A Win for Medical Marijuana

A federal appeals court in California this week struck an important blow for medical marijuana, and for the First Amendment. It held that the government cannot revoke the licenses of doctors who recommend marijuana to their patients. The federal government should now abandon its misguided policy of targeting doctors and sick people to fight marijuana use.

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The decision, in addition to vindicating the speech rights of doctors and patients, should prompt federal and state governments to reconsider their policies on medical marijuana. The war on drugs surely has better targets than cancer patients and terminally ill people who use marijuana, on the advice of doctors, to reduce their pain.

We teach palliative care on our wards. Our underlying philosophy states that the dying patient should not suffer if we can provide relief. If marijuana can provide relief to the dying patient then we are obliged to not just recommend it, but to fight for the patient's right to use it. This is an ethical and moral judgement on my part. We do not care how much narcotics we prescribe for the terminal patient having pain. Addiction is not a question, death with dignity (dignity for both the patient and the family) is the answer. We need every possible tool to help patients. I am glad the courts understand.

Report: Health care quality looking up

Government agencies are moving in the right direction to improve health care quality, but they should share information and coordinate their efforts, the Institute of Medicine said Wednesday.

The institute, an arm of the National Academy of Sciences, said federal agencies can help improve Americans' health care by setting a good example.

"In the absence of strong federal leadership to address safety and quality concerns, progress will be slow," said Dr. Gilbert Omenn of the University of Michigan, chairman of the panel that prepared the report.

In the wake of reports of medical errors across the country, Congress asked the institute to review the health quality efforts of Medicare, Medicaid, the State Children's Health Insurance Program, the Defense Department TRICARE programs, the Veterans Administration and the Indian Health Service.

The panel concluded that the agencies have begun redesigning their programs and are moving in the right direction to reduce medical errors and improve quality.

But the efforts are not coordinated, the committee said. It suggested that the agencies work together to develop common ways to measure performance and make comparative quality reports available to the public.

So our friends at the IOM are now praising themselves for pointing out our problems with medical errors. They recommend some changes, and applaud those changes.

I am involved in quality research. We do studies aimed at improving adherence to clearly accepted guidelines for care. Let me give some examples. In diabetes, one should document the FLECK (foot care, lipid management, eye care, control, screening and treating kidney disease). All experts agree on those aspects of diabetes care.

After a myocardial infarction, the patient should take aspirin, be advised to stop smoking, take a beta blocker and an ACE inhibitor, and probably be taking a statin. Our research looks at methods for helping physicians improve their adherence to these recommendations.

This research is both interesting and important. Given the stresses of practice (and for the non-physicians believe that practice is stressful) and the competing pressures, how can we provide physicians the information or reminders to provide high quality care. We are proud of our studies, and believe we are learning to make a difference. But ...

In order to study quality, one must have enough patients with the condition. We 'cherry pick' for our studies. We focus on common treatable problems where the data show that our care can make a difference.

How does one study quality diagnostic skills? What criteria can we use for less common diseases? How can we really study prescription practices? Are we just measuring the physician's skill in documentation?

The quality push sometimes reminds me of the famous joke about the man who lost his key. "I was reminded of the old joke about the idiot that lost his key in the dark but began to search for it beneath the light. In response to suggestions that the search was futile as the key had not been lost at the spot where the idiot was searching, he replied 'I know I lost it in the dark but it is easier to look for it in the light'. " (Never, Never, Never) I fear that our quality push focuses on what we can measure and ignores what we cannot measure. Much medical care occurs in the dark area.

Study: More Survive Heart Failure. Today's NEJM has two reports on heart failure. The first demonstrates something that we know - we treat CHF more successfully than we did 50 years ago (success defined as decreased mortality).

The study of 10,317 people compared death rates from heart failure for 1950-69 with the next three decades. A total of 1,075 developed heart failure and they were followed for 10 years. The researchers calculated that the risk of death fell by about one-third.

In the 1990s, 59 percent of the men had died within five years, a drop from 70 percent in the earlier period. For women, the five-year death rate dropped to 45 percent from 57 percent.

``It's not a huge change. But it's the first time that such a study has showed our treatments are impacting on the survival of patients,'' said Dr. Margaret M. Redfield of the Mayo Clinic, who was not involved in the study.

The researchers suspect the number of new cases for men remained unchanged because of gender differences in the causes of heart failure. Treatment has improved vastly for high blood pressure, a prominent cause for women. More people are surviving heart attacks, a main cause for men, and the damage to their heart makes them vulnerable to heart failure, Levy said.

The second study performed a retrospective analysis of the digoxin study data. They found that women taking digoxin had a slightly increased death rate compared to placebo (33% vs. 29%). This translates (for us number geeks) to NNH of 25 (NNH is number needed to harm). I am not sure what I will do with this information. I guess that I will use digoxin more cautiously in women, waiting for more clear indications that the patient needs it for improved quality of life.

Beaver State Bolshevism: Will Oregon voters approve a Leninist approach to health care?

But none of this seems to have registered on Democrats, Greens and the NAACP in Oregon, where they have put on the ballot in next week's election a Leninist plan for health care under which the government and only the government would provide, deliver, regulate and finance medical services to Oregonians. The services provided would include comprehensive health care and everything related thereto-- from brain surgery and prescription drugs to marriage counseling and massages, from inpatient hospital care to long-term care for the elderly. And they would all be absolutely free to individuals and families--no deductibles, no copayments, no premiums.

The cost to taxpayers would be enormous. The ballot initiative would authorize $9 billion in new expenditures on top of the $16 billion Oregon currently spends on all government services, a 56% increase in the cost of government. The American Association of Health Plans estimates that about $15 billion in new taxes will be required to finance the program, an average of $5,000 per resident.

To pay for these "free" services, Oregon would increase its top income-tax rate--which applies to married couples earning as little as $12,500--to as much as 17% from an already high 9%, giving Oregon by far the highest income-tax rate in the country. Payroll taxes on employers would increase to 11.5%, doubling or tripling the current rate (depending on salary levels), an enormous financial burden on businesses that would guarantee a significant drop in employment.

His rant continues with more explanation of the problems. While I believe he skillfully uses hyperbole, he does make some interesting points. I wish the solution to our health care crisis was simple; I fear that it is anything but simple.

EDITORIAL: Safety for Research Subjects (The government must ensure better protection of human guinea pigs used in the development of drugs that defend against biological and chemical weapons.)

George Painter is the president of a San Diego-based biotech start-up called Chimerix that hopes to develop a pill to combat smallpox. Capitalists, he notes, often fail to invest in companies tackling such important goals because they fear prohibitively expensive pain-and-suffering lawsuits.

The government needs to confront that obstacle. But first Congress and the Bush administration must fix obvious flaws in the Common Rule. That 1991 law lays out guidelines for research on human subjects, but only for publicly funded research conducted by 17 federal agencies. Inexcusably, institutions not receiving federal funds need not comply with any of the safeguards in the rule.

Legislators can find at least two sensible blueprints for reform. One is a 1995 report by a federal task force that suggested expanding protections to even classified research, "requiring the informed consent of all human subjects." Another is a 2001 report from the National Bioethics Advisory Commission recommending that the Common Rule be applied without exception to "all government agencies, academe and the private sector."

There is no reason why Washington can't encourage more private investment in anti-terrorism research while demanding that scientists fully inform and offer strong protections to every human guinea pig who heroically volunteers to test lifesaving chemical and bioterrorism antidotes.

This is a very serious issue. Our research enterprise is threatened by lawyers (what a surprise). We need better guidelines and better protection from opportunistic lawsuits.

You know that I love this one. The power of lifting weights

Yet the metabolic rate -- a measure of how many calories your body needs to function -- is rarely responsible for weight-loss woes. "The metabolic rate is remarkably similar in most individuals," Evans says, once you control for these two critical factors:

Lean body mass, the percentage of body weight that comes from muscle, bone and organ.

Restrictive dieting, consuming significantly fewer calories than you expend.

Arguably the single most important determinant of metabolic rate is lean body mass. "The more lean tissue you have," Evans says, "the higher your metabolic rate."

Muscle mass boosts metabolism because muscle is active tissue that helps convert food into water, heat and energy. Fat is more passive, acting primarily as a stored form of body energy. So when your body is deciding what to do with the food you've eaten, the more muscle you have, the more calories it can send to muscle cells to be burned. This leaves fewer calories to go to fat cells to be stored.

Their higher proportion of muscle explains why, in general, men have higher metabolic rates than women and younger people have higher metabolic rates than older people. Starting around age 30, muscle mass in sedentary individuals declines by about 2% to 5% per decade, says Evans, adding that caloric requirements -- and metabolic rate -- decline accordingly. This is why an active, muscular 20-year-old can eat much more than a sedentary, pot-bellied 55-year-old without gaining weight.

Dieting also can ratchet down metabolism. "When you go on a restrictive diet, your body senses starvation and slows your metabolic rate to conserve energy," Evans said.

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"What's remarkable is the change you can make in your metabolic rate with strength training," he adds. "Several excellent new studies suggest that formerly sedentary adults who do a program of strength training for three months gain about 3 pounds of muscle -- that's a pound of muscle a month."

Researchers found that this 3-pound increase in muscle mass boosted the participants' resting metabolic rate by about 7%, Westcott says. "So with just three months of strength training you can reverse decades of the aging process."

I am a firm believer. Weight training is part of my personal program. The benefits include the higher metabolic rate. Proper leg training cured my knee tendonitis (caused by a weak vastus medialis from running without strength work). Several other pains are cured. I feel better and apparently look better. It does take a committment and some hard work. I love the sense of physical achievement as I can do more in the gym each month. If you want easier weight control, you should consider adding weight training to your program.

Physicians agree that the concept of medical errors is both real and overestimated. My colleagues (medpundit and RangelMD) have written beautifully on this subject. To limit redundancy let me give you 3 links.

Docs weigh in on medical errors - CNN's report.

Errata - Medpundit's rant (especially denouncing the IOM).

Physicians believe that medical care is better then what the public believes - in which Rangel rants and explains errors well.

I personally found the IOM report sensational and overly provocative. What were they thinking? Why give lawyers so much ammunition?

Hospitals Battle For-Profit Groups for Patients

As doctors in some of the most lucrative fields of medicine rush to invest in upstart specialty hospitals, community hospitals around the country are striking back by stripping the defectors of medical privileges or setting up physician groups to compete against them.

The raw battle for profitable patients is unraveling longstanding relationships, setting doctors against doctors and pitting health care entrepreneurs against established institutions.

The rebellious doctors, seeking new ways to make money in an era of falling reimbursements, are joining with a number of small companies to build hospitals specializing in fields like orthopedics, cardiology and oncology and sending their patients to the new facilities.

The community hospitals worry that they will lose patients whose fees subsidize money-losing services like emergency rooms and care for the poor. "You cannot stand by and watch people rip whatever profitable veins there are in the institution away from you," said Michael Curtin, the board chairman of Mount Carmel Health System in Columbus, Ohio.

This concept is not new. HealthSouth (which started here in Birmingham) has done this for years at a less exclusive level. They focus on orthopedics and rehabilitation (both very lucrative) but do supplement with other services. The newer concept may even be worse. I understand the financial thinking, but I am bothered ethically.

Corporations Just the Tonic Drug Benefit Effort Needed.

Georgia-Pacific was contacted by a top executive of Eli Lilly, who told the paper company to withdraw from a coalition of big corporations pressing Congress to help reduce drug prices. Georgia-Pacific complied, believing it would lose a lucrative paper contract with Lilly if it did not. Marriott Corp. also withdrew, saying it had been warned by another drug company that if it did not, drug industry conferences would be moved to another hotel chain.

President Bush's action last week to speed up the availability of lower-priced generic drugs was widely seen as an effort to help Republican candidates running in areas with high concentrations of seniors. But it also was a victory for those corporations that challenged the pharmaceutical industry and refused to be intimidated.

Under the banner of Business for Affordable Medicine, about a dozen big companies, including General Motors, had pressed Congress to limit litigation by drug manufacturers that has slowed the introduction of lower-priced generic drugs to the market. Although Congress failed to pass it, the Bush administration took a similar step by executive order that could save employers and insurers an estimated $3-billion a year.

Scott Ingham, spokesman for Business for Affordable Medicine, said the companies are pleased their complaints prompted the president to act.

"We were able to bring together a number of well-respected drug purchasers who had a good story to tell," Ingham said. "Our coalition will continue to look at cost-containment strategies both at the federal and state level."

The president's action is seen by many experts as a possible turning point in a war where every previous political battle had been won by the pharmaceutical industry.

Study: Few older men given osteoporosis treatment. Osteoporosis occurs in men - especially when risk factors exist (like steroid therapy for COPD). At our VA hospital I have to send bone densitometry to another hospital, a major inconvenience.

Of the estimated 10 million Americans afflicted with the disease, about 2 million are men. But the percentage of men affected rises with age, and those studied were aged 80 on average. Still, just 4.5 percent of them had been prescribed osteoporosis treatment after they were discharged from a hospital following their fractures. Up to five years later, only 11 percent had had a bone-density test and just 27 percent were using any kind of osteoporosis treatment, the researchers found.

Thirty-two percent of the men died within a year of their fractures. Many deaths were likely from ailments linked to the weakened condition of being immobilized by the fractures, which may have been preventable with treatment for osteoporosis or underlying conditions that can cause it, Kiebzak said.

This should provide some food for thought. Consider your patients and think about those at risk. You might help some old men.

It's Your Money -- You Decide . A link to Robert Prather last week referred to this type of plan.

Consumer-driven plans are so new that only about 80,000 subscribers in the United States have signed up for a few existing programs so far. Basically, a consumer-driven plan offers a slightly lower monthly premium and almost complete discretion over how to spend a specified number of health care dollars. Subscribers can use these dollars to visit any doctor or practitioner they choose, select a chiropractor over an osteopath, use an emergency room without pre-approval, choose generic or brand-name drugs, or spend all their money on monthly massage sessions. They can parse out their dollars carefully or blow them all on a semi-private room at the hospital.

But -- and you knew that word was coming -- once that assigned amount of money is spent, subscribers are then on their own, at least for a while, to pay for their health care costs at market rates. Only after annual medical expenses exceed a certain figure does a layer of more traditional insurance kick in, providing protection from huge bills due to unexpected surgeries, injuries or diagnoses.

Think about this concept carefully. The subscribers (our patients) will become partners in their medical expenses. We want a chest X-ray; they want an understanding of why we need that test.

I like the concept, and suspect that it could decrease many system abuses. It would certainly keep us alert and thoughtful. We could more easily convince patients to take Aciphex than Nexium - just look at the cost differential. Less patients will demand Vioxx when ibuprofen works as well in most patients. Think about this, you might like it. Office fees should be paid nicely in this system.

Score One For Low- Carb Diet .

In a head-to-head comparison between two popular and distinctly different eating plans, the Atkins diet trimmed significantly more pounds and body fat in obese but otherwise healthy women than a traditional low-fat diet, according to a report released last week at the annual meeting of the American Dietetics Association.

The study enrolled 53 women, aged 31 to 59, for six months. Half followed a low-fat approach, eating 30 percent of calories from fat. The other half ate according to the very-low-carbohydrate diet popularized by physican Robert Atkins.

Those in the Atkins group shed on average 18.5 pounds -- about 10 of it from body fat. (The rest was due to loss of water and lean muscle.) By comparison, the low-fat group lost about nine pounds, about five of them from body fat.

Despite the results, the study's lead author cautioned against drawing too many conclusions or abandoning a low-fat approach to weight loss. "I'm not sure that there is a take-home message from this study, except that there is more research needed," said registered dietitian Bonnie Brehm, assistant professor in the College of Nursing at the University of Cincinnati. "This is one, relatively short-term study. Our conclusions are that in the short term, a low-carbohydrate diet produces loss of weight and body fat. . . . We by no means are recommending the Atkins diet from this one study."

Read the rest of the article. Atkins does work as advertised! It does not provide the solution to weight loss maintenance. That may be the sticky wicket.

Get ready for Zetia (ezetimibe), the first in a new class of cholesterol-lowering agents that inhibits the intestinal absorption of cholesterol. FDA Approves New Cholesterol Drug and FDA Approves ZETIA, ezetimibe, for Cholesterol Reduction.

There are about 13 million patients taking statins, the most common class of drug used to treat cholesterol. Approximately, 60 percent of those patients don't reach their desired cholesterol level. When Zetia is added to patients' regimen, studies showed 72 percent of patients reached their goal.

On average, Zetia added to an ongoing statin treatment provided a 25 percent additional reduction in cholesterol, compared with a 4 percent reduction for placebo. Zetia can be taken alone, but only reduces cholesterol by about 18 percent, while statins alone lower it by about 40 percent.

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The fundamental question is whether adding Zetia is clinically and economically better than just increasing the dose of the statin, which doesn't increase the cost but can increase side effects.

The wholesale cost for a 30-day supply of Zetia is $57.90. That will be on top of the statin's cost. Merck's statin, Zocor, has a wholesale price of $105.81 for a 30-day supply regardless of the dose.

Executives from the MerckSchering-Plough Pharmaceuticals LLC joint venture said doubling the dose of a statin will only reduce cholesterol by 6 percent. But Bernstein Research analyst Richard Evans said that 6 percent reduction will be enough to get 75 percent of patients who haven't met their goal to achieve it.

This drug will provide us an interesting adjunct to statin therapy. I do not expect lthat we will place large numbers of patients on this new drug, but it probably will be a worthwhile addition, since it does represent a different mechanism.

How old is too old? This physician confronted this concept and she challenged him. When Doctors Say Don't and the Patient Says Do.

A surgeon might favor surgery, while a nonsurgical neurologist might say that because some of the damage to the cord was irreversible, Why take the chance of scarring and inflammation from the surgery? On the other hand, doing nothing meant living with the unremitting pain, not to mention leaving the spinal cord vulnerable to further damage.

In patients older than 90, there was no disagreement. It was hard to find any doctor who would recommend corrective surgery when the statistical risks at advanced age of a postoperative complication or poor outcome were so great.

But this time the patient herself insisted. Even when the risks, including paralysis, were explained to her, she simply replied that tap-dancing was her life.

"Can the surgery make me dance again?" she asked me.

"It's possible."

"Then I'll take my chances."

This article makes a very important point (albeit implicitly). When considering how to treat a patient, we should try to understand their values and aspirations. As a golfer, I would approach some injuries differently than someone who does not golf. I would hate to lose that outlet. This elderly woman needed to tap dance. It defined her. She gambled that surgery would make her whole.

Health costs are spiraling into another year of double-digit increases. Patients, employers and government health programs are feeling the financial pain.

But where is the money going? And why do health costs continue to rise when in so many other parts of the economy — from cars to clothes to computers — prices are falling and profit margins are being squeezed?

The big winners for now include hospitals, particularly those that have assembled networks that dominate local markets, and makers of ingenious medical devices like advanced heart pacemakers and the latest hip and knee replacements that cost more than the earlier versions. Nurses, in short supply through much of the country, are getting big raises and better working conditions.

And the strongest managed care companies — even though they long ago lost their power to check health care costs — are reporting sharply higher profits, as premiums rise even faster than do underlying costs.

By contrast, the growth of spending on drugs is slowing, after a decade-long bonanza of profits for drug companies. As health plans require members to pay a steeper share of drug costs, more consumers are turning to lower-priced generic versions of blockbuster drugs like Prozac whose patents have expired. Doctors are writing more than eight times the new prescriptions for the generic version of Prozac, fluoxetine, than for Prozac itself, according to IMS Health, a health care information company.

This excerpt comes from a good overview - The Healthier Side of Health Care. Note, the generalists are not getting the money. Posted by at 06:27 AM | Comments (1) | TrackBack (0)

More Hormone Perplexities

Brain to blame for mystery back pain

Some people may suffer from mysterious back pain because their brains are ultra-sensitive and wired up in a different way, say researchers.

They have found that some people with lower back problems that appear to have no obvious physical cause seem to register pain much more easily than most people.

A gentle squeeze so soft that it was not registered by healthy people was enough to trigger pain signals in their brains.

A similar effect was also seen in patients with fibromyalgia, who suffer pain in the muscles, ligaments and tendons.

But healthy people had to be squeezed a lot more sharply to feel the same level of pain - and it registered in different areas of the brain.

Intuitively most physicians knew this, but could probably neither prove it nor explain it. This research line might help us better understand how to help these patients who: are frustrated, frustrate us, and account for too many narcotic prescriptions.

Many physicians suffer burnout. We often are better at caring for others than caring for ourselves. Many characteristics that help us achieve medical school acceptance and success can lead to problems later in life. Surviving (and even enjoying) medicine

Hands up if you recognise any of the following psychological traits: perfectionist, overly conscientious, tendency to seek approval ("people pleasing") and need to control others, great sense of responsibility, chronic self doubt, uncomfortable with praise, and ability to delay gratification. It's a given that most people who enter medicine will hold many of these characteristics.

It's not something that happens to us at medical school---although a lot of what happens there does account for later problems---it's what we medics tend to bring with us. It's what attracts us to medicine in the first place. Acknowledging this helps. Acknowledging it early enough, and adopting self caring practices, will help to ensure that we do not burn out and that we remain safe and competent at our jobs, and we may even reverse the trend of seeking early retirement. Most doctors suffer from an episode of depression at some point in their career, and every medical school should include lectures on "burnout prevention" alongside those on anatomy and physiology. According to a recent US conference on physicians' health in South Carolina, organised by the American and the Canadian Medical Associations, we doctors are sitting ducks for becoming burnt out. With thanks to some of the conference speakers, here are five practical tips on how to survive, succeed, and sustain interest in a career in medicine.

Five ways to survive as a doctor

• Make sure you do things other than work
• Create your dream work schedule
• Learn to say no, without feeling guilty
• If you need help, ask for it
• Seek peer support

I have seen too many physicians burnout during my career. I have tried to follow these points - and work on doing so continuously. Striking the balance is the first in a series of articles about protecting ourselves. You can find more from this author at - the doctorscoach website!. I submit that these concepts are important for ourselves and for many of our patients. If you are burnt out, think about starting to improve today. You owe it to yourself, your family and friends and your patients.

Thanks to Robert Prather for his email. He writes - Canadian And U.S. Health Care . This long rambling rant discusses the merits of the Canadian system and then makes a proposal on the US system.

We have our own difficulties in health care, of course, but most are related to cost and could be fixed with minimal government meddling or by reducing the existing government meddling.

Providing care for the poor is the only compassionate thing to do, but how it is done is another matter entirely.

Currently we have five major government programs that I can think of: Medicare, Medicade, the Childrens Health Insurance Program (CHIP), the VA system and the insurance system for federal workers. Even if I've forgotten one you can see the point: the government already has a large presence in the health care system and can influence it greatly just by changing its own policies.

Changes in the way the government dispenses health care can lead to private sector emulation, if what the government does is worth emulating. I'm going to be getting into a bit of a fantasy world here -- I'll try to keep both hands on the keyboard -- but the use of medical savings accounts in combination with traditional insurance, either fee-for-service or the HMO / PPO model could work nicely to make people more aware of the cost of their health care, reduce the bureaucracy, regulations and paperwork. Also without reducing the amount of coverage.

His rationale for MSAs (medical savings accounts) is well stated.

The reason I mentioned the five government programs is that if they were converted to such a system it would create an incentive for private sector companies to follow. As it stands right now, the private sector will likely be well ahead of the government in making a change.

As I see it, getting people in touch with the actual cost of their health care is the best way to reduce cost and make medicine more consumer driven.

I am not sure that his solution would work, but I like the underlying concept. Many problems in health care come from the total disconnect between costs and services. We do need the consumers to care more about costs This plan could possibly work.

Bloviator clued me to this link - DYING WORDS.

Oncologists give bad news to patients some thirty-five times per month on average, telling a patient that he has cancer, that his tumor has come back, that his treatment has failed, that no further treatment would be helpful. And yet there is no agreement among specialists about how to deliver such news. More than forty per cent of oncologists withhold a prognosis from a patient if he or she does not ask for it or if the family requests that the patient not be told. A similar number speak in euphemisms, skirting the truth. Today, in most of Europe doctors often do not tell patients that they are dying.

Until recently, many doctors rarely informed their patients that there was nothing to be done for them; conventional wisdom had it that patients ought to be spared the anguish of knowing that they were going to die. The renowned physician Sir William Osler, who, at the turn of the last century, wrote the seminal textbook "The Principles and Practice of Medicine," emphasized the importance of keeping the patient optimistic. "It wasn't the style to be specific," Dr. David Golde, a former physician-in-chief at Memorial Sloan-Kettering Cancer Center, said of his medical training, which began in 1962. "The patient's questions and the doctor's answers—both avoided detail. And doctors never volunteered to give more information. Of course, there were no formalized end-of-life directives. The doctor's duty to ease the path was unspoken." When I asked him what he meant by not being specific, he said, "The doctor would say, 'Yes, you have a serious disease.' "

In 1969, a book called "On Death and Dying," by Elisabeth Kübler-Ross, which later became a best-seller, made death an acceptable subject for discussion between patients and doctors for the first time. In the nineteen-eighties, cultural and political changes in America—some precipitated by AIDS—introduced the notion that a patient had a right to know everything his doctor knew. In 1993, Sherwin Nuland's book "How We Die," which won the National Book Award, described in detail the psychology and physiology of death.

As medical practice grows more sophisticated more people are living longer with the knowledge that they may be dying. Decisions made in the late stages of illness are increasingly an aspect of treatment. Dying requires emotional and physical stamina from the individual and his family. And the difficulty of negotiating all this has an effect on doctors as well as patients. A recent article reported that more than half of the oncologists interviewed say that the frequent witnessing of death leads to an overwhelming sense of fatigue and futility; the profession has one of the highest burnout rates in medicine.

Despite this, during my nine years of medical school and professional training in the nineteen-seventies, I was never instructed in how to speak about dying to a gravely ill patient and the patient's family. It was presumed that, as medical students, we learned how to deliver bad news through careful observation of our mentors, just as we learned how to lance a deep abscess by watching doctors and then trying it ourselves. But most physicians preferred to speak to their patients in private. And the subject was never raised in our classrooms.

This long article is worth reading. I believe that the generalist can discuss these issues more successfully than can specialists. We usually have an existing relationship with the patient. Moreover, we have perspective. We understand the entire patient and how to intepret the various issues the patient will face. Read the article. What do you think?

I do not take a daily vitamin. My reading suggests that my balanced diet should provide enough vitamins, and I do not like taking unnecessary pills. Should you take vitamins?

EXPERTS ARE divided on who exactly should take a vitamin supplement. Recent reviews by two Harvard University physicians in the Journal of the American Medical Association, for instance, make a strong case for all adults to use a daily vitamin supplement. Meanwhile, the American Dietetic Association emphasizes that decisions about supplements should be based more specifically on individual needs.

Indeed, the Food and Nutrition Board, the agency responsible for setting U.S. Recommended Dietary Allowances, and the American Dietetic Association have identified certain groups most likely to benefit from supplements:
* Women of childbearing age are urged to get 400 micrograms of folic acid from a daily supplement or fortified food to prevent certain birth defects.
* A daily supplement or fortified food to provide vitamin B-12 is advised for those over age 50 — since age can impair the body’s ability to absorb it — and for vegetarians of any age who avoid all animal products.
* Calcium and vitamin D supplements are recommended for those who avoid or minimize dairy products, and perhaps for those whose needs have increased with age.

This remains a controversial area and I do not discourage patients who want to take a multivitamin daily. For now I think I will continue to pass.

Doctors Told Alcohol Gels Are Better Than Washing. I wrote about this issue a few weeks ago. I read this article early this morning before making rounds. What a pleasure to use the gels after each patient, rather than trying to wash my hands with soap and water. This is truly an advance.

The government issued guidelines today urging doctors and nurses to abandon the ritual of washing their hands with soap and water between patients and instead rub on fast-drying alcohol gels to kill more germs.

The goal, the government said, was to reduce the spread of viruses and bacteria that infect an estimated 2 million hospital patients in the United States each year and kill about 90,000.

Many hospitals, expecting the new guidelines from the Centers for Disease Control and Prevention, have already made the change, and studies show that this can cut their infection rates in half.

Soap and water have been the standard for generations. But washing up properly between each patient can take a full minute and is often skipped to save time, especially in busy intensive care units where the risk of spreading germs is greatest.

While the alcohol-based gels and solutions kill more microbes, the main advantage is that they are easier to use. With vials clipped to their uniforms, nurses can quickly swish their hands while on the move without stopping at a sink. The disease-control centers estimates that this saves an hour in an eight-hour intensive care shift.

I agree with this entirely. I plan to keep some gel at home also. It works, it is simple, and it does not dry out my hands.

I like fish. Apparently not everyone does. Generally when I go out to dinner I order seafood. This may be helping me! Fish 'lowers dementia risk'. This report refers to an article in today's BMJ - Fish, meat, and risk of dementia: cohort study . "Elderly people who eat fish or seafood at least once a week are at lower risk of developing dementia, including Alzheimer's disease." As my mother always said when she gave me chicken soup when I was sick - 'it couldn't hurt!' Regular fish eating is a reasonable habit to encourage.

Antibacterial Soap a Waste of Time, Experts Say. This article explains that plain soap works as well as those fancy antibacterial soaps.

Soap and water works by literally washing away germs, although soap itself can kill bacteria and viruses.

Larson noted that several studies suggest that alcohol-based gels are better ways to kill germs instead of washing them away and may be a good alternative for health care workers whose hands are damaged by repeated washings.

Sometimes we get too fancy in our society. This is probably one of those times.

Disease Related to Anemia Drug.

Eprex, which is sold only outside the United States, has been associated with pure red-cell aplasia, a condition that can destroy a person's ability to produce red blood cells, leaving them dependent on transfusions to survive. Although the drug has been on the market more than a decade, almost all the cases have occurred since 1999 and Johnson & Johnson has not been able to identify the reason for this increase. Other drugs similar to Eprex, including those sold in the United States, have been associated with only a few cases of aplasia.

I suspect that Eprex is a form of erythropoietin - but cannot be sure. This form is unlikely to be released in the US.

Lower Medicare Payouts Concern Bush Officials

Bush administration officials say they have become deeply concerned that a cut in Medicare payments to doctors, to be announced next week, will prompt many doctors to limit their participation in the program, reducing access to health care for the elderly.

Medicare payments to doctors were cut 5.4 percent in January, and Medicare officials said that next week they expected to announce a further cut of 4.4 percent, effective on Jan. 1.

Asked to describe the likely effects, Thomas A. Scully, administrator of the Medicare program, said: "You'll have mad doctors. There will be access problems, and seniors will feel it."

The cuts result from a formula specified in the Medicare law. The Bush administration says it has no discretion to halt the cuts, a contention disputed by doctors and by some influential lawmakers.

In March, doctors in a dozen states said, in interviews with The New York Times, that they were refusing to take new Medicare patients because Medicare was paying them too little to cover their costs. A second cut will accelerate the trend, doctors said this week.

Many private insurers link their payments to the Medicare fee schedule, compounding the effects of any cut in Medicare reimbursement.

Tommy G. Thompson, the secretary of health and human services, said this week that he and Mr. Scully were "very concerned" about the impending cut.

Administration officials said President Bush's chief of staff, Andrew H. Card Jr., and his senior political adviser, Karl Rove, had taken an interest in the cut, in part because the administration did not want to alienate doctors or the elderly two weeks before Election Day. Democratic candidates are always hunting for evidence to back their argument that Republicans want to cut Medicare.

This long article goes on to outline the reasons why this has occurred and why the Congress did not fix it this year. Physicians are tired of excuses. Who will care for the patients? We already lose money taking care of Medicare patients.

Those in favor of a single payor health system need only look at this experience to understand why many physicians fear such systems. Congress and the Administration both know that these rates need repair. Nonetheless our political process is unable to develop a solution.

A comment on my piece about WHOs new recommendations admonished us to focus on kids. I am an internist and often do not note articles about kids. This one caught my attention though. Exercise more crucial than diet for fat kids: Study looks at ways to avoid diabetes

Exercise appears to be more powerful than dietary changes in helping overweight inner-city children improve their health and prevent diabetes, researchers have concluded.

They also found that an intensive intervention program -- consisting of parent and student education, school cafeteria changes and an after-school health club -- helped reduce blood sugar levels significantly in children already diagnosed with diabetes.

The results are based on the first year of a large-scale study involving the Bienestar program in San Antonio schools.

I have written before that we must invest in physical education. I believe that we need to provide programs that will lead to life long fitness. It can be done, and our public health system should support these programs.

I am not always a fan of BC/BS, but they may be on the right track here. Study: Tech, mergers drive up health costs

Expensive — and often unproven — new medical technology along with hospital mergers are leading factors driving current double-digit health care cost increases, the Blue Cross Blue Shield Association says in a study out today.

The assessment is one of the first to try to quantify what's behind the rapid rise in hospital spending, now the fastest-growing component of health spending.

And it is the latest in a series of reports from various players in the health care industry blaming other segments for rising costs. Earlier studies have blamed everything from prescription drug prices to overly demanding consumers.

Many hospitals are embracing expensive new technology before making sure it is more effective than older therapies, and some hospital mergers have not resulted in the savings promised, says Scott Serota, president and chief executive of the association of Blue Cross health insurers.

The good news, Serota says, is that something can be done to control such costs:

* Put more emphasis on evaluating new technology's effectiveness and doing cost/benefit analyses before hospitals install new devices, treatments or therapies.
* Get better at regional planning to reduce duplicated services, such as every hospital in the area having the same expensive new scanner or open heart surgery program.
* Be more cautious about approving mergers or other efforts that reduce competition.

This report asks for technology assessment. I have spent the last 3 days at the Society for Medical Decision Making. Members of the society have expertise in technology assessment. In the past, technology assessment was attacked by the business community (at least those businesses involved in making and using the technology). Giving the high cost of many new technologies, we need independent, unbiased analyses. Some technologies work for specific indications. Once one releases the technology, many physicians will use the technology for other indications. Often this occurs because they lack information on indications. This is a very important component of health care costs, and deserves more scrutiny.

Surgeons are wary of aspirin. They are wary of anything that could increase bleeding. Study Favors Aspirin Use for Patients Having Bypass

Giving patients aspirin in the first 48 hours after heart bypass surgery can greatly reduce their risk of death and serious complications involving the heart, brain, kidneys and digestive tract, doctors are reporting today.

The new finding, based on a study of 5,065 people, may change medical practice, physicians who were not part of the study said in interviews. They said the study provided strong evidence that bypass patients should be given aspirin after surgery, the sooner the better.

People who are allergic to aspirin or have bleeding disorders or ulcers should not take aspirin, doctors said.

Several medical groups already recommend aspirin soon after bypass surgery, because it helps keep the grafted vessels from clogging. But the guidelines are not always followed, because many doctors fear that giving people aspirin too soon after surgery will cause severe bleeding. Bleeding, though, was not a problem in the new study.

The print edition of the Wall Street Journal had a good editorial on the Oregon Measure 23 vote. As one would expect, they argue against the Measure. So does Sydney Smith. She has an excellent essay - The Pacific Northworst in Tech Central Station. She follows that up today in her blog - Point/Counterpoint. I recommend reading both links if you are interested in this issue. Sometimes Medpundit and I agree, sometimes we disagree. On this issue we are walking side by side.

Long time readers know that I love this one. Exercise: Quality versus quantity

Researchers have debated whether pace makes a significant difference in protecting the heart, but the new study found that men who exercised at high intensity were 17 percent less likely to develop heart disease than those who did low-intensity exercise.

High-intensity exercise includes running or jogging at 6 mph, while low-intensity activities include walking at a pace of about 2 mph.

Researchers also have debated whether weight-training has a big impact on the heart, since it does not give the heart and lungs the kind of workout they get from aerobic activities such as brisk walking or running for at least 20 minutes.

But in the Harvard School of Public Health study, men who engaged in weight training for 30 minutes or more weekly had a 23 percent lower risk of heart disease than men who did not pump iron. The researchers said the benefits may result in part from reductions in blood pressure and body fat achieved through weight training.

Given the independent results from weight training, the researchers theorized that adding weight training to a high-intensity exercise program would reap even greater benefits.

Improve your odds and increase that exercise level. This requires dedication and slow steady increases. Serious exercise can help both quality and quantity of life.

I am on the road - will be posting this evening rather than this morning.

Ending a Drug Patent Scam

Goaded into action by election-year politics, President Bush took steps yesterday to close legal loopholes that have allowed manufacturers of brand-name drugs to keep cheaper generic versions off the market through devious delaying tactics. It was a modest step, but one that most people involved in the acrimonious debates over prescription drug prices will be able to support — except, of course, the pharmaceutical companies that have profited from the loophole.

Daily exercise, combined with a low-fat, high-fiber diet, including lots of fruits and vegetables but no added sugar or salt, can reduce blood pressure, oxidative stress, fasting insulin, and other risk factors for atherosclerosis within a 3- week period, new research suggests. While several of the outcomes examined in the study have been evaluated in relation to drug therapies, this study is one of the first to show that changes in important risk factors can be achieved by a short-term, rigorous exercise and diet regimen.

Another unique aspect of the study, lead author Dr Christian K Roberts (UCLA) told heartwire, is that the quantity of food available to study participants was not limited, only the type of food on offer. All of the men in the study were participating in the Pritikin Longevity Center 21-day residential diet and exercise intervention, which involved buffet-style meals and daily treadmill walking for up to 1 hour.

"The present study is the first to show that unrestricted consumption of a low-fat, high-fiber diet and daily exercise can mitigate oxidative stress, improve NO availability, and normalize BP in obese men within 3 weeks," Roberts et al write.

Their study appears online in a rapid access issue of Circulation, October 21, 2002.

...

" It's not difficult to prescribe a program like this, it's difficult for individuals who are given such a regimen to follow to stop eating foods forbidden in this study. It really takes a psychological change in behavior for people who don't eat any fruits and vegetables or maybe 1 or 2 a day by chance to then start eating at least 7 a day."

This, Roberts believes, is a reason why physicians have a hard time promoting major dietary and lifestyle changes, because their patients are so reluctant to make any changes. He suggests that if physicians aim for the very rigorous changes enforced in the current study, their patients will not necessarily adhere strictly to the new lifestyle, but changes will still occur. "If they aim for what we're describing here, they may not reach these same goals, but they could achieve changes that are somewhere closer to the DASH diet. Even if you don't go the whole 9 yards, you're still going to see immense benefit," says Roberts.

These excerpts come from theheart.org. I find the article important because it supports the idea of diet and exercise being so important. The author realistically understand how difficult lifestyle change is for most patients. This requires a major committment - but once adopted should makes patients feel better. Posted by at 06:29 AM | Comments (1) | TrackBack (0)

Separating Gold From Junk in Medical Studies- Jane Brody follows her article on trials from last week with a primer on reading and applying the medical literature. While her article aims to help patients, it certainly applies as a good refresher for physicians.

The AMAnews has an excellent summary of the issue - Double-digit liability rate hikes slam internal medicine, obstetrics, general surgery: The insurance market is not likely to improve in the near future.

Oregon Ponders Universal Care . My post on this issue last week has engendered excellent and impassioned comments shows how important this issue is.

The measure could pass: The most recent polling, by the Portland Tribune, found that 36 percent approved of the plan, 39 percent opposed it, and 25 percent were undecided, with a margin of error of 4 points. The initiative was winning among Democrats and women, and trailing with men, independents and Republicans. An earlier poll by the Oregonian newspaper found 49 percent against the measure and 40 percent for it, with the remainder undecided.

The next week will be crucial, because Oregonians vote by mail (their ballots must be received by Nov. 5). The organized groups opposing the health care experiment have yet to run television spots, though they have about $400,000 on hand and are expected to start their ads any day.

If the initiative actually passes, said Rachel DeGolia, a director of Cleveland-based Universal Health Care Action Network, "it will really wake people up."

DeGolia said efforts are now targeted at the state level as universal health care advocates have been frustrated in their bids to revive debate and congressional action in Washington after the Clinton administration's failed attempt to retool health care finance in 1993-94.

If this passes it will either pave the way for the country or become a measure disaster for Oregon. I hope that it would work. I agree with the ideal, but the implementation worries me.

I was talking to a frequent reader the other day. He pointed out my Democrat bashing (on trial lawyers and malpractice reform). I pointed out that I was equally harsh on the Republicans on the pharmaceutical industry and HMOs. This article eases my criticism of the Republicans a bit. Plan to Seek Faster Release of Generics

President Bush is to announce on Monday that his administration will carry out measures intended to give Americans faster access to low-cost generic versions of brand-name drugs, administration officials said tonight.

The plan, similar to but less extensive than a bill passed in July by the Democratic-controlled Senate, is intended to reduce the ability of manufacturers of brand name drugs to delay the approval and marketing of generic versions of their products.

With only 15 days to go before the midterm elections, administration officials were clearly eager to portray the president as engaged on the issue of prescription drug costs, a topic that polls suggest ranks high on the list of voters' concerns. Broader legislation to provide prescription drug coverage to retirees has been bottled up by partisan disputes in Congress. White House officials previewed the president's planned announcement in an abruptly scheduled conference call with reporters at 7:45 tonight.

In a speech in the Rose Garden, Mr. Bush is to say he will put in force recommendations by the Federal Trade Commission to make it harder for brand-name drug companies to exploit loopholes in existing law, the officials said.

This is a good start. I hope that we do get some speed on generics release.

Give me Strength!

Researchers are learning that a moderate strength-training (weight-lifting) program can do wonders for our bodies. After we turn 30, we lose about 10 percent of our muscle per decade, or a half-pound of muscle every year. That may not sound like much - but by age 70 it means we've been sapped of at least 40 percent of our strength. Lugging a 20-pound bag of groceries at age 30 may be a chore; by age 70 it could be a pipe dream unless we do something to maintain muscle.

Whether you are 20 or 90, strength training stops muscle loss and builds new muscle tissue. That muscle will burn calories, give your body shape, influence your flexibility and sense of balance, and protect you against several diseases.

To a certain extent, strength training even reverses some of the changes normally associated with old age, such as decreased stamina, energy and balance.

I am a zealot. Read the entire piece and consider. We should encourage weight training for many patients. This is an important part of a healthy lifestyle!

WHO: Docs Miss Boat On Heart, Strokes

Doctors are too prone to prescribe medication only for those with high blood pressure or high cholesterol, according to the World Health Organization, which will publish its World Health Report later this month.

Medication would be better targeted at those who have multiple risk factors such as smoking, lack of exercise, excessive alcohol consumption and poor diet, even if blood pressure or cholesterol levels are only slightly elevated, it said.

The main problem is that medication is usually prescribed only when blood pressure or cholesterol levels pass an arbitrary threshold, the report found.

If you would like to read the WHO press report - Cardiovascular Death and Disability can be reduced more than 50 percent: More people at risk than previously thought, particularly in developing world Conditions could be controlled quickly with medical, social interventions The CBS report goes on to summarize the recommendation. We would be prescribing many pills, and yet perhaps the key is diet and exercise. How can we get there?

Doctors should look at a list of risk factors in each patient and prescribe medications to those who have multiple problems regardless of their blood pressure or cholesterol levels, WHO experts said.

The report recommends that people with multiple but individually mild risk factors take a daily combination of aspirin, cholesterol-lowering drugs called statins and low doses of common blood pressure lowering drugs.

The drug cocktail can more than halve the chances of a heart attack or stroke, could be much more widely used in the developed world and is increasingly affordable for poorer countries, the report says.

Dr. Thomas Kottke, a cardiovascular disease specialist and professor of medicine at the Mayo Clinic, said the United States is already moving in that direction.

"They are talking about a paradigm shift here of what we think about," said Kottke, who was not involved in the report. "Certainly there are trials that demonstrate this appears to be a good idea."

Pills are not the only solution, the report said. Nationwide strategies such as reducing the amount of salt in processed foods, higher taxes on tobacco to discourage smoking and encouraging better eating and exercise habits would also help.

Rapid Weight Loss, Garbled Speech, a 'Restless Dance'.... Read this interesting presentation -

"'She's just not herself,'' began a worried-looking, middle-aged woman when I introduced myself. It was a Sunday afternoon, and because of the volume of patients, she was waiting with her mother in the noisy E.R. hallway. ''She says there's nothing wrong,'' the woman continued, ''but she's clearly not herself.'' Her brother, a pudgy, red-faced man, nodded in agreement.

They stood on either side of a gaunt elderly woman, who sat on a stretcher. Her skin hung loosely from the delicate bones of her face. She greeted me with a calm and curious gaze, but that serenity ended at her eyes. Her body was a riot of movement. Her fingers roamed restlessly across the surface of the bed, arranging and rearranging the folds and creases in the bedding. Her shoulders shrugged in a constant acknowledgment of ignorance. Her mouth moved back and forth, up and down, like a parody of a child with a mouthful of gum.

''My mother has always been independent,'' the daughter said. ''She's been living alone since my dad died 20 years ago. She cooks, she goes out every day to do her shopping and errands. Or at least she used to.''

The son spoke up. ''What scares me is her weight,'' he said. ''She's lost maybe 20 pounds in a few months. I feel like she's just wasting away in front of our eyes.''

I have a personal classification system. When someone has an irreversible problem with either an unusual presentation or the problem is unusual - that is an interesting case. When the problem is reversible, and we successfully treat it - that is a great case. In many ways this is a great case. Read it.

Mayor Bloomberg is trying to outlaw public smoking in NYC. The Smoke Nazis

Mr. Bloomberg has framed the smoking ban as strictly an issue of workplace safety — a line that is hard to assail on the merits. The mayor will tell you he strongly defends your right to smoke yourself to death, but you may not spray your toxic effluent into the airspace of innocent bystanders, in particular the waiters and bartenders whose only recourse is to quit their jobs.

There are basically three arguments being raised against him: science, economics and personal liberty. Two of them Mr. Bloomberg wins hands down, and one is open to debate.

This opinion piece nicely dissects the issues - worthwhile reading.

Judge Voids Rules on Pharmaceutical Tests

A federal judge has struck down rules that required drug companies to test their products in children. The rules were intended to give doctors and parents more information about the drugs' safety and the proper dosage.

"The pediatric rule exceeds the Food and Drug Administration's statutory authority and is therefore invalid," said Judge Henry H. Kennedy Jr. of the Federal District Court here.

In the ruling, issued on Thursday, Judge Kennedy said that the food and drug agency was overreaching, just as when it tried to regulate tobacco products. In both cases, he said, the agency's rules were inconsistent with the statutory framework established by Congress.

Our research group studies methods for improving physician practice. We try to find ways to get physicians to improve their adherence to clearly desirable guidelines. This Swedish group has confirmed one of my biases - physicians learn best when discussing cases. Efficacy of case method learning in general practice for secondary prevention in patients with coronary artery disease: randomised controlled study . I like this study.

Intervention: Guidelines were mailed to all general practitioners (n=54) and presented at a common lecture. General practitioners who were randomised to the intervention group participated in recurrent case method learning dialogues at their primary healthcare centres during a two year period. A locally well known cardiologist served as a facilitator.

I will confess to mediocrity during my first two years of medical school. The lecture - multiple choice test format does not fit either my learning style nor my teaching style. From the first day of my 3rd year in medical school, I was comfortable on the wards. Once we start discussing a patient, I want (I need) to know all the details. Patients always inform my learning. I believe that is true for physicians in general. This case based approach certainly worked in this study.

Magnesium does not help patients with STEMI (ST elevation myocardial infarction). A randomized controlled trial studied and has answered the question. "Early administration of intravenous magnesium to high-risk patients with acute myocardial infarction in the Magnesium in Coronaries (MAGIC) Trial: a randomised controlled trial" was published today in the Lancet (not linkable).

Findings At 30 days, 475 (15·3%) patients in the magnesium group and 472 (15·2%) in the placebo group had died (odds ratio 1·0, 95% CI 0·9-1·2, p=0·96). No benefit or harm of magnesium was observed in eight prespecified subgroup analyses of patients and in 15 additional exploratory subgroup analyses. After adjustment for factors shown to effect mortality risk in a multivariate regression model, no benefit of magnesium was observed (1·0, 0·8-1·1, p=0·53).

Interpretation Early administration of magnesium in high-risk patients with STEMI has no effect on 30-day mortality. In view of the totality of the available evidence, in current coronary care practice there is no indication for the routine administration of intravenous magnesium in patients with STEMI.

Recently Nevada had a major malpractice crisis. The state legislature stepped in and passed an emergency bill. Now we have an opinion that the problem may not be solved. Study for doctors calls Nevada malpractice law inadequate

"The new laws will not make a significant improvement in the problems you currently have," said William Hamm, a California-based legislative analyst who co-authored the report.

"Down the road, you will find the same reluctance of various high-risk doctors to offer care in Nevada," Hamm said. "You'll find that providers will continue to relocate their practices elsewhere or take early retirement or shift into less-vulnerable specialties because they cannot afford extremely hefty premiums."

Hamm was enlisted for the study by NM Strategies, a California-based public relations firm hired by "Keep our Doctors in Nevada," a group circulating a petition to change the recently enacted medical malpractice liability laws.

The group says the laws passed by the Legislature during a special summer session don't protect doctors enough and must be amended when the Legislature meets again in February.

The new law went into effect Oct. 1. It caps pain and suffering awards at $350,000, except in cases of gross malpractice or when a judge finds clear and convincing evidence to warrant a higher award.

The doctors' group wants the exceptions to the cap eliminated, although lawmakers said the exceptions are necessary to ensure the new laws withstand legal challenges.

"After much deliberation and compromise with the Legislature, we created a balanced law that deserves an opportunity to work," Gov. Kenny Guinn said in a statement. "I remain concerned about the cost of liability insurance premiums for our doctors and health care system. However, I am also concerned about the rights of those patients who are clearly injured."

Trial lawyers say eliminating the exceptions would violate the rights of patients hurt by doctors' mistakes.

Trial lawyers do not seem to care about society. They do not consider the overall welfare. They just want huge judgements. And they seem to have the Democrats in their pockets.

This will require some difficult decision making. A Miracle From MARS: Cutting-Edge Device Shows Promise for Patients With Liver Failure. The idea seems simple, remove the toxins that lead to the complications of liver failure. The technology seems complex.

For the more than 17,000 patients like Brandon, hope may now be on the horizon — thanks to a new and cutting-edge liver support system known as a Molecular Absorbent Recirculating System, or MARS.

This "artificial liver," developed in Germany, removes toxic substances from the blood that would normally be filtered out by a functioning liver.

The device transports a patient's blood to a filter where it is mixed with a sticky protein called albumin. The toxins in the blood attach to the albumin molecules, which then carry the poisons out of the blood, explains Dr. John Magee, assistant professor of surgery and a pediatric liver transplant surgeon at the University of Michigan.

Although still in the pioneering stages, experts agree that the albumin dialysis has tremendous potential, especially as the number of liver patients increases nationally.

"It is estimated the number of deaths from end-stage liver failure will triple in the next 10 years, says Dr. Robert F. Brown Jr., medical director of the Center for Liver Disease and Transplantation at Columbia Presbyterian Medical Center in New York City.

Developing criteria for using such a system will tax both physicians and society. We will need to understand quickly who will benefit, either because their liver failure is short term and the liver likely will regenerate given time or because MARS will serve as a bridge until a liver tranpslant can occur. Perhaps the criteria will be similar to transplant criteria.

I will keep my eyes open for more data on this new technique.

Recently I wrote about Alan Milstein. He gave grand rounds at UAB concerning the rights of subjects in medical studies. He seems to really believe that he is saving the world. He is wrong. Check out this case - Lawsuit Over Artificial Heart. I am struck by Milstein's audacity in this case. You offer a dying man a clearly experimental treatment and then complain that his quality of life was poor after receiving the artificial heart. Does this bother you as much as it bothers me?

Many readers know that I am a zealot when it comes to fitness. I have worked with a personal trainer since August 2000, and have seen major improvements in percent body fat as well as strength. Given that background, the following article attracted me strongly - High-Intensity Resistance Training Improves Glycemic Control in Older Patients With Type 2 Diabetes

RESEARCH DESIGN AND METHODS—Sedentary, overweight men and women with type 2 diabetes, aged 60–80 years (n = 36), were randomized to high-intensity progressive resistance training plus moderate weight loss (RT & WL group) or moderate weight loss plus a control program (WL group). Clinical and laboratory measurements were assessed at 0, 3, and 6 months.

RESULTS—HbA1c fell significantly more in RT & WL than WL at 3 months (0.6 ± 0.7 vs. 0.07 ± 0.8%, P < 0.05) and 6 months (1.2 ± 1.0 vs. 0.4 ± 0.8%, P < 0.05). Similar reductions in body weight (RT & WL 2.5 ± 2.9 vs. WL 3.1 ± 2.1 kg) and fat mass (RT & WL 2.4 ± 2.7 vs. WL 2.7 ± 2.5 kg) were observed after 6 months. In contrast, lean body mass (LBM) increased in the RT & WL group (0.5 ± 1.1 kg) and decreased in the WL group (0.4 ± 1.0) after 6 months (P < 0.05). There were no between-group differences for fasting glucose, insulin, serum lipids and lipoproteins, or resting blood pressure.

CONCLUSIONS—High-intensity progressive resistance training, in combination with moderate weight loss, was effective in improving glycemic control in older patients with type 2 diabetes. Additional benefits of improved muscular strength and LBM identify high-intensity resistance training as a feasible and effective component in the management program for older patients with type 2 diabetes.

I have read the article (not available to me online) and am impressed. This does represent one observation and we must use some caution. Nonetheless, many would argue that we need resistance training because we (humans) no longer use our muscles in our daily activities. The authors cite many benefits of resistance training. This concept deserves more study. I plan to recommend this to some friends and see what happens.

First, I would like to thank all the new readers coming through the UAB CME web site. I have read your comments and appreciate them greatly. I hope you find interesting content on this blog, and maybe some rants will help you in your practice.

I orginally started this blog for myself. I was delighted that other bloggers found me and liked what I was doing. One day I was meeting with the professional staff in our CME division and mentioned my blog. They reviewed it and asked if they could include it as a web offering. I was delighted, but did point out that I did not want to change my philosophy.

Medrants focuses on articles and issues that interest me. Often they are related to the science of medicine. However, I also am interested in the politics and legal issues surrounding medicine. I comment without regard to political correctness or necessarily facts when I address the scientific issues. These are my opinions and I am delighted that you care enough to disagree. I only hope that my rants lead to thinking. I do not claim to know the right answer to every question, but I do have the right to opine. If you disagree, please comment right here in the blog so that others can read your opinions. This free exchange of opinions enhances the impact of the blog.

Thanks again to all the readers. Keep reading and commenting.

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In the near future, I plan to devote more space to physician burnout. As a profession, we must address this issue aggressively. Physicians to examine pressures in profession

Doctors are experiencing more burnout, depression and family crises because of the pressures of keeping up with advancing technology, says the president of the Canadian Medical Association.

"There's more and more pressure and stresses on the system and very little political willpower to do something about it," Dana Hanson said.

But governments are starting to realize that the demands of working in a cash-strapped and understaffed health-care system are taking a toll, Dr. Hanson said before the opening of the four-day International Conference on Physician Health.

The conference is drawing delegates from Canada, the United States, Finland, Germany and Norway.

Keeping up with new technology and being able to provide access to patients can put enormous strains on doctors for various reasons, Dr. Hanson said.

"You're put in a very moral bind of 'Look, this is what the patient should have or this is what the patient should be assessed with, but how do I get it for the patient?' "

Amen!

As an internist who tries to practice evidence based medicine, I cringe at anecdotes. Fortunately, so does this author - Anecdotal evidence gives an unbalanced view of anti-depressants

The Panorama programme was based mainly on anecdotal evidence. The introduction of antidepressants in the 1950s was one of the great, if not the greatest, factor in the emptying of psychiatric hospitals. Before that, seriously depressed patients often disappeared, hidden from society’s view by high walls and well-grown laurels, for the rest of their lives.

Even before the advent of the tricylic antidepressants — the first effective drugs for this purpose — doctors were fully aware that, when a depressed patient first starts to recover, he or she may be able to summon up enough initiative and energy to kill themselves or, more rarely, beloved relatives. As they lose their inertia, they acquire the necessary insight and determination to take action so that neither they, nor those they love, have to suffer what they regard as a hopeless, unhappy and futile existence.

The scenario of the case shown by Panorama, of the man who shot himself and his family when he started treatment, would not have surprised doctors practising half a century before Seroxat was introduced. The mistake, if one can call it that, as we do not know the details of the case, was to leave this patient at home when starting treatment, as in retrospect it must be agreed that he was sufficiently ill to merit a hospital bed. Most doctors give warning that any suicidal risk is enhanced in the first days or weeks of treatment as a patient’s recovery starts. This occurs whether the return to health is natural, or hastened by a pill.

We cannot practice medicine based on anecdotal information. We must have well done research studies to analyze so that we can practice the most scientific medicine. Only by having a strong scientific base can we succeed in applying the art of medicine. Read that statement again. While the art has great importance, it requires the science as a supporting structure. One must combine these two to truly provide excellent care.

Can you afford to care for Medicare patients? Are you reimbursed enough to even break even? Medicare Cuts May Scare Off Doctors

With Medicare scheduled to cut billions of dollars from doctors' payments, a group representing physicians is urging Congress to restore the money before elderly patients have trouble finding doctors.

Unless Congress acts by Nov. 1, "more physicians will be forced to make the difficult decision to stop taking new Medicare patients into their practices," said Dr. Donald Palmisano, president-elect of the American Medical Association. The next round of cuts, which take effect Jan. 1, will be announced next month.

Palmisano said doctors have already taken a 5.4 percent cut and are facing another 12 percent in cuts, equaling about $11 billion, over the next three years. At the current rate of cuts and inflation, Medicare doctor payments in 2005 will be below the 1991 level, Palmisano said.

I am a broken record. We have a health care crisis. It is getting worse. There are no easy solutions.

The lumpectomy movement started over 20 years ago. To this day, many surgeons believe that it remains an inferior operation. Data presented in today's NEJM show that lumpectomy patients have the same results as mastectomy patients - Lumpectomy Is Seen as Equal in Benefit to Removing Breast.

Some medical experts said they hoped the findings, by researchers in the United States and Italy, might end a simmering debate over whether it is really safe to offer a lumpectomy, rather than a mastectomy, to most women with breast cancer.

One study, at the University of Pittsburgh, involved 1,851 women and compared mastectomies with lumpectomies. The other, at the European Institute of Oncology, in Milan, involved 701 women and compared radical mastectomies, which removed more tissue, with a more extensive form of lumpectomy.

The studies, both described in today's issue of The New England Journal of Medicine, have reported similar results in years past. But some experts said then that they would not be convinced until more time had gone by. Among them, many thought that mastectomies were better for women with relatively large tumors, aggressive cancers or disease that had already spread to the underarm lymph nodes.

Dr. Monica Morrow, a professor of surgery at Northwestern University, said her national survey of women with early-stage breast cancer found that just 42.6 percent had breast-conserving surgery; the worse the woman's prognosis, the more likely she was to have a mastectomy instead.

In an editorial accompanying the two studies, Dr. Morrow wrote that "breast-conserving therapy is still not accepted as equivalent of mastectomy, but instead is viewed as a less aggressive therapy appropriate only for women with a good prognosis." She said she hoped the new results would change that view.

These are important studies and important results. Once again (as I stated earlier this week) it often takes a carefully done clinical trial to resolve major debates in medicine. Kudos to the investigators and thanks to the many patients who participated in these landmark studies.

Smallpox Vaccine Data Show Small but Serious Risk of Infecting Others.

Scientists said the findings were reassuring, since the risk was so small — a few cases for every 100,000 vaccinations — but cautioned that the risk today might be higher than in the past, because more people have disorders of the skin or immune system that predispose them to adverse effects from the vaccine or close contact with those who have been vaccinated.

Smallpox vaccine has long been regarded as the most dangerous of all vaccines, both to recipients and their close contacts. For every million recipients, 15 will have life-threatening reactions, including 1 or 2 deaths, and hundreds will have severe rashes or other illnesses.

The risk to those who are unvaccinated but are in contact with those who are occurs because vaccinia, a relative of smallpox, is shed from the vaccination site for about three weeks and can make some people very sick. But the degree of risk to unvaccinated people has not been clear.

An author of the report, Dr. John M. Neff, a professor of pediatrics at the University of Washington, said the risk from vaccination or contact was "small, and it is significant."

"It is significant," he said, "because some of these adverse effects can lead to death. And it is significant because if you have a death or just one really serious adverse effect and the vaccination efforts were ill advised, you bear a heavy burden of responsibility, and it becomes very tragic.

I have opined previously that I favor a cautious approach to smallpox vaccination. We currently can only imagine an epidemic, but have no hard data to predict one. I do believe that we can respond quickly to a real case of smallpox. I fear unnecessary vaccination with this vaccine.

Today's JAMA has an analysis of bone densitometry. I will link to the abstracts (you need a subscription to have full text access). Clinical Use of Bone Densitometry: Scientific Review Their conclusions

Guidelines based on systematic reviews and a cost-effectiveness analysis have suggested that it is worthwhile to measure BMD in white women older than 65 years and perhaps to use risk factors to select younger postmenopausal women for densitometry. Other potential clinical applications of BMD that have not yet been adequately studied include screening men or nonwhite women, monitoring BMD in patients receiving treatment, and using BMD to identify patients who should be evaluated for secondary causes of osteoporosis.

Clinical Use of Bone Densitometry: Clinical Applications

Densitometry might be more effectively used in practice if strategies such as having patients fill out a short questionnaire to assess for risk factors or creating a nurse-based system were used to identify patients. Clinicians need better approaches for identifying patients most likely to benefit from screening, systems that facilitate their application, and test results that are easy to interpret.

As I read these data, I tend towards aggressive bone densitometry testing. Olendrenate works well as a once weekly treatment. The complications of osteoporosis can devastate. Prevention clearly trumps treatment for fractures.

Groups that I test include women over 65, every patient on chronic steroids, women at menopause if they are at perceived high risk (I would like a clear algorithm here). As prevention improves, we have an increasing responsibility to discover this problem early.

We would rather prevent disease than treat disease. The NHLBI released yesterday their new statement on preventing hypertension - New Recommendations to Prevent High Blood Pressure Issued: Additional Lifestyle Approaches Advised.

The National High Blood Pressure Education Program (NHBPEP) has updated its recommendations to prevent hypertension (high blood pressure). New recommendations include adequate intake of potassium and an eating pattern rich in fruits, vegetables, and low-fat dairy products and reduced in saturated and total fat. The advisory also reinforces earlier recommendations to limit consumption of sodium and alcohol, reduce excess body weight, and increase levels of physical activity.

Published in the October 16 issue of The Journal of the American Medical Association, the report also cautions that some widely publicized approaches have less proven or uncertain efficacy. Fish oil (omega-3 polyunsaturated fatty acids) and calcium supplements lower blood pressure only slightly in individuals with hypertension. In addition, the ability of herbal and botanical supplements to safely lower blood pressure is unproven, and these unregulated products can interact adversely with medications.

The message remains clear. Healthy diet and exercise improve ones chances of good health. We can decrease the probability of hypertension and type II diabetes. Physicians know this, as do patients. How do we get people to exercise (even modestly) and eat a more healthy diet? Patients and friends have given me many excuses. What do I understand that they don't understand?

I believe the problem comes from not understanding the consequences. Most people believe that you get a problem (hypertension and diabetes for example) and the doctor treats that problem. They do not really understand the health implications over time, even with excellent treatment. Most Americans have difficulty seeing the long term picture. They love to eat (I understand that as I do love to eat), and will not trade the short term perceived decrease in quality of life for long term health. We must find new ways to present these data. We need to help patients understand. Meanwhile, I keep trying, hoping that the occasional patient or friend will modify their behavior. Talking is easy.

Clinics offer controversial heart treatment A number of heart failure clinics offer outpatient inotrope therapy despite consistent study results showing no improvement in outcomes and increased mortality.

So why are inotrope clinics operating? Cindy Palmer, care coordinator of the heart-failure clinic at Our Lady of the Lake, says her clinic is helping people. "We see that our patients are doing much better on the drug than off the drug," Ms. Palmer says. "We have not seen bad outcomes." Other doctors who prescribe the treatments say their patients tell them inotropes make them feel better.

The clinic at Our Lady, which opened in 1997, isn't the only one of its kind. In recent years, numerous others, mostly in the South but also in places such as Pittsburgh and Iowa City, Iowa, have sprung up giving outpatient inotrope infusions. In part, their proliferation is the result of a 1990s Sanofi marketing campaign, aimed at encouraging such treatments. Sanofi marketing pamphlets, which prompted a letter of censure from the FDA, urged use of the drug "in the outpatient clinic" on grounds that Primacor helped the heart "work smarter, not harder." Primacor, which had U.S. sales last year of $187 million, went off patent in May. Sanofi, which still makes Primacor, known by the generic name milrinone, says it no longer promotes it and can't control how doctors use it.

Despite the controversy about the safety and effectiveness of inotrope infusions, Medicare covers the treatments. Many cardiologists suspect that is why hospitals and clinics are administering inotropes, while other forms of care for heart failure aren't covered.

I find these clinics irresponsible and dangerous. The studies are clear. This treatment neither improves quality of life nor quantity of life. Medicare should not pay for this therapy. This is wrong!

Doctor and Patient Wage Tug of War on Antibiotics. I like this story. Physicians act responsibly.

As flu season approaches, doctors and patients are gearing up for the annual antibiotic battle, when miserable patients, coughing and sniffling, demand antibiotics.

But many doctors, being pressured to prescribe fewer antibiotics over concerns of drug-resistant bacteria, are refusing to write the prescriptions. Behind the battles is the diagnostic uncertainty that surrounds most upper respiratory tract illnesses. Symptoms of viral and bacterial infections can look remarkably similar.

Patients insist that antibiotics they have taken in the past have cured them. Some doctors, echoing infectious disease experts, contend that because a vast majority of upper respiratory infections are viral, not bacterial, the likelihood that the antibiotics had any effect was minuscule. They say it is either coincidence that the viruses began to clear up after antibiotics or it was the placebo effect.

These experts add that doctors should not turn away patients who need antibiotics.

"I think that as we promote appropriate antibiotic prescribing, we need to be sure that these campaigns don't leave patients who truly have bacterial infections without appropriate therapy," said Dr. Richard E. Besser, director of the Centers for Disease Control and Prevention's Campaign for Appropriate Antibiotic Use. For example, pneumonia should always be ruled out when a patient comes in with bronchitis.

The elderly and those with underlying illnesses are two groups that should be treated with caution. "Our efforts on appropriate antibiotic use are not designed for application for elderly," Dr. Besser said.

Physicians wrote 24 percent fewer antibiotic prescriptions for children and adults making ambulatory visits in 1999 than they did in 1992.

Jane Brody has a nice summary of the importance of clinical trials today - Ferreting for Facts in the Realm of Clinical Trials.

Millions of women discovered a basic in medicine, much to their dismay, this summer when the Women's Health Initiative study showed that postmenopausal hormone replacement did not prevent heart attacks. Only clinical trials, they learned, can establish a definitive fact about the effectiveness and safety of a diagnostic technique, preventive method or treatment.

Experience with patients in doctors' offices and hospitals and observational studies like the Nurses' Health Study can offer hints, sometimes strong ones, on benefits and risks of various procedures and habits, but they are still only guesstimates.

Turning a hint into a hard-to-refute fact requires a clinical trial in which participants are randomly assigned to one procedural group or another. Even then, the findings can be applied with certainty only to the kinds of people or circumstances used in the trial.

Lifesaving Progress

Clinical trials are the backbones of medical progress. They have demonstrated the value of vaccines to prevent devastating diseases and drugs to treat them. They have shown, for example, that certain drugs given immediately after a heart attack or stroke can markedly increase survival while others do not help. And clinical trials are behind nearly all the progress that has been made in treating various kinds of cancers in the last four decades.

The article continues and balances the pros and cons of clinical trials participation. She makes the case for the importance of these trials. The editorial from the WSJ that I cited on Friday makes that case in a different way. When I wrote about that editorial, I mentioned Alan Milstein, the plaintiff's lawyer who gave grand rounds on the ethics of clinical trials. We were discussing his grand rounds yesterday, and wondered about his conflict of interest. He makes his living discussing the 'sins' of clinical trials. Can he objectively discuss the issue?

If you would like to read his cases and opinions, he sent me his web address - Alan Milstein. On the firms site, one can find their opinions on bioethics and clinical trials litigation. Some researchers only see the good in trials. Some lawyers only see the bad (and I would assume an opportunity to litigate). Where is the middle road? How should we gain knowledge? What is the proper protection for participants?

Putting Cancer Screening to the Test does a nice job of presenting the cancer screening dilemma for prostate and breast cancers. This article is balanced an quotes many physicians and patients. I tend to be a screening nihilist, since I do not see any data telling me that screening for prostate cancer could help me. I start mammography at 50, unless the patient asks for the mammography earlier, since I do know that there is some emotional value of a normal test. As the article suggests, we each should develop our own comfort zone on these issues.

I just received my September 30th issue of 'The Medical Letter'. I generally agree with their summaries. They are truly independent, receiving no moneys from the pharmaceutical industry. That issue has a nice review of dietary supplements. They point out that the 1994 law intending to keep the FDA from regulating vitamins and herbal products as drugs has led to our current problems. I will quote their conclusion (given after giving solidly referenced examples of problems with several supplements - both their danger and their inconsistency).

The main problems with dietary supplements, even if questions about their effectiveness and adverse effects were answered satisfactorily, are that their potency may vary and their purity is suspect. Physicians should tell their patients that we really don't know what's in them.

AMEN!

Once again because of unstable links I will quote both commentaries.

Measure 23 would work well

10/14/02

The Sept. 26 Oregonian editorial opposing Ballot Measure 23 (The Oregon Comprehensive Health Care Finance Act) was full of misstatements, demeaning phrases, unproved assumptions and omissions of fact. As a retired professor of health policy and administration who has followed the plan I would like to respond.

* The "measure would attempt to replace the private health insurance in Oregon with a system of socialized medicine." The Act is not socialized medicine, any more than tax supported public schools, the Oregon Health Plan, The Children's Health Program, Medicare or Medicaid. Private providers will continue to provide health care services. They will negotiate their fees with a Board, elected by citizens and Governor appointed professionals representing the various provider groups. Providers will see payments that don't deduct the large overhead of administrative and profit costs inherent in the present system.

* The "measure would soak taxpayers from every brand of alternative medicine from legitimate practice to half-witted quackery" Only licensed, registered and certified professionals will be eligible. The professional disciplines of Chiropractics, Acupuncture, and Physical Therapy and Licensed massage therapy all have supervisory boards and standards. Not quacks, these ancillary providers and their treatments are increasingly supported by the general medical community and used as ancillary therapy, often saving medical dollars in prevention and rehabilitation.

"A "vague definition of medical necessity and residency." Medical necessity is determined by the professional clinical judgment of the provider and the patient's needs. State legal counsel advised us to use the state definition of residency, which is "intent to remain in Oregon." The Board can further define medical necessity and residence in administrative rules.

* "Whopping 89% increase" in personal income tax is based on a false premise. A progressive health tax of 3 percent to 8 percent on taxable income replaces at less cost, increasingly huge insurance premiums, co-pays and deductibles and out of pocket expenses we now pay. Those at poverty level pay nothing. Top payments of 8 percent would occur only on taxable income of over $100,000. The relatively healthy writer paid 8 percent of her taxable $37,000 income in Medicare B, an HMO supplement and non-covered medical expenses. Under the Act, her expenses would be much less. The average Oregonian would pay about 4.6 percent on gross income; meaning taxable income percentage would be less. Payroll taxes of 3 percent to 11 percent, based on size of payroll would be favorable to businesses, likely less than the 13-15 percent that many now pay.

* "Improbable that the federal government would approve waivers." Oregon was the first state to achieve a Medicaid Waiver to fund the Oregon Health Plan. Many other states followed. Savings in Medicare expenses, generated by this measure would be attractive to the Federal management of that program.

* "Creating a vast enormously costly bureaucracy." We now have a huge private bureaucracy of multiple payers, paperwork, clerical workers and highly compensated CEOs contributing heavily to increased health care delivery costs, now estimated at 25%. Will a single state public corporation with all taxes dedicated solely to health care be more expensive? No! Medicare, a single-payer system, has administrative costs of 3 percent. Measure 23 caps administrative costs at 5 percent, including initial set up expenses and meeting the initial backlog of unmet medical needs.

* "No limits...break the state...drive businesses and health care providers of the state." Limits will be established by budgets and quality of care monitored by utilization review for abuses. This health care system will be accountable to the public through an elected board. Private organizations with agendas of profit and growth will not control policy and clinical decision-making. Businesses will want to stay in a state where their benefit costs are reduced, not forever rising and where those who offer insurance subsidize those who do not. Providers, who will benefit from the savings in time and money generated by reduced administrative costs, will not leave.

* "It's utopian and completely unworkable .¤.¤. reckless simplicity" The Oregon Comprehensive Health Care Finance Act was the result of a four years of research and study by the sponsor and health care professionals, using figures from the State Revenue Department, the General Accounting Office (GAO) and 12 substantial national and state studies (including the Kaiser Foundation; Lewin Group; etc.) show that single payer financing will save money while covering everyone and result in substantial saving through bulk purchasing and lower administrative costs (limited to 5% in the Act). Fiscal estimates through 2005, by a respected consulting health economist, were based on solid data.

Do we need proof that Measure 23 will work? Try this: A 2002 state-authorized California study of nine health care reform proposals reports that only three proposals to achieve cost savings and universal care were single payers plans. They did this by consolidating administration, purchasing pharmaceuticals in bulk from the Federal Supply Schedule, using a global health care budget, coordinating capital expenditures, emphasizing primary and preventive care, and linking pending growth to the GDP. Savings in administration, primary care and purchasing were 21.3 billion. Households saved $165 to $1,652. The six other multi-payer plans actually increased spending by $3 billion and left 6 million uninsured.

The GAO, which monitors how we spend our tax monies, has this to say. "If the United States were to shift to a system of universal coverage and a single payer with authority to oversee the health care system the savings in administrative costs would be more than enough to offset the expense of universal coverage." The Oregon Comprehensive Finance Plan can do the same in Oregon and set a model for the nation!

Mary Ann Holser, a retired professor of health administration and policy, lives in Eugene. She was on the steering committee that developed Measure 23.

And in the interest of balance.

No on Measure 23

10/14/02

This fall, Oregonians will cast what will be the most important vote of our lives, on Measure 23. If this universal health insurance measurepasses, we will see the demise of Oregon businesses and Oregon as we know it.

In college, an economics professor taught me one important fact. Economics 101: "You don't raise taxes in a recession." Oregon has been in a recession for three years now, going on four. This measure is trying to hit Oregon hard were it counts, the workers and the small businesses.

Here are the facts on Measure 23. If we as voters allow this measure to pass, this is how we will be affected:

The measure would give power to a 15-member board to:
* Nearly double top personal income tax rates from the current 9% to 17% and raise individual taxpayer's income taxes as much as $ 25,000 per year
* Impose a new payroll tax up to 11.5% on every employer in Oregon
* Borrow unlimited money using state revenue bonds
* Raise taxes and issue revenue bonds without voter approval
* Operate without any limit on administrative costs for the first three years
* Ration health care services to all Oregonians when budgets fall short.

Measure 23 would do nothing to control rapidly rising health care costs. This includes no cost containment strategies (deductibles, co-pays, co-insurance), ways insurance companies have implemented to spreads cost. The proponents state they would eliminate these strategies and implement a better-proven strategy. As the saying goes, rob from the rich and give to the poor through taxation. (If history serves me correct, we revolted against England for this.) The measure would provide full coverage for virtually any item or service billed by any provider licensed or registered in Oregon.

The most concerning fact is this measure would cause Oregon employers to leave the state and close their doors because this would require the largest tax increase in Oregon history. The 11.5% payroll tax and the 17% income tax would hurt Oregon's weak economy; trigger layoffs and people would leave the state. All of these repercussions would hurt the funding base for all of Oregon's major programs. The hot buttons in today's political talk are schools, under the propionates views this would save schools millions of dollars. Not only would it not save them money, it would cost them millions in lost revenues when people exit the state to find work.

The proponents of this measure know nothing about Oregon other than the liberal character Oregonians have shown in that past with the passage of Medical use of Marijuana and Assisted Suicide Laws. I believe most proponents feel this will not pass because the measure has no constraints. However what they are doing is laying a foundation for a future push in years to come for a socialized program. Just ask Canada. In September of this year, there was an article in the Vancouver paper looking and asking for ways to go back to private Medicine.

I want to encourage voters to vote NO. We need to send a clear message to the proponents that we do not want this issue back on our ballots. Defeating this measure by 70 or 80% would send a message.

Robert J. Hoover works in the financial services department of Oregon Insurance.

These commentaries (and the ones I cited recently) frame their local discussion, but may portend our national discussion. No one has a foolproof way to escape the health care crisis. Therefore, many will try to use the crisis to develop a single payor program, with the government (our taxes) the likely payor. While I understand their idealism, I only look to Canada and Great Britain to see the flaws.

Physician payment crunch: Medicare cuts hit Medicaid access: Many physician practices can't absorb losses from Medicaid any longer.

The latest physician access study, released by the Medicare Payment Advisory Commission, found a seven percentage-point drop in the number of doctors taking all new Medicare patients from 1999 to 2002. But it also shows that the proportion of practices open to all new Medicaid patients dropped during the same period from 48% to 37%.

Many believe the two are linked.

"I don't know of any physicians that get to the point that they're restricting Medicare in their practice that they haven't either restricted or totally eliminated Medicaid out of their practice," said MedPAC Commissioner Ray Stowers, DO. "In a lot of practices, even though the [Medicare] reimbursement isn't that good, it still helps carry part of the Medicaid expenses in your practice."

With Medicare rates lagging behind the cost of treating a patient, Dr. Stowers fears, practices will no longer be able to absorb the losses they incur when they treat Medicaid patients.

Aid MDs and Patients Too (LA Times articles require free registration).

Trial lawyers say the $250,000 cap, imposed in California in 1975 and never raised to account for inflation, provides far too little compensation in 2002, however. They're right. It's also very hard to find a lawyer to take a $250,000 case. To provide the same level of compensation in today's dollars, the cap would have to be about $800,000.

But regardless of the figure that Congress finally sets, some cap on these so-called punitive damages (compensation not for direct economic loss but for impaired quality of life) makes sense. The current lottery-style system hurts everyone, forcing physicians in some states to close their practices. One measure of the chaos: In California, insurance companies offer general surgeons malpractice coverage for $21,000 to $43,000 a year, whereas in parts of Florida annual premiums are as high as $159,000.

Chances are slim that the Senate will agree to the medical malpractice bill as it's now worded, for Democrats rightly argue that if Congress is going to weaken patients' ability to penalize doctors and health plans, then it must give them an alternate means of appeal and improve detection of medical errors.

Californians have enjoyed such recourse since 1999, with a law guaranteeing patients the right to an independent medical review when they believe they have been harmed by their health plan's treatment -- or denial of treatment.

Sometimes California gets it right. One can only hope that the Senate Democrats develop common sense.

'Ask Your Doctor'. So Andy Rooney sees an ad on TV - ask your doctor. He decides to try that. And he learns that talking to 'your doctor' is not very easy.

I like doctors, though. Not many bad ones. I trust all doctors except the ones who advertise in the Yellow Pages.

Things have changed for the worse for both doctors and patients though. Our relationship has gone to hell. It isn't their fault, it isn't ours. It's because of HMOs and because they have to spend more time on paperwork than on patients. What we need is more good doctors and fewer bad health plans.

I have not always agreed with Marcia Angell (the former editor in chief of the New England Journal of Medicine) and I do not agree with everything in this commentary. Nonetheless, we should all read it and consider her points. She favors a single insurer and makes some cogent arguments as to why that we help our situation. The Forgotten Domestic Crisis.

The fatal flaw in the system is that we treat health care as a commodity. That has been the case for a long time, but the effects were masked during the economic boom of the 1990's. Now, with the recession, the irrationality of that approach is exposed.

When health care becomes a commodity, the criterion for receiving it is ability to pay, not medical need. Private insurers and providers compete with one another to avoid getting stuck with high-cost patients, so they can keep more of their revenues. But this game of hot potato takes a lot of oversight and paperwork. In fact, the hallmark of the system is the extent to which health funds are diverted to overhead and profits.

Look at what happens to the health-care dollar as it wends its way from employers to the doctors and hospitals that provide medical services. Private insurers regularly skim off the top 10 percent to 25 percent of premiums for administrative costs, marketing and profits. The remainder is passed along a gantlet of satellite businesses — insurance brokers, disease-management and utilization-review companies, lawyers, consultants, billing agencies, information management firms and so on. Their function is often to limit services in one way or another. They, too, take a cut, including enough for their own administrative costs, marketing and profits. As much as half the health-care dollar never reaches doctors and hospitals — who themselves face high overhead costs in dealing with multiple insurers.

One more absurdity of our market-based system: the pressure is to increase total health-care expenditures, not reduce them. Presumably, as a nation we want to constrain the growth of health costs. But that's simply not what health-care businesses do. Like all businesses, they want more, not fewer, customers — but only if they can pay.

All piecemeal attempts to improve the system — while keeping it market-based — have run into the following dilemma: if access to services is expanded, costs rise; if costs are lowered, access is cut. That's the way it is. The only way to avoid this dilemma is to change the system entirely.

What we need is a national single-payer system that would eliminate unnecessary administrative costs, duplication and profits. In many ways, this would be tantamount to extending Medicare to the entire population. Medicare is, after all, a government-financed single-payer system embedded within our private, market-based system. It's by far the most efficient part of our health-care system, with overhead costs of less than 3 percent, and it covers virtually everyone over the age of 65. Medicare is not perfect, but it's the most popular part of the American health-care system.

She continues to lay out her plan and why we would have better health care than Britain and Canada. I admire her thoughtfulness, but fear her solution. She states that Medicare is the most popular part of the health-care system. I am not sure who thinks that. Few physicians believe that Medicare is great. Medicare has not supported first contact physicians. Medicare makes arbitrary decisions on payment for services. It may have low overhead costs but it causes high overhead costs. The bureaucracy has created byzantine rules for coding which no one understands. And (Catch-22 here) they can fine you for not coding correctly.

This commentary is very important, but I fear the solution. I agree with much of her analysis, but as usual the single payor solution is fraught with danger. Her solution would give a governmental bureaucracy too much control. And we all know what happens when governmental bureaucracies develop too much control.

Patients with the syndrome - diabetes, hypertension, hypercholesterolemia, vascular disease - clearly benefit from statins. These data address the complexity of how they help so much. Statins Seem to Improve Plaque Stability, Reduce Inflammation

To study whether a statin improves serological markers of inflammation and plaque stability, Dr. Koh's team assigned 63 patients with coronary artery disease to follow the American Heart Association Step I Diet for 14 weeks. Half of the patients also used simvastatin, while the others received placebo.

Serum levels of C-reactive protein were significantly lower in patients who used simvastatin than in those who used diet alone, the team found. The same was true of plasma levels of tumor-necrosis factor-alpha (TNF-alpha), a proinflammatory cytokine that stimulates MMP-9 synthesis and secretion.

Levels of total MMP-9, MMP-9 activity, tissue inhibitor of MMP-1 (TIMP-1), and the ratio of MMP-9 activity to TIMP-1 were lowered significantly in simvastatin-treated patients compared with the controls, but the difference did not reach statistical significance.

"Although diet alone tended to reduce MMP-9 activity and MMP-9/TIMP-1 ratios from the respective baseline levels, diet alone did not change C-reactive protein, TNF-alpha, total MMP-9, and TIMP-1 levels despite significant changes in lipoproteins," the investigators summarize. "Our present observations support nonlipid mechanisms of statins."

Fortunately, we do not see many side effects from statins. I would like to know about dose effects now. We have pushed statin levels to lower cholesterol. Do we also help the inflammation and placque stabilization? We need to know this, but I doubt that the pharmaceutical industry will sponsor these dosing studies. We probably do not need outcome studies at this time, rather studies like the one cited here should lead us to better decision making.

We would like to think that part of our poor eating is availability. The fine citizens of the republic of Berkeley thought that. We were wrong. Health Food Fails Test at School in Berkeley

"It's good for them, but they're not going to eat it," Mr. Trahan said of the students who clamor for fries, hot dogs, sausages and the occasional vegan burger. "You don't see Carl's Jr. and McDonald's advertising veggie dogs."

In this politically fractious city where cuisine is king, an experiment that offered fresh, nutritious, locally grown food at Berkeley High is defunct. Parents and drafters of a Board of Education policy recognizing the sharing of food as "a fundamental experience for all peoples" are reeling and trying to figure out what went wrong.

This article sets out our problem. How do we get Americans to change their eating preferences?

This remains a national problem. Our Just (Burp!) Desserts discusses this in depth.

Americans like to talk the talk of svelteness, but they walk the walk of obesity. Diets and exercise equipment are obsessions, but they can be run through as quickly as a platter of buffalo wings on a football Sunday. Abdomenizer and Deal-a-Meal infomercials fill the airwaves, but a few months later, the Abdomenizers are hidden in the backs of closets and the Deal-a-Meal cards are the stuff of yard sales.

Low-fat foods have become a popular product category in supermarkets, but for many people, eating them does not result in weight loss. After all, there may be only a few grams of fat in a serving of low-fat cookies, but not if your idea of a serving is polishing off half a box while watching "Survivor."

I keep talking about exercise and diet. Sometimes I feel like I am talking to the wall. In our society, it probably has to become an obsession. I feel fortunate to have become obsessed.

I wrote earlier this week on the Oregon measure for universal health coverage. I am quoting two editorials from the Oregonian rather than providing links because those links appear unstable.

Should we have universal health care? YES

10/07/02
BRITT McEACHERN

This fall, we Oregonians will cast what likely will be the most important vote of our lives, on Measure 23.

The Health Care for All initiative will give this state a chance to stand up and tell insurance companies that we cannot afford to pay skyrocketing premiums that cover a diminishing number of services.

We have the opportunity to tell them that it is unacceptable to have a health-care system in this country that has left more than 41 million people uninsured and 50 million more underinsured. We can tell them that it is unreasonable to have insurance executives taking home tens of millions of our health-care dollars every year while they force seniors to choose between food and medicine.

Measure 23 will make these and other problems of a failed industry a thing of the past, by using a designated part of state income taxes to finance health care for every Oregonian. At the same time, it will save most people money by eliminating deductibles, premiums and co-payments.

Opponents of Measure 23 love to scare you with claims that this plan has no cost controls and will be run by bureaucrats. These claims are baseless. Insurance corporations are expected to funnel millions of dollars into this campaign to spread their propaganda and dismiss the simple facts of Measure 23.

The main cost control that insurance companies use is denying care to sick people. Instead, Measure 23 will result in the use of proven cost controls, ones that are in place in other parts of the country. Bulk purchasing of prescription drugs and medical equipment, a focus on preventative care and reducing the crippling administrative costs of the current system are just a few approaches Measure 23 takes to lower health care costs.

These cost controls will provide a great benefit to the organizations that need them most, public schools. Writers of Measure 23 sent this plan to school districts around the state and found that schools would save millions. Had this plan been in effect in 2000, North Clackamas schools would have saved more than $3.5 million; Eugene, more than $2.3 million.

Right now, 25 percent to 40 percent of every dollar we spend on health care goes to administrative costs. This broad category includes outrageous CEO salaries, paperwork and the millions spent on advertising. These costs will be capped at 5 percent after the first three years. This cost control alone will save Oregon billions of dollars every year.

In our current system, businesspeople are making out health decisions rather than our doctors. When an MBA in a cubicle denies vital medicine to a child, he or she cannot be held accountable. With Measure 23, our doctors, not the insurance executives, will determine the treatment we receive, and the people of Oregon will vote for the people to manage the system.

By offering far better care for less money than what we are spending now, Oregon will once again blaze the trail for reforms in this country.

Britt McEachern is communications director of the Oregon Yes on 23 Campaign.

And now the opposing view.

Should we have universal health care? NO

10/07/02
LISA TRUSSELL

Measure 23 would replace the current private health insurance system and create instead a costly taxpayer-funded system that would cripple Oregon's economy.

Few argue with the goal of providing essential health care to every Oregonian. Measure 23, however, goes far beyond essential care, in providing free treatments from any type of provider.

It would roll out the welcome mat to anyone outside Oregon seeking free health care. To be a "resident" under Measure 23, people would need only indicate their intention to stay in Oregon.

State officials estimate Measure 23 would cost more than $10 billion per year, nearly doubling the entire current state general fund budget and risking further reductions in state budgets that fund the K-12 education system and other priority state programs. Proponents put the cost at more than $20 billion per year.

How will the state pay its massive new health care bill? New taxes. Measure 23 would nearly double Oregon's top income tax rate, from 9 percent to 17 percent. Each taxpayer's income taxes could rise as much as $25,000 per year.

Employers also would face a new tax on their payrolls of up to 11.5 percent. Such a huge tax increase would force many businesses to leave the state or close their doors. It would be a devastating blow to Oregon's economy.

Measure 23 puts the full authority for the implementation of the new health care plan in the hands of a new 15-member Oregon Comprehensive Health Care Finance Board. Ten members of the board would be elected and five would be appointed by the governor.

The new board would have broad powers to tax, borrow and ration health care. The board also would set reimbursement rates for physicians, hospitals and other providers.

Because Measure 23 eliminates current cost-containment tools, such as co-payments and deductibles, its wide-open coverage and lack of any cost constraints would mean health care expenses would rise dramatically. In addition, Measure 23 would replace proven workers compensation cost-containment tools, as well as a treatment review process that ensures workers get appropriate care for their injuries.

Once costs overwhelm the tax system, the board would have the authority to ration health care benefit levels for all Oregonians. Canada has a similar national health plan. Canadian residents needing heart bypass surgery have to wait as long as a year to receive the surgery and many die while waiting.

Rationed care is not what Oregonians need.

Take a close look at Measure 23. It vests enormous power -- too much power -- in a board of state-paid bureaucrats.

If Measure 23 passes, health care costs in Oregon would soar. State budgets would be nearly tripled, and other priority state programs, such as schools, would be imperiled. The state's economy would be ravaged by the steep, new taxes. And ultimately, Oregonians would get less care than they do today.

Lisa Trussell is chief operating officer for AOI Healthchoice.

Earlier this week I referred to this week's articles on obesity. Jane Galt commented on those articles also - Apparently, many Americans are clinically obese, but don't know it.. Over on Jane's site, many comments centered on the definitions of overweight and obesity. I believe that we should use a combination of BMI (with its flaws) and waste circumference. Let's review some data.

An article in the current issue of the American Journal of Clinical Nutrition ( Waist circumference and obesity-associated risk factors among whites in the third National Health and Nutrition Examination Survey(NHANES): clinical action thresholds) addresses this issue in a careful and systemic manner. The investigators used the NHANES data to ask whether measures of obesity predicted cardiac risk factor presence (one of low HDL, high LDL, high blood pressure or high glucose). This study only examines white participants.

Using complex statistics, they determined thresholds for BMI and waist circumference as predictors of cardiac risk factors. They derived a variety of results, but I will focus on the point of standard risk (i.e., above that measure you have increased risk, below that measure you have decreased risk). For BMI in men that point equals 26, for women it equals 25. For waist circumference in men that point equals 96 cm (37.8 inches), for women it equals 85 cm (33.5 inches). They also showed that waist circumference predicts these cardiac risks better than BMI.

An accompanying editorial (no link available) discusses this issue in depth. They make several important points. First, waist circumference is the best anthropomorphic measure of total body fat. Second, the editorial and article debate the appropriate cutpoints or action thresholds.

The article proposes the following action thresholds: overweight = waist circumference greater than 90 cm (35.5 inches) for men or 83 cm (32.7 inches) for women; obesity = waist circumference greater than 100 cm (39.3 inches) for men or 93 cm (36.6 inches) for women. I propose a two pronged approach, only because waist circumference takes more time and effort to follow. We should measure patients at their first visits (accurate height and weight as well as waist circumference). If the waist circumference is less than the overweight threshold, one need not address weight as a risk factor. If the waist circumference shows either overweight or obesity, then one might calculate the BMI for correlation. If the BMI and waist circumference show similar values, one can then simply follow the weight, measuring the waist circumference again after weight loss. This strategy will help classify the tall (for whom BMI works less well) and the very fit (who often have an elevated BMI from muscle weight). When the waist circumference looks good, yet the BMI looks elevated, one should believe the waist circumference.

How should we measure waist circumference? "How to measure waist circumference: With a tape measure, comfortably measure the distance around the smallest area below the rib cage and above the umbilicus (belly button)." Waist circumference I like waist circumference because we can each follow our own waist circumference easily.

Now for those with elevated waist circumference, how do you lose weight? I have written extensively on this issue. The principle is simple - you must eat less and burn more. There is no magic. Weight loss requires life style change. So does maintaining weight loss.

Maintaining Weight Loss

How do people successfully lose weight and keep it off?

Healthy low-calorie and low-fat diets as well as high levels of physical activity are the foundation for success, according to the researchers who maintain the National Weight Control Registry (NWCR), a database of people who have self-reported successful weight loss and maintenance of weight loss.

Although the criteria for entry into the NWCR is the achievement and maintenance of weight loss of 30 pounds or more for at least one year, the average NWCR participant has lost about 60 pounds and kept it off for about five years.

When participants were asked questions about how they maintained their weight loss, the NWCR researchers found that:

* 92 percent limited their intake of certain foods (one example: eating at fast food restaurants less than once a week).
* They consumed an average of 1400 calories per day, of which 24 percent of calories was from fat, 19 percent protein, and 56 percent carbohydrates.
* They ate five times a day, on average.
* They burned an average of 2,800 calories a week through exercise (an equivalent of about 400 calories day).
* 75 percent weighed themselves regularly - at least once a week.
* About one-third described weight maintenance as hard, one-third as moderately easy, and one-third as easy.
* 42 percent reported that maintaining their weight loss was less difficult than initially losing the weight.

Approximately 80 percent of NWCR respondents are women, 97 percent are white, and 54 percent have an undergraduate or graduate degree.

To read more about sustained weight loss - The National Weight Control Registry

One of the most popular myths about weight loss is that everyone who loses weight will eventually gain it back. The National Weight Control Registry is a research study which has exploded this myth and shown that successful weight loss is indeed possible. Developed by Rena Wing, PhD, at Lifespan, Brown University and the University of Pittsburgh, and James Hill, PhD, at the University of Colorado, the National Weight Control Registry has identified nearly 3,000 individuals who have lost significant amounts of weight and kept it off for long periods of time.

So I have given you a long answer to our initial question. We should not ignore overweight and obesity. They do greatly increase your chances for disease. Patients can address this problem. We physicians must continue to motivate the patients. Many will fail, but if a few succeed than we have done a good job.

Earlier today I posted on the cessation of a lipid lowering study. Theheart.org (link on the left) has more details on the study.

The International Steering Committee of the independent Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) has announced that it formally stopped the atorvastatin (Lipitor® - Pfizer) portion of the trial on October 1 at the recommendation of the ASCOT Data Safety Monitoring Board because the patients on atorvastatin "suffered significantly fewer heart attacks and strokes compared with those receiving the placebo treatment."

"It is too early to quantify the precise size of the effect, but we expect to see a reduction in heart attacks of about one third among those taking a statin," according to ASCOT study cochairs Björn Dahlöf (Sahlgrenska University Hospital, Sweden) and Peter Sever (Imperial College, UK).

...

Only the patients with cholesterol levels of 6.5 mmol/L (250 mg/dL) or less were eligible for the atorvastatin part of the study, which investigated the effect of the statin on a hypertensive population with only slightly elevated or normal cholesterol levels. These 10 297 patients received either 10 mg of atorvastatin or placebo in the trial.

...

The trial began in 1998 and enrolled 19 342 patients from the UK, Ireland, and across Scandinavia, making it the largest European-based prospective randomized hypertension trial ever conducted. Entry criteria are high blood pressure and the presence of at least 3 other prespecified cardiovascular risk factors. Patients in the trial are between 40 and 79 years old.

The primary end point of the trial is death or nonfatal MI. A large number of other cardiovascular events, including stroke, are identified as secondary end points in the study.

My points on reading this:

• I suspect a formal report on this study within 6 months
• The atorvastatin dose is low (unlike the MIRACL study)
• The devil may be in the details, but the indications for statins seem to be increasing.

Trial Lawyers and Clinical Trials: Medical research falls deeper into bureaucracy. I am not going to quote from this article, rather plead that you read the entire text. I imagine that many readers will have the same sense of frustration and anger that I believe the writer (a non-physician) portrays.

To meet IRB requirements, we had a plaintiff's attorney give Grand Rounds this week - Alan C. Milstein. I spent time with him, and was impressed that he believes he is helping society. I must disagree. I plan to email him this opinion piece and ask for a reply. I will post it if he permits.

Heart drug could save lives.

Trials of a drug which could dramatically reduce the number of people having heart attacks and strokes in Britain have been halted ahead of schedule after producing outstanding results.

Researchers decided the trials had been so successful that it would be unfair to continue giving some patients a dummy version of the pill.

The tests show that the drug, atorvastatin, was effective on patients who had high blood pressure, but whose cholesterol levels were not so high that they would usually be considered for drug treatment.

Researcher Professor Peter Sever, from Imperial College London, told the BBC the trial, carried out on nearly 20,000 patients, was scheduled to run for five years, but had been stopped after three.

He said: "The magnitude of the benefit was so great in terms of reducing strokes and heart attacks that we felt morally and ethically obliged to stop the trial.

"We feel we have an obligation now - if the drug regulatory authorities allow us to - to offer the active drug to those who were previously receiving the dummy tablet."

Several questions are not answered in this article.

• What dose of atorvastatin?
• Was there any cholesterol level entry requirement?
• Were there any side effects?

The data for aggressive statin use keep growing. I would love to believe these studies all report a class effect rather than a specific effect for the tested statin. The new issue of the Mayo Clinic Proceedings has a nice review article on statins and heart disease.

Medical marijuana users sue U.S. over arrests.

Two of the plaintiffs, Angel McClary Raich and Diane Monson, are patients with serious medical conditions who have obtained recommendations from their doctors to use marijuana to relieve some of their symptoms. The two unnamed co-plaintiffs are marijuana growers who supply McClary Raich with the two ounces of pot she says she needs each week to alleviate her suffering.

Named as defendants in the lawsuit are the U.S. Attorney General John Ashcroft and Asa Hutchinson, administrator of the Drug Enforcement Administration.

The lawsuit is the second time attorney Robert Raich has tried to bring the issue to the U.S. Supreme Court. A year ago, the Supreme Court ruled against his client, the Oakland Cannabis Buyers Club, in its claim that medical necessity overrides federal law. This time, Raich has broadened his argument while narrowing the number of plaintiffs.

The lawsuit contends the four plaintiffs grow their own marijuana solely for their own medical use within the borders of California, thus removing any federal authority under interstate commerce laws. The suit also claims constitutional protection under clauses guaranteeing state sovereignty and due process.

If granted, the injunction would prevent the arrest and seizure of property -- including marijuana -- of only the four defendants, but Raich predicts it will serve as a precedent for the entire country.

"This case obviously involves only the four plaintiffs who brought the case. However, it would then lay a template for any other similarly situated seriously ill patient, in California or any other state with a medical cannabis law," he said.

States's rights versus federal control is not a new argument in our country. If one could show a significant medical benefit to cannabis, why should the federal government legislate against the drug. I do believe that this should become a medical care issue, rather than a legislative issue.

The CDC has a web site devoted to adult immunizations - Recommendations
Adult Immunization Schedule (Anyone over 18 years old). In our clinics the flu vaccine has arrived (I took my vaccination on Tuesday). This link provides a printable chart to remind us of vaccinating our adult patients. We have seen 2 cases of tetanus in older patients over the past 3 months. Therefore, everyone has a responsibility to check on tetanus vaccination - tetanus is a very unpleasant and avoidable disease.

Gene spells danger for prostate patients

The problem for doctors is identifying those in which the cancer is likely to spread rapidly beyond the prostate gland itself.

These need to be powerfully treated quickly if the man is to survive, as once the cancer has spread, it is very difficult to treat.

The latest research, from the University of Michigan in the US, focused on a gene called EZH2.

After examining tissue samples taken from a thousand men with prostate cancer, the researchers noticed that the gene was far more active in cancers which later spread beyond the prostate.

The more aggressively the cancer spread, the higher the "expression" of the gene.

The finding means that doctors, in theory, could test a tissue sample taken when a man is first diagnosed, and predict far more accurately whether it was an aggressive cancer.

Those without high levels of the gene in their samples could be spared immediate treatment, but simply monitored closely to make sure the cancer showed no early signs of spread.

I hope this research does allow us to identify which prostate cancer patients need aggressive treatment. This could help resolve much of the debate about prostate cancer screening and management of early cancers.

Two Genes Linked to Congestive Heart Failure. We are slowly reaping the benefits of the new genetics. Now that investigators have mapped the genome, we can do the necessary epidemiologic studies looking for associations between our genetics and predisposition to disease. This article - Synergistic Polymorphisms of ß1- and {alpha}2C-Adrenergic Receptors and the Risk of Congestive Heart Failure - in today's NEJM reports on the association of genetic variants of a beta and alpha receptor with the incidence of CHF.

This finding makes sense now that we understand the neurohormonal hypothesis of CHF. It may also explain we some CHF patients (but not all) benefit greatly from beta blockade.

Dr. Liggett knew that genes controlling the hormone norepinephrine make the heart pump more blood. Maybe, he reasoned, some people inherit versions of those genes that stimulate the heart too much. After decades of such overstimulation, the result might be heart failure.

One of the genes, an alpha-2 adrenergic receptor, controls the release of norepinephrine in the heart. The other, a beta-1 adrenergic receptor, locks the norepinephrine onto heart muscle cells, making them contract.

Laboratory studies led Dr. Liggett to suspect that alterations in the genes might be important in heart failure. The altered alpha-2 receptor might flood heart cells with norepinephrine, and the altered beta-1 receptor might make the cells respond more forcefully to the hormone.

An accompanying editorial - Adrenergic-Receptor Polymorphisms and Heart Failure puts this finding into context.

Despite the plausibility of the results, there are important limitations to genetic-association studies14 such as those described by Small et al. The limitations include the possibility of genetic stratification of the population resulting in a spurious association between a polymorphism and a disease simply because both the disease and the unlinked sequence variant are found in the same subpopulation. It is difficult to attribute causality to a particular polymorphism, since each polymorphism is inherited together with many other variants, either elsewhere in the candidate gene or in other nearby genes on the same chromosome, in so-called linkage disequilibrium. For example, both loci considered in the study by Small et al. are in genomic segments close to genes encoding other adrenergic-signaling molecules — the {alpha}2A-adrenergic receptor and GRK5 genes, in the case of the {beta}1-adrenergic receptor, and the GRK4 gene, in the case of the {alpha}2C-adrenergic receptor. Functionally important sequence variants in these other genes may be in linkage disequilibrium with the polymorphisms described, thus confounding the results. Prospective replication of these important findings in genetically distinct populations, with the use of extended haplotypes to encompass neighboring genes, will be a critical confirmatory step.15 Studies in much larger populations of black patients with congestive heart failure will be required. It will be interesting to see whether these polymorphisms act as modifier loci in monogenic forms of heart failure. As the genome projects unravel the extent of common genetic variation, it may be possible to define the role of such variation in disease only with the use of models that permit the study of both multiple genetic manipulations and integrated physiology.

I think that is a very complicated way to say that first we need confirmation of the finding. Then we need to test the implications of the finding, i.e., can we identify patients with this predisposition and delay or prevent heart failure using 'blocking' drugs. I suspect this article heralds a new understanding of CHF and a story which will unfold over the next several years.

Generic Drug Delays Decried Anniversary Prompts Protest

On the first anniversary of the date that the popular heartburn medicine Prilosec was supposed to become available in a cheaper generic form, a coalition of government and business leaders complained Monday that continued delays are costing state and federal programs, as well as consumers, billions of dollars.

''This is a budget buster,'' said Brad Cameron, speaking for the coalition, Business for Affordable Medicine, which represents 12 governors and large corporations like General Motors and Wal-Mart.

The delay is also hurting Andrx, a Davie pharmaceutical company, which was the first to apply for a generic version of Prilosec -- a bid that has been tied up in court for more than a year.

This link is just a reminder. I have addressed this issue repeatedly. As I tell my housestaff - 'Just so No to Nexium'. (By the way, the AstraZeneca rep avoids me like the plague as I will not even sign for free samples of Nexium).

The last 2 days I have linked to two very good rants on pain control. This article discusses a different opinion - Study: Don't Avoid Opioids to Treat Back Pain: Drugs are sometimes abused, but they have great benefits. What are we to do? We (physicians) generally hate dealing with pain, because it is so subjective. We all know patients who fake pain just to get opioids. We know patients who doctor shop for pain meds. We all have received the classic telephone calls - "My wife knocked my pain meds into the toilet, I need another prescription" (by the way this never happens with their antihypertensives). Therefore, we are suspicious. We are censored for over prescribing and criticized for underprescribing. I personally find non-specific pain the most frustrating symptom. I suspect many of you do also.

Look around and what do you see - huge bellies, and big butts. We are getting fatter and this study proves it. Study Finds That in U.S., 1 in 3 Are Obese

While waistlines are expanding across the board, the study shows that some groups are getting fatter faster than others. For example, more than half of black women 40 and older are obese, and more than 80 percent are overweight.

The findings suggest that "we are totally losing the battle to prevent and treat obesity," said George L. Blackburn, chairman of nutrition medicine at Harvard Medical School.

Also troubling is the rise in extreme obesity, according to the study, which is one of three papers on obesity published today in the Journal of the American Medical Association. Obesity is defined as having a BMI of 30 or greater, while extreme obesity is defined as having a BMI of 40 or greater. The number of adults with extreme obesity -- equal to a 5-foot-10-inch person weighing 280 pounds or more -- rose from 3 percent to nearly 5 percent from 1999 to 2000, according to the CDC. That trend worries public health officials, because this group is at greatest risk for severe health problems, including diabetes, high blood pressure, heart disease and kidney failure.

"The greatest concern is about African American women," said William H. Dietz, director of the CDC's Division of Nutrition and Physical Activity and co-author of the JAMA paper on extreme obesity. "More than half are obese, and 15 percent have a BMI greater than 40."

One can easily define the problem. Unfortunately, we do not know how to address the problem.

I vaguely remember Economics 101. During that course Dr. Elzinga taught us about elasticity. If demand for an item changes as the price changes, then demand is elastic to price. An article in this week's JAMA shows that drug spending is elastic to co-payments. Drug Spending Falls As Co-Payments Rise: Many Forgo Prescriptions, Study Finds.

This finding interests me. Patients can easily substitute some more expensive medications with cheaper OTC meds. However, I worry that patient's will have to forego necessary medications because of cost.

I am attending a journal club for our residents tonight. We will discuss a patient being discharged after a non-ST elevation myocardial infarction (NSTEMI). We will debate which of two drug classes the patient should use his limited resources to buy - clopidogrel (Plavix) or a statin. This hypothetical case obviously is very real to all practicing physicians. High drug costs are very real to patients, especially as the co-payment increases.

Ore. Considers Universal Health Plan

Every man, woman and child in Oregon would receive full medical insurance -- no co-payments, no deductibles -- under a measure on the Nov. 5 ballot that would create the first universal health care plan in the nation.

The question is whether Oregonians are willing to pay higher taxes for a plan so generous it would cover even acupuncture and massage therapy.

``What we are proposing is ambitious and audacious, but we believe the health care system now is in a crisis,'' said Mark Lindgren, spokesman for the Health Care for All Oregon campaign, sponsor of Measure 23.

This vote is worth following.

Should the FDA ban ephedra products? This Senator thinks so. Experts, Senator Criticize Ephedra

I like this editorial - Medicine men at NIH

Somebody is as busy as a bee, wasting your money on moonshine. Congress is spending it on "scientific" research to explore alternative mind-body healing techniques. These can include "aromatherapy," how perfume from the petals of flowers can affect mood and energy, "ayurveda," a 5,000-year-old practice from India that uses body, mind and spirit to treat disease and "Reiki," Japanese for the laying on of hands to balance a patient's "vital energy" and heal emotional, mental, physical and spiritual problems.

It all began because Sen. Tom Harkin of Iowa thinks bee pollen helped his allergies. The counterculture lives (and high on the hog). Armed with a budget of more than $100 million, the National Center for Complementary and Alternative Medicine (NCCAM), one of the 27 institutes of the National Institutes of Health, is having a high old time. NCCAM explains on its web site (nccam.nih.gov) that it has a mission to "explore complementary and alternative healing practices in the context of rigorous science," train researchers in the field and disseminate authoritative information to the public and professionals. But it does not explain how rigorous science can be applied to these studies. Complementary alternative medicines that publicly funded research can investigate extend to guided imagery, art, music and dance therapy, pet therapy and native American healing. (Pentecostal faith healers need not apply.)

This is a poor use of federal research moneys - but what do you expect when politicians influence medical research.

Read this preliminary report on blood testing for osteoarthritis - New Test Detects Osteoarthritis Faster

The researchers found that people with osteoarthritis had lower levels of a substance that helps with cartilage production and higher levels of a substance that causes cartilage degradation.

"It's nice to finally have a marker," says Dr. Robert Quinet, head of rheumatology at Ochsner Clinic Foundation in New Orleans. "People have been interested in finding markers for many years. This is the best study so far, but there's no therapy to use. We don't yet have a drug that will impact on these findings."

These data are preliminary. How would such testing impact practice?

Making a definitive diagnosis of osteoarthritis would clarify physician and patient concerns. Having clear diagnostic criteria would advance our ability to design treatment trials. Generally, as we better understand the spectrum of disease, we also learn about the basic science of that disease - leading to treatment insights.

Somehow I am now on the Pennsylvania Medical Society Alliance mailing list. They sent me this update today which I will pass on for your interest

from the Washington, PA Observer Reporter
Tuesday, October 8, 2002
House passes medical malpractice measure

HARRISBURG (AP) - Plaintiffs in medical malpractice cases would be required
to file their lawsuits in the county where the alleged malpractice occurred
under a measure approved by the state House of Representatives Monday.

The measure, which passed 186-12, is intended to eliminate so-called "venue
shopping," which refers to plaintiffs seeking out courts that are most likely
to favor their cases, said Rep. Thomas P. Gannon, its sponsor. In many
instances, that has meant seeking to have a case tried in Philadelphia, he
said.

"Jury verdicts in Philadelphia historically have tended to be higher, and in
some cases excessively higher, than in other jurisdictions. That was the rub
for many hospitals," said Gannon, R-Delaware.

Gannon said the bill was another attempt to ease spiraling malpractice
insurance costs that doctors say are still driving them out of Pennsylvania,
despite legislation passed in March to try to rein in rates.

The earlier legislation, signed by Gov. Mark S. Schweiker in March, included
a provision to gradually phase out the Medical Professional Liability
Catastrophe Loss Fund in 2009 and turn it over to private insurers.

The fund, supplied by surcharges assessed to medical professionals, covers
doctors and other professionals when their own malpractice coverage is
depleted.

Democratic leaders opposed Gannon's measure and urged the House to vote "no."
House Minority Whip Mike Veon, D-Beaver, called the measure an
"unconstitutional legislative intrusion into the Pennsylvania Supreme Court's
rulemaking authority."

"If we are going to do something about these rates, about what doctors are
paying for medical malpractice insurance, what we need is a mandatory rate
rollback on medical malpractice insurance," Veon said. "Let's give doctors
immediate rate relief."

Pennsylvania is one of 12 states where rising premiums, tied to awards by
state juries in malpractice cases, are creating a crisis, according to a
survey released in June by the American Medical Association.

The AMA lists six states as having their malpractice situations under
control: California, Colorado, New Mexico, Wisconsin, Indiana and Louisiana.

Gannon's measure was amended into a Senate bill that would increase pay for
jurors who sit on multicounty investigating grand juries. It now returns to
the Senate, which must agree to the amendment.

As usual, the Democrats are against malpractice reform. I just do not understand.

Yesterday I referred to Medpundit's excellent summary of the problem of pain control. RangelMD has expanded on her excellent post - check him out - PAIN! The fifth vital sign!?

The Lean Plate Club: Healthier, Yes; Health Food, No. Sally Squires of the Lean Plate Club has written a very nice article about fast food and snacks.

Here's how to help make snacking part of a balanced, healthy Lean Plate Club approach to eating:

Read the fine print. Just because a snack food contains broccoli (or other vegetables) doesn't necessarily make it a health food. Take Terra Chips (made with sliced sweet potato, yuca, taro root, balata and parsnip). A one-ounce serving contains seven grams of fat -- one gram more than Tostito's White Corn taco chips. The Terra chips have three grams of fiber -- that's two grams more than the taco chips -- but they have half the calcium. You'll get identical amounts of iron from both types of chips, and each contains one gram of saturated fat. As for calories: Terra Chips clock in at 140 per serving while the Tostitos contain 130.

Check portion sizes. You've heard it before, but it can't be underscored enough: Portion size really does count. And just because a package of snack food looks like a single serving doesn't mean that it is. Take pretzels. Some vending machine packages contain 2.5 servings per bag. Ditto for microwave popcorn, which pops about 12 cups per bag, enough for three servings -- or about 420 calories, including 12 grams of fat, 2.5 of them saturated.

Boost nutrition with snacks. Registered dietitian Mercer, of Ann Arbor, Mich., eats snacks to embellish her diet with healthy food. She has a banana for a mid-morning snack, low-fat string cheese with whole-wheat crackers as a late-afternoon snack and a small, pre-measured portion of nuts (with healthy fat) while she's preparing dinner. And when she yearns for chocolate, she eats a Crave bar, a snack item from Kellogg's.

Medpundit and I apparently disagree about smallpox vaccination. I believe that we can wait until we know of an index case. Apparently many medical societies agree - Doctors Urge Caution on Smallpox Vaccinations

To be balanced, I must include this link to our fear - Experts: Iraq May Have Smallpox (LA Times requires registration).

Go read this - Medpundit does a great job of describing how we have problems when patients state they are in pain. Anguish Hath Taken Hold of Us, and Pain

Does Variety In Exercise Matter? Not really.

Still loading: There's quite a ways to go for Web-based continuing medical education
Online CME was going to be the next big thing, but reading journals on the Web is boring, and you need broadband to walk through a virtual lab. Solutions look to wed education and technology in new ways. Patience is a virtue.

Read it, but you might not like it. Senate unveils proposal for Medicare pay fix, regulatory reform: Legislation would begin to shrink the gap between rural and urban Medicare payments. Unfortunately, Senators worry much more about re-election than doing the right thing. In this case, giving fee relief without a drug benefit would appear to anger AARP. The Democrats would never want to appear to anger AARP.

The American Medical Association called on the Senate to pass Medicare payment relief before Nov. 1, when CMS will announce the final update for 2003 and physicians begin to consider whether to continue their Medicare participation agreement for the upcoming year.

"When you put the Medicare cuts together with the professional liability crisis, there is such difficulty for physicians to maintain their office overhead," said AMA President Yank D. Coble Jr., MD. "With these huge reductions, it's clearly creating major problems for physician offices and patients' access to care. The House of Representatives has passed a correction, and hopefully the Senate will do the same."

The Senate proposal's adoption of the House-passed payment fix removes some potential conflicts between the two bodies over the legislation's content. But the measure still faces several major hurdles. At press time, Senate leaders were leaning toward bypassing the Senate Finance Committee and bringing the measure directly to the Senate floor.

There, the bill would have to withstand challenges based on budgetary concerns, as well as the controversy surrounding addition of a Medicare outpatient prescription drug benefit -- either of which could sink the entire package. Earlier this year, the Senate considered four different prescription drug benefit proposals, but none was able to garner the needed votes.

Going into the November elections, senators may be unwilling to risk the political fallout from the senior citizens' lobby that could result from passing payment increases for doctors and others without also adding a drug benefit.

"Our members would not understand why Congress could find money again to increase provider payments above and beyond a reasonable and appropriate level, but could not help them with their prescription drug need," the AARP said earlier this year. "Every dollar that is attributed to a givebacks package means one dollar less for a Medicare drug benefit."

Forecast MD shortage: Debate: Primary care or subspecialists more needed. This article nicely summarize an issue which I have addressed often over the past few months.

During the 1980’s and 90s, the accepted notion was that the nation would have a surplus of physicians by the year 2000. Now that the millennium has come and gone, many are suggesting that there will be a growing shortage of physicians developing over the next twenty years. The Association of American Medical Colleges (AAMC) has begun to reconsider their workforce position and suggest the possible need for increasing enrollment in medical schools and graduate programs. Richard A. Cooper, MD, director of the Health Policy Institute at the Medical College of Wisconsin puts it succinctly: “The per-capita physician supply is slowly declining, while demand for physician services is increasing.”

Cooper and colleagues have developed a model considering the four long-term trends that determine the supply and use of physician services, The four trends accounted for in his model are economic expansion; population growth; the work effort of physicians; and services provided by non-physician clinicians (NPCs). Assuming the rate of medical education remains unchanged, the model projects a shortage (see chart) of as many as 200,000 doctors by the year 2020.

While the notion that more doctors will be needed is gaining acceptance, the projected physician workforce mix is another matter entirely. Cooper, for one, envisions a healthcare system built around the growing prevalence of conditions requiring specialty care. “The shortage will be more severe in specialties”, he explains. “Specialists will be principally responsible for a large segment of patients with chronic diseases like diabetes. Disorders that previously were untreatable now flash on the radar screen for definitive therapy. Hip and knee replacements are now routine. Patients in my own specialty of heme-onc are living longer. But as they live longer, they also require more care.”

As for the primary care physicians (PCPs) he says, “In terms of redefinition, I suspect that internists will properly redefine themselves as physicians for patients with acute and chronic disease rather than as givers of primary care, whatever that is.” Arguing against the perceived shortage of primary care physicians, he notes movement of care away from PCPs toward nurse practitioners and physician assistants on the outpatient side, and to hospitalists on the inpatient side.

Richard Roberts, MD, American Academy of Family Physicians (AAFP) board chair and professor of family medicine at the University of Wisconsin, suggests that the supply of PCPs may already be insufficient. “In the U.S. about one of out four physicians are primary care doctors”, he explains. “There are 820 million doctor visits annually. The PCPs see about 420 million of those patient visits, so one quarter of the doctors are seeing more than half the visits.”

“I think the bottom line for the country is that we’re facing a diminishing pool of primary care physicians and that’s going to be a serious problem in the not-too-distant future”, agrees Herbert Waxman, MD, senior vice president for medical knowledge and education for the American College of Physicians - American Society of Internal Medicine (ACP-ASIM). He notes a strong shift in the career choices being made by medical school graduates. “For a while, there was the appearance of some difficulty getting jobs as subspecialists in internal medicine. That seems to have changed. It now looks like people are very successful at finding positions in the subspecialties, and at compensation levels that are pretty high. People who might have been on the fence between internal medicine as a primary care direction and as an entry into the subspecialty world are clearly shifting direction toward the subspecialties.”

I have previously written that I believe general internal medicine will move away from society's new definition of primary care - db revealed. However, I believe that we are developing an overall shortage of primary care (by my definition) that nurse practioners and physician's assistants cannot solve. We need good family MDs - and many more of them. However, few students will now enter that field. Thus, we need to restore their prestige and finances.

Meanwhile, many fields have a specialist shortage. I hope that we can logically address these concerns - the medical establishment working with the government (since the government funds much of training).

The Danger of Too Much Iron. This story discusses iron overload disease - hemochromatosis. Apparently there is some controversy in this area. Some experts are recommending screening older patients with iron and ferritin.

'New vitamin' could fight brittle bone

A new form of vitamin D has emerged as a promising possible treatment for the crippling disease osteoporosis, say scientists.

Thousands of people, many of them post-menopausal women, suffer from the condition, which can increase the risk of damaging fractures.

In animals with conditions similar to osteoporosis, the vitamin increased bone density.

Dr Hector DeLuca, from the University of Wisconsin-Madison, conceded a new drug could be several years off but said it could eventually be important.

These data are published in the Proceedings of the National Academy of Sciences.

I agree - Pediatricians Urge Smallpox Limits

The American Academy of Pediatrics says the nation's smallpox plan should involve limited vaccinations if a case occurs, not universal inoculations before there's even an attack.

Potential side effects are too severe, and available vaccines have not been tested on children, who may be at higher risk for bad reactions, the academy said in a policy statement released Monday.

``We're talking about a disease that hasn't existed in the world since the 1970s and a vaccine that we know can cause death,'' said Dr. Julia McMillan, a Johns Hopkins School of Medicine pediatrics professor and co-author of the policy.

Based on studies from the 1960s, 15 out of every million people vaccinated will face life-threatening reactions, and one to two will die.

Generally I have used 'The Sunday Issue' as a soapbox for my opinions on the plight of primary care or rants against insurance companies and pharmaceutical companies. This week I have decided to add a new format - reviewing important recent articles. I find that on ward rounds I tend to stress certain articles repeatedly. I hope that some readers will find these mini-reviews helpful. Having them collected on this blog will give me a reference for my students, interns and residents. Let me know if you find this worthwhile. I would also appreciate recommendations of very important articles from the past several years. I will include originial articles, reviews and guidelines.

Two years ago, the HOPE trial expanded the indications for ACE inhibition - Effects of an Angiotensin-Converting–Enzyme Inhibitor, Ramipril, on Cardiovascular Events in High-Risk Patients (subscription to NEJM required). This week I will review this important study and discuss its implications.

The first thing I do when reading such a study is to study the patient population. I want to know who the investigators studied, and see if the data will fit my patient population.

A total of 9297 high-risk patients (55 years of age or older) who had evidence of vascular disease or diabetes plus one other cardiovascular risk factor and who were not known to have a low ejection fraction or heart failure were randomly assigned to receive ramipril (10 mg once per day orally) or matching placebo for a mean of five years. The primary outcome was a composite of myocardial infarction, stroke, or death from cardiovascular causes.

The patients in that study were at least 55 years old. They either had known vascular disease or THE EQUIVALENT (diabetes plus another risk factor). They did not have another clear indication for ACE inhibition. This study population seems general enough to cover many patients that I see.

The intervention was simple, ramipril versus placebo. The study design was appropriate - a randomized controlled trial.

The reduction in the risk of the composite outcome with ramipril therapy was evident within one year after randomization (169 patients reached the end point in the ramipril group, as compared with 198 in the placebo group; relative risk, 0.85; 95 percent confidence interval, 0.70 to 1.05) and was significant at two years (326 vs. 398 patients; relative risk, 0.82; 95 percent confidence interval, 0.70 to 0.94). The relative risk was 0.78 in the second year, 0.73 in the third year, and 0.74 in the fourth year, when the data on patients who were still alive at the end of the preceding year were analyzed.

Ramipril helped patients in a variety of subgroups - both men and women, diabetics and nondiabetics, above and below 65. The results impressed me when I first read the article in 2000; they impress me today. Given the previous information that we had on ACE inhibitor benefits (all classes of CHF, slowing the protection of diabetic nephropathy, preventing CHF after myocardial infarction) these data fit into a pattern.

So what do I do in 2002. I work hard to place all patients with known vascular disease on ACE inhibitors. Most diabetic patients that we see are also hypertensive, in those patients we use ACE inhibitors as first line therapy. In the patient with adult onset diabetes who is normotensive but has another risk factor (hypercholestemia, family history, 55 yo man or 65 yo woman) I generally start an ACE for protection based on the HOPE trial. Even though the study required patients to be at least 55 years old, I will extrapolate the data and make the same decisions in younger patients.

For two good reviews of this study - The HOPE Trial: Implications for Primary Care and An ACE inhibitor in the hole for cardiovascular prevention

Kudos to Medpundit - she has summarized the issues in the HMO class action suit beautifully - Doctors and Insurance Companies. The Bloviator has challenged us with a number of strawmen arguments - HOUSE CLEANING. I understand his point, but I think he is guilty of hyperbole. Many malpractice cases are faulty. Physicians do not receive a jury of their peers. Physicians are doing a better job of self policing every year. We continuously work on improving that. However, when we try to police ourselves, guess who enters the picture - yep, lawyers. Restricting a physicians practice often leads to law suits. Surprise!

The purpose of the HMO suit is to get one party (the insurance companies) to treat the other party (physicians) fairly under the contracts the physicians have signed. Dirty HMO tricks cause all the problems that Medpundit describes. If it takes a class action suit to get everyone's attention, so be it. Patients are suffering because of the HMOs - and that is not hyperbole.

The other day I castigated the Democrats over malpractice and trial lawyer support. Today the Republicans land in my doghouse. Give Consumers a Break; Pass Schumer Drug Bill.

Republicans fancy themselves champions of the free market. So why can't Democrats in Washington get the Republican-controlled House to vote on a bill to speed generic drugs into the marketplace?

The bill would increase competition and drive drug prices down by closing loopholes that allow drug companies to use lawsuits and sweetheart deals to extend their right to exclusively market drugs after their patents have expired. Consumers pay for that exclusivity. Patented drugs cost about 60 percent more than their generic equivalents.

The Senate passed the generics bill, sponsored by Sens. Charles Schumer (D-N.Y.) and John McCain (R-Ariz.), with bipartisan support. The nonpartisan Congressional Budget Office says that if it became law, consumers would save $60 billion in drug costs over 10 years. But the Republican House leadership has refused to bring the bill to the floor.

On different issues, both parties make bad decisions.

This article addresses an interesting question - how should one choose amongst the plethora of multivitamins. Consumer Guide to Adult Multivitamins

Our Criteria for Rating Adult Multis

We looked at 16 of the 22 top-selling national brands of adult multivitamins and carefully examined their labels and the actual pills. Some brands sell several multis that vary in potency, so we selected their basic formulas to make fair and meaningful comparisons. The multis that best met our criteria are listed as our Best Bets. Those that came close received an Honorable Mention. There are separate lists for men and women because of their very different needs for iron.

Three Keys for Sizing Up Adult Multivitamins

1. Does the supplement provide both vitamins and minerals?

None of the supplements we saw are perfect, but our Best Bets contain each of the following: Vitamin A, the B vitamin group (thiamin, riboflavin, niacin, B-6, B-12, folic acid, biotin and pantothenic acid), Vitamin C, Vitamin D, Vitamin E, Vitamin K, calcium, chromium, copper, iodine, iron (for women), magnesium, manganese, molybdenum, selenium and zinc.

2. Is it a high quality product?

Check for compliance with U.S. Pharmacopoeia (USP) quality standards, and an expiration date.

3. Does the multivitamin include all nutrients for which there is a Daily Value (DV)?

Among the supplements we tested, missing nutrients included: Vitamin K, biotin, chromium, magnesium, manganese, molybdenum and selenium. It should have 50 - 150 percent of the DV for most nutrients, with the following exceptions:

* No more than 100 percent DV for vitamin A (excluding beta-carotene, which the body converts to vitamin A as needed; it's not toxic).
* At least 10 percent of the DV for calcium and magnesium.
* No more than 100 percent of the DV for iron for women, or more than 50 percent of the DV for iron for men.
* No more than 15 percent of the DV for phosphorus.
* No more than 2 percent of the DV for sodium.
* Ignore potassium, chloride and minerals (such as boron, nickel silicon, tin and vanadium) without a DV.

This seems well thought out. There are specific brand recommendations in the article.

Menopause experts: Limit hormone use

The society's new recommendations say hormone supplements should be limited primarily to treating symptoms such as hot flashes and vaginal dryness and that lower than standard doses should be tried, for the shortest possible time. The society also said hormones should not be used to help prevent heart disease, and alternative medication should be considered for prevention of osteoporosis.

Medpundit has written about this issue extensively. I will refer to her for wisdom. Meanwhile, this article summarizes my feelings. New Set of Potential Risks: Experts Say Vaccine Would Kill Some, Injure Others

Abba Eban's famous comment, "The Palestinians never miss an opportunity to miss an opportunity." could apply to the pharmaceutical industry. Drug Makers Cutting Back on Discounts for the Elderly. My initial reaction to the headline was - STUPID! Then I read the article, and the explanations are not much better.

Bristol-Myers Squibb and GlaxoSmithKline said that they had raised the prices they offer in a widely promoted discount program out of concern that federal officials will demand similar deep discounts for the government Medicaid program, which provides health care for the poor.

But federal officials expressed surprise at the moves and said that they had not taken any action against the discount plans.

At issue is whether the discounts by the two companies — as well as those offered by five other drug companies, all under a program called Together Rx — are subject to a federal law requiring drug makers to offer the Medicaid program the lowest price available to any buyer.

For some of the 300,000 low-income people participating in Together Rx, the higher prices will hurt. For example, Bristol-Myers said it had been offering a month's supply of the cholesterol-lowering drug Pravachol for $15 to elderly people with incomes of $18,000 or less. On Tuesday, the company raised the price to $59.

Under GlaxoSmithKline's plan, patients will get roughly a 25 percent discount from retail drugstore prices, the company said, rather than 33 percent. For asthma patients, for example, an Advair Diskus will cost $118. Previously, patients paid $106 for that drug.

Thomas A. Scully, administrator of the Centers for Medicare and Medicaid Services, said this week that he was perplexed by the moves to reduce the discounts. "We have had hours of meetings with them trying to make sure we did not impact their discount programs," he said.

Mr. Scully said he believed that the two drug companies had decided to raise their prices for a reason unrelated to the government.

So what does this mean? Patients once again will choose between food and medications. If you are on a fixed income as subsistence levels, that is the choice. We can deliver outstanding medical care. It costs money. How will we pay?

California Jury Allots Damages of $28 Billion to Ill Smoker. While I do not really like the cigarette companies, this is a bit 'over the top'.

Today's British Medical Journal has 2 articles and an editorial on PSA testing for prostate cancer.

• Why men with prostate cancer want wider access to prostate specific antigen testing: qualitative study
• Natural experiment examining impact of aggressive screening and treatment on prostate cancer mortality in two fixed cohorts from Seattle area and Connecticut
• Editorial: Prostate specific antigen testing for prostate cancer

Quoting from the editorial

In this issue we see contributions to the debates about risk in relation to prostate cancer. Yu-Lao and colleagues seem to bolster the arguments for caution in the debate on screening for prostate cancer by prostate specific antigen testing. Their findings show that more intensive screening and treatment with prostatectomy and external beam radiotherapy are not associated with lower prostate cancer specific mortality through 11 years of follow up.

Although the experts continue to argue about the evidence on screening, the public has come to different conclusions, as shown by Chapple and colleagues, who show that trial, epidemiological, or clinical evidence may play a small part in the public's demand for screening for prostate cancer by prostate specific antigen testing. Instead, the irresistible logic of finding the cancer early, the drive to avoid regretting later the decision not to have the test, the right to obtain information about oneself by testing, and a perceived right to parity with women's access to screening may all be more important arguments.

These lay arguments for prostate specific antigen testing have their own logic and validity. What they mostly do not recognise are the costs of screening.8 Screening is the business of changing identities; it is the business of producing patients. Becoming a patient is not a trivial matter. It has profound health, social, psychological, and economic consequences. Screening therefore raises important ethical problems. As Cochrane and Holland pointed out three decades ago: "If a patient asks a medical practitioner for help, the doctor does the best possible. The doctor is not responsible for defects in medical knowledge. If, however, the practitioner initiates screening procedures the doctor is in a very different situation. The doctor should, in our view, have conclusive evidence that screening can alter the natural history of disease in a significant proportion of those screened." Reconciliation between today's risk conscious citizens demanding tests or pressing to initiate screening programmes and authorities becoming more cautious about their provision will come only through initiatives that engage with the public not through authoritarian insistence on the "rightness" of the science.

I have included a short excerpt from a powerful, thoughtful discussion. Why should we screen for a disease? I have considered this issue many times during my career. My philosophy has centered on 'First Do No Harm'. I have assumed that screening when early detection does not change outcomes probably had negative effects. This discussion argues that patients may find knowing a diagnosis beneficial.

I do not have a strong position here. In general, I try to dissuade patients from routine prostate screening. I personally choose not to have screening (although I always have to argue with my primary care physician). When patients feel strongly, I do screen. Perhaps this decision is more about philosophy and one's ability to handle uncertainty than it is about science. Perhaps the medical community with the assistance of the media have sold the concept of screening at face value. This issue bothers me greatly. Does it bother you?

HMOs' Shell Game to Avoid Paying Doctors Hurts the Patients: Health care suffers as practitioners scramble to stay afloat financially. The author of this commentary is the chief of cardiology at UCSF. He summarizes the reasons behind the class action lawsuit against the HMOs.

In frustration, doctors and several state medical associations have turned to the courts for relief. The result is a landmark case being pressed against some of the nation's largest for-profit HMOs. The managed-care industry suffered a major setback last week when the Miami federal judge overseeing the case certified the doctors' suit as a class action.

If you and I don't pay our insurance bills, in full and on time, we're cut off.

It's time that HMOs are required to meet the same standards as the rest of us.

The entire commentary is well written, and at times chilling. I hate that physicians have to use the court system to solve this problem. But I hate the shenanigans of the HMOs more.

Wake up Democrats! We have a serious problem that affects the delivery of health care. Patients will suffer (and probably already have). Pa. Doctors Rally Over Insurance

Doctors rallied Thursday in two Pennsylvania cities, saying soaring malpractice insurance rates threaten emergency room service around the state.

Doctors and patients demonstrated in Scranton, where a medical center is trying to line up coverage for 10 emergency room doctors who were notified last week their current policy was being canceled.

At a similar rally in Philadelphia, physicians called for a state law to limit damage awards in malpractice cases as a way of reducing rates. Speakers urged tort reform modeled on a California law that caps jury awards for pain and suffering in medical cases at $250,000.

Orthopedic surgeons, neurosurgeons, obstetricians and others have said rising malpractice rates may force them to stop performing surgery or leave the region.

``It now costs me more to practice in the city of Philadelphia than I can possibly hope to get paid,'' said Dr. Adrienne Cresswell, a plastic surgeon.

We need the Senate to pass the legislation that the House already passed. Physicians deserve to make money. We should not have to donate our services. Do you think patients want their insurance moneys and office payments funding trial lawyers? The madness must stop. What are the Democrats thinking?

Diabetic gastropathy and neuropathy are serious complications. They have major impact on quality of life. This interesting report from Medscape (registration free for physicians) describes observations concerning these problem. Diabetic Neuropathy, Gastropathy Respond to New Treatments

Because diabetic neuropathy can be a painful condition that may be associated with nitric oxide (NO), investigators tested a spray containing isosorbide dinitrate (ISDN), a common NO donor used for heart patients, and found that it reduced overall neuropathic pain and burning with no effect on other symptoms. A letter in the same issue reported on two patients with diabetic gastropathy in whom sildenafil improved gastric emptying and clinical symptoms, suggesting a possible mechanism and new therapy for diabetic gastropathy.

Probably not quite ready for prime time, but I will certainly monitor further investigations of these hypotheses.

Patients wait days to see GPs . This article speaks to the problem of insufficient primary care physicians. We have a worldwide problem, not just a US problem.

Sugared Soft Drinks Make You Softer in Middle. We should file this one under 'duh', however the data may help in patient counseling.

So say Danish scientists who conducted a study of 41 overweight, middle-aged people for 10 weeks, asking them to add sweet drinks to their regular diet. Half the participants were given sucrose-sweetened drinks and half were given drinks sweetened with artificial sweetener. Participants were not told which type of beverage they were drinking.

Those whose drinks were sugar-sweetened gained an average of three pounds, while those who drank diet drinks lost a little more than two pounds on average.

"We were astounded that these soft drinks could change weight that much. We didn't expect soft drinks to have this fattening effect," says Dr. Arne Astrup, a nutrition professor in Copenhagen and an author of the study, which appears in the October issue of the American Journal of Clinical Nutrition.

So the states sued the big tobacco companies, getting a huge settlement. Have they used the money to help patients or decrease smoking? Most anti-tobacco money diverted: Tobacco-producing states invest little in cessation programs

Under a landmark 1998 legal settlement, the tobacco industry agreed to pay the 46 states $206 billion over 25 years to compensate for the costs of smoking.

Although states could spend the money however they chose, the hope was that much of the cash would be used to follow the example of California and Massachusetts, where powerful anti-tobacco campaigns have yielded sharp declines in smoking.

Instead, only 6 percent of the money states received in 2001 went to tobacco control programs, according to a study published in Thursday’s “New England Journal of Medicine”.

I should be outraged, but actually I am not surprised. If one keeps one's expectations of politicians very low, one is seldom surprised.

We have all seen the patient. You put him/her on a statin. They come back and report that their muscles hurt and they think they are a bit weaker. You test their CK and find it normal. So you assume that they have a problem above the neck. Well maybe they are right. Heartfelt Hurt: Why statins are making some patients really sore. This well done article refers to an article and accompanying editorial from the current Annals of Internal Medicine. I happened to read those articles yesterday.

Here is the gist of the finding. If you take patients who complain of muscle soreness will taking statins, and expose them in a double blind fashion to statin or placebo, they can tell when they are on the statin. The article only reports on 4 patients. But those patients had muscle biopsy changes and demonstrable weakness. These 4 patients came from a pool of 21 patients who thought they had the syndrome.

Thus, we have a rare, but real side effect of a very important drug class. We should expect more information on this observation over the next year or so. Read the article, it may help you understand a few patients.

Yanking the Yuck Factor From Medicine

Scientists from Linguagen Corp recently received a $746,000 grant from the U.S. government to develop a compound that would block the bitter taste of many over-the-counter medications.

Celebs step into generic drug debate Trade group ramps up efforts to thwart pro-generics bill. Give me a second to let the anger settle. Going to the BAM (Business for Affordable Medicine) web site, I found this article and quote Generic Drug Bill Encounters Growing Fight: Tauzin Won't Commit to Holding Vote on Politically-Charged Issue

Legislation designed to speed low-cost generic drugs to pharmacy shelves sailed through the Senate in July, but it has run aground in a House committee chaired by Louisiana Congressman Billy Tauzin.

Despite a broadly bipartisan Senate vote approving the measure, Tauzin has voiced doubts about the legislation, which is intended to make it harder for brand-name drug companies to use legal maneuvers to extend their patents and block cheaper generic competitors from getting on the market. Tauzin promised to hold a hearing soon, but he wouldn't commit to scheduling a vote on the popular bill.

"It's premature to say we will vote on anything until we have all the facts," he said.

Tauzin, R-Chackbay, has found himself at the center of a gathering storm over the politically sensitive issue of prescription drug prices as the Nov. 5 midterm congressional elections approach. The influential brand-name drug industry staunchly opposes the legislation, saying it will thwart innovative research. But double- digit annual increases in drug costs have drawn together a politically potent coalition of governors and corporate leaders demanding relief.

Legal maneuvering

The bill, by Sens. John McCain, R-Ariz., and Charles Schumer, D- N.Y., is designed to curb an increasingly prevalent strategy used by brand-name drug companies to extend their lucrative market monopolies and keep generic competitors at bay.

As their patents are about to expire, brand-name drug makers sometimes file lawsuits against generic drug makers that are poised to put lower-cost copycat drugs on pharmacy shelves. The lawsuits invoke a provision of the 1984 Hatch-Waxman Act, which, though intended to speed generics to market, instead gives brand-name drugs up to 30 more months of patent protection and market exclusivity while the dispute is settled.

A Federal Trade Commission study released on the eve of the Senate vote July 31, found that the provisions of Hatch-Waxman "may have prevented the availability of more generic drugs . . . (and) have the potential for abuse."

The FTC, a five-member board headed by a President Bush appointee, found that brand-name pharmaceutical companies, in particular makers of big-money "blockbuster" drugs, increasingly are filing multiple lawsuits against potential generic competitors and extending their monopolies years past the expiration of their patents.

The problem here comes from the pharmaceutical companies wanting to extend their patent protection. They do make a lot of money, even with their investments in research. I believe this bill would give balance and relief to patients.

As physicians we learn principles of good care. Get you patients to wear seatbelts, exercise, eat right, do self examinations. Teach your women patients to do their breast self examinations properly. It makes sense - but - Study: Breast self exam may be a waste. This does not mean that we should ignore masses that women find, only that the careful meticulous exam does not have any evidence of benefit.

Men and women have this in common, many of us are unhappy with our bodies. Men suffer body image disorders

Writing in the journal, the researchers said: "If more men are taking to the gym in order to increase their musculature, some may be at risk of developing muscle dysmorphia."

They add: "In a changing culture where men's bodies are becoming more visible alongside an increased acceptance of physical exercise as a desirable activity, MD in men may be one negative consequence of physical exercise behaviour, particularly weight training, being motivated primarily by physical appearance.

"How to prevent this and, if it occurs, what to do about it are important questions for both researchers and practitioners."

This is not a joke. Expect to learn more about this as knowledge increases.

Today the Washington Post has a series devoted to walking for one's health. I am linking the main article - you can find the supplementary articles. This one may be worth saving for patient eduction! Take a Walk: Despite the Proven Benefits of Walking, the Nation Remains Unmoved. It's Time to Step Up

Drug Industry Is Told to Stop Gifts to Doctors

The government warned pharmaceutical companies today that they must not offer any financial incentives to doctors, pharmacists or other health care professionals to prescribe or recommend particular drugs, or to switch patients from one medicine to another.

The government informed the industry that many practices commonly used in the marketing and sale of prescription drugs could run afoul of federal fraud and abuse laws.

Specifically, the government said that drug makers could not offer incentive payments or other "tangible benefits" to encourage or reward the prescribing or purchase of particular drugs by doctors, health plans or companies that manage drug benefits for employers and insurers.

The new standards, the first of their kind, were issued by Janet Rehnquist, inspector general of the Department of Health and Human Services, as guidance to the pharmaceutical industry.

What if I gave you a great way to save time? As I write often - time is money! So get this, let the patient talk without interruption (unless they ramble longer than 5 minutes). Your job is to guess how long they will talk. Do I hear 3 minutes? How about 4 minutes? Wrong, they will speak on average 92 seconds. Of course we would not know that since we interrupt patients after approximately 22 seconds! Perceptions: When Patients Have Their Say. Read the NY Times article. If you want more information read the article in the BMJ - Spontaneous talking time at start of consultation in outpatient clinic: cohort study . In my experience, letting the patient talk saves time. You also just might understand their agenda.

Read this important article - Salve for the Body and Mind: Palliative care is traditionally aimed at the terminally ill. But it should also treat sufferers of chronic disease, says Ann M. Berger of the National Institutes of Health

Pharmacia's Hypertension Drug Approved

Pharmacia now has a green light from the U.S. Food and Drug Administration to market a new hypertension drug. Inspra, previously known by its generic name, eplerenone, is the first in a new class of drugs to treat high blood pressure. Analysts are expecting sales in the billions of dollars.

This drug - eplerenone - will probably create a much larger buzz than hypertension. Eplerenone is spironalactone without the side effects (or at least that is the plan). Spironalactone works well, but has a major rate limiting step - gynecomastia. With the latest data on spironalactone's effectiveness in severe heart failure (the RALES study), a major key for this new drug will be the results of ongoing heart failure studies. You can read more about this drug at Heart.org (free registration for physicians).