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.
technorati tag: multiple sclerosis

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.

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.

technorati tag: multiple sclerosis

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."

Link

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.

technorati tag: multiple sclerosis

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. john.zajicek@phnt.swest.nhs.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.

technorati tags: multiple sclerosis, medical marijuana

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.

Link

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 Slate.com 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.

Link.

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)

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.

Link

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)

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)

Drug ads: overselling the serotonin boost?

From nature.com:

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)

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.

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.

Link.

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.

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)

Health policy: outsourcing medical care

There's an interesting article at washingtonpost.com 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

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 Newsday.com
technorati tag: multiple sclerosis

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...