. You, however, have a higher marginal tax rate, maybe 35%, so you save $700. Lucky you-- the government gave you the same subsidy as me, plus a set of golf clubs. Not to mention the carribean cruise you got in added tax savings from the mortgage interest deduction for your McMansion.

For taxpayers, a penny saved is a penny earned, but for the government, a penny in tax revenue forgone through a tax deduction or exemption is a penny spent. Are we spending these pennies wisely?

It's enough to turn a blue-stater into a flat-taxer.
Although subsidizing health insurance may seem a worthy effort, a positive contribution to the goal of universal coverage, it is among the most inefficient spending in the nation's fiscal arsenal. 'If you had $150 billion to play with, you could come very close to universal coverage,' said David Cutler, an economics professor at Harvard. One reason that we are 45 million people short of that goal is that the money isn't being spent on them.

According to President Bush's advisory panel on tax reform, about half of the tax break for health insurance accrues to families making more than $75,000 a year. More than a quarter goes to families making over $100,000. These families would surely hate to lose the subsidy. For a family making $100,000 a year in, say, Los Angeles, the tax break cuts the cost of employer-provided health insurance by about 35 percent in federal and state income taxes. On a typical family policy costing $11,500 a year, that is equivalent to some $4,000.

Health Care for All, Just a (Big) Step Away - New York Times

Sunday, December 18, 2005

Puppy Love: Let's Dance!

Count me among the many who thought dancing with dogs was just a goof from "King of the Hill." But no, it's real, and it's called "freestyle." I know I'm supposed to offer some kind of smart-ass remark here, but I'm stumped.
To maintain decorum, freestyle competitions keep the costuming of the animals to a minimum, though the handler can get away with dressing up like Charlie Chaplin for theatrical effect. And among the main organizations, including the Canine Freestyle Federation and the Musical Dog Sport Association, there are philosophical differences over freestyle moves and issues like attire and how much dancing the humans should do.

'We want the dog to be the star,' said Ann Priddy, a freestyle teacher in Richmond, Va., and the vice president of the Musical Dog Sport Association, which formed this year.

The efforts to define canine freestyle as it grows also include a possible name change. 'People think it's swimming,' Loren Jensen Carter, founder of a two-year-old regional group in Arizona called Sonoran Canine Freestylers, said of the name 'freestyle.' She is among those advocating 'K-9 dance sport' instead.

Link (free reg req'd)

Saturday, December 17, 2005

In the news: NYT on being sick and being employed

This is a must-read:
The Catch-22 of the American health care system is that while many people work 'for the insurance,' when they become too sick to work and are most in need of that insurance, they are most at risk of losing it. This is particularly true of workers at small companies, which are not covered by existing law. (The Family and Medical Leave Act, for instance, only applies to workplaces with 50 or more employees.)

One employee at such a company, who asked that her name not be used because she feared retribution from her former boss, learned the significance of this distinction the hard way when she had a brain tumor removed five years ago. Her employer, she said, 'told me that my tumor came at a really bad time for the company.' The woman had recently received a significant raise, $20,000. Her workplace was small - about a half-dozen employees - and a few months after her illness was diagnosed, the group's insurance premiums jumped. 'My raise was rescinded, to cover the increase,' she said.

At the very end of the article, there's a mention of an issue that's a big deal for me and probably for lots of people with MS. It's about the conundrum of working part-time, maybe to hang onto insurance or, in my case, to accommodate increasing fatigue, versus the resulting decrease in one's disability coverage.

I would love to go from full-time down to about 80%, maybe working half days a couple days a week. As it is, I sometimes feel like I'm only working at 80% even though I'm present at my desk for the full 40 (or more) hours each week. The problem is that going 80% decreases the amount of protection I have in the event I need to take disability. My disability benefit is calculated as a percentage of my income at the time I stop working. While I'm working full-time, my benefit would be 80% of my current salary. If I go 80% part-time, my benefit would be 64% (80% of 80%) of my current salary.

So the question becomes whether I think my family and I are better off if I work full-time until I keel over entirely or if I work part-time, cutting both my current income stream, and the income I'd get on disability. Fortunately, I'm confident that the decision is mine to make, that my employer would allow me to go to 80% if I chose. But I go back and forth: am I better off protecting that income stream, or do I stand a better chance over the long haul by reducing the energy I put into work and increasing the energy available for taking care of myself?
Link (free reg req'd)

Thursday, December 15, 2005

In the news: Stem cell researcher's pants on fire?

From the NYT:

SEOUL, South Korea, Dec. 15 - Hwang Woo Suk, the scientist who stunned the world by announcing breakthroughs in stem cell and cloning research, faked a landmark research paper, one of his South Korean co-authors said today in television and newspaper interviews. Dr. Hwang and his aides, who had vehemently defended the paper published in the journal Science in June, were not immediately available for comment on the assertion by Roh Sung Il, , one of Dr. Hwang's 24 co-authors for the June paper, that the scientific finding was falsified.

Mr. Roh, the administrator of MizMedi Hospital in Seoul, told the South Korean daily Hankyoreh that there were no authentically created stem cells presented for the Science paper, according to an article on the newspaper's Web site this evening. In an interview broadcast on MBC television, Mr. Roh said Dr. Hwang appeared to have created stem cell lines that were later destroyed because of a virus infection. Dr. Hwang took stem cell lines from Mr. Roh's laboratory that had nothing to do with Dr. Hwang's research and presented them for the Science paper, Mr. Roh said. He said that nine of the 11 stem cell lines in the study were faked and that the other two were dubious.

In the June paper, Dr. Hwang's team reported that it had cloned human embryos and extracted the 11 stem cell lines, which Dr. Hwang said matched the DNA of patients. That result seemed a major breakthrough because it raised hopes that scientists might one day help patients suffering from illnesses like Parkinson's disease or diabetes grow their own replacement cells to cure their ailments.

Link (free reg req'd)

Wednesday, December 14, 2005

Puppy love: FrankenFido?

Slate's William Saletan has an interesting angle on the news that scientists have sequenced the dog genome:
In the course of engineering dogs to look, feel, and act as we wanted, we ruined millions of them. We gave them legs so short they couldn't run, noses so flat they couldn't breathe, tempers so hostile they couldn't function in society. Even our best intentions backfired. Nature invented sexual reproduction to diversify gene pools and dilute bad variants. By forcing dogs into incest (which we ban among humans, in part for biological reasons), we defied nature. We concentrated each bad gene in a breed, magnifying its damage: epilepsy for springer spaniels, diabetes for Samoyeds, bone cancer for Rottweilers. That's why the dog genome is so nifty: We can find disease genes just by comparing one breed's DNA to another's.

Well, too bad for the dogs. But three cheers for us and our experiment. "The dog genome is a wonderful playground for geneticists," exults the New York Times. "A treasure trove," says the San Francisco Chronicle. "A convenient laboratory," agrees Reuters.

Man's best friend, indeed.

I'm a dog lover, and I can't imagine life without these critters. At the same time, I know that my species' love of dogs has resulted in the infliction of boundless cruelty on an animal that seems uniquely capable of perceiving that cruelty. If only we could explain to the dogs that we are equal-opportunity despots; that we can be just as cruel to other humans -- maybe then dogs wouldn't seem to take it so hard.


Tuesday, December 13, 2005

Research: Pain control by force of will?

I'm still working through the prerequisites to prior authorization for Lyrica. For the last week, I've been adding nortryptaline to my Neurontin, and I'm feeling a little doped-out. It's been harder than usual to stay awake at work after 3:30 or so , I'm unable to empty my bladder completely, and I haven't noticed any decrease in pain. Next week, it will be amitryptaline.

Meanwhile, from the London Times, an article about a pain-control technique using what I think you'd call a sort of bio-feedback:
Scientists in the United States have successfully taught eight patients to reduce pain from injuries by showing them live scans of their brains while they performed a set of mental exercises. The findings, from a team at Stanford University in California, have opened up the possibilities for treating chronic pain, which often responds poorly to standard therapy and leaves patients suffering throughout their entire lives.

Dr Mackey’s team used a new scanning technique, known as real-time functional magnetic resonance imaging, to capture live images of activity in a part of the brain called the rostral anterior cingulate cortex, that handles painful stimuli. As the patients watched the scans, they undertook mental exercises designed to alter brain activity and reduce pain. The goal was to train the brain to process pain in a different way, so that the patients would experience it less severely. The scans allowed the subjects to see what effect their thoughts were having on a small region of the brain, helping them to concentrate on changing its activity.

“We asked them to think about changing the meaning of the pain,” Dr Mackey said. “Instead of thinking of it as a terrible experience, to think of it as something relatively pleasant.” Over time, subjects showed an increased ability to modulate their pain. The study suggests that it may be possible to train people to change the way in which the pain centres of the brain process painful stimuli, making the perception of pain less intense.


Research: Azathioprine (Imuran) for MS

From WebMD:
Using magnetic resonance imaging, researchers showed that new brain lesions that indicate multiple sclerosis (MS) progression were reduced by more than half in 12 of 14 patients treated with the drug Imuran. The drug is now used primarily to prevent rejection in transplant patients and in the treatment of patients with rheumatoid arthritis and other autoimmune disorders. Imuran has been studied by MS investigators for several decades. Previous studies have shown that Imuran can reduce relapses in patients with multiple sclerosis. However, the new research is the first to show that the drug can slow disease progression by decreasing the presence of new lesions.

Study researchers say their findings are similar to other studies' results looking at the use of injectable interferon-beta and brain lesions in MS. But a spokesman for the National MS Society tells WebMD that larger studies are needed to prove this.
'If these findings are confirmed then we would have a less expensive oral medication that is of comparable benefit to the current treatments,' says John Richert, MD. 'These data show that it is worthwhile to invest the resources to try and prove that this drug alters disease progression.'

Link to WebMD article (the study will be pubished in the Archives of Neurology in December).

Update: Link to abstract for Imuran study

Compare this:
[Cost-utility analysis of relapsing-remitting multiple sclerosis treatment with azathioprine or interferon beta in Spain]

[Article in Spanish]

Rubio-Terres C, Dominguez-Gil Hurle A.

HERO Consulting, Health Economics and Research of Outcomes, Virgen de Aranzazu 21, E-28034 Madrid, Spain.

AIM: To carry out a cost-utility analysis of the treatment of relapsing-remitting multiple sclerosis (RRMS) with azathioprine (Imurel) or beta interferon (all, Avonex, Rebif and Betaferon). MATERIAL AND METHODS: Pharmacoeconomic Markov model comparing treatment options by simulating the life of a hypothetical cohort of women aged 30, from the societal perspective. The transition probabilities, utilities, resource utilisation and costs (direct and indirect) were obtained from Spanish sources and from bibliography. Univariant sensitivity analyses of the base case were performed. RESULTS: In the base case analysis, the average cost per patient (euros in 2003) of a life treatment, considering a life expectancy of 53 years, would be 620,205, 1,047,836, 1,006,014, 1,161,638 and 968,157 euros with Imurel, all interferons, Avonex, Rebif and Betaferon, respectively. Therefore, the saving with Imurel would range between 327,000 and 520,000 euros approximately. The quality-adjusted life years (QALY) obtained with Imurel or interferons would be 10.08 and 9.30, respectively, with an average gain of 0.78 QALY per patient treated with Imurel. The sensitivity analyses confirmed the robustness of the base case. The cost of one additional QALY with interferons would range between 413,000 and 1,308,000 euros approximately in the hypothetical worst scenario for Imurel. CONCLUSIONS: For a typical patient with RRMS, treatment with Imurel would be more efficient than interferons and would dominate (would be more efficacious with lower costs) beta interferon.

Link to abstract.

Monday, December 12, 2005

Darcy Wakefield dies at 35

A while back, I blogged a bit about Darcy Wakefield, a woman about my age who was diagnosed with ALS and then became a sometime commentator for NPR. Darcy Wakefield died on Saturday. She wrote her own obituary, which was published in the Portland Press Herald.

Medical marijuana: Researcher challenges federal monopoly on production

For decades, the federal government has been the nation's only legal producer of marijuana for medical research. Working with growers at the University of Mississippi, the National Institute on Drug Abuse has controlled both the quality and distribution of the drug for the past 36 years. But for the first time the government's monopoly on research marijuana is under serious legal challenge. The effort is being spearheaded by a group that wants to produce medicines from currently illegal psychedelic drugs and by a professor at the University of Massachusetts who has agreed to grow marijuana for the group if the government lets him.
"By controlling who can research marijuana and how they can do it, the DEA has greatly limited promising research that could lead to [government] approved medications," [Richard] Doblin [president of the Multidisciplinary Association for Psychedelic Studies (MAPS)] said. The problems, he said, are not limited to winning approval to buy the Mississippi marijuana. Doblin and other researchers contend that the government marijuana is low in quality and potency and could never be a stable source of basic ingredients if the Food and Drug Administration ever did approve a marijuana-based medication.

To me, this bears some resemblance to federal government funding restrictions on stem cell research: complex political and societal judgments about right and wrong stand in the way of research that, if successful in producing technology that reduces human suffering, would likely result in adjustments to those judgments. On the other hand, there's no sense in giving science a blank check just because its purpose is noble.

What to do?

Link to Washinton Post story.

Saturday, December 10, 2005

Current events: Richard Pryor on MS 10 years ago

I was poking around for a story that would shed some light on what Pryor's experience of MS was like, and stumbled on an article by David Schumacher that appeared in Ebony in 1993. At this point, Pryor had only recently stopped working as an entertainer. Here's a bit of his diagnosis story:
"MS is a very strange disease. I didn't know anything was wrong at first, [it] just crept up on me. Then one very strange day [director Michael] Apted said, 'Richard, come here.' And I did. Well, I thought I did. My brain told my body, 'Go see what the fella wants.' But my body said, 'I'm gonna f--- with you a bit, Rich.' Apted thought I was joking around. He said, 'Come on, Richard, stop goofing around.' I told him, 'Well, I'm not! trying real... hard to get there!'

They sent me to this wonderful place called the Mayo Clinic for a checkup. They did all these tests on me... After a week, I was told I had MS, not an extreme case, not enough to kill me, but just enough so that I can't masturbate."


R.I.P. Richard Pryor

From the AP:
Richard Pryor, the caustic yet perceptive actor-comedian who lived dangerously close to the edge both on stage and off, has died, his ex-wife said Saturday. He was 65.

Pryor died of a heart attack at his home in the San Fernando Valley sometime late Friday or early Saturday, Flyn Pryor said. He had been ill for years with multiple sclerosis, a degenerative disease of the nervous system.

The comedian was regarded early in his career as one of the most foul-mouthed comics in the business, but he gained a wide following for his expletive-filled but universal and frequently personal insights into modern life and race relations.

His audacious style influenced an array of stand-up artists, including Eddie Murphy, Arsenio Hall and Damon Wayans, as well as Robin Williams, David Letterman and others.

A series of hit comedies in the '70s and '80s, as well as filmed versions of his concert performances, helped make him Pryor one of the highest paid stars in Hollywood. He was one of the first black performers to have enough leverage to cut his own Hollywood deals. In 1983, he signed a $40 million, five-year contract with Columbia Pictures.

His films included "Stir Crazy," "Silver Streak," "Which Way Is Up?" and "Richard Pryor Live on the Sunset Strip."


Thursday, December 08, 2005

Shiny shiny: RocketFM USB audio transmitter

I just got a nifty new gadget- it's an FM audio transmitter that plugs into the USB port on my desktop. It's a handy solution for those of us who want to pipe audio from the computer to other places in the house, but are too cheap to pop for AirPort. With shipping, it cost about 30 clams, and I had it working in a couple minutes.

The cool part is how easy it is to open the case and extend the internal antenna so that it becomes a three-inch external antenna, greatly improving the devices range. It's almost it was designed with this hack in mind.

If you're running WinXP or OS X, you can use the included software to change the frequency the device transmits on. I'm stuck in the dark ages with Win2K, and my machine wouldn't run the software, but the gizmo is still plug-and-play, it's just limited to one frequency- 88.1 FM.

Here's what I'm using it for as I write: time-shifting NPR programming. Where I live, my NPR affiliate only broadcasts All Things Considered until 6 pm. If I had my druthers, ATC would run until 7 or later so I could listen while I'm making dinner. Now, all I have to do is pull up an internet simulcast for a station that's further west--say, KCRW in Santa Monica--and I can time-shift my NPR. Plus, I get to hear about how awful the traffic is out there while I'm in my cozy little house having a glass of wine.

The audio quality isn't fabulous-- it's FM, and for listening to music, it's just not up to snuff. But I love getting NPR when I want it, and I think I'm going to enjoy listening to international stuff like the BBC, too.

Wednesday, December 07, 2005

Current events: Social Security benefits may be cut to pay off student loans

A ruling from the Supreme Court today says the government can dip into your Social Security benefits to recover unpaid student loans. I'm not familiar with the issue in the case, and I don't doubt that Congress authorized this kind of action. Here's what's interesting to me: Generally, it's incredibly difficult to escape student loan debt, but if you're permanently and totally disabled, the government will cancel your student loans. A few years back, the government tightened up the regulations on getting a disability cancellation, narrowing the definition of disabled and requiring a 3-year period of "conditional discharge," in which you need not make payments but the debt continues to exist. If you're still disabled after three years, the debt is cancelled.
Here's the problem: the IRS considers the amount of discharged debt to be income, for tax purposes. So maybe you manage to get out from under student loan debt, but then you end up suddenly owing the IRS a big chunk of tax money. And who would you rather have on your back: the Department of Education, or the IRS?

Link to NYT story on today's ruling (free reg req'd)

Journal: Are there wheelchairs in heaven?

This morning, I caught the tail end of a commentary on NPR by Ben Mattlin. Mattlin's a lifelong quadriplegic, and spoke about attending a funeral for a friend who, while also a quad, ended up there as a result of a motorcycle accident. At the funeral, there was talk about how Mattlin's friend was, in death, freed from his wheelchair; how, in heaven, he was restored to his pre-injury body, he was "in a better place." Mattlin was stung- did they mean that his friend was better off dead than in a wheelchair?

Mattlin notes that people who become disabled often find that they experience a depth and intensity to life that they didn't feel pre-disability. I'm probably one of those people. But if offered the choice, would I trade depth and intensity for good health? Absolutely.

What does that mean about my view of disability? For all of my convictions about rights of the disabled, about the worth of a person who is disabled, I have to admit that I see myself as something less than a whole person. Because of MS, there's something missing, something that used to be there that isn't any more, and that hole isn't filled by depth and intensity.

Is this a problem?

Tuesday, December 06, 2005

Journal: First, something cheaper

Yesterday, I was back at the pain clinic for an appointment with the nurse practitioner who does medication management. It was a follow-up visit I'd scheduled months ago, but the timing ended up being just about perfect. For the last month or so, I'd been feeling more than a little bit unraveled: the pain was starting earlier in the day, it was more intense, it was spreading from my legs to the bottoms of my feet. I was struggling to concentrate at work, and I noticed I was avoiding social contacts, I was avoiding physical activity, I was irritable and depressed. I also started to notice that as I was trying to fall asleep, my legs were playing this odd involuntary soccer match, which I was told was a consequence of the large quantities of Neurontin that I've been taking for the last couple years.

So I was happy to hear the nurse practitioner say that there's a brand-spanking-new drug available to treat neuropathic pain called Lyrica (pregabalin), that they've had good luck with it, and that it has fewer side effects than Neurontin. I was not happy, though, to learn that Navitus, the pharmacy benefit manager for my HMO, would not pay for Lyrica unless and until I've tried 1) Neurontin + imipramine, 2) Neurontin + nortryptaline, and 3) Neurontin + amitryptaline.

Now, I understand the valuable function that pharmacy benefit managers serve in the system in ensuring that the HMO's pharmacy dollars are spent wisely. I understand that if the HMO paid every time somebody wanted the latest-and-greatest drug, maybe a drug that was advertised on TV, instead of trying effective, cheaper alternatives first, my premium would be a lot higher than it is.


I wish I could talk to one of the medical directors at Navitus. I wish I could explain that over the last three or four years, I've been through a succession of drugs to deal with the ever-increasing burning pain in my lower extremities, that I started out with imipramine, tried a handful of different anticonvulsants before settling into a Neurontin habit that has me taking a pill every 2 1/2 hours, on the suggestion of my neurologist, shelled out a few hundred bucks to try acupuncture, started meditating and doing yoga, and I still feel like pain has been a significant factor in the way I've lived my social and professional life. I still feel like most difficult part of living with MS for me is not the end of the physical, active life I used to live, not the indignities of bladder problems or sexual dysfunction, or the looming uncertainty of increasing disability in the future; the most difficult part right now is that every day at about 3:30 in the afternoon, my legs start to burn so badly that I want to chop them off.

So I need to wait. Maybe it will turn out that the neurontin + tricyclic combination is effective and doesn't leave me feeling dopey and sluggish. Maybe, but I'm still mad as hell.

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Monday, December 05, 2005

In the news: Teri Garr on NPR

Today on NPR, Terry Gross spoke with Teri Garr about her career (including dancing in 9 Elvis movies) and about MS. I've read some critical comments about how Garr handles her MS in public. I haven't seen her TV appearances, so I'm not sure what the issue is, but I really enjoyed this interview. If Garr has become the Designated MS Celebrity Ambassador, it's a role she plays with grace and humor, and a little ambivalence.

She's got a book out, of course, called "Speedbumps." Garr says she was going to call the book "Does This Wheelchair Make Me Look Fat?" I'm guessing she's already used that joke in her TV appearances.


Wednesday, November 30, 2005

Current events: NYT aritcle on "problem docs"

Had a bad experience with a doc? The NYT continues its series on being a health care consumer with an article ("When the Doctor Is in, but You Wish He Wasn't") about patients' bad experiences with physicians and some strategies used to prevent such experiences:
At the Rochester Independent Practice Association in New York, with 3,000 doctors, patients are surveyed, and their satisfaction scores can account for 20 percent of a doctor's pay. At Tufts Health Plan, 3,000 to 4,000 doctors had all or part of their bonuses withheld last year because their patients did not rate them highly, said Richard Lynch, the plan's vice president of network contracting.
In California, said Dr. Ronald Bangasser, the past president of the California Medical Association, eight major health insurers have a new program in which they divide $30 million among 35,000 physicians depending on how their patients rate them. 'It could be $3,000, $4,000 or $5,000 per physician,' Dr. Bangasser said. 'That would get their attention.'

Should doctors be motivated to make their patients like them more? Sure, as long as the incentive to provide quality care remains much, much stronger.
Link (free reg req'd)

Research: Is EAE a good model for MS?

MS research often involves experiments with animals that have been induced with experimental allergic encephalomyelitis. Like MS, EAE is a demyelinating disease, and can be induced in rats, mice, guinea pigs, rabbits, and monkeys. Studies involving EAE led to the development of Novantrone and Copaxone. But what if EAE wasn't as good a model for MS as we thought?
Despite many years of intensive research, multiple sclerosis (MS) defies understanding and treatment remains suboptimal. The prevailing hypothesis is that MS is immune mediated and that experimental allergic encephalomyelitis (EAE) is a suitable model to elucidate pathogenesis and devise therapy. This review examines critically the validity that EAE is an adequate and useful animal model of MS and finds credible evidence lacking. EAE represents more a model of acute central nervous system inflammation than the counterpart of MS. We propose to reconsider the utilization of EAE, especially when this model is used to define therapy. This will also force us to examine MS without the restraints imposed by EAE, as to what it is, rather than what it looks like. Ann Neurol 2005;58:939-945.

Link to abstract.
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Shout-out: Bug off, my spammy friend

It probably shouldn't bother me as much as it does, but it really irks me that somebody's trying to market health insurance policies to the six or seven people who drop by this blog by leaving bogus comments about how health insurance is a "major aspect of many people's lives." These comments are attributed to "Blue Cross of California," but link to an insurance agent's web site.

It's one thing if you're selling like P3N1S 3NLARG3M3NT or h/e/r/b/a/!++v0!0a0g0r0a, but I don't know why anyone would think this is an effective way to market
something like health insurance. I doubt this is a technique sanctioned by Blue Cross, and I doubt it generates more good will than ill. Maybe you get some hits by associating yourself with "health insurance" and "Blue Cross of California," but eventually some irate blogger who isn't as nice as I am will associate your name with "spam" or "jerk" or "fraud" or "California Insurance Commissioner complaint" or "serial masturbator."

Don't come around here no more.

Monday, November 28, 2005

Research: Badonkadonk interfering with IM injections

Doctors at a Dublin hospital report that fat tissue in the buttocks of patients, particularly obese women, may exceed the length of needles commonly used to deliver intramuscular injections:
Dr. [Victoria] Chan's research found 68% of the injections do not reach the muscles of the buttock. Dr Chan said her work suggested that patients were either not receiving the maximum benefit of a drug or receiving no benefit at all.

Professor Richard Guy, an expert in pharmaceutical sciences at Bath University, told the BBC News website the effectiveness of vaccines could be particularly compromised. They tend to be made up of large molecules that would only slowly diffuse out of fat tissue. He said: "Whether using longer needles is a practical solution, I'm not sure, as these are unlikely to be terribly popular."

Link to BBC News item.

Journal: Zero to miserable in less than 10 doses

I canned my second try with Cymbalta after about a week. Maybe I'd forgotten why I quit the first time around, but I think my second try was worse than the first. After a couple days, I was either getting up to pee or to put a dry pad on the bed three times a night. By last Wednesday, I was feeling sleep-deprived and achey, which was a bad thing because we were hosting a small crowd for Thanksgiving.

After a draining day of housecleaning, Thanksgiving dinner (and a generous dousing of white wine) left me feeling completely deflated, several helpings of turkey notwithstanding. On Friday, I stayed home and did nothing. Nothing at all. That morning, I quit taking Cymbalta. Again.

I've been sleeping better and better since then. I'm also trying to get back into swimming a couple of times a week. I'll be seeing the nurse practitioner at the pain clinic in a week or two, and I'm hoping she'll have a new angle for me.

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Tuesday, November 22, 2005

Current events: Vaccine controversy makes for daunting journalism

Daniel Schulman writes at the Columbia Journalism Review about coverage of the vaccine-autism controversy. Schulman's take is that the reporting on the subject has generally been too reluctant and generally too accepting of the CDC party line and too dismissive of contrary information. Schulman gives a helpful account of what some anti-vaccine folks see as evidence of a cover-up, and serves up a critique of a New York Times piece by Gardiner Harris and Anahad O’Connor that appeared on the paper's front page on June 25. Schulman notes that the issue is uniquely flammable:
Journalists agree that the thimerosal story is one of the most explosive they've ever encountered. In addition to the vitriolic response Anahad O'Connor drew from readers, he also said he received a number of e-mails praising him and Harris from fellow reporters who had been interested in covering the thimerosal controversy, but had "gotten scared away from really tackling the subject . . . they were afraid of getting hate mail."

Some reporters who have portrayed this as an ongoing scientific controversy have been discouraged by colleagues and their superiors from pursuing the story. A reporter for a major media outlet, who did not want to be identified for fear of retribution, told me that covering the thimerosal controversy had been nearly "career-ending" and described butting heads with superiors who believed that the reporter's coverage "in treating the issue as a two-sided debate" legitimized a crackpot theory and risked influencing parents to stop vaccinating their children or to seek out experimental treatments for their autistic sons and daughters.

The reporter has decided against pursuing stories on thimerosal, at least for the time being. "For some reason giving any sort of credence to the side that says there's a legitimate question here. I don't know how it becomes this untouchable story, I mean that's what we do, so I don't understand why this story is more touchy than any story I've ever done."


Monday, November 21, 2005

Journal: Giving Cymbalta another try

A couple months after quitting in frustration, I've decided to give Cymbalta another try. The Zonegran I've been adding over the last couple months to my usual load of Neurontin hasn't seemed to do much for the burning neuropathic pain in my legs. And the shortened days have left me feeling impatient, frustrated, lonely. The bottom line, I guess, is that the pain relief and mood enhancement I got from Cymbalta may be worth waking up in my own pee a couple times a night.

It's just been a few days since I started the Cymbalta, but I think I've noticed a small decrease in the pain already: when I woke up this morning, I didn't feel the same dull ache that has made it so difficult to get out of bed. I haven't been sleeping well, though. I think last night I got up to pee like five times.

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Friday, November 18, 2005

MS and medical marijuana: "limited evidence" of longer-term effect on disability

Do results like these mean that more pot research is needed or that we should direct those resources to something else?
J Neurol Neurosurg Psychiatry. 2005 Dec;76(12):1664-1669.
Cannabinoids in multiple sclerosis (CAMS) study: safety and efficacy data for 12 months follow up.
Zajicek JP, Sanders HP, Wright DE, Vickery PJ, Ingram WM, Reilly SM, Nunn AJ, Teare LJ, Fox PJ, Thompson AJ.
Room N16, ITTC Building, Tamar Science Park, Plymouth, Devon PL6 8BX, UK.

OBJECTIVE: To test the effectiveness and long term safety of cannabinoids in multiple sclerosis (MS), in a follow up to the main Cannabinoids in Multiple Sclerosis (CAMS) study. METHODS: In total, 630 patients with stable MS with muscle spasticity from 33 UK centres were randomised to receive oral Delta(9)-tetrahydrocannabinol (Delta(9)-THC), cannabis extract, or placebo in the main 15 week CAMS study. The primary outcome was change in the Ashworth spasticity scale. Secondary outcomes were the Rivermead Mobility Index, timed 10 metre walk, UK Neurological Disability Score, postal Barthel Index, General Health Questionnaire-30, and a series of nine category rating scales. Following the main study, patients were invited to continue medication, double blinded, for up to12 months in the follow up study reported here. RESULTS: Intention to treat analysis of data from the 80% of patients followed up for 12 months showed evidence of a small treatment effect on muscle spasticity as measured by change in Ashworth score from baseline to 12 months (Delta(9)-THC mean reduction 1.82 (n = 154, 95% confidence interval (CI) 0.53 to 3.12), cannabis extract 0.10 (n = 172, 95% CI -0.99 to 1.19), placebo -0.23 (n = 176, 95% CI -1.41 to 0.94); p = 0.04 unadjusted for ambulatory status and centre, p = 0.01 adjusted). There was suggestive evidence for treatment effects of Delta(9)-THC on some aspects of disability. There were no major safety concerns. Overall, patients felt that these drugs were helpful in treating their disease. CONCLUSIONS: These data provide limited evidence for a longer term treatment effect of cannabinoids. A long term placebo controlled study is now needed to establish whether cannabinoids may have a role beyond symptom amelioration in MS.

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Wednesday, November 16, 2005

Research: Decaf coffee is bad for your heart (unless you're overweight)

Decaf coffee can raise your bad cholesterol. If you're overweight, though, decaf can raise your good cholesterol. "Only half a cup? Have you lost weight, Steve?"

From The Guardian:
Researchers funded by the National Institutes of Health, the prime public health bodies in the US, reported their 'very surprising' findings by poster at the American Heart Association's scientific meetings in Dallas. They compared levels of caffeine in the blood and indicators of general heart health before and after three months of steady coffee drinking or abstinence. The coffee drinkers, who had three to six cups of home-brewed black coffee a day, were in two groups, one on a caffeinated brand, the other on decaf.

The study found the decaf group experienced an average 18% rise in fat in the blood, the fuel that increases bad cholesterol, and had higher incidence of a protein called ApoB, which is associated with bad cholesterol. There was little overall difference generally in levels of a particular form of good cholesterol called HDL2, although within the decaf group there were significant differences depending on people's body fat.


Driveway moment: Howard Dully and the 'ice-pick' lobotomy

On Jan. 17, 1946, a psychiatrist named Walter Freeman launched a radical new era in the treatment of mental illness in this country. On that day, he performed the first-ever transorbital or 'ice-pick' lobotomy in his Washington, D.C., office. Freeman believed that mental illness was related to overactive emotions, and that by cutting the brain he cut away these feelings.

Freeman, equal parts physician and showman, became a barnstorming crusader for the procedure. Before his death in 1972, he performed transorbital lobotomies on some 2,500 patients in 23 states.

One of Freeman's youngest patients is today a 56-year-old bus driver living in California. Over the past two years, Howard Dully has embarked on a quest to discover the story behind the procedure he received as a 12-year-old boy.

In researching his story, Dully visited Freeman's son; relatives of patients who underwent the procedure; the archive where Freeman's papers are stored; and Dully's own father, to whom he had never spoken about the lobotomy.

'If you saw me you'd never know I'd had a lobotomy,' Dully says. 'The only thing you'd notice is that I'm very tall and weigh about 350 pounds. But I've always felt different -- wondered if something's missing from my soul. I have no memory of the operation, and never had the courage to ask my family about it. So two years ago I set out on a journey to learn everything I could about my lobotomy.'

Link to NPR page with archived audio. Note the helpful "Lobotomy Resources" at the top right-hand corner.

Research: Can monks contribute to neuroscience?

An article at by Daniel Engber notes the controversy over an appearance by the Dalai Lama at the annual meeting of the Society for Neuroscience. His Holiness believes that the Buddhist discipline of meditation can offer much to the study of consciousness, but more than 600 members signed a petition to keep the DL out of the Society's meeting. It's an interesting take on the science-vs.-religion thing:
The Buddhist scholar Carl Bielefeldt argued that Buddhist monks don't use the scientific method at all. A student who makes an unexpected discovery through introspection might be told by his master that he made a mistake. 'It looks like creation science,' he said. 'There are certain norms that cannot be questioned.'
The similarities between Buddhism and neuroscience that the Dalai Lama sees, however, extend beyond methodology. Practitioners of both disciplines-whether they're monks or psychiatrists-aim to replace sad feelings with happy ones. In this regard, he says, Buddhist inquiry has advanced far beyond Western mind science. Over a hundred generations, monks have used meditation as way of controlling their bad emotions. If neuroscientists really want to reduce suffering, they should study the effects of meditation on the brain and test it as a clinical tool.
A few presentations at the conference showed off the latest research in this area. A lab in Wisconsin used electrodes to measure brain activity in meditating monks and showed an increase in Gamma waves, which are associated with focused attention. A Harvard researcher suggested that regular meditation could thicken the cortex in certain parts of the brain. Another scientist found surprising perceptual abilities among Indian monks.


Tuesday, November 15, 2005

Research: Being cold increases the risk of catching a cold

In the winter, when I was a kid, my mom used to yell at me to wear at hat when I was outside. "You'll catch a cold!" Being a smarty-pants nerd, I thought, Yeah, right, mom- wearing that hand-me-down Minnesota Vikings stocking cap will magically ward off the virus that causes the common cold. Well, mom was right, sorta:
[I]n winter the cold weather outdoors causes the blood vessels in the lining of the nose to constrict, a reflex mechanism to save heat. This reduces the blood supply to the nasal lining where viruses can gain a foothold and become established. "The effect of the cold is that it reduces the flow of white blood cells, the body's immune response, cutting off the troops to fight the infection. The cold also slows the flow of mucus in the nose which is needed to trap the virus so you swallow it and destroy it in the stomach," Professor Eccles says.

Link to item in The Independent.

Steve McQueen and Laetrile

Steve McQueen died of cancer 25 years ago this month. A piece in the NYT focuses on how McQueen, who had mesothelioma, turned to alternative therapies, including Laetrile:
When his doctors told him they had run out of options, McQueen secretly met with Dr. William D. Kelley, a dentist and orthodontist who had devised a controversial treatment regimen he claimed had cured his own pancreatic cancer.
Dr. Kelley had been blacklisted by the American Cancer Society and had his license suspended in Texas. But McQueen was interested in the treatment, which was based on the notion that cancers arose and grew from a lack of enough pancreatic enzymes.
In July 1980, McQueen secretly traveled to Rosarita Beach, Mexico, to be treated by Mexican and American doctors using Dr. Kelley's regimen. He received not only pancreatic enzymes but 50 daily vitamins and minerals, massages, prayer sessions, psychotherapy, coffee enemas and injections of a cell preparation made from sheep and cattle fetuses. McQueen was also given laetrile, a controversial alternative treatment made from apricot pits.

Link (free reg req'd)

Monday, November 14, 2005

Research: Is This a Solution?

In the Washington Post, Robin Marantz Henig sees danger lurking in the new techniques for obtaining stem cells without destroying living embryos. To Henig, these techniques represent science that has been compromised to accommodate the moral and religious objections of those who control federal funding:

"There's a long history of using science to get around religious issues, otherwise we'd be sitting in the dark on the Sabbath," said Laurie Zoloth, a medical ethicist at Northwestern University, at the Genetics and Public Policy Center panel last week. "Whenever you have an absolute rule in a rule-based system," she said, whether in observant Judaism or in following the federal restrictions on embryonic stem cell research, people "figure out some way to stay within the confines of the rule" and still do what they want to do. These latest experiments, she said, were "something like tofu cheeseburgers," a compromise created for Jews following kosher laws that forbid mixing meat and dairy in the same meal.

And scientific good can come from adjusting to ethical concerns, as the example of animal experimentation shows. Not only were research results more reliable when the laboratory animals were subjected to less stress in response to activists' concerns, but when non-animal models were used instead, the experiments were often less costly and more easily reproduced.

Could a good outcome happen with stem cell research, too, as investigators begin designing experiments to satisfy their critics? Perhaps. But there's a greater danger here than there was with animal experimentation. The danger is that stem cell scientists will address what they believe to be their critics' major stumbling blocks in a way that both subverts the science and fails to respond to the critics -- the worst of both worlds. "How many hoops do you have to go through as a scientist," George Daley, a stem cell researcher at Harvard University, was quoted as saying when the Nature articles appeared, "when you don't think you are doing anything wrong?" It's in trying to parse out religious objections they don't always share or even understand that scientists can run into trouble.


NYT: Big pharma's image problem hurting sales

The NYT reports that big drug companies, while still profitable, are feeling the effects of an "industrywide credibility crisis." Going back to vaccine refusniks and my sister-in-law, this must a factor in driving some people away from the scientific medical establishment:
Overall, prescriptions continue to rise slightly, but an increasing share of prescriptions are going to generic drugs. Also, consumers seem to be less responsive to aggressive drug marketing. 'A lot of the demand that the industry has created over the years has been through promotion, and for that promotion to be effective, there has to be trust,' said Richard Evans, an analyst covering drug stocks at Sanford C. Bernstein and Company. 'That trust has been lost.'

A poll last month showed that only 9 percent of Americans believed drug companies were generally honest, down from 14 percent in 2004. In contrast, 34 percent of people said they trusted banks, and 39 percent trusted supermarkets. "The incessant direct-to-consumer advertising on television I think has boomeranged," said Dr. Marcia Angell, a former editor-in-chief of The New England Journal of Medicine and a frequent industry critic. Dr. LaMattina and other executives say that perception unfairly disregards the billions of dollars that drug companies spend on research each year and the hundreds of important medicines they have discovered since World War II. Even the industry's staunchest defenders agree that it needs to explain risks better.

"We've created an impression with the American public that when a drug is approved, it's perfectly safe," said Billy Tauzin, president of the Pharmaceutical Research and Manufacturers of America, a lobbying organization for brand-name drug companies. "We have not done a good job about educating the patients of America that all drugs come with significant side effects."

Link (free reg req'd)

Friday, November 11, 2005

Research: Race-based medicine?

The NYT reports on the discovery of a gene that raises the risk of heart attacks in African-Americans by 250%. Six percent of African-Americans carry the gene, called leukotriene A4 hydrolase (catchy, isn't it?), which is involved in the synthesis of leukotrines, agents that maintain a state of inflammation. There's a drug currently in phase III trials that affects a different gene that is also involved in control of leukotrienes. Should a separate study of the drug with only African-American subjects be conducted?
Dr. Troy Duster of New York University, an adviser to the federal Human Genome Project and a past president of the American Sociological Association, said he saw no objection to a trial, provided it focused on African-Americans with the risk-associated variant of the gene and took into account that people with ancestry from different regions of Africa might show variations in risk. But Dr. Charles Rotimi, a genetic epidemiologist at Howard University, said a separate study of African-Americans would not be desirable. The variant gene may be overactive in African-Americans because of their greater exposure to deleterious environments, Dr. Rotimi said.

If that's what Dr. Rotimi said, does he mean that a drug shouldn't be studied because all we need to do to eliminate the increased risk for African-Americans with the leukotriene A4 hydrolase gene is to eliminate their "greater exposure to deleterious environments"? Yeah, forget the pill, we'll just ensure that African-Americans are no longer disproportionately exposed to deleterious environments. I'll just make a few phone calls...

Link (free reg req'd)

Wednesday, November 09, 2005

Drug ads: overselling the serotonin boost?

Can depression be explained by a simple chemical imbalance in the brain? A pair of researchers has complained that the evidence for this is weak, and that drug companies should not be allowed to push this message in their advertisements.

After being bombarded by messages that depression is caused by the lack of a certain chemical in the brain, say the researchers, patients may be sceptical of other kinds of treatment, including other drugs and talking to a therapist. 'That message [in the advertisements] is at odds with what's in the scientific literature,' says Jonathan Leo of the Lake Erie College of Osteopathic Medicine in Bradenton, Florida, who co-authors an essay on the subject in PLoS Medicine this week. The duo would like the Food and Drug Administration (FDA), which regulates drug advertising in the United States, to take a look at antidepressant ads and issue warnings to any firm that does not comply with its rules.

Link (free reg req'd)

Current events: Federal appeals court upholds Maine law regulating pharmacy benefit managers

A federal appeals panel has upheld a Maine law that imposes disclosure and other duties on pharmacy benefit managers (PBMs). What's a PBM? Here's a summary largely drawn from the court's opinion:

PBMs act as middlemen between pharmaceutical manufacturers and pharmacies and health benefit providers (e.g., my HMO, your insurance company, etc.). PBMs use their market power to negotiate volume discounts and rebates with drug manufacturers. PBMs may also have "therapeutic interchange programs" that allow them to substitute a drug for the one your doctor actually prescribed.

What's good for a PBM, though, may not be good for your HMO. For example, in cases of "therapeutic interchange," a PBM may substitute a more expensive brand name drug for an equally effective and cheaper generic drug so that the PBM can collect a fee from the manufacturer for helping to increase the manufacturer's market share within a certain drug category. Or a PBM might get a discount from a manufacturer on a particular drug but not pass any of it on to your HMO, keeping the difference for itself.

Under the Maine law, PBMs must act as fiduciaries for their clients (i.e., HMOs, insurance companies, etc.): they must disclose conflicts of interest, disgorge profits from self-dealing, and disclose certain financial arrangements with third parties.

The Boston Globe describes the lawsuit this way:
The association had argued that Maine's Unfair Prescription Drug Practices Act was unconstitutional and could end up harming consumers because benefit managers use confidential information to get drug companies to compete with each other by lowering their prices. But supporters view the law as a means to promote transparency by giving health plan clients access to information about discounts, drug switching programs and any conflicts of interest involving benefit managers.

Link to Boston Globe story.

Current events: 5 cases of polio in Minnesota Amish group

From the NYT, in case you haven't seen it:
The 8-month-old Amish girl, whose name has been withheld by health officials, has an immune deficiency that makes her unable to rid her body of the [polio] virus. How she contracted the virus remains a mystery. She may have been infected in a hospital by another immune-deficient patient who nursed it for years. A doctor or nurse may have served as a go-between. Or there may have been a chain of carriers in the Amish community. The virus is spread from stool to mouth, a surprisingly efficient form of transmission.

Regardless, the girl is now a wellspring for polio, a modern-day Typhoid Mary who can pass it along to others. Anyone who has not been vaccinated is vulnerable. And though vaccination rates in the United States are at historic highs, an increasing number of parents are resisting inoculations for their children, fearing that they may cause disorders like autism, a connection scientists have almost universally discounted.

Link (free reg req'd)

Tuesday, November 08, 2005

Health policy: physician reaction to parents who refuse vaccination

The Washington Post reports on a study of pediatrician attitudes to vaccine refusal:
A team of pediatricians from three major Chicago medical centers surveyed more than 300 of their colleagues around the country about their attitudes toward vaccine refusal. Slightly more than half of pediatricians said that in the previous year they had encountered at least one family that refused all vaccines, while 85 percent said they'd had a parent turn down at least one shot.
More surprising to the authors were two findings: 39 percent of those surveyed said they would consider turning away a family that refused all shots -- researchers had expected the number to be about 20 percent -- while 28 percent said they'd think about severing a relationship with a family that refused some shots.

My sister-in-law has three little kids, the most beautiful, healthy-looking kids I know-- Gerber babies, all of them. None have been vaccinated. I don't know if they ever see an M.D. When they're sick, they visit a chiropractor/naturopath/kinesiologist. On a daily basis, they take an array of herbal and homeopathic preparations.

Shortly after she had her first kid, my sister-in-law had an illness that doctors were unsuccessful in helping her overcome. I'm not sure about the details, but the important bit is that a friend got her to try a wheat- and gluten-free diet, and it made her feel a lot better. She read books like "The Yeast Connection" and got connected, in part via the internet, to a network of people who were skeptical of the traditional medical establishment. She became a devotee of applied kinesiology, bought a Chi Machine, started using magnets.

It used to make me crazy. I couldn't believe that she'd dedicated her life to quackery, that she'd entrusted the health of her children to people who defied science. I was furious when she'd send emails and links to articles about how Nutrasweet causes MS or how supplement-and-diet-book peddler Dr. Mercola considers interferon drugs for MS "a waste of money." These days, though, I'm more or less over it. We do not live in an age of reason. For whatever reason, people distrust science and the authority it claims. A Gallup Poll in February of 2005 found that about half of all Americans think "God created human beings pretty much in their present form at one time within the last 10,000 years or so." This is apparently one of the things that my sister-in-law is teaching her kids.

Now, it's a free country and you're free to believe pretty much any kooky thing you want. But isn't there a public health problem lurking here? Don't we all have an interest in maximizing the number of people receive vaccinations? What about the dreaded bird flu pandemic? What if a significant number of people refuse to follow science-based advice? More generally, as a practical matter, in our health care system, don't we all run the risk of paying for the consequences of bad health advice?

Which takes me back to the article: apparently, if you're a parent who refuses vaccination, you run a significant risk of being "fired" by your doctor. What do these docs think are the likely consequences of terminating these people? I'll venture a guess that a refusnik parent who's been fired by her pediatrician is more likely to explore so-called complementary medicine, more likely to venture further and further from science. Is this desirable, from a public health perspective?

Link to WaPo article.

Monday, November 07, 2005

MS research: update on hematopoietic stem cell transplantation

Here's the abstract:
Acta Haematol. 2005;114(4):239-47. Related Articles, Links
Autologous hematopoietic stem cell transplantation for autoimmune diseases.
Tyndall A, Daikeler T.
Department of Rheumatology, University Hospital, Basel, Switzerland.

Ten years have passed since the first published consensus statement on the use of hematopoietic stem cell transplantation (HSCT) in the treatment of severe autoimmune disease (AD) appeared. During that time, around 700 patients suffering from severe AD have undergone HSCT in the frame of phase I/II clinical trials from over 20 countries including the US. The majority have received an autologous HSCT using one of a limited number of regimens, consistent with the original consensus statement. Long-term drug-free remissions, remission then relapse, no response and treatment-related mortality (TRM) were seen in all the subgroups of AD. An overall TRM of 7% was observed, with marked variation between ADs, i.e. 11% in systemic lupus erythematosus (SLE) and only 1 patient in rheumatoid arthritis (RA). Phase III prospective, comparative randomized trials are running or being planned in multiple sclerosis (MS), systemic sclerosis (SSc), SLE and RA. Basic science programs are also being undertaken to study the immunological mechanisms underlying the clinical events observed. Copyright (c) 2005 S. Karger AG, Basel.

Journal: I made the pot roast

Most of the day yesterday, my wife and my father-in-law were climbing about in our attic, putting in the wiring for some new lights for our kitchen. The day before, he had been up and down the step ladder, cutting holes in the ceiling while clumps of insulation and bits of drywall fell on his head. My in-laws were visiting for the weekend, ostensibly to attend a concert, but a day before they arrived, we asked my father-in-law if he'd be willing to help us put in a few recessed lights before the insulation people came by to add another foot and a half of fluff to the attic.

I thought that I might at least be of use in cutting the holes, or possibly in doing some wiring from below, even if I wasn't a great candidate for working in the attic (for a number of reasons). As it turned out, my father-in-law did pretty much the whole thing, with my wife assisting. I consulted as to location, and I handed a few things up to the attic, but mostly, I made dinner and manned the couch.

Around 7 or so last night, we sat down to dinner. With the kitchen a bit torn up, I'd fired up the crock pot for pot roast. From where I was sitting, I had a pretty good view of the TV. On Extreme Makeovers, the emotive Ty Pennington was unveiling the over-the-top remodeling job given to the home of what looked to be a gaggle of disabled kids and their adoptive mom. Suddenly, they all lived in a mansion with Kenmore appliances, a fountain-adorned pool out back, and a fabulous new Ford Fusion in the garage. That's a lot of pot roast.

Sunday, November 06, 2005

Health policy: Medicare drug benefits=the end of drug co. charity programs?

Drug companies have touted their charity programs in an effort to improve their image. But as the feds roll out Medicare drug benefits, some patients are being told they must choose between the charity programs and the Medicare drug benefits, as the NYT reports:
Mr. Bach, 65, who is blind, received worrisome news last month from Bristol-Myers Squibb. The free Plavix he gets from the company's charitable foundation will stop if he enrolls in the new Medicare prescription program that begins in January.

Mr. Bach says that his free Plavix, a $125-a-month blood thinner that reduces the risk of heart attacks and strokes, is more valuable than the immediate benefits he would receive from signing up for the Medicare program, even taking into account the three inexpensive generic drugs he also takes.

The letter telling Mr. Bach that he must choose between Bristol-Myers's program and the new Medicare drug benefit speaks to an unintended effect that the new Medicare plan is having on the pharmaceutical industry's charity drug programs. Some companies are simply eliminating their charity programs for older people, taking the position that the recipients are now eligible for Medicare drug coverage.

Other drug companies, like Eli Lilly, are discontinuing their charity programs entirely.
Link (free reg req'd)

Saturday, November 05, 2005

Health policy: outsourcing medical care

There's an interesting article at about southern California HMO's that require their patients to receive nonemergency care in Mexico. Maybe this only seems mindblowing to me because I live so far north of the border with Mexico:
Five years ago, California became the only state to regulate insurance programs that require border crossing for basic health care. Since then, more than 700 non-agricultural businesses have offered plans requiring treatment in Mexico. Hundreds of farms offer similar coverage for about 120,000 migrant laborers.

At the Santaluz golf resort in San Diego, where Gonzales supervises golf course maintenance, workers can sign up for a Blue Shield of California plan called Access Baja. Their doctor visits are covered in the United States or Mexico, while their families are covered only in Mexico. Dale Standfast, the resort's controller, said several workers whose dependents were not covered switched plans to cover their families.

Offering Access Baja saves the resort about $1,000 per month in premiums, he said. This year the club used the savings to offer vision coverage to all employees for the first time, Standfast said.Lower-priced labor, malpractice insurance and overhead in Mexico mean both basic and sophisticated medical procedures can be performed at a small fraction of the cost. A hysterectomy that averages $2,025 in the United States costs $810 in Mexico, said Mary Eadson, director of legal compliance for the Western Growers Association, an agricultural organization that provides health insurance for California workers in Mexico.
Passport to Health Care At Lower Cost to Patient

Friday, November 04, 2005

Health policy: Americans pay more, get less

Hey, another study says Americans spend more on health care and get less. Yawn. Throw it on the pile, I guess.

Clearly, it's going to take something more than studies to get some kind of traction on health care reform. Note that we still come out ahead in one important measure: getting access to specialists. Maybe that's enough to make us feel like we're getting better care than we are: even if we're not getting the best care for our money, at least we're getting attention. Maybe we value that more.
The survey of nearly 7,000 sick adults in the United States, Australia, Canada, New Zealand, Britain and Germany found Americans were the most likely to pay at least $1,000 in out-of-pocket expenses. More than half went without needed care because of cost and more than one-third endured mistakes and disorganized care when they did get treated.
Americans had the easiest access to specialists, but they experienced the most problems getting care after hours, and Americans and Canadians were the most likely to report problems seeing a doctor the same day they sought one.

Americans were also much more likely to report forgoing needed treatment because of cost, with about half saying they had decided not to fill a prescription, to see a doctor when they were sick or opted against getting recommended follow-up tests. About 38 percent of patients in New Zealand reported going without care; the numbers were 34 percent in Australia, 28 percent in Germany, 26 percent in Canada and 13 percent in Britain.

Link to article in Washington Post.

Government in action: DEA gets veto in painkiller approval

For the second year in a row, language tucked into an appropriations bill gives the Drug Enforcement Agency (DEA) the power to veto new narcotic medications. While I can understand the desire to prevent another crop of Oxycontin addicts, I don't understand why it's necessary to involve DEA at this stage in the process:

Before the provision was passed last year, the DEA's role with prescription drugs was primarily to decide how much of a controlled drug each company got to make, and then to monitor the use of those drugs on the market. Now, however, the DEA must sign off on any new FDA-approved medications containing controlled substances before they can be sold.

The FDA's deputy commissioner for medical and scientific affairs, Scott Gottlieb, said yesterday that the agency opposed the legislation, which for the second year in a row was added by the House to the yearly appropriations bill for several major departments. 'Specific language attached to the appropriations bill would ultimately delay access by physicians and their patients to important, safe and effective pain management and palliative care medicines,' Gottlieb said. He said giving DEA authority over traditional FDA territory could upset 'a delicate balance for managing both safety and access.' Although the dispute is ostensibly over a limited change in how controlled drugs are approved and labeled, it has become something of a stand-in for a larger battle over whether DEA's actions are intruding into the practice of medicine and denying pain sufferers relief they need.

Link to Washington Post article.

Research: have another helping of turkey?

I absolutely guarantee that at this year's Thanksgiving dinner, Aunt Janice will present you with a clipping of an article about this study:

A team of scientists in California and Germany have prevented paralysis in mice with multiple sclerosis by feeding them a synthetic version of a by-product of an important amino acid. The body uses the amino acid, tryptophan, for many things, including regulation of the neurochemical serotonin. The new findings, published today in Science, suggest that tryptophan also interacts with the immune system to reduce abnormal inflammation of the myelin sheath, the protective coating around nerve cells that is damaged in MS.

Link to item at
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Tuesday, November 01, 2005

Current events: motorcycle powered by 24 chainsaw engines

I quit riding a motorcycle about ten years ago, because it was just too scary, but every now and then, I think about maybe getting back on a two-wheeler. This machine might just do it:

The plans call for individual engines coupled together with a double-sided drive belt in sets of three in alternating V configurations. In other words, a set with one engine above and two below alternated with a set of two above and one below. An additional drive belt will be arranged between the rows of engines. The original centrifugal clutches on the chainsaws will be used. And a two-speed transmission is suggested to transmit the power to the rear wheel. (Later a 5-speed Harley-Davidson transmission is substituted.) The bike will be called the Dolmette.

The engines are the PS-7900 professional chainsaw engines. In standard trim, each of these high-performance, air-cooled, 79-cc engines generates about 6.3 horsepower at 9,500 r.p.m. For use in the Dolmette, the engines were tuned and tweaked to deliver about 7.1 h.p. at 10,000 r.p.m. Maximum torque delivery is 4.1 foot-pounds at 7,750 r.p.m.

Ultimately, the design for the powerplant was increased to 24 engines. When all are combined, the result is a 24-cylinder unit with a displacement of 1.9 liters and output of 170 h.p. and 95.9 foot-pounds of torque at the centrifugal clutches, both large for a motorcycle.

Link to article in Chicago Tribune (free reg req'd)

Health policy: Massachusetts bill aims for universal coverage

The Massachusetts legislature is considering legislation aiming to create universal coverage in that state by taxing employers who don't provide insurance and by requiring everyone to obtain insurance.
Official filing of the House bill yesterday sets the stage this week for the most sweeping healthcare debate in Massachusetts in a decade, when the state expanded the number of people covered under Medicaid. Governor Mitt Romney and Senate President Robert E. Travaglini also have plans to dramatically expand health insurance but have not included a payroll tax for universal coverage. They say their proposals can meet the same goals without raising new revenues.

DiMasi said the business levy, which would raise $650 million to $700 million annually, is needed to pay for such an ambitious expansion. Among other things, the bill would expand Medicaid coverage to 147,000 low-income families and create a subsidized insurance program for about 100,000 low-income people who don't qualify for Medicaid. Estimates vary, but the state has around 500,000 uninsured residents.

Combined with a proposed mandate that individuals obtain health insurance, the business levy in the House bill would place Massachusetts at the vanguard of states trying to establish universal healthcare coverage for its citizens. No other state has both, advocates and political leaders said.

Link to story at Boston Globe (free reg req'd).
Link to somewhat more skeptical story at Boston Herald.

I imagine Harry and Louise have been notified...

Monday, October 31, 2005

Health policy: more young adults uninsured

One-third of Georgians ages 18-24 are uninsured, and private health insurance coverage has declined 11 percent among this age group in the past five years, according to a new study from the J. Mack Robinson College of Business at Georgia State University.

Aside from the immediate cost of providing care for these uninsured young adults, there are long-term implications for the health-care industry, researchers say. The uninsured are less likely to get primary and preventive services, which means they may end up with more advanced and costly illnesses later in life. For those who do end up in a major accident, they could become "uninsurable" for life. "The worst-case scenario is they decide not to invest in insurance and they have a terrible accident and become uninsurable for life," said Minyard, alluding to the difficulty people with major health problems have in buying individual health insurance plans.

And if you're an uninsured 21-year-old who develops MS, what do you do? When it happened to me, I decided to get married and go to law school. So far, so good. If it happens to you, I'll be happy to lend you my LSAT study books.

Link to item at
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Sunday, October 30, 2005

MS bladder therapies: a good review of the basics

I stumbled across this review in Nature Clinical Practice Urology of how MS affects bladder function and what can be done to help. Includes a discussion of Botox injections into the bladder detrusor:
Voiding-diary data are showing exceptional clinical efficacy for BoNT/A, with significant improvements compared to baseline of urinary urgency, frequency and incontinence episodes at 4 and 16 weeks postinjection. Urodynamic parameters, namely maximum cystometric capacity and detrusor pressures during filling, have also shown significant and sustained improvement.64 Because there is an increased incidence in incomplete bladder emptying following treatment in patients with neurogenic bladder dysfunction, patients must be willing and able to perform [intermittent self-cath], if they are not already doing so.

The full article, not just an abstract, is available for free here, but you'll need to register.
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Saturday, October 29, 2005

Health policy: NYT on "concierge care" for those who can afford it

NYT's health care reporting continues with a piece about "concierge care":
These doctors charge fees as high as $10,000 a year, depending on the services promised. The majority charge $1,500 to $2,000. Basic services consist of same-day or next-day appointments and 24-hour telephone access to the doctor. The most expensive may also promise the doctor will make home visits, deliver medications and accompany patients on visits to other doctors.

"Concierge care is like a new country club for the rich," Representative Pete Stark, Democrat of California, said at a joint economic committee hearing in Congress last year. "The danger is that if a large number of doctors choose to open up these types of practices, the health care system will become even more inequitable than it is today."

Link (free reg req'd)

Tag cloud: interesting

My new tag cloud is brought to you courtesy of I thought it might be an easy shortcut to generating tags, because Blogger doesn't seem to support an easy method for generating tags.

Tagcloud generates the cloud from my RSS feed, which is nifty, though somewhat problematic. The initial 100-item cloud included items like "obviously" and "apparently" and "reg req'd". So apparently, I use the word "apparently" too much, and, obviously, "reg req'd" isn't really a topic of interest.

So some editing is necessary. But once the editing is done, the tag cloud seems to emphasize the extent to which one repeats oneself. Anyway, now I've got some functional tags for finding stuff about certain stuff. ("Stuff" was another item I had to take out of the tag cloud.)

Friday, October 28, 2005

Current Events: Cat sails to France

I'm not really a cat person, probably because I didn't grow up around cats, but I tip my hat to Emily, who made her way from Wisconsin to France:

Lesley McElhiney now figures her cat went prowling around a paper warehouse near home and ended up in a cargo container that went by ship across the Atlantic Ocean and was trucked to Nancy, a city in northeastern France near the border with Germany. Employees at a French lamination company found her in the container, checked her tags and called Emily's veterinarian, John Palarski, in Kimberly, just east of Appleton. Palarski called the McElhineys Monday to tell them their pet was safe, if a little hungry.

"It probably had access to food and water," Palarski said. "I doubt if it went three weeks without it. There must have been a lot of mice on the boat. Even if it was in the cargo department, you would assume there was water down there. She had to have something."

Link to story at Chicago Tribune (free reg req'd)

Wednesday, October 26, 2005

Oh my gawd: awake during surgery, but paralyzed

Can you imagine?
The American Society of Anesthesiologists, meeting in Atlanta, approved the group's first-ever standards on preventing a rare but terrifying situation in which patients wake up during surgery and sometimes feel excruciating pain without being able to cry out. Such awakenings occur in one or two cases out of every 1,000, the group said. But the phenomenon received press coverage following some lawsuits by patients, and after the Joint Commission on Accreditation of Healthcare Organizations last year urged hospitals to better monitor patients for the problem and ask them about it after surgery.

Carol Weihrer, who won an out-of-court settlement after her anesthesia failed during a five-hour eye surgery in 1998, was disappointed. Now a patient advocate, she said that technology that might prevent a patient's suffering should be used and also called for the society to help establish a registry for case reports of surgical awareness. "It's nothing," Weihrer said of the society's action. The 54-year-old Virginia woman was awake but paralyzed while doctors cut and gouged to remove her right eye seven years ago.

Link to article in Seattle Post Intelligencer.

Politics: Harriet Miers, "Bar weenie"

Non-lawyers may not appreciate the relative insignificance of what have been touted as the jewels in the crown of Miers's resume: her election to lead the Dallas and American Bar Associations. I belong to my state's bar association, because a lawyer can't practice law in my state unless he or she is a member. Back when I was in private practice, I belonged to the bar association of the county in which I live, and to the American Bar Association. It wasn't required, but between the two, I got access to some decent seminars, a magazine, and discounts on Avis car rentals.

Each year, I receive and complete a ballot for state bar president. I read the candidate information and I look to see who endorses whom. I do this because I think it matters who's running the state bar. Each year, I have to send the bar a big check to cover membership dues, and the bar, in turn, takes the lead in many of the legal issues that arise in my state. I wish I didn't have to belong, but because I do, I'm interested in who's in charge. On the other hand, I had no idea who ran the county bar or the ABA when I was a member, because it just didn't ever seem worth my time to care.

A piece at by Mark Obbie nails it:
Guess who seeks election to [lead the voluntary bar associations]. Not the busiest, in-demand lions of the bar. Instead, it's usually the second stringers, the runners-up in the lawyer game. Real lawyers, for the most part, snicker about "bar weenies"—much as they did about the goofs in high school who ran for class president. Does David Boies spend his $800-an-hour time going to committee meetings and wrangling over the ABA's next convention schedule? Hardly. He might deign to give a speech at a bar gathering if he can fit it into his busy trial schedule. But bar weenies—their slightly kinder name is bar junkies—are the ones holding the Town Car door open for Boies when he arrives at the hotel. And when they're not doing that, they're jabbering endlessly about legal-regulatory policy questions that even most lawyers find stupefying.


Tuesday, October 25, 2005

"Divine protection," not health insurance

An article in the Washington Post reports on groups of evangelical Christians who have formed a kind of health insurance co-op, paying into a common pot of money to cover members' medical expenses. It's an interesting counterpoint to the recent NYT article about the growing financial risk borne by those who have health insurance:

Huff and his family are among the 60,000 members of Medi-Share, the largest of a little-known group of nonprofit organizations that market themselves as faith-based alternatives to health insurance. The half-dozen plans, which claim a total membership of more than 120,000 Americans, are especially popular in the South. The appeal of these 'church plans,' as they are known in the insurance industry, is both economic and religious. Because their monthly cost is roughly half that of conventional health insurance premiums, they appeal to those who find medical insurance difficult or impossible to afford. And because their membership is strictly limited to evangelical Christians certified as regular churchgoers by their pastors, they cater to people opposed to 'subsidizing high-risk, sinful lifestyles,' in the words of Medi-Share's Web site.

"These plans function just like health insurance, but they operate in a regulatory black hole," said Mila Kofman, an assistant research professor at Georgetown University's Health Policy Institute. "There is no accountability, no oversight, and the people who participate have no protection." Unlike insurance companies, which are required to have reserve funds to pay claims, church plans do not maintain reserves.


Journal: I heart the Cool Moms

Each day, during my daily commute, I end up stopped at a red light next to this day care center that obviously caters to the Cool Moms. Each day, I watch the Cool Moms walk their tots from their Subarus to the door. These are tots, I'm sure, with cool old-timey names like Ella and Gus. The moms and tots are dressed in hip, sensible layers of woolly and fleecy things, and they look happy.

My wife and I have decided not to have kids. We've been married for 13 years (!) now, and it's been an ongoing conversation with us, but as our biological clocks start to run out (we're both 35), we agree: we don't have the time or energy, we don't feel a baby-shaped void in our lives, we're living happy lives without kids, etc.

And yet I think both my wife and I see each other as a potential perfect parent. And yet it's an indescribable frustration to me that my illness should play such a large part in this decision (and it does). And yet I'm envious of the Cool Moms and their Subarus and woolly and fleecy get-ups and whatever it is that seems to make them so happy.

Maybe I need to take a different route to work.

Sunday, October 23, 2005

NYT: When health insurance is not a safeguard

The NYT's series on health care continues with a piece about the increasing gap in the protection afforded by health insurance:
After decades in which private and government insurance covered a progressively larger share of medical expenses, insurance companies are now shifting more costs to consumers, in the form of much higher deductibles, co-payments or premiums. At the same time, Americans are saving less and carrying higher levels of household debt, and even insured families are exposed to medical expenses that did not exist a decade ago. Many, like the Dorsetts, do not realize how vulnerable they are until the bills arrive. Lawyers and accountants say that for the more than 1.5 million American families who filed for bankruptcy protection last year, the most common causes were job loss and medical expenses.

Link (free reg req'd).

Friday, October 21, 2005

The political consequences of new techniques for obtaining embryonic stem cells

At, William Saletan lays out the ethical and political implications of research suggesting that scientists might be able to harvest stem cells from an embryo without harming it ("biopsy"):
If you've opposed federal funding of [embryonic cell] research on the grounds that embryos shouldn't be killed, biopsy solves your problem. The only people bound to oppose biopsy are those who 1) oppose [in vitro fertilization] because it's artificial or 2) object to exposing embryos to the same risks involved in [pre-implantation genetic diagnosis]. The billion-dollar question is which way President Bush will go. His past statements indicate that his concern is embryo killing and that he's looking for a way forward. Both factors suggest that he'd allow funding of research on ES lines derived from biopsy.


"Consumer-directed" health plans: providing the consumer with just enough rope

The Washington Post reports about the emergence of high-deductible "consumer-directed" health insurance plans:

Today's consumer-driven health plans typically require deductibles of $1,000 to $2,000 for individual coverage and $2,000 to $4,000 for family coverage, after premiums, before the insurance policy kicks in. Many policies also require coinsurance payments after deductibles are met, and patients seeking care out of network face steep charges. Now, as millions of workers enter open-enrollment season to choose next year's health insurance benefits, many will consider high-deductible policies for the first time. According to the Kaiser Family Foundation, only 5 percent of large employers offered such policies in 2003; this year, 20 percent did, and more will do so next year.

For workers who've seen premiums jump sharply for HMOs, PPOs and point-of-service offerings, the lure of lower premiums and fewer restrictions on provider selection can be tantalizing. But those opting for such insurance "should expect to have less health coverage," says Karen Pollitz, project director at Georgetown University's Health Policy Institute.


Journal: Going out, and art

Last night, my wife and I went out to see The Decemberists play a show, the first show we've been to in maybe a year. Their Melvilleian pop was charming, and they played a great show, but I felt pretty out-of-place. The show was at an old movie theater in which the bathrooms are in the basement, which meant that not only did I have to do the excuse-me-pardon-me-excuse-me-pardon-me thing to get to the aisle four times during the show, I also had to haul my sorry ass up and down the stairs four times. Also, everyone in the theater was standing, so if I wanted to see anything (and there was a lot to see: a six-piece ensemble fronted by a man wearing a pink-and-white-striped suit coat), I had to stand. Or, if I didn't want to stand, I could truck up to the balcony where the view was unobstructed, but each trip to the men's room required twice as many stairs. And this, I suppose, is why I haven't been out to a show in a year.

It's an example of how I sometimes feel MS has cut me off from experiencing art: I used to be a voracious reader, but I find I lack the concentration to stick with anything longer than a New Yorker cartoon. I used to enjoy making (mediocre) music, but I lost a lot of sensation and manual dexterity in my fingers, making it frustrating to sit down at the piano or pick up a guitar. I used to do some printmaking from time to time, but I haven't felt like I had the stamina, time, or inspiration for it. I'm reluctant to go out to see art in museums or galleries because it means extended periods of standing around and walking. Unfortunately, art increasingly seems like a luxury I don't have the time, energy, or motivation for; tending to the necessities comes first.

Here's a bright spot, though: for whatever reason (MS, maturity, contaminated drinking water?), I think art elicits a much stronger emotional response from me than it used to. I've had an iPod for a year or so now, and the experience of listening to good music through a good set of headphones can be amazing; it can, and regularly does, make me cry.

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