I will be away from my computers for the next 2 days. In the event that I cannot find reasonable internet access - I will next post Wednesday p.m.

I am off to give a workshop on Metabolic Acidosis at the SHP (formerly the NAIP) meetings in San Diego. The workshop is based on 5 cases of Metabolic Acidosis. If readers are interested, I can develop a series over the next couple of weeks presenting and discussing the cases - let me know.

Have a great day!

No good news on the SARS front. Rather than linking to multiple news stories, I will link and quote from the latest CDC briefing - CDC Telebriefing Transcript: SARS Update - March 29, 2003

We continue to regard the new coronavirus as the leading hypothesis for the etiology of this condition. The evidence is mounting from a number of international laboratories, that this is indeed the case; but we are also exploring other potential viruses as are our collaborators, and we will keep you posted as we go forward on that part of the scientific investigation. A number of things are in progress, including sequencing of the whole virus genome, and we'll have more information on that, potentially next week or the week thereafter.

The experts are mostly focussing on the coronavirus hypothesis. While they have more studies to complete confirmation, the data are becoming convincing.

We believe, based on what the investigations have shown us so far, that the major mode of transmission still is through droplet spread when an infected person coughs or sneezes and droplets are spread to a nearby contact. But we are concerned about the possibility of airborne transmission across broader areas and also the possibility that objects that become contaminated in the environment could serve as modes of spread.

Coronaviruses can survive in the environment for up to two or three hours ,and so it's possible that a contaminated object could serve as a vehicle for transfer to someone else.

In health care settings, we have already initiated guidance to protect against droplets, airborne and contact spread of this virus, and today we're issuing an update on how to protect people in homes of SARS patients.

We know that the individual with SARS can be very infectious during the symptomatic phase of the illness. We don't know how long the period of contagion lasts once they recover from the illness and we don't know whether or not they can spread the virus before they have the full-blown form syndrome.

But most of the information that the epidemiologists have been able to put together suggests that the period of contagion may begin with the onset of the very earliest symptoms of a viral infection, so our guidance is based on this assumption.

Understanding how SARS spreads remains crucial. When do infected individuals become infectious. Once we truly understand this epidemiology, then we can better gauge future spread and how to prevent it. While close contact certainly puts one at great risk, some evidence in Hong Kong suggests that this virus might spread in more routine common cold fashion.

CDC is working with FDA and NIHD and USAMRIID and others to try to identify drugs that might have activity against this coronavirus, but as of today we have no leading candidates on the shelf, that we could recommend for clinical treatment.

The patients in the United States are being treated according to the guidance that we've issued to clinicians as well as standard management for pneumonia, and that does include treatment empirically for other causes of pneumonia, because at the initial presentation this disease could easily be confused with other common things for which we do have specific therapy.

So clinicians are advised to have a broad differential, to initiate antibiotics, if that seems appropriate under the clinical circumstances, and as they learn more, and more diagnostic testing is done, to stop those unnecessary treatments if, indeed, the condition does seem to be most consistent with SARS.

We have no evidence, unfortunately, right now, that any specific anti-viral therapy, or steroid treatment, or other agents that are targeting this virus, are of any benefit to patients. We hope we'll learn more as we go but that is the status of clinical care today.

At the current time, we have no candidate treatments. Most patients will recover with good medical care - but 3-4% will die.

Currently, sites of outbreaks are using aggressive epidemiological controls, trying to prevent the spread of this virus. We must remain alert and keep informed as this story unfolds.

Hormone users take the chance

Now, the subsequent experiences of women who went cold turkey have driven home a key point -- for some individuals, hormone therapy may be worth the risk. An estimated 10% to 20% of menopausal women are tormented by severe symptoms, particularly hot flashes, and alternatives to hormones often prove inadequate. For them, life without hormones can be miserable.

"We hear from women who have these severe, flaming hot flashes who can't get through the day the way they need to," said Cynthia Pearson, executive director of the National Women's Health Network, a consumer advocacy organization in Washington, D.C. "Hormone replacement therapy is the only real alternative."

I agree entirely. Sometimes quality of life demands hormone replacement therapy. We are trying withdrawal each year, but do not know who often affected women will successfully withdraw.

I understand their financial motivation. I question their ethics. While it is easy to blame the insurance companies for many evils, we still should make responsible choices. Selling supplements (including Ephedra) does not seem a responsible, morally defensible choice. Bottom Line in Mind, Doctors Sell Ephedra

Pressed by rising malpractice insurance premiums and shrinking managed care payments, Dr. Tim Berry was struggling to keep his practice from turning into a high-volume rat race. Some months, he was dipping into his own pocket to pay overhead.

Then, a year ago, Dr. Berry and his wife, Debra, a pediatrician, started a weight loss program, clearing out rooms in their offices in Etowah, Tenn., for exercise equipment and heart monitors. He had few takers until he began selling dietary supplements, some containing the powerful but unregulated stimulant ephedra.

"By the six-week mark, my regular patients couldn't find parking spaces," he said. "It spread by word of mouth: `Dr. Berry has great products that work.' "

To judge by Dr. Berry's practice and others, there is little doubt about ephedra's appeal. Today, he says, he has 200 patients on supplements, a third of them on Biolean, a product made of ephedra and caffeine, and virtually all are shedding pounds.

What is he thinking? While money is not necessarily the root of all evil, it certainly can cloud ones judgement.

No reliable statistics exist on how many doctors sell such products, and those who do are breaking no law. Yet for many experts, legality is beside the point.

"You can't exploit the patient for your own financial interest," said Dr. Leonard Morse, chairman of the American Medical Association's council on ethical and judicial affairs. "This is a doctor-patient relationship, and your patient's interest transcends your financial interest."

Dr. Stephen Barrett of Quackwatch, a medical watchdog Web site, put it this way: "I tell people to avoid doctors who sell vitamins. It's a sign of bad judgment; you've made a wrong scientific judgment, in addition to which you're selling to a captive audience at a price that's inflated."

Doctors who sell supplements argue that this stance ignores their increasingly frustrating financial reality.

"Physicians are trying to survive today," Dr. Berry said. "If I can help my patients with the best products out there and customize them to their needs, I should be rewarded for it. I should be paid."

He declines to say how much he makes from supplement sales, but he says it is money that "the insurance companies can't take away from me."

Dr. Berry gets his products from Wellness International Network Ltd., which uses its literature to exploit doctors' anger at incomes pinched by managed care. The doctor is one of at least 100 whom Bob Wagner, a top distributor for Wellness, says he has signed up since the late 90's.

Another company, Unicity Network of Utah, says it counts many doctors among the thousands who sell its dietary supplements, including ephedra products.

One can only hate ranting about such behavior. One can understand their reasons, but reasons should not become excuses. They are wrong.

As I read the literature, treatment for carotid artery disease carries great risks. When a patient has had a TIA (transient ischemic attack) or RIND ( reversible ischemic neurologic deficit), and has significant carotid artery disease, then carotid endarterectomy can help prevent subsequent strokes, but only at the risk of intraoperative stroke. Overall, surgery does help, but the surgery does carry significant risk.

Researchers have announced results of stenting the carotid artery - but the link gives few details. Study Said to Back Guidant Artery Device

Researchers presented new evidence today that a minimally invasive technique might be the best way to treat high-risk patients with clogged arteries in the neck who are at risk of a stroke. The study, released at a meeting of cardiologists in Chicago, showed patients who were poor candidates for surgery fared well when tiny, wire-mesh tubes called stents were implanted to prop open clogged carotid arteries.

A trial of 513 patients treated with a stent found the procedure to be safe and effective at treating those who are at high risk in about 92 percent of cases.

Certainly promising results, which we need to scrutinize carefully. Which patients entered the study; what were the complications; was the there a control group? One should hesitate at developing too much enthusiasm from a newspaper report. We need to read the articles.

Sitting here, back at the Q&A desk. Today I will share both questions and comments. Receiving these comments provides a great reward - it tells me that some readers really care about my rants. And that is a wonderful feeling!

Reframe the discussion how ever you feel is convenient. The bottom line is state medical boards do a pretty lousy job of patrolling the profession for substandard care, based in large part on failure of professionals and health service organizations to self-report problem physicians, and budget and staffing support received from state legislatures. And responsibility for budget and staffing support limits, as well as limited grounds upon which to trigger an investigation or disciplinary action, can be placed at the feet of the provider interest groups.

This represents one of my excellent comments from the Bloviator (you should read his page regularly - just look over to the Medical Blog list). He forwards an interesting viewpoint on self-policing. I hope he is reading this rant - do lawyers do a good job of self-policing?

He points out that State Medical Boards do not receive adequate funding. Thus, they have difficulty becoming proactive in searching for "problem physicians". He has served as counsel to a State Board - so I would not dare challenge him on that point.

However, I believe this issue is indeed a side issue. Our problem stems from how our society defines and pays for malpractice. The entire concept of punitive damages is quite problematic. How can anyone adequately define those?

As I (and many readers) have said repeatedly, the problem with malpractice settlements should concern everyone. If malpractice premiums and rewards continue to rise, then no rationalization for the high rewards will matter. If physicians cannot afford to practice, then patients will really suffer. In some ways we are considering the penalties for errors of commission, and as a society ignoring the costs of paying those penalities.

I empathize with true malpractice victims. However, our current system works more like a lottery than a true check and balance.

Trial lawyers are the problem here. We need an alternate system for judging and paying for real malpractice. Our health care system really does an excellent job of caring for most patients. But we never get extra rewards for great care. When we make an important diagnosis or help a patient through a crisis, we receive the same fees as when we care for a more straightforward, simple diagnosis. If the patient has a bad outcome (even if we really did everything right), we just might get sued. That cannot make sense to anyone. Our system of judging malpractice is broken. The penalties for malpractice are broken. As a result, medical care actually suffers. The current malpractice system discourages improvements in health care.

I am a second year general surgery resident at a busy metropolitan academic center.  I enjoy reading your medrants whenever I can find the time.  Major kudos is due to you and your site.

You have written often about the 80-hour workweek issue.  I agree with most of what you have written.  I can tell you though, from my own experience and from talking to friends that I have in other surgical residencies around the country, that compliance by surgery programs will be very poor.  My program director has hatched a plan of pseudocompliance.  "You can go home 6 hours after you finish call if you want to, but everyone else is staying.  By the way, if you stay to work extra, its on your own time and you can't count it on your timesheets."

 This comment does not surprise me. I suspect many surgery programs will try such tactics, and some will get caught. Such programs will probably penalize residents who do not play their game. But if they fire those residents, the residents will likely sing.

Surgery programs have attitude (yes I know this is a generalization - but many colleagues around the country confirm that generalization). They truly believe they understand training better than any outside group. Some programs will comply; some programs will have the above attitude. We will have to follow the changes in July to see which specialities adapt well and which struggle.

An endoscopy the other day revealed "very mild" gastritis (probably from taking Advil on an empty stomach), also "very mild" esophogial irritation from a bout with heartburn that I had during a particularly stressful period several months ago. The doc, who is does a great job with the endoscopy, does not do such a good job with followup and simply gave my husband on the way out a script for Nexium, with little direction. I have so many questions! First of all, I have lowish platelets, around 100,000. Does Nexium, like Tagamet, interfere with platelet counts. Secondly, is this drug really necessary??? If both problems are "mild," and if I really don't even feel heartburn anymore, can't I a)change my behaviors and cure the gastritis and b)assume that the esophagial damage is from an old problem and that the esophagus will heal itself, given time? By the way, I am a 47-year-old woman who takes no scripts, who hates taking pharmaceuticals and likes to believe she can heal herself holistically -- until something life-threatening comes along, at which point I will be grateful for life-saving drugs. I don't see this situation as a life-threatening one. Thanks for listening and for whatever advice you can offer.

Thanks for the question. Giving advice on medical issues without actually talking with a patient and examining them and their medical record is a bad idea. Thus, I will couch my answer in generalities.

I am not aware of proton pump inhibitors (the class which includes Nexium) causing problems with thrombocytopenia. A quick search did not find any such problems. Tagamet is a histamine-2 blocker - a different drug class.

Not knowing your history of gastritis and esophagitis, I can make no comments on treatment. If you truly have endoscopic evidence of esophagitis, then I doubt holistic treatments will work. In general weight loss does help esophagitis.

If your gastroenterologist does not discuss your diagnosis well, you might try going back to your internist or family physicians. They should be able to sit down and discuss your management strategy. If you do not have a generalist, you need one (as I rant about regularly).

"We teach residents to consider a complete differential, but to concentrate on the four most common diagnoses - undiagnosed asthma, ACE inhibitor cough, post-nasal drainage, and gastroesophageal reflux disease (GERD)."

How about chronic bronchitis?

This comment came from a rant about cryptic cough. I did not make clear that I was talking about cryptic cough. Chronic bronchitis, in my experience, is rarely (if ever) cryptic). These patients have a productive cough and fit into a classic syndrome. If we take all cough presenstation, then chronic bronchitis is an important consideration.

I knew one attending whose favorite retort to the "natural" argument was to snap, "Well, poison ivy's natural
too!"

Well stated.

and what about the "natural course of an illness?" We all know that over 90% of common maladies like Otitis Media, Sinusitis, and Pharyngitis will resolve with NO intervention. Try saying THAT to the next patient with a runny nose who asks for a "natural cure."

While I do think we should prescribe antibiotics for bacterial otitis, sinusitis and pharyngitis, I agree that we are too quick to give patients antibiotics for viral infections. Why do we do this? It saves time and the patient expects it. I have always tried to avoid this behavior. Unfortunately, I see too many colleagues, residents and even students who start "a Z-pak" whenever they get a cold. We need to do a better job here!

A pre=emptive apology for this rant.

This is old news to the average otolaryngologist. OVERHWELMINGLY, patients who I see for chronic cough have underlying GERD. I'd guess that 80% have GERD, 10% have chronic sinusistis, and then there are about 10% "other." Most are not difficult to diagnose on history alone (not to sound facetious- most are easy to diagnose my simply LOOKING at them). Chronic sinusitis is easy to rule out- order a CT scan. The only problem you'll run into in that regard is that our radiology colleagues have a penchant for overreading these scans. (I would LOVE to see a blinded study of sinus CT scan interpretations by radiologists. I would wager that you'll get a substantially different interpretation by 5 out of 10 readers.)

I have a pet peeve: I IMPLORE my generalist colleagues (and others) to stop using the term "post-nasal drainage" so flippantly. I peer into pharynges every day of my working life (X 20 years) and I can tell you that it is RARE to actually spot any kind of discharge trailing down the posterior oropharyngeal wall. The only other time one sees this is as a subtle finding on endoscopic exam- a modality that is not available to the average generalist. I'm constantly astounded at how many patients come in telling me that their Primary care doctor "spotted drainage down my throat." Don't you find it odd that everyone and his cousin talks about "post-nasal" drainage" and yet this is not a term that is loosely used by the one specialist in human medicine who ought to know the most about it?

Sadly, most of my day is spent UNDIAGNOSING "sinusitis." These patients are almost always complaining of facial pain (shockingly, predominantly female, often depressed; usually with a background history of headache and other pain syndromes) i.e. "another sinus infection" and/or "post-nasal drainage" i.e. almost always symptoms of GERD. Is it any surprise that they don't get better with antibiotics? And the ones that do are often responding to a placebo effect.

There has been, and continues to be, a lot of gold to be minded treating "chronic sinusitis" surgically. Please spare your patients needless antibiotics and surgery. Concentrate on SYMPTOMS, not preconceived diagnoses. If you do, you'll almost always come upon the right assessment the first time.

Sometimes readers have better rants than DB. This is a great example. Thanks to Dr. Kranky for this post!

Do you know of a medical study on use of Singulair for people with chronic sinusitis? I do not have asthma but have had injections for years, had 2 sinus surgeries and suffered 10 years of infections every 3 months (average). I've slightly improved via acupuncture, but still need help. (It does not help living in the humid Washington, DC area) 

First, read the comment about. Second, do you have chronic sinusitis or allergic rhinitis, or both. If you have allergic rhinitis, then Singulair can help (but is not better than nasal steroids). You might benefit from a fresh look at your symptoms and treatment. Again, not talking with you and having access to all your records, I cannot completely answer your question.

One way to calculate the benefit is to measure the number of specialty referrals generated in a "shared" practice vs. the model that most of us feel is more beneficial- per given condition (or tentative diagnosis). AND factor in the number of visits to each primary care model BEFORE the referral was made.

It's been my experience as a consultant that too many conditions were turned into "chronic" or "complicated" this or that, simply because there were 3, 4 different primary care physicians (sometimes PA's of NP's) on the given patient's care.

Another excellent comment which complements (in my opinion) the point I tried to make. Continuity certainly has important benefits on satisfaction (for both patients and physicians). It also often leads to better care. I agree with the comment, although I do not know of a good study to confirm this observation.

...

Once again, thanks for the comments and questions.  
When there is no continuity in the thought process on a given patient's situation, is it any surprise that delay
and anxiety result?

Many readers remember my opposition to widespread smallpox vaccinations. I argued - as did many others - that we would put vaccinees (and their patients) at a small but significant risk that probably was greater than the risk of smallpox reappearing. I obviously had greater concern about making an error of commission than the risk of an error of omission.

Now we may have a problem. The data are not yet clear, but apparently smallpox vaccine can cause cardiac problems. 2 States Suspend Smallpox Vaccinations

People at high risk for heart trouble, not just those with heart disease already, should avoid the smallpox vaccine, federal advisers recommend in a move that would place new limits on the troubled anti-terrorism program.

The recommendation Friday would eliminate even more people from the pool of potential vaccinees at a time when the government is trying to increase its numbers.

Two states, New York and Illinois, temporarily suspended their programs while questions about the link to heart disease are investigated.

To date, 17 recipients of the vaccine have suffered heart problems afterward, and federal health officials are looking for a possible link to the vaccine. Three people have died, including a 55-year-old National Guardsman that the Pentagon announced Friday.

One can easily argue that the deaths all occurred in patients with heart disease. They might have died anyway. We will probably never know the truth here. Nonetheless, we have the perception of creating illness because of a postulated risk.

The CDC panel had considered a more drastic step: Excluding anyone over the age of 50. But members worried that would essentially kill the program.

Still, at least one member of the panel want to go even further and suspend all vaccinations while the heart question is investigated.

"There still hasn't been a case of smallpox anywhere in the world," said Dr. Paul Offit of The Children's Hospital of Philadelphia.

"There are a lot of people who have heart problems and may not know it," he said, suggesting that the screening system might not find everyone at risk.

No matter what the recommendation, news of the deaths is likely to make health care workers even more wary of the vaccine, said Dr. Deborah Kamali of the University of California, San Francisco, who helped organize area doctors to write the CDC and urge that the program be halted.

She and her colleagues argue that known risks of the vaccine outweigh the unknown risks of an attack with smallpox, which was wiped from the Earth more than two decades ago.

"I think it will definitely make health care workers more reluctant. This is something they can relate to," she said. "As a field, we've already been reluctant."

Patients want a relationship with their physician(s). Most physicians also want a stable relationship with their patients. And it helps medical care. Evidence Supports the Importance of Continuity in Primary Care

Continuity of care in primary practice benefits patients and doctors alike, and both parties value the mutual liking and trust generated by long-term relationships, British researchers write in the Journal of the Royal Society of Medicine.

This article appears in response to a move in Great Britain to have patients register with a practice rather than with a specific doctor. Such decisions only occur when managers try to make medical practice more efficient .

The doctor-patient relationship, when it works, benefits all. I believe this phenomenon is not restricted to primary care, but applies to any chronic illness (e.g., rheumatoid arthritis patients and rheumatologists, psoriasis patients and dermatologists, and you can imagine many more such relationships).

One additional thought comes to me. As physicians try to see more patients per session, they have less time to develop that relationship. The greatest attraction to the generalist fields is, in my opinion, the long term relationship one develops with patients. These relationships take time to develop. They benefit from taking a small amount of time to chat. Perhaps this represents another appeal of retainer medicine. It gives the physician time with the patient. But managers and insurers cannot understand how to calculate that benefit. Some benefits are difficult to quantitate. Not being able to quantitate a benefit easily does not invalidate the benefit.

Is SARS confusing you? This article does a nice job of summarizing what we currently know. The Mystery Virus: A Guide to Origins, Symptoms and Precautions You Can Take . As a brief added note, the evidence for coronavirus seems significantly greater than paramyxovirus at the present time.

Can we control SARS? Will travel restrictions help? Canada will try. Given the amount of travel between the US and Canada, this could help us greatly. Canada to Screen Airline Passengers for Respiratory Ailment

Responding to international concern over the spread of a mysterious respiratory disease, Canada said today that it would screen all passengers boarding international flights in Toronto for high fever and other flulike symptoms. The health minister, Anne McLellan, said today that in response to a request by the World Health Organization, anyone displaying such symptoms would be told not to travel. The illness is known as SARS, for severe acute respiratory syndrome.

I hope such measures work. Unfortunately, I assume that some will travel during the incubation period, not becoming sick until they alight in a new location.

I hate the word. Gatekeeping - AAAAAAAAAAARRRRRRRRGGGGGGGGHHHHHHH! I am not a gatekeeper, have never been one, will never be one. This is a gatekeeper: . The current issue of the British Medical Journal has an intelligent discussion of the "gatekeeper" model for health care. The author discusses several important issues, and provides a wonderful economic background. I find his conclusions relevant.

A recent editorial in the New York Times expressed a sentiment common in the United States: that gatekeeping is a failed experiment by managed care organisations. On the front line delivery of health care, the primary care gatekeeper has become the lightning rod for consumers' discontent with healthcare delivery. There is no question but that patients value the input of their primary care physicians into medical decisions. At issue is how to manage patients' demand for specialist care in a healthcare environment rich in specialists that promotes expectations for direct access and reliance on invasive technologies over less invasive primary care interventions.

Many UK analysts assert that gatekeeping is responsible for the country's low healthcare expenditures relative to other European nations. Although it is true that countries with gatekeeping systems spend less on health care than those without such management of referrals, gatekeeping is not directly responsible for the lower costs. Rather, gatekeeping systems have emerged in societies with scarcer healthcare resources. The lower costs are a function of supply side controls, rather than demand management at the primary care-specialty care interface. Cost arguments aside, primary care gatekeeping provides an important filter to specialist care. Patients who go directly to specialists are less likely to be ill, increasing the chances that diagnostic and therapeutic procedures will be applied inappropriately and outcomes will be threatened. Despite consumerist trends in most developed nations, patients will continue to need primary care practitioners to guide them through an increasingly complex healthcare system and to assure an equitable distribution of resources by matching services to healthcare needs.

If we could have this author help correct our reimbursement system. He understand the generalist value. Why doesn't everyone?

No commentary is necessary here. Just read this and shudder. China's Response to Illness Was Typical

This just might work. Health Screening Is Sought for Some Airports

To help control the spread of a mysterious respiratory illness, the World Health Organization yesterday urged airports in affected cities to ask international passengers about their health at check-in and to discourage those with a fever within the previous 24 hours from flying.

The organization recommended that airport officials also ask passengers whether they have a cough or difficulty breathing and whether they had had contact with someone with the ailment. It is known as SARS for severe acute respiratory syndrome.

...

The World Health Organization, which can only make recommendations to governments, is focusing on flights leaving places where the disease is spreading locally: Toronto; Singapore; Hanoi, Vietnam; Hong Kong; Taiwan; and in Beijing, Shanghai and Guangdong Province, China, where SARS is believed to have first spread, last November.

While this seems a drastic measure, the medical rationale is clear. However, I remain skeptical that it will work. Patients seem to have a latent period during which they are not sick. If they are not aware of exposure, then they certainly could still carry the infection on the plane and to a new location.

Scientists say SARS virus identified

They also said they had developed a diagnostic test that will allow doctors to tell within eight hours whether someone has the disease, according to Reuters.

The microbiologists from the University of Hong Kong said a new strain from the family of coronaviruses, which are the second-leading cause of colds in humans, was to blame.

Now the search for treatment continues. As the number of known cases increases, we will better understand the epidemiology. Having a diagnostic test will allow us to understand transmission. We should start to better gauge risk. This remains a frightening to me. A common cold virus becoming a serious pathogen will challenge our health care delivery system.

This blog will remain 99% medicine. However, I must comment on Daniel Patrick Moynihan.

I generally vote Republican. My political philosophy is best described as Libertarian domestically and neo-conservative internationally. (see Robert Prather to better understand this - Neocons Vs. Paleocons.

Regardless of ones political inclinations, Daniel Patrick Moynihan should represent the ideal in politics. He based his stands on principle and intelligence. Even when one disagreed with him, one had to reconsider ones own position, because he was so damn smart. Read this outstanding tribute from George Will - A Beautiful Mind. Oh, but that we could have the Congress full of his like!

China Raises Tally of Cases and Deaths in Mystery Illness

Officials in Guangdong Province, the center of China's epidemic, reported an estimated 792 cases and 31 deaths as of the end of February, a rise from the 305 cases and five deaths they had previously reported.

The new tallies mean that China now probably has had more cases and deaths than any other country, although the latest estimates have not been officially approved by China's Ministry of Health or reviewed by international health officials. About 500 cases have been reported elsewhere in the world.

The new figures are being released just days after a World Health Organization team arrived in China to help investigate this country's epidemic of the mystery pneumonia, which goes by the name SARS, for severe acute respiratory syndrome.

For months, Chinese officials tried to hide the problem, health experts said, and in recent weeks world health officials have applied increasing pressure on China to improve its cooperation and statistical reporting on the disease.

While all other countries that have experienced cases of the new pneumonia, including Vietnam, Singapore and Canada, send daily updates of cases and deaths to the World Health Organization, China has been consistently unwilling or unable to provide such information.

Even today's newly revised estimates, which officials of the World Health Organization praised as a "great step forward," cover only cases through the end of February and provide no information about cases in the past four weeks. The previous tallies covered only cases reported up to Feb. 10.

"We want to keep the spotlight on folks here and to encourage them to be part of the solution," said Dr. Rob Breiman, of the International Center of Diarrheal Disease Research Bangladesh, who is a member of the W.H.O. team currently in China. "We want to use the incredible amount of information they have collected here to help solve the problem."

Meanwhile, I can find no new news on the virology. I am still intrigued by the two virus hypothesis (see yesterday's rant and a similar Medpundit rant today).

On the containment front today's Wall Street Journal Online (subscription required) has an article on the Singapore response to SARS. While some might consider them draconian, one can easily argue that such measures are needed to control a potential disaster.

Singapore, on the other hand, has been both transparent and proactive in fighting the spread of SARS. Although there have only been 69 cases and one fatality in the city state, much fewer than Hong Kong, it has taken several decisive steps. The government closed all schools and designated the Tan Tock Seng Hospital to handle all cases and closed it to other admissions. It has also forcibly quarantined 841 people who had exposure to the victims; those under a quarantine order can't leave their apartments for 10 days under penalty of a $2,832 fine.

Hong Kong appears to now be emulating this approach. HK orders mystery virus quarantine.

Finally, at least one editorial recognizes that the US public health system has acted aggressively and appropriately in anticipation of a possible outbreak in the US. SARS and public health preparedness

The SARS outbreak has shown how much public health preparedness has changed for the better since the anthrax attacks of 2001. However, many improvements should be made. The next disease to emerge could be aimed at the United States, and might not be natural in origin.

Alice, the author of Feet First, frequently provides insightful comments here. She wrote one such comment yesterday, and I noticed she had a blog. So I clicked and found this story - Now I'm Really Mad. Please read the entire story - this excerpt will only give a slight taste of the entire meal.

I called up Medco to make my case for continuing to maintain the patient on 300 mg. During my conversation with the pharmacist, I told them how ridiculous I thought this was and that I had never seen such a request before. "Is it really worth it to do this?" I asked. "How much money can they possibly be saving?"

The pharmacist stated that he didn't know, but that the company must be saving a significant amount of money or they wouldn't have begun this protocol.

Later that day, to satisfy my curiosity, I called the pharmacy downstairs from me and asked for a price quote on a month's supply of ranitidine, both for 150 mg and for 300 mg.

Thirty 150 mg tablets cost $13.

Thirty 300 mg tablets cost $15.

Let's do the math here, folks. That's two dollars a month.

The rant goes on and one quickly shares her frustration. I have added her blog to my medical blog list (she writes both about medicine, as well as anything else she cares to consider). Nice work Alice!!!

This blog has several recurring themes. One concerns paying generalists enough money to allow them to provide excellent care. This issue has more complexity than one might first assume. Some would argue that generalists make a good living - why are they complaining? When I talk to practicing generalists, they bemoan the time that they can designate to each patient. Financial considerations drive visit volume. Financial considerations continue to decrease the supply of new generalists. Thus, we have generalists retiring and retreading; we have a decreasing supply; and is yesterday's rant on Medicare suggest, we have increasing demand for services. We also should do more at each visit - improving medical care options require more time. A specific example is preventive care. Prevention is like motherhood and apple pie, everyone is in favor of prevention. Why do we do such a mediocre job? Time!!!! Not Enough Time for Primary Prevention

For an average-size practice, performing all the recommended preventive services would take about 7.4 hours per day, according to a report in the current issue of Research and Practice, dated February.

"Currently recommended preventive services for the US population require an unreasonable amount of physician time," write Kimberly S. H. Yarnall, MD, and colleagues from the Duke University Medical Center in Durham, North Carolina. "The magnitude of the problem is likely to increase as new genetic tests become available."

Using published and estimated times needed to provide services recommended by the U.S. Preventive Services Task Force (USPSTF), the authors determined that it would take 1,773 hours per physician per year, or 7.4 hours per working day, to provide these services at the recommended frequency to a population of 2,500 patients.

Changing the age distribution of the patient population would not significantly change the time requirement, which was 0.61 hour per year per child and 0.66 hour per year per adult. Performing only services with A recommendations from the USPSTF would take approximately two hours per day, or about 25% of patient care time.

We all really no this (the we being physicians). This study confirms this important concept. We must continue to push this point. One advantage of retainer medicine is the time it allows one to practice 'state-of-the-art' care. Such care does cost more than we currently pay. Explain why it is not worth the extra money.

I have added 2 blogs to my medical blogroll (in the left column).

Living with diabetes is a patient's ongoing journey to live with her diabetes. She writes well, and does her research. She is a frequent and intelligent commenter on this site.

Medical Weblogs should become a daily visit for all readers.

Medlogs is now much more than a list of medical weblogs -- it's a weblog aggregator. On the right, you can see the familiar list of medical weblogs. Below this post is an excerpt from the last five weblog posts from all of the medical weblogs that I can find. If you know of one that I'm not listing .. please post a comment below and I'll add it (the weblog must support RSS for this to work)

I am sure that I am leaving out other important sites - drop me a note and I should correct it.

The news becomes more frightening and more puzzling. How easily does SARS spread? Could the syndrome depend on a dual infection - two viruses? Casual SARS transmission?

IN RECENT weeks the disease has spread beyond Hong Kong hospitals, where dozens of health care workers became infected, to schools, with at least four schools closed for several days.

Hong Kong officials also said Tuesday that nine tourists apparently came down with the deadly disease after a mainland Chinese man infected them on a March 15 Air China flight to Beijing.

If severe acute respiratory syndrome, or SARS, can be more easily spread through the air - rather than through close contact with infected people - it could force travel and other restrictions to contain the disease.

 "We would want to be sure that it was people sitting next to that person and not the ventilation system in the airplane which was spreading the disease," said Dr. David Heymann, head of communicable diseases at WHO.

So the epidemiologists continue to work on the mode of communication. We cannot control an epidemic unless we understand transmission.

Meanwhile on the virology front things become even more confusing.

MORE THAN ONE MICROBE?

 "We are a bit puzzled because we are not only dealing apparently with one pathogen but with two. The reason why we believe that both pathogens should be given equal attention is that there is consistent finding of both pathogens in individual patients or of either of the pathogens in other patients," he said.

 "What we are seeing actually are three hypotheses."

SARS might be caused by one of those two viruses or "these two pathogens have to come together to cause this very severe outbreak."

The latter theory is that the coronavirus - which Stohr said lives in immune cells that fight off disease - destroys or weakens the immunity in the patient so the second virus "has practically an open door to go in and to sicken the patient beyond what this virus would be able to do normally.

"But more research is being done to verify that."

I find this very interesting speculation and also very concerning. If we need to address two viral infections simulataneously, then we have a much more complex situation.

Will we have a major epidemic? This is the big question. I remain very concerned. Until we really understand both the transmission and the etiology, we can only guess at treatment and containment strategies.

This is ridiculous. We need protesters in the streets. We need a UN resolution. But will anyone notice? Please spread this outrageous story throughout the blogosphere. China Bars W.H.O. Experts From Origin Site of Illness

We are trying to understand and contain a severe respiratory infection from which around 4% of the patients die. This is an astonishing death rate. Investigators are making great progress, but China will not cooperate.

Chinese officials have reported 305 cases in Guangdong from November to Feb. 1, 5 of them fatal. They say the disease died out on its own.

But because outside experts have been stalled in their efforts to go to Guangdong, there has been no independent verification of the number of SARS cases in China, whether cases have occurred elsewhere in the country and whether transmission has stopped. Epidemiologists investigating SARS elsewhere say they suspect the number of cases in China may be much higher than 305.

The team also wants to interview patients who became ill, doctors and other health workers who cared for them and laboratory scientists to find out what they found in specimens from patients with the ailment. The cause of SARS is still unknown, though scientists suspect either or both of two viruses.

The experts also want to be certain that the illness in Guangdong is in fact SARS, which the world organization says has caused at least 487 cases in 13 countries since Feb. 1, including 17 deaths. The symptoms include high fever, cough, shortness of breath and difficulty breathing.

Chinese health officials have said, most recently when a delegation of them visited Hong Kong on Saturday, that they are working on the disease and want to be cooperative with the international community. But they have declined to provide any details other than to say that they believe the problem is under control.

Dr. David L. Heymann, executive director in charge of communicable diseases for the world organization expressed hope yesterday that the team would be invited to visit Guangdong. "Certainly our wish would be that the government will permit us to work with them in all aspects of this outbreak," he said at a news conference.

Ridiculous! I am speechless.

Medicare Recipients Face 12.4% Rise in Premiums

Medicare beneficiaries face a large increase in premiums next year, and doctors' fees will probably be cut because Medicare spending surged unexpectedly last year, federal officials said today.

Richard S. Foster, chief actuary of the Medicare program, estimated that the Medicare premium would rise to $66 a month, an increase of $7.30, or 12.4 percent, the largest increase in 11 years.
Medicare officials said they now estimated that the fees paid to doctors for treating Medicare patients would be cut 4.2 percent next year.

Premiums charged to the elderly and the amounts paid to doctors are computed according to complex formulas set by law.

Once again both patients and doctors are scheduled to financially suffer - because we are providing more (and better) care for patients. We have a significantly flawed formula for calculating premiums and physician reimbursement.

Dr. Yank D. Coble Jr., president of the American Medical Association, said the impending cut showed that Medicare's formula for paying doctors was severely flawed.

"Under the formula," Dr. Coble said, "physicians are penalized if services to Medicare patients grow more rapidly than the gross domestic product. At times of slow economic growth, it is likely that Medicare spending on physician services will exceed the target and trigger cuts in physician payments. But the health care needs of America's seniors don't change with the ups and downs of the economy."

This finally starts to become clear. The Congress developed a formula based on the economy rather on the costs of the services. They pass laws requiring more administrative overhead, yet they link payment to the economy. But overhead is not linked. I think they will quickly hear that a crisis is imminent.

Medicare spent $45 billion on doctors' services last year, an increase of $3 billion, or 7 percent, from 2001, even though the average fee for each service was reduced.

Thomas A. Scully, administrator of the Medicare program, said the fee cut was offset by "a stunning 8 percent increase in the volume" of doctors' services to Medicare patients last year.

Medicare pays doctors under a fee schedule that sets payment rates for more than 7,000 procedures.

Thomas L. Grissom, director of the federal Center for Medicare Management, said, "The estimated reduction in physician fee schedule rates for 2004 is due, in large part, to substantial growth in 2002 in the volume and intensity of physicians' services."
In other words, doctors are performing more procedures and tests.

And every quality measure that Medicare uses is improving. Perhaps this care has good indications. Perhaps some testing occurs in response to the malpractice crisis. Should we not ask why rather than have a formula that just reacts to numbers? As I say repeatedly, improvements in technology and pharmacotherapeutics may lead to an increased percentage of GNP going to medical care. Why should we try to fix that percentage? We should strive to provide the best possible care. Or should we just try to control costs?

So where is the money going? Medicare has broken the data down into categories.

Mr. Foster, the chief actuary, itemized some of the increases in Medicare spending last year:

¶Inpatient hospital care, up 10 percent, to $104.9 billion.

¶Outpatient hospital services, up 10 percent, to $15.4 billion.

¶Skilled nursing homes, up 9 percent, to $14.6 billion.

¶Home health care, up 14 percent, to $10.5 billion.

¶Durable medical equipment, including wheelchairs, up 20 percent, to $6.5 billion.

¶Hospice, up 24 percent, to $4.6 billion.

All good reasons for doctors' fees to decrease. (I only hope that my sarcasm bleeds through!)

As an internist, I know little about autism. Occasionally somone will ask me about it. I have even received at least one email which I could not answer. This article will have great interest to some readers - it discusses the thimerosal hypothesis - and gives all the evidence against thimerosal as a cause of autism. Vaccines and Autism, Beyond the Fear Factors

In Medicine, Nature Plays Dirty Tricks

Like most doctors, I hear the word "natural" a dozen times a day. People ask for a "natural" treatment for their insomnia, constipation or sinusitis. They discuss the "natural" vitamin-based remedy they have found on their own. They stop a prescription medication because it isn't "natural" and head for any of a variety of herbal cures instead.

These natural alternatives are not always inexpensive: profiteers lurk in that arena just like any other. Vitamins are made with exactly the same sophisticated chemical techniques as any drug. Herbs are not always gentle, effective or safe, as the recent spate of ephedra-associated deaths shows.

But no matter the age, sex, education or income of a patient, "natural" is, it seems, preferable these days to the synthetic unnatural treatments that unenlightened agents of orthodox medicine like me are condemned to dispense.

When exactly was it that Mother Nature picked up such a reputation for benevolence? It seems that at some point everyone forgot that if it's natural you want, serious disease is one of the most natural phenomena of all.

Every time I hear the word "natural" I think of Charlie, a man whose right foot should have been cast in bronze and displayed in a museum as graphic evidence of "natural" at its worst.

Read the rest of the article to learn about Charlie, his diabetes, and the results of ignoring medical advice.

The CDC is honing in on a variety of coronavirus. More information in this article - Cold Virus Linked to Outbreak CDC Says New Version of Coronavirus Is Likely Cause

No drugs are known to work against coronaviruses. But the CDC is working with the Defense Department to test existing antiviral agents to see if any kill the virus, and to develop tests for the virus. A test would help confirm suspected cases, and determine whether healthy people can carry the virus.

Nine of 11 laboratories working together around the world to identify the cause of the new disease have found evidence of a paramyxovirus in patients, Heymann said. But in addition to the CDC, two other laboratories have found evidence of a coronavirus.

The disease, known as severe acute respiratory syndrome (SARS), is the first new life-threatening infection that can be spread from one person to another to emerge in decades.

Medical research does work fast when necessary!

Information comes fast and furious on SARS. Here is the latest - New Coronavirus Suspected as Cause of Severe Acute Respiratory Syndrome

During a telebriefing Monday, the director of the US Centers for Disease Control and Prevention, Dr. Julie Gerberding, reported that the agency now has "very strong evidence supporting coronavirus in the etiology of severe acute respiratory syndrome or SARS."

It may be a "new or emerging coronavirus," she said.

According to Dr. Gerberding, the CDC has been able to culture coronavirus in tissue from two of four affected patients. "That, in and of itself self does not prove causality," Dr. Gerberding said, "but what is interesting to us is that not only are we culturing it but we are finding it in affected tissues." In one patient, the virus was found in lung tissue and secretions as well as the kidney, she said.
Moreover, Dr. Gerberding said the patient had a negative early antibody test for coronavirus, but by the end of the illness had seroconverted "using a very specific assay for this new coronavirus."

She said CDC also has evidence of coronavirus infection in seven other people. "A total of three have seroconverted and we are actively getting late serum to see if others will seroconvert as their illness progresses."

"We know from sequencing pieces of the virus DNA that it is not identical to the coronaviruses that we have seen in the past. This may very well be a new or emerging coronavirus infection, but it is very premature to assign a cause," Dr. Gerberding told reporters.

So what is coronavirus? I found this link that gives some information - Human coronavirus. It appears to be a cause of the common cold. At this time we must suspect a mutation has allowed this virus to cause pneumonia. As regular readers know, we will follow this story closely as it unfolds.

Patients often present to their generalist complaining of a common cough. We teach residents to consider a complete differential, but to concentrate on the four most common diagnoses - undiagnosed asthma, ACE inhibitor cough, post-nasal drainage, and gastroesophageal reflux disease (GERD). This month's CHEST has a very interesting article on the later diagnosis. This link probably will only work if your library has a subscription to CHEST online - Chronic Cough and Gastroesophageal Reflux Disease* Experience With Specific Therapy for Diagnosis and Treatment

One hundred eighty-three patients were identified with chronic cough and were included in the study. Thirty-one patients were disqualified because of abnormal chest radiographic findings, inadequate follow-up, or cough being not the primary complaint. Fifty-six patients were identified as having GERD-related cough.

This simple paragraph suggests that approximately 30% of chronic cough patients have their cough related to GERD. This is important information. They then ask the important question - does treatment matter?

GERD was the single cause of cough in 24 patients (43%). Twenty-nine patients (52%) had GERD plus another cause, and 3 patients (5%) had GERD with more than two causes. Twenty-four patients (43%) had cough only, while 32 patients (57%) had other symptoms of GERD. Proton-pump therapy was successful in 42 patients (79%). Twenty-four patients responded to proton-pump inhibitor therapy, and 18 patients responded when metoclopramide or cisapride was added. The remaining two patients responded to a histamine type-2 blocker or cisapride alone. The cough was eliminated or markedly improved in 38 patients (86%) after 4 weeks and by 8 weeks in the remaining 6 patients. Six of the nonresponders had aspiration diagnosed by bronchoscopy. Four patients had fundoplication recommended, and two patients responded to alternative interventions.

Many patients need a 'prokinetic agent' in addition to the PPI. We no longer have the option of using cisapride, thus we will generally try metoclopramide (Reglan). This study helps place GERD into perspective as a chronic cough etiology. An accompanying editorial (by a fellow UAB faculty member) places this into clinical context.

Also, who should be considered for an empiric trial? Obviously, patients with esophageal symptoms should be considered. However, a large number of patients have clinically "silent" GER. Irwin and Madison6 have described the clinical profile of a patient with cough due to silent GER, as someone who is a nonsmoker, is not receiving an angiotensin-converting enzyme inhibitor, has not been exposed to environmental irritants, who has a normal or near-normal chest radiograph finding showing nothing more than stable inconsequential scarring, and in whom asthma, rhinosinus diseases, and eosinophilic bronchitis have been ruled out or have been adequately treated.6 These patients also should be considered for an empiric trial.

Her excellent editorial - Chronic Cough Practical Considerations

Being a physician is a constant source of pride. When I look in the mirror each morning, I know that my goals are to improve people's lives. Navy Docs can believe the same thing. 'Devil Docs' operate on friend and foe: In field operating room, wounds matter more than sides . This is as it should be!!

The most badly wounded fighters from the front lines are treated first, regardless of whether they are friend or foe.

"It's a medical decision based on the patient's physiology and the wound," said Capt. John Percibelli, the chief surgeon. "That's how we decide who goes first."

I often rant about exercise and diet. The information in this link is not new - even to this blog. However, it is important enough to highlight once again. Eat less and walk more to keep diabetes at bay.

Problems with insulin resistance are not confined to obesity and have much wider metabolic implications ? hence the other term for the condition, the metabolic syndrome. As well as a resistance of the body tissues to insulin, the patient may have high levels of circulating blood insulin, obesity, high blood pressure, abnormal blood fat levels ? the combination of high blood pressure and raised triglyceride blood fats is a particularly ominous one ? and type 2 diabetes. In women, there is also an association between insulinresistance syndrome and polycystic ovarian syndrome. In the present epidemic of childhood and adolescent obesity, it is found that however the fat is distributed, an overwhelming number of patients are insulin-resistant and potential candidates for type 2 diabetes.

There is a strong familial and racial pattern to insulin- resistance syndrome. It is common in Asia, but in all countries of the world it is increasing. One way of countering it and the ever-increasing numbers of patients suffering from type 2 diabetes that stems from it is to reduce the prevalence of obesity. This may be achieved by reducing the calorie intake, and by increasing exercise. The change doesn?t have to be dramatic; by cutting the calorie intake by 600 a day, and by walking briskly for an extra half mile a day, a dramatic difference may be observed after a year.

Professor Thomas Wadden, from the US, had an interesting observation on the obesity associated with insulin-resistance syndrome. He has found that many of these patients are binge-eaters. Between 15 and 20 per cent of the obese patients who attend his clinic fall into this category. Many of the binge-eaters he treats are also depressed and have a typical depressed patient?s diurnal variation ? that is to say they become progressively more jolly as the day wears on. This has an effect on their eating pattern. Although they are hearty eaters at supper time and night-raiders of the fridge, they are anorexic at breakfast and have a very light lunch.

As I rant incessantly - diet and exercise - exercise and diet.

Singapore and Vietnam are home to a third wave of SARS cases. Fortunately, investigators can still link these cases directly to previous cases (in terms of exposure). As evidence accumulates, one must have close contact to an infected individual. Barrier precautions do apparently work. Respiratory Illness Spreads to a Third Wave of Cases.

Scientists at the University of Hong Kong, a member of the W.H.O.'s collaborative network, have isolated a virus in recent days that is a prime suspect. Yesterday, the agency reported further progress in identifying the virus and developing a test for it.

Scientists seeking to identify the virus are taking the utmost precautions as they work in highly secure laboratories categorized at the "three-plus" level, half a step below the maximum-security level-four labs. They wear masks and gowns, all materials in the room are burned after use, and the room is steam cleaned before it is used again.

Dr. Klaus Stöhr, who is leading the W.H.O. scientific team investigating the illness, said members of the agency's laboratory network would not distribute the suspect virus to any laboratory without three-plus level capability until it was determined that it was safe to do so.

The illness "still looks like a disease you get only after close contact with an ill person," said Dr. Heymann, executive director in charge of communicable diseases for the W.H.O. The new information, he said, "shows a typical epidemic curve of successive waves of transmission of a disease that is transmitted person to person," referring to graphs that epidemiologists construct to plot the progress of outbreaks.

It appears that approximately 10 per cent of cases become very severe.

The W.H.O. has established a network of doctors who have cared for at least one patient with the illness. After speaking with each other in teleconferences, their initial impression is that about 10 percent of the cases become so-called rapid progressors because the condition of the patients declined so quickly, Dr. Heymann said.

About half of the rapid progressors ? 5 percent of total cases ? develop such severe difficulty in breathing that they have to be connected to mechanical respirators. Most deaths have occurred among those who needed mechanical respiratory support. Even among the other patients, many experience breathing trouble, one reason that an overwhelming majority remain in hospitals.

We can only hope that precautions will allow containment of this infection. However, we are already in the 3rd wave and this could get worse. We must follow this story carefully and be ready in case this infection becomes endemic. As an aid to keeping up to date, here is the CDC web page with the latest information - CDC - Severe Acute Respiratory Syndrome.

How am I suppose to chose? Am I prepared to die on the operating table, NO. Do I want to die slowly by staying 362lbs, NO. So now what? I know most people think obese people should be able to just stop eating and the weight will come off, but it doesn't work that way for everyone. Me being one of those people. I have a 12 yr old son that I want to live for. I want this surgery but how can I say, as I'm being wheeling into surgery "see you soon" knowing that he may never see me again..all because I want to be healthy. I'm so confused!

This eloquent paragraph defines the problem of obesity. You know that your weight is a major problem, yet cannot succeed with conventional methods.

Most physicians and readers do have difficulty understanding your situation. Peronally, I have succeed in modifying my diet and enhancing my exercise program. That must not work for you.

So what are you to do? No one can make this difficult decision for you. When does one risk everything (albeit a low probability) to gain everything? I can tell you that on average having surgery will benefit you. But averages work for populations, not for individuals. Talk to some surgeons who specialize in this surgery. Interview them, and they might help you with your decision making. Good luck - we all hope you make the right decision for yourself.

I'm not a doctor... my wife has Atrial Flutter. She feels much better in Sinus Rhythm. So isn't it a good idea to have "rhythm" control just from a quality of life point of view?

And if she is in sinus, are the data clear that she should still be on warfarin? How about going back to warfarin if she should go into AF, but otherwise don't take it. She's been in sinus for several months now.

Thanks for this interesting question. Let me first describe the difference between atrial fibrillation and atrial flutter. Heart rhythm normal starts with the atria (the 2 smaller chambers) contracting, and very soon thereafter the ventricles (the larger chambers) contract. In normal hearts these contractions synchronize to maximize blood flow through the heart and out to the body.

Atrial fibrillation occurs when the atria no longer have coordinated contractions, rather they fibrillate (fibrillate refers to the act of fibrillation - muscular twitching involving individual muscle fibers acting without coordination). Thus, the atria "quiver" but do not send coordinated impulses to the ventricles. The ventricles receive irregular signals to contract. Thus, the rhythm becomes irregularly irregular.

One danger of atrial fibrillation comes from the "quivering" in the atria. Since they do not contract properly, the blood tends to pool, allowing coagulation to occur. (oops another medical term - coagulation means that clots can form). The clots are the problem. They can grow to a large enough size that they cause problems when they "break loose" from the atria. Thus, the risk of stroke in untreated atrial fibrillation.

Atrial flutter is a different rhythm. In this rhythm the atria do have coordinated contractions - usually at a very fast rate (think around 300 times per minute). This atrial rapid rate is usually modified by the electrical connection to the ventricles (what we call the AV node). The AV node handles the electrical impulses from the atria - passing on a signal to the ventricles to contract. A rate of 300 is too fast to pass on to the ventricles. Usually every other or every third signal gets through.

Because atrial flutter usually causes symptoms immediately, most patients receive treatment to restore sinus rhythm. The unusual patient with chronic atrial flutter does have some risk for thrombi and emboli (blood clot terms - thrombi when they form - emboli when they break off and flow elsewhere and cause problems).

When atrial flutter is succesfully treated, anticoagulation is generally not needed. If it became intermittent one might anticoagulate (especially if the patient alternated between atrial flutter and atrial fibrillation).

I hope this complex answer helps.

I just started taking Zetia after a muscle bout with Lipitor. What side effects will I have with Zetia? Hope to hear from you.

Having not yet treated any patients with Zetia, I have to look this one up. The FDA says stomach pain and tiredness can occur. FDA information on Zetia. I hope that helps.

Will the vaccine prevent other hpv like common warts and also when will it be available?

Great question, which I cannot answer! I suspect that the vaccine will prevent some warts - but will probably only work against a small subset of HPV strains (those which most commonly cause cervical cancer). I have no idea on the timetable for this vaccine.

Well, maybe. Services are services. But what about the consumer? I am facing 4 or 5 hours of work to sort out insurance problems caused either by the insurance company or by the doc's office. I've got a dentist who has filed 4 times for the same services (and was paid fully), and an internal medicine practice that just billed the insurance co. for services 8 months ago. Straightening this out will cost me 3 or 4 hours of weekend time. And no reimbursement! :) I have to go through this two or three times a year.

First, thanks for the comment, and I do understand your frustration. The object of your frustration is the insurance companies not the health care professionals. Why should we charge you for filling out forms? Because we are running a business and time is money! The forms that I imply are extra forms. Another comment states it well -

I am all for it. (Speaking as an MD.) Doctors spend huge amounts of time filling out these forms. I'm sure I don't have to convince *you*, but here is a partial list:
- Disability forms
- Jury duty forms
- health clearances for school, work, prospective adoptive parents
- Life insurance forms (death claims)
- Letters to health clubs allowing patients to get out of their memberships
 
It's unbelievable. It adds a significant amount of time to the time spent in the office. I think it's time to start charging.

And that is the point of the rant.

And is use of hormones also a placebo for those of us who have had hysterectomies with oophorectomies, or those twenty-somethings in premature menopause? Since we are lumped in with all other women and all conceivable forms of hormones are now too dangerous to use (and goodness knows there are no side effects or risks in the antidepressants, bone-density enhancers, statins, antihypertensives, false teeth, dried-up-eyeballs, and, let me not forget, copious helpings of KY to "treat" that vag atrophy that we'll be switching to), I can only guess not.

Gee, if hormones are that evil, maybe women should ALL have oophorectomies before menarche. Think of all the problems that would prevent!

Premature menopause and oophorectomies represent a totally different situation than the studies address. One difficulty in medicine is the balance between belief and data. I prefer data. We must criticize studies carefully, but then understand what they tell us. I would prescribe hormonal therapy to patients with oophorectomy or premature menopause until around 50 years.

With specific reference to vaginal atrophy, I understand that vaginal estrogen does help a great deal. Also, continued sexual activity seems to retard atrophy.

...

Thanks for the many excellent comments and questions. I hope some of these answers are helpful. And thanks for reading!!
 

Crude Test Offers Hope for Tracking Mystery Virus. The data are sparse, but investigators claim to have developed an immunofluorsence antibody test.

The test, which has been found to be accurate in a pilot study of only four patients, was derived from blood from patients who were sick long enough for their immune systems to develop antibodies to a previously unknown virus that is suspected of causing the illness.

The organization, a unit of the United Nations, expressed hope that scientists could quickly improve the sensitivity of the test so it could detect the illness, called SARS, for severe acute respiratory syndrome, at earlier stages.

Dr. Klaus Stöhr, the virologist and epidemiologist in charge of the investigation for the health agency, called development of even a crude test a "real ray of sunshine" because of its potential use in slowing transmission of SARS.

"We have something in our hands on which to build a diagnostic test," Dr. Stöhr said in an interview.

Dr. Stöhr and other experts cautioned that independent laboratories must repeat the test to verify the findings. Such work is expected to begin this weekend, and even more work is needed to identify the cause of SARS, Dr. Stöhr said.

Dr. Julie L. Gerberding, the director of the Centers for Disease Control and Prevention in Atlanta, expressed skepticism about the test at a news conference. When you do not have a cause, she said, "It's very unlikely you could have a reliable diagnostic test."

The mystery continue to unfold. Investigators are honing in on a true answer. I want to read more about the possible treatment with ribavirin.