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.

What is knew on SARS today? First, the viral origin is gaining more credence. Second, the antiviral ribavirin seems to have some positive activity. Courtesy of the BBC - Drug helps mystery bug patients

Scientists believe they have identified the cause of the illness as a virus from the paramyxoviridae family - which includes the viruses that cause measles and mumps.

The evidence that the disease is viral has been boosted by the news that treatment using the anti-viral drug ribavirin has shown some benefits among the most seriously-affected patients.

Having a drug to try is encouraging news. For those who want more information on ribavirin - Ribavirin (Systemic) . We know this drug in adult medicine primarily for its use against hepatitis C. However,

Ribavirin (rye-ba-VYE-rin) is used to treat severe virus pneumonia in infants and young children. It is given by oral inhalation (breathing in the medicine as a fine mist through the mouth), using a special nebulizer (sprayer) attached to an oxygen hood or tent or face mask.

Very interesting developments! It is important for us to follow this story carefully.

So how are we going to pay for those expensive drugs? One interesting way is to use the therapeutic maximum allowable cost. In this plan, you get the low cost alternative or you pay for the high cost alternative. Benefits Cap May Help Treat Drug Costs.

Eager to tame the rising price of employee health benefits, U.S. companies are taking a closer look at how some European countries manage prescription drug costs.

It's an approach known as ``therapeutic MAC,'' for maximum allowable cost, which caps the amount health insurers pay for specific groups of prescription medications.

...

Potential savings depends on how the benefit is designed, where the cap is set and the rebates and refunds drug companies pass onto the health plan.

Take the cholesterol fighting drugs known as statins.

According to calculations by Jack Holton, and analyst with human resources consultant Towers Perrin, prices on these drugs run from $110 for a 30-day supply of Merck & Co.'s Zocor to as low as $31 for a generic.

A common three-tier drug plan charges employees $10 a month for a generic drug. Copayments for name-brand prescription drugs are $20 or $40, depending on whether the drug is categorized as ``preferred'' or ``non-preferred.''

Zocor, which is a ``preferred'' name-brand drug under the formularies for several health insurers, would cost employees $20 a month, leaving the employer to pay the remaining $90. The copayment for a prescription of Pfizer Inc.'s Lipitor, which costs less than Zocor, is $40 a month because the drug is ``non-preferred.''

Under a benefit plan designed by Holton that uses reference pricing and a 20 percent copayment a $31 generic drug would cost an employee $6 for a 30-day supply, Zocor would cost $57, Bristol-Myers Squibb Co.'s Pravachol would cost $27 and Lipitor $15. The employer's portion of all three drugs is $53.

``It puts in direct alignment the cost of the drug and what people pay,'' Holton said. ``Under the current system, just because something is a preferred name-brand drug does not mean it is the lower costing drug.''

This approach actually makes a lot of sense. It would encourage the pharmaceutical industry to compete on price rather on marketting. This would encourage real capitalism.

For a very interesting insite into the pharmaceutical industry - please read an outstanding comment that I received - The Pharmaceutical Industry Fights Back. The comment author, a former pharmaceutical rep, outlines the real world of pharmaceutical marketing. I greatly appreciate her candor.

Scientists should avoid political agendas. I fear that the principal investigators of the ALLHAT study wanted to advance an agenda with their initial press conferences about the results. Apparently I am not alone. Two ALLHAT Investigators Say Results Misinterpreted and Misused

"Diuretics probably are not the preferred antihypertensive therapy in most North American patients," said Dr. Houston, who, along with Dr. Weber, was one of the many investigators in the NHLBI-sponsored Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. The study compared cardiovascular outcomes among 42,418 patients age 55 and older who had at least one heart disease risk factor.
In an undated statement given to reporters Wednesday, NHLBI director Claude Lenfant acknowledged the on-going controversy. The NHLBI "recognizes that ALLHAT's data can be variously interpreted, and the Institute is looking into other conclusions," he said in the statement, adding that the NHLBI-sponsored hypertension treatment guidelines are in the midst of revision.

Drs. Houston and Weber charge that the ALLHAT study results will be used as the rationale in those guidelines for putting an even greater emphasis on using diuretics as a first-line treatment. The guidelines, formulated by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, will be issued at the American Society for Hypertension meeting in May.

Even though a majority of physicians don't follow the JNC guidelines, the group's backing will add to the perception that diuretics are best, said Dr. Houston.

...

Dr. Houston said that ALLHAT's design was flawed, leading to muddied results, particularly for African Americans. Overall, he said, when the study is adjusted to reflect the underdosing in people randomized to the ACE inhibitor lisinopril, all the drugs studied show an equal reduction in heart attack, with perhaps a slight edge for lisinopril.

He argued against emphasizing diuretics as a first-line therapy, claiming that the drugs might be nephrotoxic, and cause more diabetes. Plus, said Dr. Houston, there's a huge body of evidence that contradicts the ALLHAT findings.

Dr. Weber agreed that chlorthalidone was no more effective in reducing myocardial infarction, and he said it had not done a better job at reducing mortality.

"Diuretics are a necessary treatment in many patients," said Dr. Weber, who told Reuters Health that 70% of his patients are on a diuretic, but as part of a multidrug regimen. "They should not be the foundation for antihypertensive therapy," he said.

It is nice to see that reason is starting to prevail here.

More clues emerge on SARS. A hotel in Hong Kong may hold even more clues. Deadly virus clues emerge.

The Hong Kong Health Department reported Wednesday that seven of the people with SARS stayed at the same hotel in the Kowloon district between February 12 and March 2.

Chinese health officials are trying to identify links among the seven. Two of them were known to have had close contact.

No new cases have been detected there since then and no hotel employees were infected, which is consistent with health officials' belief the virus is transmitted by close contact.
The hotel has closed off the floor the infected people used and it is being disinfected as a precaution, Hong Kong health officials said.

The common hotel provides an interesting clue. We can expect epidemiologists to mine this aggressively today.

Doctors at the World Health Organization and the CDC said Tuesday preliminary results of tests indicated the same link between SARS and the virus class known as paramyxovirus.

Scientists stress that even if SARS patients have been infected with this class of virus, that does not necessarily mean it is the virus causing the atypical pneumonia. The patients also could be infected with another organism that might be the culprit.

This raises in interesting speculation. Patients with influenza often develop bacterial pneumonia. The experts are considering the possibility of an enabling viral infection - i.e., a viral infection which allows a more serious (as yet unknown) infection.

Paramyxoviruses cause several respiratory diseases in humans and animals.

One of the viruses, parainfluenza, infects almost all children before they reach their 5th birthday, causing illnesses ranging from colds to pneumonia, according to the National Institutes of Health.

This could be the answer. I stress the word - COULD.

More as new reports have information to share.

This is my second posting on Off-Wing Opinion. I will continue to periodically discuss sports related medical issues in dual postings - there and here

We shudder when we hear or read about an athlete dying young. Let me share three names - Hank Gaithers, Flo Hyman, and Pistol Pete Maravich. All died young. All died on the court. Why does this happen? Could we screen for these deaths?

They died from different causes, all heart related, but very different etiologies. None had a classic heart attack. Prevention of Sudden Death During Exercise.

Hank Gaithers had hypertrophic cardiomyopathy, which often causes abnormal heart rhythms. He technically died from an arrhythmia, which was clearly secondary to the hypertrophic cardiomyopthy.

Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiac death in young American athletes. In HCM, there is abnormal thickening of the left ventricle (heart main pumping chamber), making it harder for the heart to pump blood into the aorta. Hypertrophic cardiomyopathy can be fatal when it causes malignant heart rhythms.

We do not know what causes this problem, and as I will discuss later, we often do not make this diagnosis prior to death.

Flo Hyman died from Marfan's syndrome - which lead to a ruptured aortic aneurysm. Marfan Syndrome: A Silent Killer Again quoting from the Prevention of Sudden Death article

A connective tissue disorder that causes weakening of he blood vessels seen in people who are all tall- nicknamed Abe Lincoln disease. I the walls of the aorta are damaged by Marfan?s syndrome, they can tear during strenuous exercise as happened to Flo Hyman.

I remember a University of Maryland basketball player named Chris Patton who died of Marfan's. We could possibly screen tall athletes for Marfan's - and some have been found and managed - but they must avoid strenuous exercise.

The most bizarre cause happened to Pete Maravich. He had a congenital abnormality of his coronary arteries. Most are born with a right coronary artery, and a left coronary artery - which subdivides into two major branches. Thus, we generally have 3 coronary arteries. Maravich had a rare congenital abnormality - a single coronary artery. This represents one of a variety of unusual developmental abnormalities.

The blood vessels that run into the heart muscle do so in an irregular manner. In some cases, the patient has a single blood vessel instead of two, as was the care with Pete Maravich.

So we now have discussed how three famous athletes died suddenly. What new message do we have?

An article in the March 19, 2003 Journal of the American College of Cardiology discusses sudden death in athletes - Hypertrophic Cardiomyopathy Often Undiagnosed in African Americans

The findings are based on a study of 584 male athletes who had died suddenly and were entered in a national registry. The comparison group consisted of 1986 patients who were clinically diagnosed with HCM at one of four major medical centers.

Of the athlete deaths, 286 were due to cardiovascular diseases, lead author Dr. Barry J. Maron, from the Minneapolis Heart Institute, and colleagues note. Fifty-five percent of these deaths involved white athletes and 42% involved black athletes.
The most common cause of cardiovascular death was HCM, responsible for 36% of the cases, the authors note. The next most common etiology was anomalous coronary artery of wrong sinus origin, accounting for 13% of cases.

Although most cardiovascular deaths involved whites, 55% of deaths due to HCM involved black athletes. "In contrast, of 1986 clinically identified HCM patients, only 158 (8%) were African American (p < 0.001)," the researchers report.
Disproportionate access to healthcare could explain the racial disparities identified, the authors note. "Alternatively, it is possible that HCM in African Americans may represent a more virulent form of the disease, possibly due to a malignant genetic substrate when associated with exercise, and, thereby, predisposing to sudden death on the athletic field in susceptible individuals," they add.

"Regardless of these considerations, it is our aspiration that the present report will trigger greater awareness that HCM not uncommonly occurs and is an important cause of sudden death in young African American males," the researchers write. This should create "a higher index of suspicion and ultimately more frequent clinical HCM diagnoses in such athletes."

This article raises the question of how we should screen prospective athletes. The American Heart Association has a position paper on this topic - Cardiovascular Preparticipation Screening of Competitive Athletes . These recommendations are complex, and probably incompletely followed. Each time an athlete dies on the field or court, we must ask why. One could argue that we should perform a much more complete and complex evaluation to save some of these lives. These are difficult medical decisions; these are difficult societal decisions. Screening for rare conditions costs significant dollars. How much are we willing to spend?

Investigators are making progress. More clues have appeared. Sounds like a mystery story and it is a mystery story. What is causing those pnuemonia deaths around the world? Researchers Find Clues That a Virus Is Causing the Mysterious Illness, but Seek Proof.

This is true mystery work. The detectives are epidemiologists, and microbiologists. What have they learned thus far?

Using electron microscopes, two laboratories in Germany and a third in Hong Kong reported finding particles that seem to belong to a large family of viruses, paramyxoviridae, that includes the viruses that cause croup, respiratory disease, measles, mumps and other ailments.

Still, Dr. Klaus Stöhr, a virologist and epidemiologist who is leading the health organization's scientific team investigating the illness, said that none of those viruses had caused a disease like the one under investigation, which doctors are calling severe acute respiratory syndrome, or SARS. Instead, the findings suggest that the virus might be a hitherto unknown member of the paramyxoviridae family

The scary part of this story comes from the lack of treatments for this viral family. But the researchers caution us that the clues are just clues - not a definitive answer. We are in the midst of a mystery story. We await the denouement.

While we wait, let me point you to a fascinating exposition from Steven Den Beste's site speculating on the origins of such viral infections - why do they always come from China? Pandemic? He makes some interesting points - and he writes well. I remain a bit skeptical, but then I live my medical life being skeptical.

The NY Times weighs in on HRT today - Delusions of Feeling Better. They have read the studies and conclude that woman should never take prolonged hormone replacement therapy.

Now comes the bad news that they have most likely been mistaken. New study results just released by The New England Journal of Medicine show that the pills had no significant effect on the quality of life of a large group of postmenopausal women. Women who took the pills did not feel any healthier or more vital than comparable women who took placebos, nor did they have more sexual pleasure. Compared with those in the placebo group, their minds were no clearer, their memories no better, and their mental health no different. The pills did have marginal effects on sleep disturbances, physical functioning and pain, but these were not clinically significant and disappeared after a year or so of use.

Now that the NY Times has spoken, need we say more. Well, things are rarely as simple as they appear. MedPundit weighs in and believes the study is flawed - Contrariness. She states

To me, that says that for some women, estrogen therapy works, since that's why we prescribe it, to treat menopausal symptoms, not to cure every ailment and dissatisfaction in life. There are so many other factors that can affect one?s overall well-being besides menopause that those other parameters are worthless. Estrogen isn?t a panacea, despite what advertisements may have once claimed. And it was never prescribed that way by the majority of doctors.

Another flaw in the study is that they didn?t look at the incidence of vaginal atrophy in users and nonusers, which can be quite painful. They looked, instead, at sexual satisfication, which isn?t at all the same thing. A woman can have no sex life at all and call herself satisfied if she?s come to terms with it. A better question would have been, ?Is sex painful??

The shame of this is that the study will be touted by the media as proof that estrogen therapy is completely unwarranted when it?s considered alongside last year?s over-hyped findings (by the same group of researchers, by the way) on estrogen side-effects. And physicians, too busy to scrutinize the study, will by into the hype and discourage more women from using the drug, and perhaps refuse to prescribe it. And all the while, they'll say they're practicing "evidence-based medicine." Yet, in the end, this study is akin to asking the same questions of aspirin users and deciding that aspirin isn?t an effective drug because it doesn?t improve overall well-being. All in all, a very shoddy piece of work.

I disagree with MedPundit here. This is not shoddy work. I dislike her obvious disdain and sarcasm about evidence-based medicine.

So what do I make of this. First, I believe that data speak louder than anecdotes, yet most physicians rely on anecdotes more than data. Second, there is no perfect study. We can always criticize a study and want more information. Third, MedPundit seems to ignore other treatments for atrophic vaginitis (one does not need systemic estrogen for successful treatment).

Given the known risks of HRT, and the dubious benefits (other than treatment of symptoms during early menopause), we should probably discourage long term use. We are doing just that in the clinics that I supervise.

This rant is a repeat of a lost rant (I lost a week's worth of rants due to a hosting problem). As I stated the first time I referred to this article, I am stretching a bit.

Malcolm Gladwell writes outstanding science articles for the New Yorker. He authored the best selling - "The Tipping Point". One can only envy his ability to summarize a complex subject in a manner that makes it very understandable. He wrote in last week's New Yorker about prediction. While most of the article refers to the second guessing about why the intelligence community did not "connect the dots" prior to September 11, 2001, he does refer to medical diagnosis also. He argues that the retrospectoscope analysis often has great danger, and false promise. Connect the Dots.

None of these postmortems, however, answer the question raised by the Yom Kippur War: Was this pattern obvious before the attack? This question--whether we revise our judgment of events after the fact--is something that psychologists have paid a great deal of attention to. For example, on the eve of Richard Nixon's historic visit to China, the psychologist Baruch Fischhoff asked a group of people to estimate the probability of a series of possible outcomes of the trip. What were the chances that the trip would lead to permanent diplomatic relations between China and the United States? That Nixon would meet with the leader of China, Mao Tse-tung, at least once? That Nixon would call the trip a success? As it turned out, the trip was a diplomatic triumph, and Fischhoff then went back to the same people and asked them to recall what their estimates of the different outcomes of the visit had been. He found that the subjects now, overwhelmingly, "remembered" being more optimistic than they had actually been. If you originally thought that it was unlikely that Nixon would meet with Mao, afterward, when the press was full of accounts of Nixon's meeting with Mao, you'd "remember" that you had thought the chances of a meeting were pretty good. Fischhoff calls this phenomenon "creeping determinism"--the sense that grows on us, in retrospect, that what has happened was actually inevitable--and the chief effect of creeping determinism, he points out, is that it turns unexpected events into expected events. As he writes, "The occurrence of an event increases its reconstructed probability and makes it less surprising than it would have been had the original probability been remembered."

To read the Shelby report, or the seamless narrative from Nosair to bin Laden in "The Cell," is to be convinced that if the C.I.A. and the F.B.I. had simply been able to connect the dots what happened on September 11th should not have been a surprise at all. Is this a fair criticism or is it just a case of creeping determinism?

So how does this relate to medicine? What justifies inclusion in this 'specialty' blog? Our (physicians) problem comes in diagnosis. We would like to make precise diagnoses, since correct diagnoses allow us to treat or at least provide useful prognostic information. Failure to make correct diagnoses leave patients at a disadvantage. That disadvantage can be severe enough that we are considered to have committed malpractice.

The problem then in all prediction is understanding the problem prospectively, rather than retrospectively. Can we really separate the wheat from the chaff, the signals from the noise? Gladwell puts this prediction problem into proper perspective.

Trial lawyers love the retrospectoscope. Intelligence critics love it also. We must understand whether the critics (or lawyers) are being fair.

No one wants ambiguity. Today, the F.B.I. gives us color-coded warnings and speaks of "increased chatter" among terrorist operatives, and the information is infuriating to us because it is so vague. What does "increased chatter" mean? We want a prediction. We want to believe that the intentions of our enemies are a puzzle that intelligence services can piece together, so that a clear story emerges. But there rarely is a clear story--at least, not until afterward, when some enterprising journalist or investigative committee decides to write one.

The same can apply to many "errors" in medicine. How do we develop reasonable expectations of diagnostic acumen? This article raises more questions than it can possibly answer. I highly recommend it - and almost everything that Gladwell writes!

Physicians are often criticized as being mediocre at business. We are much more concerned about the task than the payment for the task. For years, we have talked on the phone, filled out forms, and copied medical records as a courtesy. Would any good business do the same? Does it really make sense?

Increasingly physicians are saying - pay for my time (or my staff's time). These charges should not cause controversy - although they do. We would expect such fees from a lawyer or accountant - but not a physician. Physicians adding fees for services that once were free: More practices charge for services such as phone consultations and filling out forms, adding a little revenue but risking a backlash. Such fees are included in the retainer medicine concept.

Case Against Hormones Grows . Dang!!! Just when I thought I had a good understanding of when to prescribe hormone replacement therapy, I get slammed again. I love it when we (the medical community) ask the right questions - regardless of the answers.

Pills containing estrogen and progesterone do not improve the quality of life for most women who have gone through menopause, erasing the last reason many women had for taking the once-popular drugs, a major government study reported yesterday.

The federally funded Women's Health Initiative last summer issued the landmark conclusion that the risks of hormone therapy outweighed any protection from osteoporosis and other diseases. In this new study, the initiative produced convincing evidence that for most women the hormones also fail to improve their sense of vitality, memory, mental health, sleep, sexual satisfaction or other measures of well-being.

"We found almost imperceptible differences on all the measures we looked at," said Jennifer Hays of the Baylor College of Medicine in Houston, who coordinated the new research. "For the average woman, it does not have much of an effect."

The only evidence of possible benefit was for younger women who had trouble sleeping because of severe hot flashes and night sweats. Those women -- 10 percent to 20 percent of those using hormones -- seemed to get some relief, but it appeared to be minimal and temporary, lasting only for the first year after menopause, Hays said.

Go figure! Nonetheless, many women will still demand HRT, as they believe the benefits are great. We have a difficult job reconciling scientific data with beliefs. At least this study provides important ammunition in our debate.

I have been pondering writing a book. The title came slowly, but let me know how you like it: You Bet Your Life. The idea is to provide the risks and benefits of behaviors and prevention in words that the average non-medical reader can understand. If I write this book, colon cancer will have a chapter.

Just prior to turning 50, I had a colonoscopy. While I rarely worry about things, I did want to be certain that I did not have colon cancer. I have pestered friends and family to have their colonoscopies. Last month I wrote about this subject Happy 50th - have you scheduled you colonoscopy?

Jane E Brody (writing in today's NY Times) provides a wonderful summary of colon cancer screening. She says this about colonoscopy:

Colonoscopy is the most accurate and most expensive screening exam. In people at average risk, it should be repeated every 10 years starting at age 50. It is the best test for people with special risk factors, who should be tested far more often, sometimes as often as every six months.

This test, performed under sedation, requires a thorough bowel cleansing using an oral solution to assure a clear view of the lining. It examines the entire six feet of colon and rectum using a flexible scope. A device can be threaded through it to remove any suspicious polyps.

It costs $700 to $1,100. I can assure anyone who is hesitant that while the preparation is anything but pleasant, the exam itself is painless. I've yet to feel a thing.

So read her article, or make copies to hand to your patients. Get the test. Best Way to Fight Colon Cancer: Take the Test

Mystery Outbreak May Be a New Flu Strain . Hopefully we will have more information on this infection in the near future.

I drove 10 hours today. Not much energy to blog - but - I cannot pass up a few good stories. A first step toward standardizing supplements

Millions of Americans turn to dietary supplements each day without any guarantees that the herbs, vitamins and minerals they take are uncontaminated, manufactured properly and contain exactly what's on the label.

That could change under proposed Food and Drug Administration rules -- stalled for years -- that would assure purity and consistent dosing with every batch and bottle made by a particular manufacturer. The draft regulations, released earlier this month and expected to be finalized next year, are the first attempt to more tightly regulate the $19-billion supplement industry, which is not currently held to the same standards as the pharmaceutical industry.

Although they're not completely satisfied, consumer activists and doctors have reacted favorably to the move, especially because consumers so often take product quality and reliability for granted.

"We've come out over and over showing problems with products," said Dr. Tod Cooperman, president of ConsumerLab.com, an independent testing company. Up to 40% of herbal products don't contain precisely the active ingredients listed, the company's tests have shown. Some contain less or more of plant chemicals than what's stated on the label; others contain the wrong part of an herb, such as the root instead of the leaf. Cooperman said that in two weeks ConsumerLab.com will release a new review of ginkgo products that uncovered even more problems than a similar analysis of ginkgo biloba three years ago.

Some dietary supplements have been found to contain pesticides and heavy metals such as lead, and, in rare cases, prescription ingredients. Regulators last year pulled from the market a promising treatment for prostate cancer called PC SPES after finding it contained a prescription blood thinner and an anti-anxiety drug.

While I understand that foreign policy will grab everyones attention for awhile, this remains an extremely important issue.

First, let me apologize that this will be an abbreviated Q&A. I have many good questions sitting on my home computer. But, I am visiting friends in Richmond, Virginia, so I only have access to questions since Thursday. I will address a few questions today - and hopefully start catching up later this week.

hi, my husband cannot take statins of any kind due to the severe muscle symptoms, and the elevation of liver enzymes during a course, what are Zetia's side effects if this drug is taken alone. His cholesterol is 9.9. and has the inherited gene.

This is a very fair question. I did not know the answer to this question, but through the genius of Google I can provide a good reference. Zetia Side Effects

For what? These are grown men. They clearly know the risk. Their own friends and colleagues have died from this supplement, and yet they continue to take it. If we were to ban ephedra somehow, they'd just find something else to take, rather than perhaps cutting down the number of pancakes they have at breakfast. I'm all for education, but when your buddy dies from a drug that you yourself are taking, don't you think that'd be education enough?

This comment raises an interesting point. How far should we go to protect consumers? While I understand the reasoning behind her argument, I believe it to be an oversimplification.

We have many potential users of supplements. Athletes will find performance aids, legally or illegally - as Ron Dibble explains - On Steve Bechler's death . While one would think that athletes are "grown men", I doubt that they often act like them - but many would argue grown men may be an oxymoron. Can they really make informed decisions about supplements? I read where a baseball star argued against banning ephedra because "it is legally and OTC".

Even if I grant you that they should be able to take the risk, what about college athletes, or high school athletes, or just anyone trying to lose weight. And what other supplements are putting us at risk. We should all know about ephedra now, but I doubt that we do. The information on bottles is imprecise and uninformative.

So, I will stand by my previous rant. We need to revisit the dietary and supplement act of 1994. We should not allow marketting of dangerous ineffective supplements.

...

Well that is it for the abbreviated Q&A. I owe the readers more answers. I will catch up. I will catch up. I will catch up.

Increasingly, providers are having patients sign agreements for arbitration rather than litigation for malpractice claims. For Patients, Unpleasant Surprises in Arbitration. The author has tried to frame arbritration is unfair to patients. I disagree with her assessment.

Patients who go through arbitration instead of a jury trial, however, may feel as if they have been hurt twice: first by their health care provider, then by the system that is supposed to resolve the problem. They generally have little choice in the way claims are handled. Gary and Sharon Rushford of San Jose, Calif., certainly didn't.

To me the advantage of arbitration is the skill of the arbitrator. Rather than an easily influenced jury (not that all juries are easily influenced), a skilled 'judge' renders a decision.

Selection of arbitrators varies by health care provider and by state. In California, Kaiser arbitrators are chosen by an office overseen by a 13-member board composed of Kaiser stakeholders and members of the public. The parties in a case choose an arbitrator from a large pool assembled by the office, but if they cannot agree on one, the office chooses. The arbitrators are usually retired judges.

Trial lawyers will dislike this, because their antics, manipulation of emotions, and obfuscations will not work as easily. Others complain of the secrecy of the proceedings. They also complain that the arbitrators become beholden to the insurers (after rewarding major settlements, they are no longer selected).

This might form the basis of major malpractice reform. We could have an independent pool of arbitrators with random selection for any case. Having a professional solves a philosophical problem for me. If I were sued, I am entitled to a jury of my peers. If you sue me, you are entitled to a jury of your peers. But we do not necessarily have the same peers. Perhaps the jury system is a major part of the problem. It is not designed to handle such disputes efficiently or rationally. I hope my friend the Bloviator will comment on this one.

We continue to discover new infectious diseases. During my medical lifetime, I can remember the initial descriptions of Legionnaire's, Lyme Disease, erlichiosis, HIV, hepatitis C, etc. We may have another new dangerous infection. Rare Health Alert Is Issued for Mystery Illness

W.H.O. and American officials urged all travelers to be aware of the main signs. In addition to the breathing problems, the illness can cause a dry cough and other flulike symptoms that are thought to develop two to seven days after exposure. They usually start with a sudden onset of high fever and go on to include muscle aches, headache, sore throat and shortness of breath.

Standard lab tests often show low numbers of white blood cells and platelets, which help blood to clot.

The health agency said any passenger or airline crew member who developed such symptoms should immediately seek medical attention and ensure that information about their recent travel was passed on to the health care staff. "Any traveler who develops these symptoms is advised not to undertake further travel until they have recovered," it said.

This description is generally nonspecific. We should follow the investigation of this mysterious infection. Knowledge may help us diagnosis and treat the patients. As usual in these cases, the unknown is quite scary.

Hard Cures

There was a time when every large city hospital had wards for diphtheria and scarlet fever. Doctoring in that pre-antibiotic era was mostly about observation and hope (that the body would win the battle). That passive medicine has given way to aggressive, interventionist care, reflected in our modern intensive care units, newborn nurseries and transplant units. Organ bouquets are harvested here and planted there. Tubes routinely pierce bladder, vein, artery, heart, trachea or ventricle of the brain; each tube serves a vital function, but at the same time breaches one of our physical defenses. Meanwhile, chemotherapy, antibiotics, steroids all compromise the immune system even as they produce other desired effects. Progress has a price, and it's often infection. A century ago, to have E. coli or one of the other bacteria we carry in our bowels cause bloodstream infection was almost unheard of, worthy of a case report in The New England Journal of Medicine. Now bloodstream infection by these bacteria is a major cause of the estimated 100,000 deaths a year from sepsis. It's not so much that these bacteria have changed (they have); instead, this increase reflects the present invasive nature of hospital medicine. But sepsis as a consequence of heroic treatment does not constitute negligence. To prove malpractice, you need more than a bad outcome; there has to be significant deviation from the usual standard of care.

Still, I suspect the great majority of malpractice suits are for bad outcomes. Take a woman who has had no prenatal care and who turns up in a hospital in premature labor. An obstetrician and a neonatologist get involved and deliver the best care, but the baby is born damaged. A personal-injury lawyer (who learns about the case through paid touts in the hospital) encourages the mother to sue. The lawyer knows that bringing the affected child into the courtroom will have a powerful effect on the jury, which will be persuaded to believe this is negligence, not just a bad outcome. Insurance companies settle rather than take a chance with a jury.

The author displays much wisdom here. I like one of his solutions.

Solutions are desperately needed. I think we could start by sending all malpractice suits to regional panels of judges, physicians and consumer advocates to screen and eliminate those with no merit. And organized medicine could rein in the professional-physician expert witness: much like jurors, specialty physicians might serve as expert witnesses when their turn comes up for a nominal fee. Lawyers would not be able to shop around for an expert witness with just the right testimony. (A disclaimer: In 20 years, I have served as an expert witness four times.) And when we are patients, we could insist on being equal partners in our care. We might bring along family and friends when we interact with doctors and see that all our questions are answered and our expectations realistic. Medicine is fantastic in what it can accomplish, but there are real and clear risks.

We need intelligent, thoughtful physicians to work on real answers. This is a reasonable suggestion. The trial lawyers will never make it easy on anyone. They want uninformed juries. They want "hired gun" expert witnesses. We just want the truth.

Medicine's Progress, One Setback at a Time. What a nice article! The author, a teaching internist, discusses the progress of medicine. Like most physicians, she uses patient examples to highlight medical knowledge change.

Unlike many professions, medicine cannot remain static. Our knowledge changes daily - many such changes are discussed in this blog. Theories are rejected and new theories advanced.

What does this mean for patient care? We try to practice medicine using the available knowedge. We try to practice the best medicine as we know it. That practice might change next month. Changing information and therefore changing approaches do not make us bad physicians. Rather it provides us a challenge.

The big challenge in medicine is "keeping up". As you become more general in your scope, you have more to keep up with. Managing all the new information is our most important need.

Those readers who are patients, please read the article and empathisize with medical practice. We cannot always get it right the first time. Sometimes our knowledge base changes. Bear with us, and understand that we do the best we can given the data and theories of the moment.

Some Flout N.F.L.'s Ephedra Ban in Off-Season. They must know the risk. Yet they take it anyway. Most of us cannot understand their motivation.

These players say that ephedra use remains high in N.F.L. circles, especially among linemen, because it is viewed as crucial for weight loss and training. The lineman who gained 50 pounds attributed the increase to "too many banquets and too many desserts" and said his usual breakfast consisted of about 20 buttermilk pancakes and 12 strips of bacon.

The players, who spoke on condition of anonymity, say they do not fear adverse health reactions because they use the weight loss pills responsibly. They say they do not fear the league's off-season drug testing program, either, because ephedra leaves the bloodstream too quickly for random tests to catch. A positive test can lead to a four-game ban.

Conversely, these players say, they would not use anabolic steroids because those can stay in the system for months, and so it is far easier to be caught.

The players interviewed estimated that before the ban two years ago, 50 percent to 70 percent of all N.F.L. players used products with ephedra. That number, they said, has dropped, but they said they believed that somewhere from 20 percent to 40 percent of players still used it.

We clearly need a new Dietary and Supplement Act. But I doubt that we get it.

The President is serious about this. House Acts to Limit Malpractice Awards. The President worked hard to get this passed. Now Dr. Frist will lead the charge in the Senate.

The bill the House passed today does not limit jury awards for medical and funeral expenses. But the caps it imposes on pain and suffering damages apply not only to lawsuits filed against doctors, but also to those filed against insurers, pharmaceutical companies and medical devices ? a provision that Representative Henry A. Waxman, Democrat of California, called "another reward that Republicans are giving to the pharmaceutical industry."

Democrats, adopting the argument of trial lawyers and consumer groups, say the House bill will unfairly prevent innocent victims of medical malpractice from seeking legal recourse. They also argue that there is no evidence the bill will actually reduce liability premiums.

We will definitely follow this story.

When Medicare Can't Guarantee An M.D.

When Army veteran Joe Barry retired to Virginia Beach, the last problem he thought he'd have, was finding a doctor.

He called six different physicians, and, as CBS News Correspondent Wyatt Andrews reports, each one told him they no longer were taking new Medicare patients. One receptionist even told him if he needed help, to call Congress.

Barry says he was told, "You should bring it to the attention of your congressman cause it's something the government has to fix."

Dr. Mitch Miller is one of the physicians who turned Barry down. He says for years Medicare has paid physicians less than what it costs for patient care. For example, Miller receives $44 for a Medicare patient visit that costs him more than $50. He's not kicking any patients out, he says. He just can't afford any more.

We must examine critically why this is becoming a problem. Two problems intersect here: (1) the law of supply and demand and (2) the law of supply and demand!

First, we must consider the supply of physicians. We have decreasing incentives for physicians to entire generalist professions. We do not produce enough physicians in this country! Previous predictions suggested a physician glut, so we controlled physician output. Those predictions were wrong. They also predicted a subspecialty glut and in fact with have manpower deficiencies in many subspecialties (cardiology, gastroenterology, nephrology to mention a few). Generalists are underpaid relative to other physicians. Thus, we have a decreasing number of generalists.

Given that scenario, generalist appointments become harder to obtain. In that situation, the financially savvy generalist must try to maximize his/her income. Medicare patients pay less and take more time. I have ranted repeatedly on the problems of time and pay. As patient care increases in complexity, one must budget adequate time for care. That should occur with increased income. Unfortunately, our payors have price controlled the patient visit. We do not charge by the minute. A longer visit costs us more money, but we receive a fixed amount.

We are nearing a crisis situation with Medicare. I do not think that Congress understands. Do Medicare aged patients understand? When will they start lobbying on this issue?

Until we fix our reimbursement system for generalists, this problem will worsen. I believe it will get fixed - but Congress will probably only respond to a crisis. We are on the verge of that crisis.

This is a reasonable proposal - but only if they guarantee the use of the tax money. Taxing the Binge

In the next few months, legislators across the country, struggling with the worst fiscal crisis to hit states since World War II, will cut the financing of social programs. This will probably mean the demise of many alcohol and drug programs that keep adults out of jails and emergency rooms and children out of foster care and juvenile halls.

There is a solution: raise alcohol taxes to pay for social services. Taxes on alcohol don't even begin to pay the costs of alcohol abuse. Federal estimates put those costs at $185 billion, while federal, state and local alcohol tax revenues total about $18 billion.

Alcohol excise taxes used to be a significant slice of federal budget receipts, representing 11 percent in 1941. Today, they're less than 1 percent and dropping. Because of pressure from the alcohol industry, federal liquor taxes have increased only twice since 1951, and beer and wine taxes only once. Meanwhile, a few states have raised taxes a little while others have cut them. With inflation, the real value of state alcohol taxes has fallen by half since 1966.

Read this case report - it discusses an important yet infrequent diagnosis. I now understand that I suffered this syndrome once - and blamed it on an allergy. Now I know that it was really scombroid - Was it something she ate? Case report and discussion of scombroid poisoning

We commonly care for patients having atrial fibrillation. Recently a debate emerged over the best management of these patients. First, we learned that all such patients should receive anticoagulation to prevent strokes (unless the risks of anticoagulation in that particular patient exceed the benefit). The results of anticoagulation are dramatic, reducting stroke from 6% yearly to 1.5% yearly.

The second debate involves the effort to convert to sinus rhythm and try to maintain that rhythm. Proponents argued that sinus rhythm obviates the propensity towards embolic phenomenon and improves overal cardiac function. Opponents argued that the medication used to maintain sinus rhythm were poorly tolerated, and did not work very well.

A new editorial in the Canadian Medical Journal Rhythm versus rate control for atrial fibrillation management: what recent randomized clinical trials allow us to affirm discusses the results of those studies.

Neither trial found a beneficial effect of rhythm control on mortality rate or other principal outcome variables. On the contrary, a variety of adverse outcomes were noted in the rhythm-control groups. In the AFFIRM trial, adverse events more common in the rhythm-control group included torsades de pointes (0.8% rhythm control, 0.2% rate control), severe bradyarrhythmias (0.6% v. < 0.1%), readmission to hospital (80% v. 73%), pulmonary events (7.3% v. 1.7%) and gastrointestinal events (8.0% v. 2.1%). Five-year mortality was marginally higher in the rhythm-control group (23.8% v. 21.3%, p = 0.08). In the smaller Van Gelder study, mortality from cardiovascular causes was 7.0% in the rate-control group and 6.8% with rhythm control. The composite primary endpoint was nonsignificantly more prevalent in the rhythm-control group (22.6%) than in the rate-control group (17.2%), largely because of higher rates of heart failure (4.5% v. 3.5%), thromboembolic complications (7.9% v. 5.5%), adverse effects of antiarrhythmic drugs (4.5% v. 0.8%) and pacemaker implantations (3.0% v. 1.2%). Of note, adverse outcomes in the rhythm-control group were particularly frequent in female and hypertensive patients. This observation is consistent with the known predilection of women and patients with organic heart disease to proarrhythmic drug reactions;4 however, more information is needed about the specific composition of adverse events by group.

I have interpreted these data to generally use rate control for "chronic atrial fibrillation" (this excludes patients who acutely develop atrial fibrillation while acutely ill). The editorial writer, a cardiologist, holds out hope for more specific therapies.

The results certainly reflect the limitations of current sinus rhythm maintenance therapy. As such, they are an argument for the development of improved approaches to maintaining sinus rhythm. Areas under active investigation include new devices for AF prevention, novel ablation approaches to curing AF, new forms of antiarrhythmic drug therapy that may be more atrium selective and novel approaches to preventing the development of the AF substrate. Hopefully, these efforts will bear fruit and make sinus rhythm maintenance a more achievable and favourable goal in the future.

Take home message - for now, most atrial fibrillation patients deserve good rate control and warfarin.

An article in today's Wall Street Journal (subscription fee required on the web also), discusses the price of generic lovastatin. For those who do not remember, lovastatin was our first statin (trade name Mevacor). While newer statins have better cholesterol lowering, lovastatin does work. Andrx is a generic drug company which markets generic lovastatin under the name Altocor. They will make a discount card available for anyone paying cash (i.e., without drug insurance benefit). They plan to market this card to the Medicare population. With the card the cost per pill will decrease to approximately $1.50. Comparable trade name products cost approximately $3.00 per pill. To place this into perspective, generic lovastatin will cost less than $500 per year as opposed to greater than $1000 per year.

Lovastatin works. While it does not have as dramatic cholesterol lowering, many patients will have excellent results with lovastatin. This is a reasonable option for many patients.

JAMA calls for rules on supplements: Journal editors say dietary aids should be regulated by FDA

EPHEDRA LIKELY would never have been approved had it undergone such review, JAMA Editor Dr. Catherine DeAngelis said Monday. She called for legislation to require FDA regulation of supplements claiming to have a biological function ? including weight loss, increased exercise endurance and enhanced sexual function.

?This has to go under the same kind of rules and regulations of any drug. That means it should not be available until its efficacy has been proven,? DeAngelis said.

Existing law does not require dietary supplement makers to provide evidence of safety or efficacy before marketing the products. Once these products are marketed, the FDA must demonstrate that they are unsafe before it can take regulatory action, according to an editorial to be published in the March 26 edition of JAMA.

She is right. This is a national crisis - and Congress has committeed the political equivalent of malpractice!

The AMA president has written eloquently about medical tragedy and subsequent suits. Please read his remarks. Tragedy and torts: Bankrupting medicine not the answer

Bush to AMA: Tort reform a must

"There are too many frivolous lawsuits against good doctors, and the patients are paying the price," Bush said, generating a standing ovation by his physician audience. The federal government loses $28 billion a year from the direct cost of liability insurance and the indirect cost of defensive medicine, he added. "Something which affects our budget so significantly requires a national solution."

Bush and Republican leaders in Congress have advocated for legislation that would cap awards for noneconomic damages at $250,000. A House bill, based on a California law that physicians say has been successful in keeping liability insurance premiums in check, also would limit the proportion of awards that trial lawyers could claim.
Speaking at the meeting, Senate Majority Leader Bill Frist, MD (R, Tenn.), vowed to address the issue this year. Liability reform legislation was passed by the House last year but never made it to the Senate floor.

Dr. Frist called the court system the wrong place to address medical errors. "The way you fix a system's failure is to fix the system," he said, adding that the way to fix the system is to allow physicians to discuss problems without having trial lawyers use it against them.

Rep. James Greenwood (R, Pa.), who has spearheaded liability reform in the House, said he hoped to send his bill, the HEALTH Act, to the Senate by mid-March. He said opponents would try to slow the passage of the bill, but that arguments for tort reform are stronger than ever.

The article includes a link to the text of Bush's speech to the AMA.

I love ranting against Nexium. My housestaff know this is a pet peave. I am not alone!!! Medicare Head Tells Doctors Not to Prescribe Nexium

Thomas Scully, who heads the federal Centers for Medicare and Medicaid Services tore into the company over the purple pill, suggesting to doctors at an American Medical Association conference that the company was using the drug to rip off consumers and the government.

"You should be embarrassed if you prescribe Nexium, because you're screwing your patients and you're screwing the taxpayers," Scully said.

AstraZeneca gained Food and Drug Administration approval for Nexium (esomeprazole) in February, 2001. The new drug was widely seen as an important new revenue stream after a similar AstraZeneca ulcer drug, Prilosec, lost its patent exclusivity.

Scully, who was integral in formulating the Bush Administration's plan to finance a prescription drug benefit for Medicare beneficiaries, accused the company of "coming up with games" that keep patients paying for new, high-priced drugs.

Bravo!! Bravo!!!

Due to a problem with my server - I have lost all of last week's files. AAAAAAAAARRRRRRRRRGGGGGGGGGGGGHHHHHHHHHHHHHH!

I will repost some of the better links.

Sometimes a reader says things much more elegantly than I do. The following is so good, that I could not relegate it just to a comment section.

Broken is right. These days, no practice I know of takes the issues of reimbursement lightly. I tell my patients--those interested enough to ask--that the days of doctor shopping, cushioned by ready acceptance of Medicare reimbursement, are over. Leave one doctor, and you might find it difficult to get another. And there isn't a supply-side answer, unless we as a nation are willing to accept lower-quality care.

The elder generation of doctors that is within ten years of retirement (not me) is the lowest-cost cadre of medical doctors we will ever see. Recent medical graduates have paid recent tuition rates, have recent and heavy debts, are buying homes at today's prices, have to establish and maintain practices at today's costs and if they are lucky, will have to provide for their own retirements at today's interest rates. Many are truly squeezed, both personally and as businessmen. They are not going to be able to allow for uncompensated care in their practices with costs offset by better-paying, insured patients. That was how things worked in the past, before Medicare became a money-loser. That latter group is gone today, covered now by private managed care plans that are as aggressive as any payer around at getting the lowest rates.

It is a fool's dream to think that we as a country can simply vote our way to cheap care and expect to consume as we do today. That just cannot be done. Pointing to the models of government-paid insurance in countries like Canada, Britain, Germany and Australia as if we can simply emulate them and enjoy their successes ignores other very real differences between our country and theirs. We would have to subsidize education much more than we presently do, accept sharp limits to availability of advanced technology we now take for granted, endure longer waits for elective treatment, and most improbably, embrace real and substantial limits to our present suit-happy and expensive litigation culture. Even if we could do these things, it is worth noting that these other countries are struggling to meet the healthcare demands of their citizens.

Grandiose proposals for nationwide government buyouts are not helpful. We need affordable and practical alternatives that have yet to be implemented: better MSA alternatives, opportunities to buy insurance that covers catastrophic and other selective needs at lower prices while leaving more routine services to the patient, and broader opportunities to buy insurance through non-employer groups--churches, professional or social organizations, community organizations and co-ops.

Amen!!

After travelling all day (LA to Birmingham), I finally sit down to a large number of excellent questions and comments. I may have to do a second Q&A later this week. Here are some highlights.

While this is an easy proposal to attempt to marginalize as impractical or unfavorable (or socialist), fortunately, this is not the only universal coverage proposal being discussed right now. Howard Dean and Dick Gephardt both offer universal coverage planks in their presidential platforms. To pull a quote from a Los Angeles Times article appearing today, "To me, what's exciting is that the universal coverage debate is back on the national agenda. That in itself is huge."

I respectfully disagree. I really do not think that universal coverage is really back on the national agenda. Yes, our health care system needs a boost, but this debate will not provide a constructive contribution (in my opinion).

Perhaps this type of thing must be allowed, but if the case is not proven to the satisfaction of both judge and jury some penalty should be exacted.

Alas, someone will eventually "win" a case on an emotional basis. If not against McD or other fast-food outlet, then against their suppliers or the ranchers and farmers.

The reader makes a powerful suggestion. What if these suits carried a penalty for losing? A losing suit does create costs to society and to the entity sued. Should there be a penalty for losing suits? Perhaps our friend the Bloviator can rant back on that one.

I appreciate your opportunistic jabs at the pharmaceutical industry--they are big business and thus an easy target. Historically speaking, any industry (US Steel, Microsoft, Standard Oil, etc. etc.) which turns a profit at greater rates than other businesses is made to feel that it is doing something wrong, either by the media, the government, or consumers that support it. It would prove to your readers that you truly are against the extravagances of the industry if you printed those stocks in your own 401K minus the dollar amounts) --I personally would be interested to see if pharma stock is absent or for that matter, any health care stock (particularly managed care stock). If you are like most doctors, most all of you benefit via retirement plans, annuities, ROTH's, etc from the profitabilty of an industry that you love to hang in effigy each and everyday. Most of you take great pride in claiming that you don't support the gifts, company incentives, and marketing ploys; however the purchase of stock in these companies makes your rage against them comical and nothing short of hypocritical. I have yet to meet a doctor who doesn't know what is going on with Pfizer, Merck or J&J stock. Why is that?

This is a fair critique. In the interest of full disclosure, I have no idea what stocks are in my 403(b) (working for a medical school I have a 403(b) rather than a 401(k)). My money goes into TIAA-CREF as mutual funds and bond funds. I do not know what stocks they buy. I have never bought a pharmaceutical stock, and believe that to do so would be personally unethical.

I was on Prilosec; harmacy gave me the generic - yep- Omeprazole! I had stomach aches for a week, and then had an "episode" with acid-the pain was so gut-wrenching, I was doubled over and in tears. To top it off, I gave the pills to my husband (who is on Prilosec too), and after one pill, he had a stomach ache three hours later! Who listens to these stories? How do we know the "right" people are hearing this AND can do something about it? I also want my money back!

As I have previously said, we do need a study of this issue. Knowing the chemical and the FDA rating, I remain skeptical. However, I continue to get many comments on this issue. I will remain vigilant for any news concerning generic omeprazole (brand name Prilosec).

Boxing is only dangerous when not played by professionals

Wrong! Boxing has as a goal creating brain damage (for that is what a knockout is). Amateur boxing is much safer than professional boxing. Nontheless, both should be banned (if I were the king of sports).

Did it ever occur to anyone that maybe the insurance companies should have a cap on their costs? Why should a patient who loses an arm, a leg, or worse have a cap put on the damages that they can collect? Oh, yes, I know, if we penalize the insurance industry it will jepordize our free enterprise system. Oh, heavens!! Far better to limint the awards those "little" people might collect for an incompetant doctor.

I do understand the desire to penalize the "incompetent doctor". Several problems exist in this response. The first is the assumption one makes of incompetence. Can a jury really judge medical competence? Sometimes yes, but not always. The next problem relates to the impact of large judgements. As a society we must balance the individual good with the societal good. Large malpractice awards penalize the innocent physicians and therefore their patients. The money must come from somewhere, and it is not coming from the physicians, even if he/she did commit malpractice.

The large damage awards and resulting high insurance costs may partially repay the public for the huge amount of time the doctors force us to waste. The money is just not distributed correctly.

Go into any doctor's waiting room and you find numbers of patients waiting, wasting time. A 2:00 o'clock appointment usually keeps you sitting for an hour or two in the waiting room, then half an hour or so in a small, sterile treatment room, finally about ten minutes with his eminence. This costs you a half days work. No wonder juries go against doctors. The jury members have been mistreated in this way too many times.

This comment uses gross generalizations and comes to illogical conclusions. First, most juries find in favor of the physician. Second, the reader is partially right - ideally we would rather not keep you waiting. Sometimes the exigencies of practice do cause these delays. Most physicians would like to see you on schedule, but we must "squeeze in" other sick patients, or have patients who need more time than we scheduled. I do understand you angst and hope you can find a physician more suited to your schedule.

...

More at a later date!

U.S. to Allow Wine Labels That List Health Claims Very interesting decision made here.

The directional label proposed by the Wine Institute would direct consumers to government dietary guidelines that state, in part: "Drinking in moderation may lower risk for coronary heart disease, mainly among men over age 45 and women over age 55. However, there are other factors that reduce the risk of heart disease, including a healthy diet, physical activity, avoidance of smoking, and maintenance of a healthy weight. Moderate consumption provides little, if any, health benefit for younger people.

"Risk of alcohol abuse increases when drinking starts at an early age. Some studies suggest that older people may become more sensitive to the effects of alcohol as they age."

I'll drink to that!

Government Moves to Curtail the Use of Ephedra. Finally, the FDA is at least putting a warning on ephedra and curtailing advertising - but companies can still sell it.

But contrary to recommendations of the American Medical Association, some members of Congress, some scientists and consumer groups, which say there is abundant evidence linking ephedra to many injuries and deaths, the government stopped short of proposing an outright ban.

Tommy G. Thompson, the secretary of health and human services, said at a news conference that he was considering a ban, as well as measures to restrict the use or limit the potency of ephedra pills and capsules. But, he said, he wants to collect more evidence to meet the law's tough standards for a ban, which require at the very least an unreasonable risk that a supplement will inflict injury.

"Throughout America," Mr. Thompson said, "there continue to be tragic incidents that link dietary supplements containing ephedra to serious health problems in consumers who use these products. I would not take ephedra. I would not give it to my family. I don't know why anyone would take these products. Why take the risk?"

I personally would like to see ephedra banned. So would many experts. I expect that it will be banned in the near future.