AHA Raises Alert on Cardiovascular Disease Risk in Kidney Disease Patients

atients with chronic kidney disease represent the population at greatest risk for cardiovascular morbidity and mortality, the American Heart Association (AHA) warns in a new Scientific Statement.

The Statement is published in the October 28 issue of Circulation.

The authors, led by Dr. Mark J. Sarnak of Tufts-New England Medical Center in Boston, Massachusetts, report that the approximate prevalence of clinical ischemic heart disease is 8%-13% in the general population, compared to 40% in patients on hemodialysis or peritoneal dialysis.

The prevalence of left ventricular hypertrophy is approximately 20% in the general population, versus 75% in patients on dialysis.

For those who want to read the statement - Kidney Disease as a Risk Factor for Development of Cardiovascular Disease

Earlier this morning (2 posts down) I blogged about physicians who complain about substandard care. I have read the newspaper stories now and find them chilling.

These articles point out the conflict between hospital administration and physicians. Most physicians worry first, second and third about the quality of care that their patients receive. They know that good quality care requires excellent nursing care, accurate laboratory and radiological facilities, and much more. We can develop a care plan; we can write orders; but we do not provide all the care.

When we complain about substandard care, we are (in my opinion) directly challenging the hospital administration. We are saying that they have not provided an environment and sufficient personnel to provide high quality care.

Some administrators have the patients as their highest priority. Unfortunately, I believe that some administrators are more concerned about the "bottom line" and make staffing decisions based more on finances than quality. When physicians complain, those administrators will sometimes become defensive. This defensiveness can turn into aggressive measures against the physician whistle blower.

I understand why we need hospital administrators. I understand the importance of the bottom line. What I do not understand is a lack of interest in prioritizing quality patient care. What I do not understand is an attitude that physicians who complain about documented nursing errors are trouble makers.

If you have the time, read the stories. From my perspective, they make Stephen King look lame.

Readers will remember that I favor legalizing drugs. I believe that the costs of the "war on drugs" greatly exceed any possible benefits. This decidely libertarian approach bothers many.

One issue which I have not considered (but which bolsters my argument) appears in this op-ed piece - High politics

Eradication of illicit crops destabilizes local governments in the Third World by delegitimizing them in the eyes of the local population that is frequently dependent on the growth of drugs for meeting basic needs.

In conditions of severe poverty, poppy, coca and marijuana represent not only the most profitable source of livelihood, but frequently the only source of livelihood: 1) they are more sturdy plants than many of the legal crops ? try growing tomatoes in winter in Afghanistan; 2) the revenues from them are much less subject to international price fluctuations than legal commodities ? the plummeting of international coffee prices is pushing many peasants in Colombia to grow drugs despite President Uribe's eradication efforts; and 3) producing them is associated with smaller transaction and overhead costs for the farmers than producing legal crops.

By destroying the drug fields, governments alienate large segments of the population by depriving them of means of survival. Local warlords and guerrillas exploit this alienation by serving as protectors of the drug economy from local governments and the United States and against unscrupulous narcotraffickers. Afghan warlords, often connected to al Qaeda, the FARC and the paramilitaries in Colombia, are thus establishing themselves as powerful rivals of the central governments.

Crop eradication is counterproductive to the U.S. war on terrorism in yet another way. Alienated, the local populace stops providing crucial intelligence on guerrillas, especially those who protect their drug fields.

Points well made!!

Not much time this morning (have to go workout soon), but I plan to read this entire series later today and then comment. Thanks to a reader for pointing me to this link - The Cost of Courage: How the tables turn on doctors

America's physicians, sworn to protect their patients from harm, increasingly face a surprising obstacle -- their own hospitals.

In medical centers as small as Centre Community Hospital in State College and as prestigious as Yale and Cornell, doctors who step forward to warn of unsafe conditions or a colleague's poor work say they have been targeted by hospital administrators or boards.

Instead of receiving praise or even support for trying to improve care, they're disciplined or dismissed for being "disruptive" or for violating patient confidentiality. Frequently, the hospital turns the tables on the whistleblowers and accuses them of poor care. They also threaten internal investigations that could result in listing the complaining doctors in the National Practitioner Data Bank, which can make finding a similar position at another hospital all but impossible.

Not even whistleblower laws, designed to give legal protection to those trying to report wrongdoing, safeguard the doctors in many cases. And all too often, state and federal agencies and national accrediting groups do little to protect these physicians or make sure patient care problems are corrected.

This link starts a week long series. It looks most interesting.

I guess I always knew this, but I love having the reference - Merry Melodies

If you really want to get out of a foul mood, try listening to a little music.

A new study out of Penn State finds that music really can sooth the savage breast, up to a point, and it really doesn't matter what kind of music you listen to. As long as you like it.

"If you like music and choose to listen to it, it's probably going to make you feel better regardless of what type it is," says associate professor of psychology Valerie N. Stratton.

Stratton and associate music professor Annette H. Zalanowski, of Penn State's Altoona campus, teamed up to take music research out of the laboratory and put it in the real world in which we live. They wanted to see when people listen to music, what types of music they prefer, and what types of moods that music induces.

It turns out that most of us listen to it a lot, but usually when we're doing something else.

"We've been looking at music and behavior for quite a few years, and it finally struck us that most of the things we were doing, and most of the things that other people were doing, were within lab settings," says Stratton. "There was really very little out there that looked at how people listened to music in their daily lives."

And their findings:

The results of the study suggest that music is terrific when it comes to reinforcing, or elevating our positive moods, and can chase away some of our negative feelings, with one peculiar finding.

Among the non-music majors, sad, hateful and aggressive moods eased up a bit. But that didn't work for the music majors. For them, those feelings remained either unchanged, or rose slightly.

As a non-music major, I do find that music helps me relax and work. Perhaps it has a major positive effect on my mood. Regardless, I do enjoy listening to music - and believe it rewarding for its own sake.

Medpundit clued me in to Derek Lowe's excellent analysis - Harsh Words

Our athletic ability does deteriorate with age. At 54, I cannot do the same things I could do at 35. This econometrician has developed models to show the phenomenon. For Aging Runners, a Formula Makes Time Stand Still

Dr. Fair is a professor of economics at Yale best known for devising a mostly accurate formula to predict winners of presidential elections. He is also the finisher of 17 marathons and counting, and he has turned his social scientist's eye to a question that many a serious runner has considered: how can you keep racing against yourself long after you can no longer catch yourself?

His answer comes in the form of the most enjoyable research paper he has written, he said, and a chapter in his recent book, "Predicting Presidential Elections and Other Things" (Stanford University Press, 2002). Studying world records for runners all the way up to 92 years old, Dr. Fair has developed tables that try to track the body's physical deterioration and set an ever-moving target.

If a 50-year-old finishes the race on Sunday in four hours, 10 years after having run it in 3 hours 45 minutes, for instance, she can know that she is aging no more quickly than the world's fleetest runners.

"I'm right now at the age where things are getting worse in a bigger way," said Dr. Fair, 61, using colloquial language to describe the increase in second derivatives on his chart. "But there's always something to shoot for. It keeps you young, psychologically, even when you're not up there in the front anymore."

Having been published in The Review of Economics and Statistics, Dr. Fair's work has an academic credibility rare in matters of sport. But his tables are also part of a growing effort to help runners track their times over a lifetime.

I found this article fascinating. A quick web search found this reference to more details on his analysis - Marathon Times with link to his article "How Fast Do Old Men Slow Down," The Review of Economics and Statistics, February 1994, 103-118.

Sometimes you just want to eat fast food. Apparently the choices have increased dramatically. In the Temples of Supersizing, Eating Light Draws Converts

The threat of lawsuits and, some say, Americans' changing tastes, have sent the fast-food industry scurrying to find alternatives to the high-fat staples on its menus. Almost all are offering main dish salads with low-fat dressing. French fry sales are plummeting, while the market for chicken breasts and iceberg lettuce is hot.

The NPD Group, a consumer market research firm in Port Washington, N.Y., says the proportion of lunch orders in which salad was the main course rose to 6 percent this year from 4.5 percent last year. And the percent of lunches that included fries dropped to 22 percent from 25 percent.

"You just never see that happen," said Harry Balzer, vice president of the firm.

Fast-food customers "are gravitating toward products they perceive as healthier and fresher," said Andrew Barish, a securities analyst for Banc of America Securities. "They aren't just talking about being health conscious and weight conscious and then when they go out to eat, indulge."

Recent lawsuits accusing fast-food restaurants of making their customers fat have given the companies further incentive to trim calories.

While I strongly disagree with the lawsuits, perhaps the attention that they attracted have encouraged people to reconsider their diets, and fast food companies to reconsider their offerings. Sometimes a bad process yields good outcomes. Still when I want fast food:

Subway is proud of Jared Fogle, who says he went from 425 pounds to a mere slip of a man at 190 pounds in a little less than a year, eating nothing but sandwiches from Subway. When my only choices are fast-food stops or nothing, if there's a Subway it's where I head. You are in complete control of the contents of those sandwiches. There are seven subs, each with only six grams of fat, and there are two decent choices: sweet onion chicken teriyaki and red wine vinaigrette club.

If you put on enough red onion and black olives, green pepper and a bit of hot chile sauce on top of the lettuce and tomato (be prepared for pink tomatoes) on a six-inch piece of honey oat bread ? hold the sweet pickles and cheese ? and go with the dressing they recommend, it's O.K. The chicken sandwich has a mildly pleasant Asian flavor though the chicken could pass for almost anything and vinaigrette makes the club quite zesty. The chicken sandwich has 380 calories, 5 grams of fat, 1,100 milligrams of sodium and 5 grams of fiber so long as you put it on honey oat bread. The club sandwich has 350 calories, 6 grams of fat, an eye-popping 1,520 milligrams of sodium and 5 grams of fiber.

I personally like the turkey!

The FDA got this one right. Acting Quickly, U.S. Bans Newfound Steroid

Although its safety is untested, it is so closely related to known steroids that the F.D.A. "believes that its use may pose considerable risk to health."

The F.D.A.'s move to ban THG was surprisingly quick, experts said. Dr. Don H. Catlin, head of the Olympic drug testing lab at U.C.L.A., which decoded the drug this summer, called the F.D.A. action "wonderful."

"They understood, they got the message," he said, "and that's really very, very nice."

The chemical, which does not show up on routine urine tests, is at the center of a doping scandal in which dozens of top Olympic and professional athletes, including Barry Bonds, Jason Giambi and Marion Jones, have been subpoenaed by a federal grand jury. The British sprinter Dwain Chambers has admitted taking it.

Not all sports bodies test for steroid use, but many of those that do, including the National Football League and those for track and field, swimming and rugby, have announced that they will re-examine stored urine samples to see if they contain THG. Any athlete whose urine sample tests positive would then be subject to the doping policies of his or her sport, including possible suspension.

I would bet that this scandal will spread. For more on this topic check my previous posts - A new steroid for elite athletes, More details on the new steroid controversy, and More on the designer steroid controversy.

I finally did address the Florida case yesterday. One comment reads:

I can agree that this patient should be DNR, and that if she were on a ventilator, I could understand removing it.

But to withhold food and water, and I know that it is through a gastric tube) seems to me to be beyond the pale.

Dying from dehydration and starvation is certainly not the way to go. A gastric feeding tube is not an extreme measure.

If you're not going to feed and water her why not just give her a large bolus of morphine, that would be quicker and painless. (Not that I advocate that either. To me either way is proactive in bringing on death...and neither is something that I could partake in.)

The reader raises an interesting point. How do we distinguish between active and passive euthanasia? I strongly disagree with the first, and accept the second. I found this commentary from a Rabbi's sermon on the High Holy Days: On euthanasia - for those interested, scroll down to the second sermon. To be the key paragraph in this intelligent sermon reads:

In commenting on this, Moses Isserles makes a distinction between accelerating the death of a gosaiys, which Isserles agrees is forbidden, and removing obstacles that impede death, which he allows.

"Thus it is forbidden to accelerate a person's death. For example, one may not remove the pillow or mattress of a person who has been a gosaiys for a long time and is unable to expire, on the grounds that some claim that the feathers of certain birds can be the cause of this condition"-you can't hasten the death by removing the feather pillow. "Likewise, such a person is not to be moved, and it is forbidden to put the keys to the house under the head of a person in order to cause the person to die. However, if something is present which preventing the soul from leaving-for example, the sound of pounding near the house as is made by a woodcutter . . . and this is preventing the soul from leaving, it may be removed inasmuch as this does not constitute an act in and of itself beyond removal of the impediment. "

So we find ourselves with a complex philosophical point. Are we obliged to supply nutrients to a patient who cannot acquire them? This patient cannot feed herself in any way. Is a discontinuation of nutrition a legitimate and moral passive euthanasia?

I believe that this is a moral and compassionate option. I believe in states "worse than death". I would not wish this poor woman's condition on anyone.

I understand that others would disagree with this opinion. I hope you can understand the philosophical basis of this opinion.

I often link to articles in Medscape. Medscape is a free service. I consider it the best single source for medical stories (article reviews, presentation reviews, news releases). If you are a physician and have not done so, I recommend registering (free), and checking out releases on your specialty daily. Medscape.

I often blog about hospice and palliative care. We have an outstanding program at our VA hospital. Because of the program (and its dynamic leadership) our residents and attendings think palliation more broadly than most physicians. We do place many COPD patients into palliation/hospice. Apparently we are different. Few End-Stage COPD Patients Discuss End-of-Life Plans With Physicians

The five-year mortality rate for patients with severe chronic obstructive pulmonary disease (COPD) is around 50% and it is upwards of 60% if the patient has been admitted to an intensive care unit and required mechanical ventilation in the previous year. Despite this, 83% of patients with advanced COPD have not discussed end-of-life plans with their physicians, New York investigators have found.

A team at Staten Island University Hospital reviewed the pulmonary function tests of all patients admitted to their institution between 2000 and 2002, selecting those with a forced expiratory volume at one second (FEV1) that was 50% less than predicted for study. Excluded were smokers with a history of less than 20 pack-years, patients with cancer or asthma and those younger than 50 years. A total of 83 patients completed the study.

Michel Chalhoub, MD, from Staten Island University Hospital in New York, told attendees of CHEST 2003, the annual meeting of the American College of Chest Physicians, that one quarter (26%) of patients were unaware of their diagnosis and what it meant.

"These patients have worse mortality than patients with stage one lung cancer," Dr. Chalhoub said. "Telling a patient 'you have emphysema' is not good news, it's bad news," he said.

Fully 83% of patients had not discussed their end-of-life wishes with their physician, although 78% expressed a wish to do so. Twelve patients in the study had received mechanical ventilation in the past. Of these, 83% were not asked about their wishes beforehand and 50% said they did not want to repeat the experience.

"We discuss [end-of-life] issues with cancer patients and AIDS patients but not with COPD patients," Dr. Chalhoub told Medscape.

"There is a problem on both sides," moderator Robert McCaffree, MD, from the Veterans Affairs Medical Center in Oklahoma City, Oklahoma, said in an interview with Medscape. "There is a mistrust on the part of many populations for the medical system, and studies show that physicians don't initiate the discussion [of end-of-life decisions] often enough. We may even need to push it a little bit."

Dr. Chalhoub added that "you can't bring it up right away with [new] patients or they won't come back...but most of these patients were seeing their doctor on a regular basis."

Our experience (admittedly anecdotal) suggests that many COPD patients willingly participate in these discussions. We do push hospice, because the patients seem to receive better home care. The patients appreciate the attention. I believe we improve their quality of life. And that is important.

F.D.A. Intensely Reviews Depression Drugs

The Food and Drug Administration issued a public health advisory yesterday that makes clear that the agency has grown increasingly skeptical that there is any link between antidepressant use and the risk of suicide in teenagers and children.

"I think probably that we have backed off a little bit from the advisory issued in June, which recommended against using Paxil," said Dr. Thomas Laughren, a psychiatrist and an F.D.A. official. "I believe our position now is that we just don't know."

The F.D.A. plans to convene a panel on Feb. 2 to examine the relationship between suicide and antidepressant drug therapy. The panel will be asked to decide if the drugs should be prescribed to teenagers and children, if the drugs' warnings sections should be changed, and what studies should be done to determine if there is a link between antidepressant use and suicide in teenagers and children.

I certainly would not want to be a member of that panel. The panel will try to view the evidence dispassionately.

The advisory committee meeting in February will probably be controversial. The F.D.A. convened a similar panel in 1991 to discuss claims that Prozac and similar pills might lead adults to become suicidal. The panel was mobbed by spectators and heard hours of testimony from people who thought they or their loved ones had become violent or suicidal after taking Prozac.

Many do not want to view the data. Anecdotal evidence is really an oxymoron. We need to carefully evaluate this issue. The panel will take its job seriously. I hope we can take their conclusions seriously.

Doctors Tread a Thin Line on Marijuana Advice

Some doctors are relieved that the United States Supreme Court let stand a lower-court decision two weeks ago that barred the federal government from punishing doctors who advised patients that marijuana might ease some symptoms.
But some doctors are also perplexed, and even inhibited, by part of the underlying court decision at the center of the case. That decision essentially affirms the federal government's right to hold physicians accountable if they actually take steps to help patients obtain marijuana.

"This decision says that it's fine and appropriate to talk with patients about medical marijuana, and I can even say, `I think you can benefit from it,' " said Dr. Steve O'Brien, who estimates that a fifth of his H.I.V. patients at the East Bay AIDS Center in Oakland, Calif., use marijuana for medical purposes. "But does that mean I can now sign a form from a medical pot club or write, `I recommend marijuana,' on a prescription pad? I don't know. It's still kind of murky."

I doubt that I would consider marijuana a first line agent for most patients. Clearly, we need well done studies to understand the risks and benefits of marijuana as palliation. However, when dealing with palliation, one want to have all possible tools available. Even if marijuana became a "last resort" drug, why should we not have the means to help patients?

So physicians have won a battle, but we still have a war to win. We need to perform the correct studies to either show significant medical benefit or not. This should not be a political decision. This should not be a moral decision. This should be a medical decision.

Wow! I have tried to avoid this issue. But I do feel controversial today, and, Rangel has nailed this issue - A long slow death in Florida

Like many such issues, the current arguments are rarely based on knowledge. Rather belief and hope reign. Rangel has beautifully discussed the details and implications of this unfortunate case. Please read his post. If you want a contrary view - check out Medpundit (Thursday Oct 23, and Friday Oct 17) - unfortunately her permalinks just never work.

I side with Rangel's commentary. He has researched this issue and removed the hype. I also understand the controversy as I have seen such cases first hand.

You know that I love controversy and debate. When one must marshall arguments, thoughts should clarify. Read this debate over the retainer medicine movement - New practice designs deviate from tradition

The question:

A growing number of physicians are converting their practices to boutique or concierge medicine. The AMA has not found such practices to be inconsistent with a pluralistic means of health care delivery, but it has identified ethical concerns that warrant careful attention. What are the arguments for and against this type of practice?

A sample of the arguments against:

There is no ethical dilemma here. Healing has been a "free enterprise" for eons. The ill are always willing to pay for what might make them well. Those who choose to set up their own retainer or club practices are an extension of our traditions.

I would argue that most should not follow this route because as a profession we have chosen over the last 100 years to move together to define and defend our core skills and values and should remain together for the future. Those who set up clubs are moving out of this powerful and important tradition, one not based on some meaningless notion of professionalism but rather on the insight of our predecessors that we work better individually and together when we collaborate, sustain and enhance our core skills.

The much more important issue here is why the average physician working average hours with the average devotion, talent and knowledge is being seduced by the attraction of "club medicine" to make more money and have less stress. Certainly, those of us who choose to remain in our traditional roles owe it to each other to answer this question.

And arguments in favor:

The most damaging aspect of our current health care financing system is that the needs of government, employers and insurers now hold sway in an arena that was once the sacred ground of patients and doctors. Patients are reminded daily that their care will be determined by their plan, not by them or their physician.

It is in this context that boutique or concierge medicine has emerged. These terms coined by the press are unfortunate, implying fashionable medical care for the lucky wealthy few. But many of these practices are more egalitarian and revolutionary than that. Through myriad variations on the theme, they offer patients a chance to improve and control medical care using their own money. They support patient choice. They create a new marketplace in which doctors once again work directly for patients.

Some of these practices are marketed to the wealthy, and many are designed for the middle class. As the concept matures, less expensive versions will become widely available, since there is an enormous market for high-quality inexpensive care.

Although some of these new practices seem designed to serve the financial needs of physicians, most are constructed in ethically admirable ways, including free or discounted care for patients who cannot afford the additional fees. These designs are very likely to be popular with both patients and physicians.

All of these new practice designs also share the virtues of any well-designed market system. Doctors who wish to succeed must provide the care their patients seek at a price they can afford, or the practice will fail. This promotes efficient pricing, something insurance designs have failed to do.

Physicians who run these practices also know that they must provide care that is satisfying to their patients and palpably better than care provided elsewhere in the community. This means increased availability, more time spent with patients, higher quality staffing, better communication, and fewer excuses. Patients are aware that their physician no longer has a conflict of interest if he or she is not dependent upon funds from a third party, reinforcing the patient-physician relationship and simplifying communication with patients.

Those who mistrust these practice designs assert that they provide care for the rich at the expense of the poor. So far there is little evidence that the current medical care system provides any but the most rudimentary care for the poor, and much less evidence that these new practices will worsen that situation.

I love the debate format. Retainer medicine (I refuse to use the more value laden terms) as a movement will help our society rethink the doctor patient insurance relationships. In many ways this movement represents the best of capitalism. It may help us (generalists) understand better what our worth is in the marketplace. I bet our worth is greater than the HMOs realize!!

You know that I love controversy and debate. When one must marshall arguments, thoughts should clarify. Read this debate over the retainer medicine movement - New practice designs deviate from tradition

The question:

A growing number of physicians are converting their practices to boutique or concierge medicine. The AMA has not found such practices to be inconsistent with a pluralistic means of health care delivery, but it has identified ethical concerns that warrant careful attention. What are the arguments for and against this type of practice?

A sample of the arguments against:

There is no ethical dilemma here. Healing has been a "free enterprise" for eons. The ill are always willing to pay for what might make them well. Those who choose to set up their own retainer or club practices are an extension of our traditions.

I would argue that most should not follow this route because as a profession we have chosen over the last 100 years to move together to define and defend our core skills and values and should remain together for the future. Those who set up clubs are moving out of this powerful and important tradition, one not based on some meaningless notion of professionalism but rather on the insight of our predecessors that we work better individually and together when we collaborate, sustain and enhance our core skills.

The much more important issue here is why the average physician working average hours with the average devotion, talent and knowledge is being seduced by the attraction of "club medicine" to make more money and have less stress. Certainly, those of us who choose to remain in our traditional roles owe it to each other to answer this question.

And arguments in favor:

The most damaging aspect of our current health care financing system is that the needs of government, employers and insurers now hold sway in an arena that was once the sacred ground of patients and doctors. Patients are reminded daily that their care will be determined by their plan, not by them or their physician.

It is in this context that boutique or concierge medicine has emerged. These terms coined by the press are unfortunate, implying fashionable medical care for the lucky wealthy few. But many of these practices are more egalitarian and revolutionary than that. Through myriad variations on the theme, they offer patients a chance to improve and control medical care using their own money. They support patient choice. They create a new marketplace in which doctors once again work directly for patients.

Some of these practices are marketed to the wealthy, and many are designed for the middle class. As the concept matures, less expensive versions will become widely available, since there is an enormous market for high-quality inexpensive care.

Although some of these new practices seem designed to serve the financial needs of physicians, most are constructed in ethically admirable ways, including free or discounted care for patients who cannot afford the additional fees. These designs are very likely to be popular with both patients and physicians.

All of these new practice designs also share the virtues of any well-designed market system. Doctors who wish to succeed must provide the care their patients seek at a price they can afford, or the practice will fail. This promotes efficient pricing, something insurance designs have failed to do.

Physicians who run these practices also know that they must provide care that is satisfying to their patients and palpably better than care provided elsewhere in the community. This means increased availability, more time spent with patients, higher quality staffing, better communication, and fewer excuses. Patients are aware that their physician no longer has a conflict of interest if he or she is not dependent upon funds from a third party, reinforcing the patient-physician relationship and simplifying communication with patients.

Those who mistrust these practice designs assert that they provide care for the rich at the expense of the poor. So far there is little evidence that the current medical care system provides any but the most rudimentary care for the poor, and much less evidence that these new practices will worsen that situation.

I love the debate format. Retainer medicine (I refuse to use the more value laden terms) as a movement will help our society rethink the doctor patient insurance relationships. In many ways this movement represents the best of capitalism. It may help us (generalists) understand better what our worth is in the marketplace. I bet our worth is greater than the HMOs realize!!

I counted on Robert Prather expanding on my economic arguments concerning health care. Read his comments - The Cost Of Health Care

By the way, you should really read Robert Prather everyday. Unfortunately, or perhaps interestingly, he changes his blog's name every few months. He finishes today's post with these words of wisdom:

People already routinely complain of the cost of drugs, yet we are about to enact a prescription drug benefit for Medicare that will further divorce seniors from the cost of their medical care. The decrease in cost for the end consumer will lead to an increase in demand for drugs and an increase in price on the back end. There is still no free lunch to be had. Ever.

Robert Prather has written often about the problem of dissociating health care costs from patients. This NY Times piece explicates the problem beautifully. Do Some Pay Too Little for Health Care?

Consider what would happen if employers paid for their workers' car insurance and if that insurance covered routine maintenance. No doubt, the cars would spend a good deal more time in the shop, and the price of repairs and the cost of auto insurance would skyrocket.

By the same token, some health policy experts say, Americans see doctors more often, have more procedures and take more medicine than they need because most, if not all, of the cost is covered by insurance.

"When consumers don't have to pay any regard to price, they overconsume," said Kate Sullivan, director of health policy at the United States Chamber of Commerce. "You get more value for what you buy when you have a stake in it."

But there would be another consequence if people's cars received more service: they would run a lot better and last a lot longer. This analogy may also apply to health care. "People who have affordable and good health insurance get good preventive care and treatment when they need it," said Christine Owens, a health policy specialist at the A.F.L.-C.I.O. "People who don't have good, affordable health care delay treatment and are in poorer health."

There you have it. We have a system which encourages overuse of some health care (actually, most health care plans underpay for prevention, making the analogy in this article more a straw man than real argument). Thus, libertarians (this includes me) would like a system which encourages patients to participate in the finances of medical decision making. "Liberals" define health care as a right, thus we should pay regardless of the stress to our society. I hope that I have correctly characterized the tension. And economists continue to debate:

But in almost all cases, the expense is not so great that workers change their behavior ? not enough, say, for most patients to ask doctors in advance what they charge. Jonathan Gruber, an economist at the Massachusetts Institute of Technology who was a deputy treasury secretary in the Clinton administration, argues that to limit overuse of health care, people should have to pay enough of the cost out of pocket that it pinches. Perhaps poor people should be exempt from cost sharing, he said, but "people with union contracts are affluent enough that they can afford some co-pays."

Some economists disagree with Mr. Gruber. Market principles do not apply to health care, they say, because most people believe good health is priceless.

"If you make people pay more for their health care," said Uwe Reinhardt, a health economist at Princeton, "all you are doing is rationing health care according to income. People like you and me would continue to get all we want, and those without means would have to do without."

Some economists who are comfortable with the principle of making people pay more are not sure how much it would take to keep overall costs down, because all insurance plans would still cover catastrophic expenses. A large proportion of total costs are attributable to a relatively small number of people who are very sick, and their bills generally exceed the ceiling on catastrophic expenses.

There is no conclusive evidence that people's health would deteriorate if they were charged more for care. Mr. Gruber said he was convinced that "the health gains" from generous health insurance "are not large enough to justify the additional costs in aggregate."

But Mr. Reinhardt was skeptical and fell back on the auto insurance analogy. "When I was young and could not afford regular maintenance, my cars constantly broke down," he said. "Now my cars run forever."

I find this debate healthy. Those in my research field (Medical Decision Making) have understood this problem for 25 years. We have always discussed the constraint of limited resources. This concept drives the entire field of cost-effectiveness analysis. We could make the decision that health care is a right, and we should pay whatever it takes. If so, then we should not complain about rising health care costs. If we want to control costs, then everyone (physicians and their patients) should work to make cost decisions. Our current system does not stimulate such work.

Medicare represents a double edged sword. Certainly many 65 and older can afford care which they might not afford without Medicare. However, the Medicare program requires a bureaucracy with political oversight. As one contemplates that sentence, most would admit that bureaucracy with political oversight must lead to a bizarre system.

Generous Medicare Payments Spur Specialty Hospital Boom

Medicare ? which pays for some $100 billion of inpatient hospital care annually, and sets the pattern for many private insurers, as well ? is not the sole driver of this investment. But health executives say that Medicare's payment system for hospitals, with its emphasis on procedures and its weak ties to the actual costs of providing care, exerts a strong influence on which medical needs in a community are met.

Amid the building boom here in Indianapolis, some hospitals are laying off employees or scaling back programs, like psychiatric care, that are less generously reimbursed. Preventive care and case management, health experts add, get short shrift.

"The incentives are terribly misaligned," said Samuel R. Nussbaum, a doctor and former hospital executive who is now the chief medical officer of Anthem, a large health insurer here.

Creating Excess Demand A study of Indianapolis health care last year concluded that the construction of so many new heart hospitals could create excess demand for treatment rather than produce better cardiac care.

"Improving clinical quality did not appear to be a driving force for new facilities or services," said the report, by the Center for Studying Health System Change, a nonprofit research group. "Given these market conditions, provider competition could, alternatively, result in higher use rates and costs."

In Washington, lawmakers rushing to complete a compromise bill that would establish a Medicare prescription drug benefit are now turning their attention to the growth of specialty hospitals. The Senate version of the Medicare bill would make it harder for doctors to invest in and refer patients to such hospitals, and full-service hospitals are lobbying hard for the provision.

So the Senate wants to close a "loophole". What they must realize is that the system will always create loopholes (some would call these opportunities). A bureaucratic system with political oversight must (it seems to this observer) to muddle through health care, making the mistakes that all bureaucracies make, creating the unintended consequences that all politicians create.

"We're working on a payment system that has been jerry-rigged so many times, we've been looking for the loopholes," said Jack C. Frank, an executive at Community Health Network, which opened the Indiana Heart Hospital this year in partnership with local doctors.

...

As a cost-control mechanism, the system has been largely successful. The problem, say hospital executives and industry analysts, is that after 20 years, the payments are out of whack: Medicare frequently pays too much for some kinds of care and too little for others.

I hope readers understand (please read the entire article) why many physicians find Medicare so frustrating. They create winners and losers, and do not even know that they create them. For those keeping score, health care does not reach its potential. But the intentions are pure.

A colleague blog (Family Medicine Notes) responds to my discussion of general internal medicine with an excellent discussion of his own - Internal Medicine. First, I must correct one minor error. The article appears in the Journal of General Internal Medicine - not Academic Medicine. Jacob Reider (the blog author) makes several important points.

It is not uncommon that I call an Internist friend to ask for advice in a situation that involves a very complex adult problem. Why? Because in some cases, the training of an Internist simply prepares them better for handling such situations. A good generalist knows the boundaries of his/her skill -- and while most family physicians are capable of providing excellent care to children, adults, the elderly, and pregnant women -- there are some situations in which we are better off having the help of someone who specializes. "You are worth it" I tell my hesitant patients. They sometimes seem to wish I could do everything for them. I can't. This is why we have specialists.

Yet with their identities as "general adult medicine" physicians -- there is no good method for me to refer a patient to an Internist for consultation. Since they are primary care physicians - there is no "referring/consulting" physician relationship between Family Physicians and Internists (or Pediatricians) .. but I think that such an arrangement would be beneficial for all.

The "other" generalists may build a better understanding of what we do (many practicing internists and pediatricians didn't do a family medicine rotation in medical school) ... and we may learn not to be so threatened by them.

Our Mantra seems to be "we provide the same care as they do." Which is accurate in many ways ... and of course .. may be innacurate too .. since I would argue that a family physician may provide better care in many ways than an internist or pediatrician - especially for a family.

But the point is that if these physicians could re-frame their identities as specialists in complex adult medicine - no longer would they be positioned as competition for family physicians, but as an available, supportive adjunct to comprehensive, coordinated care.

I found these paragraphs very powerful. Jacob nicely defines the differences between family medicine and general internal medicine.

Family medicine training has (and must have) much greater breadth than general internal medicine training. We still focus more of our training on hospitalized patients (although we have increased our outpatient teaching). We only care for adults (family docs have equal pediatric training). We have minimal training in gynecology, office orthopedics, etc. While some primary care internal medicine programs have worked hard to provide training in these additional fields, we remain internists. Our mind set comes from the complexities of inpatient medicine. We tend to attract older more complex patients.

While "keeping up" remains a major challenge for general internists, our challenge pales when compared with the challenge of family docs.

As our article discusses, the old GP often referred patients to the general internist. The Oslerian tradition was the general internist as consultant physician.

The growth of subspecialties has decreased the family doc - general internist referral. According to colleagues it still lives in many rural communities. However, in the big city, the family doc more likely refers directly to a subspecialist.

Now I love subspecialists, however, some patients (perhaps many patients) benefit from having one skilled general internist rather than 2, 3 or 4 subspecialists (e.g., cardiologist, pulmonologist, gastroenterologist and endocrinologist). Most family physicians have neither the time, nor the inclination to follow the complex patients.

I hope that our article will stimulate thought processes about generalism. I see family medicine and general internal medicine as overlapping Venn diagrams. We share skills in the shaded area. Most adult patients with routine clinical problems can benefit from either specialty (yes family medicine and general internal medicine are specialties). Family physicians, because of the broader training do a superior job caring for minor injuries, much dermatology, and other issues not traditionally taught during internal medicine residency. General internists feel much more comfortable in the hospital. We love the complex diagnostic problem (nothing more boring for most physicians than to listen to 2 general internists obsess over a differential diagnosis).

I hope that we can redefine the concept of primary care with the goal of understanding the primary care is not simple care . Rather, different patients need different types of generalists.

Thanks to Family Medicine Notes for reading and expounding on my post. And for those who really care, db stands for Dr. Bob and da boss. On the golf course my buddies all call me db, short for Dr. Bob. At work they call me db for da boss. Hence db's Medical Rants!

Do not drink excessively when running marathons. Running the Risk of Too Much Water: Hyponatremia Can Sometimes Lead to Death for Marathoners

If you run or bike long distances, please read this article.

Sometimes one must toot the horn. I am a co-author on (what I believe) is a very important article - American Internal Medicine in the 21st Century: Can an Oslerian Generalism Survive? I understand that few readers will have access to this link. I will provide a few quotes from the article.

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant-generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant-generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty-first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine.

Internal medicine prospers in America if numbers of practitioners and interest among medical students are valid measures. Never have there been so many qualified internists, and as the population ages, their scope for activity seems likely only to increase. Yet at the turn of the 21st century, the mission and identity of internal medicine are less clear than ever before. The internal medicine subspecialties prosper, but do so unevenly, proceduralists gaining at the expense of the less procedural fields such as endocrinology, rheumatology, and infectious disease. General internal medicine, after a vogue in the early 1990s, finds itself in the doldrums as primary care, prosperous and fashionable only 10 years ago, now wanes in popularity. As subspecialists continue to increase and displace generalists among internists, it can legitimately be asked whether "internal medicine" retains a coherent identity.

In what follows we will explore the meaning of American internal medicine in the past 100 years, particularly insofar as that identity has been shaped in the academic setting; in doing so we will consider the Oslerian consultant-generalist ideal, powerful in pre-World War II academic departments of medicine and then eclipsed by the 1970s as subspecialists took over from generalists. We will then consider threats to that ideal in the present practice environment and discuss how departments of medicine might act to preserve it, at least within their own institutions.

These paragraphs introduce a combination of historical perspective, philosophical musings, and the clear preferences of the three authors. We (Thomas S. Huddle, MD, PhD, Robert Centor, MD, Gustavo R. Heudebert, MD) try to place internal medicine into perspective. Even in medicine, one can learn much from history. Understanding how we arrived in our current straits helps us understand which directions we might now travel. We finish:

The evolution of American internal medicine offers a striking example of the manner in which pressure upon disciplinary boundaries can be brought by economic forces. The rise of subspecialty medicine owes much to the progress of clinical science; but that rise has been vigorously reinforced by the willingness of society to pay for its innovations. Yet, general internal medicine along Oslerian-consultant lines has no lack of intellectual vitality, as the presence of many expert generalist clinicians in academic medical centers continues to attest. Such generalism would not likely have maintained its early 20th-century importance in the latter half of the century no matter what economic arrangements it subsisted on in the shadow of rising subspecialism. Yet, in the early 21st century, Oslerian generalism is becoming impossible in practice due its inability to pay its way. General internists might preserve complexity in their practices by becoming hospitalists; but if they wish to practice such medicine in the outpatient setting, they must contend for economic arrangements that would make that possible. Failing such arrangements, internists practicing in the outpatient setting will likely be forced to give up their traditional identity and join with other exclusive practitioners of primary care.

As an academic general internist, I worry about our field. Many patients would benefit from a general internist. General internists invite complexity, and have the skills to balance the many conditions which afflict our patients. Caring for the complex patient takes more time. We want to spend that time; we want to address the myriad problems; we want to make a reasonable salary. So where does our profession go now. Perhaps we can take the wisdom of the Cheshire Cat from Alice in Wonderland:

`Cheshire Puss,' she began, rather timidly, as she did not at all know whether it would like the name: however, it only grinned a little wider.
`Come, it's pleased so far,' thought Alice, and she went on. `Would you tell me, please, which way I ought to go from here?'

`That depends a good deal on where you want to get to,' said the Cat.

`I don't much care where--' said Alice.

`Then it doesn't matter which way you go,' said the Cat.

`--so long as I get SOMEWHERE,' Alice added as an explanation.

`Oh, you're sure to do that,' said the Cat, `if you only walk long enough.'

Since most of us do care where internal medicine goes, we must proactively choose our path. I only hope that we can.

Wow! The Lancet has laid down the gauntlet. The statin wars: why AstraZeneca must retreatThe editorial ends:

Since there are no reliable data about efficacy and safety--and AstraZeneca is facing unusually acute commercial pressure to force rosuvastatin into the market--doctors should pause before prescribing this drug. Physicians must tell their patients the truth about rosuvastatin--that, compared with its competitors, rosuvastatin has an inferior evidence base supporting its safe use. AstraZeneca has pushed its marketing machine too hard and too fast. It is time for McKillop to desist from this unprincipled campaign.

And Astra-Zeneca responds: (warning, pdf file) The response.

The BBC news has this article on the subject: AstraZeneca defends its new bestseller

According to the magazine, AstraZeneca needs to eat into this market to recover from falling profits and flat sales of its ulcer pill Prilosec which is facing stiff competition from generic drugs.

When The Lancet's editorial was written, AstraZeneca's latest financial figures had been disappointing, its profits falling fast.

But on Thursday this week the drugs firm reported a reversal of its fortunes with a rise in pretax profits to $1.11bn, up from $923m during the same period earlier.

The recently launched Crestor was a major contributor to this rise, having already gained a 2% market share, and analysts expect the drug to bring in $3bn worth of sales a year.

I doubt that this story will surprise anyone. The pharmaceutical industry functions to make money for investors. Often this goal aligns with improving patient care. Sometimes the industry just looks for market share, and patient care effects are neutral. This controversy most likely reflects a drug with no major advantage for patients, but a major financial advantage for Astra-Zeneca. They have every right to market their drug. They should not complain too loudly when the are criticized. "The lady doth protest too much, methinks" - Shakespeare, Hamlet

Myeloperoxidase and Glutathione Peroxidase 1 May Predict Cardiac Events

Plasma myeloperoxidase levels are elevated and glutathione peroxidase 1 activity is reduced in patients with chest pain who are at increased risk of cardiac events, according to two reports in October 23rd issue of The New England Journal of Medicine.

...

In an accompanying commentary, Dr. Teri Manolio, from the National Heart, Lung, and Blood Institute in Bethesda, Maryland, points out that both enzymes possess two characteristics of an ideal risk marker: They provide independent information about a patient's risk and they account for a large proportion of the risk associated with heart disease.

Over time, we add greatly to our understanding of acute coronary processes. These studies add to an ever confusing set of markers. Now we need the fundamental scientists to help us understand. Then we may one day use these data to tailor patient care. Meanwhile, the studies fascinate me.

Over the past week, readership has increased dramatically. I am not sure why, but it is quite pleasing. While I write this blog primarily for my own edification and enjoyment, having readers multiplies my pleasure. Blog writers would not have counters unless they were interested in how many readers they have. Having readership growth suggests that my writing and article selections resonate with you. So thanks! Please provide me with suggestions - which, in characteristic fashion, I will consider, then do what feels right to me!

Apparently lawyers and juries can look back in time better than physicians and hospitals can look forward. Following the standard of care?

Perhaps they should have read Malcolm Gladwell's article from the New Yorker (I have cited this article previously, but it is so good and so relevant that I provide the link once again) - Connecting the Dots The retrospectoscope always works better than any other scope. Our challenge is in learning how make better decisions prospectively. Lawsuits such as the one cited here do not help the decision making process.

For those who care for myocardial infarction patients - Physical Exam Useful in Predicting Mortality in Non-ST-Elevation MI

The Killip classification, a measure of heart failure severity based on physical examination, is a strong predictor of mortality in patients with non-ST-elevation acute coronary syndromes, new research shows.

Although previous reports have questioned the value of physical examination, there is increasing evidence that examination for heart failure provides important prognostic information in patients with ST-elevation MI. However, it was unclear if such evaluation was also useful in patients with non-ST-elevation MI.

To investigate, Dr. Umesh N. Khot, from Indiana Heart Physicians in Indianapolis, and colleagues analyzed data from 26,090 patients with non-ST-elevation acute coronary syndromes enrolled in clinical trials.

Based on physical exam findings, the patients were placed into one of the four Killip classes: I--no evidence of heart failure, II--mild heart failure with limited rales, III--heart failure with more extensive rales, and IV--cardiogenic shock with systolic blood pressure less than 90 mmHg. Because so few patients met criteria for class IV, class III and IV patients were combined for the current analysis.

The current report is published in the October 22/29th issue of the Journal of the American Medical Association.

Compared with Killip class I patients, class II and class III/IV patients were older and had higher rates of diabetes, prior MI, ST depression, elevated cardiac enzymes, the authors note. However, even after accounting for these factors, the Killip class was a strong predictor of 30-day and 6-month mortality.

Mortality at both follow-up points was directly related to the patient's Killip class at initial presentation, the researchers state. For example, class III/IV and class II patients had a 2.12- and 1.52-fold increased risk of death at 6 months, respectively, compared with class I patients (p < 0.001 for both).

The important point here comes from the simplicity of this classification. The Killip criteria do not require sophisticated physical examination skills. These findings are straightforward and obvious even to brand new 3rd year students!!

Many physicians remember their VA training. No incentives seemed to encourage discharging patients from the hospital. Admissions would continue for days and weeks - for no good medical reason. Several years ago the VA changed. To many observers, these changes have surprised, and produced surprisingly positive results! V.A. Shift to Outpatient Care Is Efficient and Sound, Study Finds Kudos to the VA!!!

So how can we get Americans to exercise? Maybe incentives will work - Bribing People To Exercise?

By exercising and staying healthy, Traci and Todd Gianvito have earned enough reward points to take a trip to Florida.

And, says Destiny Healthcare member Todd Gianvito, "We'll be going to Europe next year using the airline miles and using the vacation package for part of the trip."

Destiny Healthcare offers Traci and Todd incentives every time they visit a gym or work out. They even get points for taking CPR classes and doing charity runs.

"We'll get little incentive letters saying way to go, you're earning points and here are some free movie tickets -- which I think is cool," said Traci.

And it saves cool cash for their small midwestern healthcare provider and its parent company in South Africa.

"On the financial level, it impacts dramatically on healthcare costs, people are more prudent, they are more engaged in their healthcare," said Adrian Gore, with Discovery Healthcare.

What a logical, novel, and appropriate idea!!!!

Not a fat chance

Many more Americans today take synthetic ephedra in a wide range of over-the-counter and prescription drugs to treat allergies, asthma and nasal and chest congestion. Such products, in fact, have been in use in America for about a century now, and they have been thoroughly vetted and approved by the Food and Drug Administration.

With so many people taking ephedra products, inevitably some will suffer serious illness or death from unrelated natural causes. Manufacturers of diet pills, indeed, are not serving a particularly healthy population.

A long-obese customer may finally turn to dieting too late, and suffer a stroke or heart attack after starting the diet regimen. His grieving family rushes to the medicine chest and finds the diet pills. The conclude it was the pills that caused his calamity. The same phenomenon occurs on a much larger scale with aspirin, acetaminophen (Tylenol), and ibuprofen (Advil).

Based precisely on such reports, left-wing front groups like Ralph Nader's Public Citizen have taken up a crusade to ban ephedra. Sophisticated consumers of political controversy know these groups are happy any time they can kill a company's profitable business. It's the profit they really want to ban, not ephedra.

The author avoids medical data and specializes in hyperbole. I have written often on the problems of supplements and particularly ephedra. This commentary represents the counter arguments. I would love to debate anyone on this topic. I completely disagree with the commentary - but then we promote free exchange of ideas.

Should we relive stressful situations? I have always personally preferred suppression. The Debriefing Debate: One Popular Therapy Is Called Into Question

At least two controlled studies suggest that debriefing may delay some people's recovery from trauma -- perhaps because it promotes the habit of ruminating over painful images and memories before a wounded psyche is ready to do so. In 2001, Britain's National Health Service listed stress debriefing as "contraindicated."

The entire article is interesting and provocative. Highly recommended.

The debate over stress debriefing is emblematic of a broader concern that psychology does a weak job of establishing the safety and efficacy of new therapies. If this were a drug treatment, the Food and Drug Administration would require a series of carefully structured trials to settle the question. Some researchers argue that a central body -- the American Psychological Association or the National Institute of Mental Health -- should step in to resolve the debriefing debate. Others say that the responsibility lies with the therapists who create new techniques.

Mr. Everly says that he would be happy to work together with the scholarly critics of critical-incident stress debriefing to design and conduct studies that might shed new light on this vexing question.

Prescribing medications represents my major therapeutic tool. As an internist, I have my bedside manner and medications to offer. Some patients will need surgery, however, we try our best to avoid surgery if possible.

Ask a group of generalists about medication compliance (more politically correct to use the word adherence), and they are likely to roll their eyes. Often we really know the right medications to prescribe. We have read the studies, and understand how and why the medications should work. However, no medication works if the patient does not take the pills or capsules.

The real drug problem: forgetting to take them

The issue of why people don't take their medicine, even when they need it to prolong or save their lives, belies simple explanations or demographics. Rich, highly educated people are just as likely not to take their medicine as poor or less-educated people. Some of it is human nature, an inner rebellious voice that resists the doctor's orders. Many patients mean to take their pills but don't write down what the doctor says and end up not following the instructions properly. Others forget, particularly when they have to do it more than twice a day. There is also the growing expense, even for people with insurance, as many insurers raise co-payments on drugs.

But the major reason appears to be a fear of side effects. People don't like the way they feel when they take many drugs, so they simply stop taking them.

The problem appears to be getting worse. Medications are getting better and are more effective in treating a wider range of diseases, but many need to be taken for long periods, even a lifetime. Many diseases for which patients end up taking medicine for years on end -- such as high blood pressure and high cholesterol -- often don't have overt symptoms, making patients even less likely to take medicine faithfully. In addition, more doctors are prescribing medicine for prevention, giving patients less incentive to follow instructions.

"There is a fundamental change taking place in the way we prescribe medicine," says Cynthia Rand, a professor of medicine at Johns Hopkins School of Medicine in Baltimore and an expert in the field of non-adherence. "Now there has to be a change in the way we take it."

Physicians, insurers and the federal government are beginning to address this. The National Institutes of Health now has over 35 trials under way studying ways to improve patient adherence in taking medication for a range of conditions, including depression and other psychiatric disorders.

If one reads the comments written to this blog, an incredibly high percentage discuss medication side effects. Many patients feel that if anything untoward occurs while they are on a new medication, that they should blame the medication.

Patients who take a medication which makes them feel better (like PPIs for severe heartburn) often discount the side effects. Those who take medications for prevention seem to maximize possible side effects.

I am glad that more research will occur in this realm. We need to learn how to help patients help themselves.

Are you type A? You could take this test - Type A Personality Test. Type A personalities do develop problems. This study highlights those characteristics of Type A personalities which put one at the greatest risk for hypertension - Study offers advice for Type A personalities

Advice for young men with Type A personalities: It's fine to be competitive but go easy on the hostility and impatience.

That came from a study published on Tuesday that found today's impatient and hostile young men run a substantial risk of developing high blood pressure 15 years down the road.

"The notion that a 'Type A' behavior pattern is 'bad' for your health has been around for many years," said Barbara Alving, acting director of the National Heart, Blood and Lung Institute which funded the study.

"This study helps us understand which aspects of that behavior pattern may be unhealthy," she added.

The study of 3,308 black and white men found that higher levels of impatience and hostility were "significantly associated" with developing hypertension after 15 years. No consistent pattern was found for another A personality element studied -- striving for achievement or competitiveness -- or for depression and anxiety.

The men in the study were 18 to 30 when it started in 1985 and were followed through 2000 or 2001. They were given periodic physical examinations including blood pressure tests and answered psychosocial questionnaires.

Fifteen percent of all the participants had developed high blood pressure by ages 33 to 45, the study said. The stronger the impatience or hostility the higher the risk of hypertension, it said.

According to these prospectively collected data, most aspects of type A personalities do not put one at risk. I find this welcome news, as so many colleagues are clearly type A (this is a VERY common personality type in physicians). So the rest of the day your favorite new word should become chill !

Scientist Suspects Many Athletes Are Using Undetected Steroids

Catlin said in a telephone interview that he had long believed that so-called designer steroids, which are manufactured artificially, were being used by athletes, but he had been unable to prove his suspicions. Catlin said the discovery that track and field athletes were using THG was the first documented evidence that such a designer drug exists.

Among his concerns, Catlin said, is that chemists create steroids and sell them to athletes without first conducting tests for safety.

Some of these drugs, he said, could be harmful, as are more traditional steroids.

"What is terribly disconcerting is that there are people out there creating these things, and athletes are taking them based on someone's word, without any kind of testing," Catlin said. "It's a horrible situation. Athletes don't know what can happen when they ingest them.

"We have no idea how long THG has been in use. Athletes may have been using it for months or even years. Are there more drugs like it out there? My instincts tell me yes. We really don't know how many athletes are using designer steroids, but things will become clear in the coming months."

Among the questions being pursued by federal investigators in California is who created THG and who profited from its sales. An American anti-doping official, in announcing the discovery of THG last week, said he was "fairly certain" that the drug came from Victor Conte, the owner of the Bay Area Laboratory Co-Operative, or Balco, which manufacturers nutritional supplements.

Put yourself in the athlete's position. He (she) is young and talented. This is the one time that they can profit from their talent. Once you reach a certain age, no more profit will exist.

They live for athletic success. One can view this much like the story of Dr. Faustus.

The name 'Faust' has become deeply rooted in European mythology as the name of a man who sold his soul to the devil in return for eartly power and riches. The Faust legend has been embellished and retold in many formats but its origin appears to be centred around a man who called himself Dr. Johann Faust, living in Heidelberg and employed as a calendar-maker during the early sixteenth century.

This story should not surprise anyone. The athletes are young, immortal and will do anything for success. They will obviously risk their health. And some chemists will create chemicals for them. Follow the money!

Doctors hope law boosts patient care

Texas doctors hope last month's narrow passage of Proposition 12, a law that gives the state Legislature authority to cap non-economic damages, will make it easier for them to practice medicine.

Texas is one of a few states that have recently tackled soaring medical malpractice claims and the booming malpractice insurance rates that accompany them.

Other states have adopted similar laws this year, including Idaho, Oklahoma, Florida and West Virginia, following Mississippi and Nevada in 2002. President Bush is pushing Congress to pass legislation that would limit damage awards in medical malpractice lawsuits.

Texas is one of 19 states considered to be in a "full-blown" medical liability crisis by the American Medical Association. Numerous physicians in these states have retired, left high-risk practices or changed practices because they feared litigation. These states also have high malpractice insurance premiums, an increase in jury awards and settlements, and numerous lawsuits.

The Association of Trial Lawyers in America, however, says laws capping medical malpractice claims may only benefit insurance companies without driving insurance costs down. And, they say, limiting damages only punishes the most severely injured.

If indeed malpractice cases had a positive effect on medical care, then the lawyers would have a reasonable argument. However, all evidence that I have read shows that malpractice acts more like a lottery. I have argued often that malpractice awards and higher insurance rates have a negative effect on health care access. We have a laboratory now - what happens with access in Texas compared with other states which have not passed a cap on punitive damages.

Previous studies suggested that ASA might diminish the effect of ACE inhibition on CHF. This study provides evidence against that hypothesis. Aspirin Not Harmful for CHF Patients Treated With ACE Inhibitors

Several experimental and retrospective studies have examined this issue and many have suggested a harmful effect of aspirin. The "unique feature" of the current study "is that some characteristics of our population, such as etiology, left ventricular ejection fraction, peak oxygen consumption, and the doses of aspirin and ACE inhibitors, were prospectively recorded at baseline," Dr. Pascal de Groote and colleagues note.

The study involved 693 stable CHF patients with left ventricular systolic dysfunction who were treated with ACE inhibitors. The patients included 287 who also received aspirin and 406 who did not. The median follow-up period was nearly 6 years.

During the study period, 273 cardiac-related and 46 noncardiac-related deaths occurred, Dr. Groote and colleagues, from the Hopital Cardiologique in Lille, France, note. In addition, 14 urgent and 71 nonurgent transplantations took place and 3 subjects were lost to follow-up.

The 1- and 2-year cardiovascular mortality rates were 11.5% and 19.0%, respectively, the researchers state.

The authors found no evidence that aspirin use had an adverse effect on survival. This finding held true in the overall cohort as well as in subgroups with ischemic or nonischemic cardiomyopathy.

In a related editorial, Dr. Hans Peter Brunner-La Rocca, from the University Hospital in Basel, Switzerland, comments that "taken together, the evidence for a significant interaction between aspirin and ACE inhibitors in CHF patients is minimal, as long as low-dose aspirin are used."

This is an important study which affects many of our patients.

Age, exercise may boost memory

"We thought that we were born with a brain and that brain degenerated as we aged until we died," he says. "Now we know that there are many triggers that make parts of the brain regenerate themselves."

One of those triggers may be linked to your fitness level.

"Cardiovascular exercise that's done over a longer period of time will tend to reduce the amount of tissue you lose as you age," says Stan Colcombe, a researcher at the University of Illinois-Urbana.

That includes brain tissue, and losing less of it may mean keeping more precious memories.

Designer steroid comes with own side effects

You would rather not have colon cancer. I have taken care of colon cancer patients, and I would go to great lengths to avoid this disease. Fortunately, most colon cancers can either be prevented or removed prior to spread with colonoscopy. Unfortunately many patients will not consider the test.

Comoderator Beth Schorr-Lesnick MD, FACG, assistant clinical professor of medicine at Albert Einstein School of Medicine in the Bronx, New York, noted that many patients fear conventional colonoscopy. "They're afraid of the laxative and the pain, and they fear the findings," she told Medscape.

Douglas K. Rex, MD, FACG, professor of Medicine at Indiana University School of Medicine in Indianapolis and president-elect of the American College of Gastroenterology, put it bluntly: "They are afraid of a long tube being put up the rectum. Most people don't even want to think about their rectum," he said to laughter.

I have had friends and patients ask me about virtual colonoscopy. This procedure uses radiologic techniques rather than a scope. However, it just does not work as well - Virtual Colonoscopy Misses Nearly One Third of Lesions

Using current technologies, virtual colonoscopy is not adequate as a screening tool, say researchers whose study showed that the imaging technique missed 27% of colorectal lesions, both precancerous polyps and colon cancers.

The meta-analysis of data from 16 studies showed that virtual colonoscopy missed 18% of lesions larger than 1 cm, said Aaron A. Link, MD, a resident at the University of Michigan in Ann Arbor.

"That's almost one in five patients with large lesions, which is unacceptable," he told Medscape. "These are patients at high risk, and the screen could give them a false sense of security."

In case you wondered, I put my money where my rectum is. I had a colonoscopy as I was turning 50. The prep was reasonably miserable, but did thoroughly clean my colon. I do not remember the procedure at all - the combination of medications used - Demerol and Versed (pronounced Ver - sed) decreases pain and anxiety and provides short term amnesia. Gastroenterologists tell me that sometimes a little amnesia is a great side effect.

Bottom line - when you turn 50 seek out a colonscopy. Do your rectum and colon a favor - have them checked out! Virtual colonoscopy is not ready for prime time.

The drive to be the best clearly is a double edged sword. We all admire the doggedness and hard work associated with excellence. However, we disdain the cheater.

Athletes (as a group) generally mirror society. This story speaks specifically about high performance athletes, but one could argue that it reflects how we view acceptable behavior. We do not live in a uniformly honest society. I fear we trend towards a win at any cost mentality.

One reason that I find golf attractive is that it remains an honorable sport. Baseball has a long history of corked bats, spitballs and other cheating plays. Football lineman are taught how to hold without getting caught. Basketball players learn the same types of lessons. Thus, this article should not surprise anyone.

Drug Agency Tells of Steroid Scheme by U.S. Athletes

A previously undetected steroid has been identified and a new test indicates that as many as a half-dozen athletes in track and field have recently used the performance-enhancing drug, American drug-testing officials said yesterday.

That is considered a significant number of athletes from one country in a single sport, and would constitute the biggest drug scandal to hit track and field since the Canadian Ben Johnson was stripped of his gold medal for 100 meters at the 1988 Summer Olympics after testing positive for a steroid.

"I know of no other drug bust that is larger than this," Terry Madden, chief executive of the United States Anti-Doping Agency, an independent group that conducts drug testing for Olympic-related sports, said in a conference call with reporters yesterday.

A tip from an unnamed track coach during the summer led to the identification of the steroid, tetrahydrogestrinone, or THG, Madden said. A test was developed to identify THG, which was not previously detectable in urine samples taken from athletes. Madden declined to identify the athletes or the specific number of positive tests.

Read the remainder of the article. The story is fascinating, quite disturbing, but not surprising. For another take on the story, read the Washington Post article - USADA: Elite Athletes Using 'Designer' Steroid

The fluoroquinolones are rather new antibiotics which we use frequently. Several examples of this class are ciprofloxacin, levofloxacin and gatifloxacin. We have believed that these drugs have the unusual side effect of weakening tendons. This study confirms that belief - Study Confirms Increased Risk of Achilles Tendon Rupture With Fluoroquinolone Use

Fluoroquinolone use is associated with increased risk of Achilles tendon rupture, and that increase is "true across the board for exposure to any fluoroquinolone," according to results of nested case-control study reported last week at the 41st annual meeting of the Infectious Diseases Society of America.

...

Exposure to a fluoroquinolone was associated with an apparent increased risk (RR = 1.27; 95% CI, 0.94 - 1.73) of Achilles tendon rupture. Moreover, the increase was observed in each fluoroquinolone used. A case-control study published in the Aug. 11, 2003, issue of the Archives of Internal Medicine suggested that the increased risk of Achilles tendon rupture associated with fluoroquinolones was greatest during the first month of treatment, but Dr. Seeger said his study suggests the risk is constant over the entire course of treatment.

Moreover, the risk associated with fluoroquinolones was about the same as the increased risk associated with azithromycin and combined nonfluoroquinolone antibiotics.

"Just looking at this study, fluoroquinolones alone don't appear to be an independent risk factor for Achilles tendon rupture," Kelly Randell, DPharm, a research fellow at the University of Illinois, Chicago, College of Pharmacy, told Medscape. Dr. Randell was not involved in the study.

"However, they do seem to increase the risk," she said. "Most patients who develop Achilles tendon rupture on a fluoroquinolone appear to have other risk factors that probably contribute to the [rupture]."

While the risk is minimal, Achilles tendon rupture does lead to significant disability. We generally consider the fluoroquinolones as having minimal side effects. This study reminds us that we should always think carefully prior to prescribing antibiotics. Antibiotics are very important for those with significant infections. They do not help viral infections. We must reserve their use for clear indications.

Earlier this week, the Supreme Court refused to hear a case. This case upholds the rights of physicians (in California and other states with a medical marijuana law) to recommend medical marijuana. Today's "Daily Scan" in the Wall Street Journal has three important links on the topic. High court lets stand ruling over medical pot: Doctors may discuss option with patients. This article emphasizes the states' right to regulate and censor physician practice. As I read this article, one can argue that the Supreme Court wanted to avoid ruling on an issue which is really a state issue.

Backers of Medical Marijuana Hail Ruling

Marijuana has been particularly popular as a pain reliever and appetite stimulant for people with H.I.V., AIDS and various forms of cancer. It can be administered in a number of ways, from smoking like a cigarette to mixing with tea.

"It is a real relief," Dr. Milton Estes, the medical director of the Forensic AIDS Project at San Francisco's Department of Public Health, said of the Supreme Court's action. "I can only hope it will send a message to the federal government and the attorney general that every day people with common sense understand that this is not the place for the federal government to be wielding its weight and force against people with chronic diseases."

Ed Rosenthal, the celebrity author of marijuana books and advice columns who was convicted in January in federal court of marijuana cultivation and conspiracy, said the federal government had been given "a clear signal to stay out of the state's business." Mr. Rosenthal had been growing marijuana in Oakland for medicinal purposes under the state law.

"For the first time, many doctors will start writing recommendations for cannabis," Mr. Rosenthal said. "Up until this point, they have been afraid."

The reaction among some patients who have used marijuana was deeply emotional. Michael Ferrucci, 51, who runs a music store in Livermore and who has had lung and testicular cancer, credits the drug with saving his life. Nonetheless, he said, it has carried a social and legal stigma that has been difficult to bear at times.

"I consider this an important step in turning the attitudes of Americans around," Mr. Ferrucci said. "It has been far more beneficial to me than other medications they have recommended to me, including powerful narcotics like morphine, Demoral and codeine."

Court rejects DEA press to censor doctors

The White House Office of National Drug Control Policy, led by the nation's "drug czar," John P. Walters, said in a statement that the court order dealt only with doctor-patient relationships, "not the efficacy of smoked marijuana as medicine." The office added that the "cultivation and trafficking of marijuana remains a federal offense." The Justice Department declined comment.

The movement to promote marijuana as a medicine has been frustrated for years by the federal government's refusal to relax its controls on that drug as an illegal substance. Marijuana has been on the most-restricted list of illegal drugs since the list was approved by Congress in 1970, and the government has denied repeated requests to reclassifiy it.

Although there is an ongoing debate about whether marijuana has any value as a medicine, the government has steadfastly insisted that it has no accepted medical uses.

Given that many patients (and physicians) believe that marijuana does have medical benefits (especially in palliation), having the government state flatly that it has no accepted medical uses seems disingenuous. We need well done studies of medical marijuana - especially since many patients feel so passionate about this subject. Several states have approved this in statewide votes. The people believe that it probably works. The government would better spend their drug abuse moneys supporting good testing of this hypothesis.

As a final thought, this Supreme Court decision should relieve all physicians. We would hate the federal government having the ability to punish us for our opinions on medical issues. This non-review is truly a victory for physicians. I believe it is a victory for society also.

So what are the costs and benefits of bariatric surgery? We just do not know - so Louisiana will find out! La. Testing Stomach Surgery's Cost Effect

Forty obese government employees will get weight-reduction surgery in a $1 million experiment to see whether it keeps insurance payments down over the long run by preventing other health problems.

The first job will be choosing the 40 from more than 1,000 people on the state's health plan who expressed interest in the surgery. The participants will be monitored for three years.

A few states require insurance companies to cover weight-reduction operations, such as those that clip the stomach to a fraction of its original size and bypass part of the intestine. This makes people feel full much more quickly, and digest less of what they eat.

The resulting weight loss can head off long-term illness related to being overweight. The operation is generally considered only for people who are ``morbidly obese'' -- at least 100 pounds overweight.

The Louisiana Legislature refused to require coverage of the operation after insurers objected that it would cost too much. The state health plan alone would spend an estimated $25 million in its first year if it had to cover all requests immediately, Executive Director A. Kip Wall told lawmakers this summer.

``The biggest obstacle is, for lack of a better term, pent-up demand,'' he said Tuesday.

Wall said the $25 million estimate was based on a quoted price of $25,000 per operation and the more than 1,000 letters his office got after sending a notice about the proposed test a year ago to the 250,000 people covered by the plan. Nationwide, prices range up to $40,000 per operation.

A $1 million contract was approved this month for LSU Health Sciences Center -- the state's major medical school -- to pick, treat and follow up with 40 volunteers for the pilot study.

Participants in the experiment will have to pay no more than the usual co-payment or deductibles. The amount would depend on which group benefits plan they are in.

This is very important. Some obese patients really cannot lose weight without surgery. I believe that it will save money, but we will wait and "let the data speak".

Low-Carb Dieters Can Eat More

The dietary establishment has long argued it's impossible, but a new study offers intriguing evidence for the idea that people on low-carbohydrate diets can actually eat more than those on standard lowfat plans and still lose weight.

Perhaps no idea is more controversial in the diet world than the contention ? long espoused by the late Dr. Robert Atkins ? that people on low-carbohydrate diets can consume more calories without paying a price on the scales.

Over the past year, several small studies have shown, to many experts' surprise, that the Atkins approach actually does work better, at least in the short run. Dieters lose more than those on a standard American Heart Association plan without driving up their cholesterol levels, as many feared would happen.

Skeptics contend, however, that these dieters simply must be eating less. Maybe the low-carb diets are more satisfying, so they do not get so hungry. Or perhaps the food choices are just so limited that low-carb dieters are too bored to eat a lot.

Now, a small but carefully controlled study offers a strong hint that maybe Atkins was right: People on low-carb, high-fat diets actually can eat more.

The study, directed by Penelope Greene of the Harvard School of Public Health and presented at a meeting here this week of the American Association for the Study of Obesity, found that people eating an extra 300 calories a day on a very low-carb regimen lost just as much during a 12-week study as those on a standard lowfat diet.

Over the course of the study, they consumed an extra 25,000 calories. That should have added up to about seven pounds. But for some reason, it did not.

"There does indeed seem to be something about a low-carb diet that says you can eat more calories and lose a similar amount of weight," Greene said.

That strikes at one of the most revered beliefs in nutrition: A calorie is a calorie is a calorie. It does not matter whether they come from bacon or mashed potatoes; they all go on the waistline in just the same way.

Not even Greene says this settles the case, but some at the meeting found her report fascinating.

I love studies which challenge conventional wisdom. While I do not understand how this happens, one cannot easily argue with the data. Since I want to lose around 5 pounds, I may go low carb starting next week (going to a medical meeting starting Sunday - and just do not want to start low carb until after that meeting). These results are indeed fascinating!!

I plan to get my flu shot this afternoon. The pain is minimal, and the potential benefit is great. Promoting Flu Shots for All

According to the C.D.C., influenza and complications arising from it, like pneumonia and heart failure, kill an average of 36,000 people a year in the United States, a vast majority of them elderly. The illness also leads to an estimated 114,000 hospitalizations annually.

The agency recommends vaccination most strongly for demographic groups with the highest risk for developing serious illness, among them people at least 6 months old who suffers from asthma, diabetes, heart disease and some other chronic disorders; women more than three months pregnant; and everyone 50 and older.

Although the risk of complications rises considerably after 65, the disease control agency expanded its age-related recommendation a few years ago after studies indicated that even people from 50 to 64 experienced more serious bouts of influenza.

We have the nurses offer influenza vaccination to all patients. If you do not regularly see a physician, find a place to get your flu shot. If you are worried about the effects of flu shots - go read Medpundit's excellent post on this subject from yesterday. (Her links just never work).

The (Agri)Cultural Contradictions of Obesity

The rules of classical economics just don't seem to operate very well on the farm. When prices fall, for example, it would make sense for farmers to cut back on production, shrinking the supply of food to drive up its price. But in reality, farmers do precisely the opposite, planting and harvesting more food to keep their total income from falling, a practice that of course depresses prices even further. What's rational for the individual farmer is disastrous for farmers as a group. Add to this logic the constant stream of improvements in agricultural technology (mechanization, hybrid seed, agrochemicals and now genetically modified crops -- innovations all eagerly seized on by farmers hoping to stay one step ahead of falling prices by boosting yield), and you have a sure-fire recipe for overproduction -- another word for way too much food.

All this would be bad enough if the government weren't doing its best to make matters even worse, by recklessly encouraging farmers to produce even more unneeded food. Absurdly, while one hand of the federal government is campaigning against the epidemic of obesity, the other hand is actually subsidizing it, by writing farmers a check for every bushel of corn they can grow. We have been hearing a lot lately about how our agricultural policy is undermining our foreign-policy goals, forcing third-world farmers to compete against a flood tide of cheap American grain. Well, those same policies are also undermining our public-health goals by loosing a tide of cheap calories at home.

This NY Times magazine article makes one wonder. Still, we must take personal responsibility and resist the marketing ploys to eat more.

Obesity costs businesses money. They would like to stimulate exercise. Fight Against Fat Shifts to the Workplace

Sprint planned its 200-acre world headquarters with an eye to fitness. It banned cars, forcing employees to park in garages on the far side of a road ringing the campus and walk between buildings as much as a half-mile apart. It put in hydraulic ? that is, slow ? elevators and wide, windowed staircases to encourage people to walk rather than ride between floors.

Across the country, companies, states and schools are taking more aggressive ? if perhaps passive-aggressive ? measures to get an increasingly overweight society to move more and eat less. The new methods go beyond putting gyms in office buildings or teaching children (or adults) the virtues of broccoli.

Union Pacific Railroad has begun offering some employees the latest prescription weight-loss drugs as part of a study to determine how best to get its workers to slim down. At the new headquarters for Capital One outside Richmond, Va., the architects set the food court at the end of a string of buildings, rather than at the center.

"It's a place one has to walk to," said Jim Carter, an architect with Hillier, the firm that also designed the Sprint campus. "We want people to get out of their desks and out of their offices and move around."

Programs that nudge people to move more or eat better are responding to a growing public health crisis: the federal Department of Health and Human Services puts the cost of overweight and obese Americans at $117 billion in 2000, and said that being overweight results in 300,000 deaths a year.

I stopped taking the steps at work 2 years ago, despite my office being on the 7th floor, and the VA ward being on the 5th floor. I find walking the stairs a simple but important discipline. Each time I walk the stairs I know the purpose behind my trek.

Each such act stimulates me to think about both exercise and diet. Daily consideration of these factors helps me stay motivated.

Perhaps external motivation can work as well as internal motivation. Perhaps it will stimulate a few workers to consider diet and exercise. If so, what a positive concept.

I am on the road - giving grand rounds. Unable to blog again until Monday. Please frequent the excellent medical blogs listed on the blogroll.

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The title says it all. Vatican claims condoms don't work

The WHO condemned the Church's comments.

"These incorrect statements about condoms and HIV are dangerous when we are facing a global pandemic which has already killed more than 20 million people and currently affects around 42 million," a spokeswoman told the programme.

She said "consistent and correct" condom use reduces the risk of HIV infection by 90%. There may be breakage or slippage of condoms - but not, the WHO says, holes through which the virus can pass.

I am speechless. Why is the Church not thinking?

Drug Ads Don't Say Much, but Sell Big

In one veiled television ad, a voice-over states: "It's always been our dream to run a bed and breakfast," while an elderly man pushes a wheelbarrow. Then another voice says, "Could Procrit be right for you? Ask your doctor."

The medication helps increase the body's red-blood-cell production and is meant for patients suffering from HIV, cancer or kidney disease ? not that anyone would know that from the ad.

But these types of campaigns have people asking their doctors for pills by name.

"I have patients that come in that can sing the jingle for the product, but they don't know much more," said Dr. Michael Fleming, president of the American Academy of Family Physicians (search). "It is very common now for a patient to come in for an appointment and say ?I want to know about the pill I saw on television.'"

Pharmacist Barbara Morris of Escondido, Calif., said the direct-to-consumer ads are reprehensible and prey on people's desperation to feel better.

"When you are in pain," Morris said, "and you see a grandpa playing ball with the kids in the park, or playing with a cute dog, that's what you remember ? the promise of relief ? not that the drug may cause sudden internal bleeding or other dangerous side effects."

The FDA once required direct-to-consumer ads to include thorough information on a drug's possible side effects. When that proved too cumbersome and confusing, the FDA agreed to allow TV drug ads to simply mention major health risks and advise where to go for more information.

You know how I feel about DTC advertising (I dislike it intensely). This report is "fair and balanced".

Pfizer Wins FDA Approval of Inspra for Heart Failure

Pfizer Inc. on Wednesday said U.S. regulators approved the company's drug, Inspra (eplerenone tablets), for congestive heart failure patients who have already had a heart attack.

The U.S. Food and Drug Administration approved Inspra last year for treating high blood pressure.

Inspra, a selective aldosterone blocker, will compete with older classes of drugs such as ACE inhibitors and calcium channel blockers.

I have blogged extensively on eplerenone in the past - just do a search to find the articles.

Over-The-Counter Drug Campaign

Pharmacist Stephen Setter regularly asks families of Alzheimer's sufferers what drug they use to help the often agitated patients sleep better. Tylenol PM, many respond - not knowing, Setter says, that it contains an ingredient that can further confuse someone with dementia.

He also talks of a man who needed transfusions after the painkiller ibuprofen caused stomach bleeding. The man didn't know acetaminophen would have been a better choice for an elderly person who'd already had one stomach ulcer, until Setter was called in for advice.

Over-the-counter medicines often are powerful drugs that patients don't know how to use correctly - picking the wrong one for their health problems, overdosing, or inadvertently mixing them with prescription drugs in ways that can harm.

Now a new education campaign by the surgeon general and a mix of pharmacy and consumer groups aims to help patients become more savvy about self-treatment.

"These are real medicines that must be taken responsibly," Surgeon General Richard Carmona warns.

OTC drugs are potentially dangerous and potentially valuable. All patients should think prior to taking OTC drugs, or supplements. Unfortunately, most patients do not know enough pharmacology to make these assessments themselves.

One problem with policy making occurs when good ideas have unintended consequences. We see this problem often with government regulations. We can also see this problem with hospital policies.

When I was a resident we had just opened the new medical ICU. We had a patient with resistent aplastic anemia. All known protocols had failed. The patient had profound neutropenia. Hospital epidemiology placed him on reverse precautions (all visitors had to glove and gown) to protect him from infection.

He asked us soon thereafter if we could end the reverse precautions. He understood that he might get an infection sooner, but he wanted to hug his loved ones, see their faces and enjoy his final days. His request made sense to the team, and we ended the precautions - over the vociferous protestations from the hospital epidemiologist.

The patient lived a few days. He smiled each of those days. He and his family expressed gratitude for our common sense decision.

Isolation protocols need rethinking. The Risks Of Isolation

A study says hospital patients put in isolation because of contagious infections may be more likely to suffer falls, bedsores and other preventable complications.

Some of the differences suggesting patients in isolation get lower quality care "are likely a result of the isolated patients being 'out of sight' and therefore 'out of mind,"' said Dr. Henry Thomas Stelfox of Harvard's Brigham and Women's Hospital.

Also, "the effort and time involved in donning protective equipment likely discourages some providers from visiting their patients as frequently as they otherwise would."

Thomas led the study at two large teaching hospitals - Brigham and Women's in Boston, and Sunnybrook and Women's College Health Sciences Centre in Toronto. The findings appear in Wednesday's Journal of the American Medical Association.

Isolation typically involves putting the patient in a private room, limiting the number of visitors and health workers who treat the person, and requiring protective clothing for anyone entering the room.

Sometimes isolation is very necessary. If you suspect active TB then you must isolate - to protect the health care workers. This article makes clear that we must consider both the costs and benefits of this process.

Wow! Medicare for the Fiscally Healthy

ith the government wallowing in deficit spending, it is understandable and even encouraging that Congressional Republicans are thinking about requiring high-income retirees to pay more for their Medicare coverage. This rare nod toward fiscal reality arises as the G.O.P.-led Congress attempts to deliver on campaign pledges to provide a Medicare prescription drug program.

Legislators are looking for ways to soften the financial blow of the 10-year, $400 billion drug plan now on the table. This page has questioned whether the country can afford to add new entitlements to Medicare at all, given the size of the federal deficits swollen by the Bush administration's ill-advised tax cuts. If Congress is intent on going ahead, there will certainly have to be other savings made.

Many Democrats, but not all, warn that the Republicans are venturing onto sacrosanct ground in proposing such a basic change in Medicare, a highly popular program that has always been equally available to all retirees.

But upper-bracket Americans have enjoyed disproportionate benefits under the Bush tax cuts. They can easily afford to pay the premium increases being considered for the top 2 percent of beneficiaries: individuals earning over $100,000 a year, and couples more than $200,000, in retirement. Even the possible tripling of annual premiums, to roughly $2,100, for the richest retirees would still make Medicare a bargain.

Well said, and correct logic!!!

New Doctor, New Diet, but Still No Cookies

Theories abound as to what has propelled the South Beach diet to the center of the weight-loss universe since the book bearing its name was published in April. Is it the image it conjures, of bikini-clad models picking at tropical fruit salad between sun-drenched photo shoots? Is it the aqua shimmer of the book jacket, as eye-catching as the surf off Ocean Drive?

Or is it that Dr. Arthur Agatston, the cardiologist behind the latest low-carbohydrate, high-protein diet, is on to something?

Dr. Agatston — whose office is not in South Beach, by the way, but the older, tamer neighborhood to its north — is not far from that giant of diet doctors, the late Dr. Robert Atkins, in his belief that refined sugar and white flour are the villains behind the nation's climbing obesity rate. Like the Atkins diet, the South Beach diet strictly limits bread, potatoes and other carbohydrates, especially during a two-week initiation period, and allows the dieter to eat red meat, eggs and cheese.

But while the Atkins diet allows just about any fatty food that is not also starchy, Dr. Agatston advocates mostly unsaturated fats, like those in olive oil, nuts and oily fish like salmon. Butter is nowhere in the South Beach diet meal plans, nor is bacon or anything fried. The South Beach diet also differs from Atkins in that it allows carbohydrates — though only those high in fiber, like multigrain bread and wild rice.

Dr. Agatston's premise is that most carbohydrate-rich foods are so processed that they immediately turn to sugar in the body. That, Dr. Agatston says, forces a quick spike in blood sugar and nearly as quick a decline. The spikes lead to more hunger, he says, and — this is the part that many experts dispute — to inevitable weight gain.

"Nobody in the history of man ever ate complex carbohydrates like we have," Dr. Agatston said last week during an interview squeezed between a photo shoot and a meeting about his new heart-imaging center, set to open in December. He was late to the interview, so his wife, Sari, a lawyer who is helping with publicity, filled the time by talking about how even she, a bread lover, has come to accept whole-wheat pita instead.

The diet revolves around the glycemic index — the amount that a carbohydrate increases sugar in the blood compared with the amount that the same quantity of white bread raises it. The concept of the index as crucial to weight gain or loss has been around since the early 1980's, when it was used to help people with diabetes choose proper diets. But skeptics — including the American Diabetes Association, which has not endorsed the index — say a food's glycemic index fluctuates depending on how much is eaten and what other foods are eaten.

Foods with a low glycemic index, like lentils, soy milk and low-fat, artificially sweetened yogurt, do not raise blood sugar as quickly and sharply as high-numbered items like gnocchi, baked potatoes and pretzels.

High-glycemic-index foods cause the body to release a lot of insulin, which quickly lowers the blood sugar again and causes hunger to recur, the theory goes. Those with low indexes break down into sugar more slowly, for longer-term energy.

This article describes a very interesting diet. It seems to have significant rationale. Of course we need good prospective studies to be sure. I would probably pick this over the Atkins' diet given the information I currently have.

Those With Hepatitis C Still Face Long Odds

I recommend this article as an update, and reasonable "handout" for patients.

I ran a piece yesterday about employers decreasing drug benefits. Two comments deserve my commentary -

Certainly the "market" will encourage people to make more intelligent choices about medication, as you point out. It will also encourage people with conditions like hypertension, bipolar disease, and Type 2 diabetes to be noncompliant because of expense.

I disagree. We have lower cost alternatives available. Considering cost, we can still treat patients well. For example, rather than a newer ARB we can use a generic ACE inhibitor. Rather than a newer expensive sulfonylurea, we could use the first generation less expensive generic sulfonylureas.

It's certainly too soon to claim that the market will work. In fact, it won't work because the government prevents it from working. Patent law gives pharmaceutical companies a guaranteed monopoly. The only solution is forced licensing of patents.

I disagree. You can spend money for a more expensive PPI or a much less expensive PPI. Currently, patients want the advertised drug. If cost becomes important, then market share will suffer. The pharmaceutical industry worries about market share, just like any business. If patients actually consider cost, then the market will work. I believe that it will!

Remember the Match lawsuit. It still looms. This lawsuit claims that the Match artificially suppresses housestaff salaries. But one economist argues against that claim. Harvard economist argues that Match is not anticompetitive

The National Resident Matching Program is not the culprit behind residents' relatively low wages, says Alvin Roth, PhD, a Harvard University economist and author of the Match's mathematical formula that links medical students with residencies.

Dr. Roth argued his perspective, which is contrary to claims made in an ongoing lawsuit against the Match, in an economic analysis in the Sept. 3 issue of the Journal of the American Medical Association. "The scientific hypothesis seems to say matches per se lower wages, and [the economic analysis] seems to say strongly that that hypothesis is false," Dr. Roth said.

In May 2002, three residents filed a lawsuit alleging that the Match artificially depresses resident wages and restrains competition. The plaintiffs are seeking class-action status for all residents in the country.

Dr. Roth and his co-author looked at fellowship salaries to test the premise that abandoning the Match would cause resident salaries to rise. Internal medicine subspecialty programs within the same hospitals were compared. Some of the subspecialty programs participated in the Medical Specialties Matching Program, while others did not.

"Unlike residency training, fellowships are an optional part of a career path," Dr. Roth and his co-author stated. "Thus, potential fellows have market alternatives; fellowship programs must compete not only with other programs, but with less-specialized medical positions, because fellows could practice medicine without pursuing a fellowship."

They found that wages were not significantly different for programs that used the Match compared with those that did not. Fellows had the choice of going into higher-paying practices, but fellowship wages did not rise to make the positions more attractive. This suggests that the matching process is unrelated to the relatively low wages involved, Dr. Roth said.

Lawyers should understand this concept. Many first year lawyers accept low paying clerkship jobs. These jobs pay less for that year, but generally make the lawyer more attractive in the future. These lawyers trade their immediate income for future gains.

Physicians make the same choices. They need some post-graduate training to properly practice their chosen specialty. They often knowingly choose longer training programs (like cardiology rather than general internal medicine) for various reasons. In the short run, they make less money. They generally profit in the long run.

This lawsuit makes no sense to those in academic medicine. Worse than the poor logic is the financial drain that such suits cause.

Litigating class-action lawsuits gets expensive, and with 36 defendants named in the antitrust lawsuit against the National Resident Matching Program, this case should be no exception.

Almost all of the academic medical centers and physician organizations named in the lawsuit have sought their own outside counsel instead of having one law firm represent them as a group. Lawyers associated with the case say more than 90 attorneys are involved.

Once the case moves actively into the discovery phase, legal fees alone could mount to $500,000 a year for the defendants as a group, one attorney estimated.

Frances Miller, a professor at Boston University School of Law, said, "There are so many defendants. Regardless of the outcome, the litigation costs are high even if it never comes to trial."

HHS eases interpreter mandate but doctors must pay the bills

"When physicians are required to fund written and oral interpretation services for limited English proficiency patients in their practices, as remains the case under the new guidance, this can impose severe economic losses that are difficult to sustain, especially when the cost of providing the services far exceeds the payment for treating the patient," said AMA Trustee Edward L. Langston, MD.

HHS plans to provide additional education for physicians and health practitioners on how best to provide interpreter services. The guidance cited a number of options, including using telephoneor video interpreting, training bilingual staff, pooling community resources, and referring patients to physicians with specific language capabilities.

Whenever the government mandates a program like this, physicians pay. This is a great example of increased overhead with no comparable increased fees. For those who wonder, this is a great example of a point that I make often.

I was playing golf with this guy - approximately 70 years old, and approximate BMI of 35-40. He kept complaining about his knee arthritis, and asked me what he should take. It's not the shoes but the weight gain

AMONG people older than 65, knee arthritis is about twice as common in women as men, leading some experts to blame high-heeled shoes for many cases of the painful condition. Footwear, however, doesn't appear to be the culprit.

A study comparing female osteoarthritis patients, age 50 to 70, with healthy women of the same age found that high heels had little effect on risk. The major threat was being overweight, particularly when weight gain occurred early in life.

Researchers in England interviewed 82 women with healthy joints and 29 women who had moderate knee pain or worse on most days and who were awaiting knee surgery. The participants were asked about their health history and habits since they left high school, as well as certain risk factors (such as their body weight at three stages of their life), whether they played competitive sports and if their work involved regular bending, lifting, squatting or walking. They were also shown photos of 38 styles of shoes and asked which types they wore.

The most significant risk in developing arthritis of the knee was becoming overweight before age 40. High-heel wearing was not associated with arthritis ? nor was being involved in a competitive sport or using oral contraceptives or hormone replacement therapy. Some activities, such as lifting and bending, appeared to be related, but there was no clear picture of how much of these activities was responsible for knee problems.

Just another reason to watch ones weight.

Wow, this is interesting. Forget the stretch

IF the first five to 10 minutes of your workout consists of stretching exercises to reduce the risk of injury, perhaps you should save yourself some time. Not only does such stretching fail to reduce the risk of injury, but recent studies have shown it also might hinder performance.

People who stretch before exercise have about the same risk of injury as those who don't, says epidemiologist Ian Shrier. Several years ago, Shrier reviewed half a dozen studies on the effects of stretching before exercise and found that not one demonstrated that it prevented injury. He published his findings in the Clinical Journal of Sport Medicine.

"At first people thought I was crazy," recalls Shrier, a physician at Sir Mortimer B. Davis Jewish General Hospital in Montreal. But his conclusions gained credence six months later, in August 2000, when Australian researchers published a large-scale study in the American College of Sports Medicine journal that reached the same conclusion.

That study involved 1,528 military recruits who followed the same exercise, weight and conditioning program. Half the recruits stretched before exercise; half didn't.

"A typical pre-exercise stretching protocol does not produce a clinically useful reduction in injury risk," wrote the authors. "If injury prevention is the primary objective, and the range of motion necessary for the sport is not extreme, the evidence suggests that athletes should drop the stretching before exercise and increase the warm-up."

Wow! I love studies that test conventional wisdom - and find it lacking. Interestingly, my personal trainer ask me to arrive early and do 10-15 minutes of cardiovascular warm-up prior to resistance training. He seems to have it right.

We cannot afford significant Medicare increased expenditures. From where will the money come? Well maybe those with more financial resources will pay more. Medicare Plan Lifts Premiums for the Affluent

With unexpected support from some Democrats, Republican negotiators from the House and the Senate say they are seriously considering a change in Medicare that would require elderly people with high incomes to pay higher premiums than other beneficiaries.

The discussions come as the negotiators step up their efforts to reach agreement by Oct. 17 on a bill to overhaul Medicare and add prescription drug benefits.

The proposal to link premiums to income raises a philosophical and political question: Should wealthy people pay more for Medicare?

Republicans like Senator Don Nickles of Oklahoma say such a requirement is a sensible, progressive way to slow the growth of federal Medicare spending. The Senate majority leader, Bill Frist of Tennessee, said the Medicare negotiators had "a mandate" to charge affluent people somewhat more.

In the past, Democrats have vehemently opposed the idea. But some of the social policy experts most respected by liberal Democrats now say they are receptive to it, as a way to avert cuts in Medicare and other domestic programs. Pressure for such cuts will increase, they say, as budget deficits grow and baby boomers cash in their claims to Medicare and Social Security.

Most of the 40 million Medicare beneficiaries now pay the same premium, $58.70 a month, or about $704 a year, for doctors' services and other outpatient care.

Under one proposal being discussed by House and Senate negotiators, premiums would rise gradually with a beneficiary's income. The change would affect only people with annual incomes above a certain level, perhaps $75,000 or $100,000. Individuals with incomes exceeding $200,000 could see their premiums triple, to about $2,100 a year.

AARP, the lobbying group for older Americans; labor unions like the United Automobile Workers; and some liberal Democrats, including Senator Edward M. Kennedy of Massachusetts, say levying an extra charge on affluent beneficiaries would undermine the universal nature of Medicare. Such a change, they say, would be a dangerous first step in turning Medicare from a universal social insurance program into a welfare program.

But Robert M. Ball, who worked at the Social Security Administration for three decades and was commissioner from 1962 to 1973, said: "I don't see an objection to having an income-related premium. I am opposed to varying Medicare benefits according to the income of the recipient, but I find it completely acceptable to have people with higher incomes pay more for those benefits."

This proposal seems logical. One would think that the Democrats would favor this plan, as it is really just a progressive tax. I suspect that we will see this. It does seem logical.

This picture says it all. Robert Palmer died last week of a heart attack. I have listened to his music all week, and have thought about what to say him. Robert Palmer To Have Swiss Burial

Cater said Palmer had no history of heart problems.

"Only two weeks ago he had a medical check-up which gave him a clean bill of health," he told the BBC.

But as you can see he smoked. Smoking is the number one preventable risk factor for myocardial infarction. If you smoke, stop. The day you stop your risk of a heart attack decreases. Also the risk of dying from a heart attack decreases (the carbon monoxide levels decrease rapidly, making oxygen more available to the remaining heart muscle).

I hate to see people my age dying of preventable disease. We should make good health decisions. We only get one body, and we should pamper it!

As Drug Benefits Fall, Workers Need a Strategy

As rising health care costs continue to make headlines, many employees are bracing for higher insurance premiums and co-payments for doctor's visits or medical procedures. Benefits experts also suggest keeping a close watch on prescription drug coverage in their plans - and to be prepared to pay more out of pocket for these costs, too.

There are ways for employees to keep some of their prescription costs in check, if they are willing to do a little legwork and to be flexible. For instance, they can switch to generic brands, buy in bulk and search the Internet for the lowest prices. But, most important, they should carefully review and compare the drug coverage in all the health plan offerings.

Kenneth Sperling, a health care consultant at Hewitt Associates, a human resources consulting firm based in Lincolnshire, Ill., said that 2004 "is going to be a year of change, and it's a good idea for employees not to assume that the drug benefits they had this year are what they will have next year."

Since 2001, companies' cost for providing prescription drug benefits to employees has increased 19 to 20 percent annually, according to the Segal Company, a benefits and human resources consulting firm in New York. Segal predicts an increase of 18 percent in 2004.

Benefits experts say that employers will bear much of the extra cost for prescription drugs, but that they will continue to shift some of it to workers next year, sometimes through higher co-payments. A growing number of companies will make their employees pay a percentage of their drug bills, usually around 20 to 30 percent, instead of fixed co-payments. This year alone, 47 percent of employers raised employee co-payments for prescription drugs, according to a recent study by the Kaiser Family Foundation and the Health Research and Educational Trust. The study, released last month, reviewed employer-sponsored health benefits offered by 2,800 companies.

The best way to influence the pharmaceutical industry to keep prices under control is for the marketplace to work. When a patient asks for the "purple pill" and I tell him/her that that pill costs $4-$5, and it the money comes out of their pocket, then the patient often will ask for alternatives. If they have a drug benefit, they just do not care about the cost. If they pay a percentage of the cost, they begin thinking differently. More patients will buy Prilosec OTC or generic omeprazole.

Flexible spending accounts for medical expenses may also be an answer. Last month, the Internal Revenue Service ruled that these accounts, in which untaxed income is set aside to cover an employee's unreimbursed health costs, can be used to pay for certain over-the-counter drugs. In its ruling, the I.R.S. specifically cited antacids, allergy medicines, pain relievers and cold medicines - but not dietary supplements or vitamins - as examples.

The ruling gives employers the option of deciding whether to allow these accounts to be used for over-the-counter drug purchases for 2003 or for future years. Still, in a recent survey of large employers, the Washington Business Group on Health found that virtually every employer planned to allow for the coverage. Fifteen percent would make the coverage retroactive for at least part of this year, while 56 percent planned to make coverage available as of Jan 1.

I believe the marketplace will have a greater effect on pharmaceutical pricing than any legislation. And as this article predicts, the marketplace will soon begin to work!

No matter how well I diagnosis the patient, without excellent nursing care, the patient may have a less than desirable outcome. Nursing care is extremely important. Actually, well educated nurses make a major difference.

We have a growing nursing shortage. While one could postulate many reasons for the shortage, we better spend our energies understanding the solutions! This editorial addresses some ideas. Nursing shortage could kill you

Just go read the editorial. It is good and it is important!

Diabetes, obesity on rise in U.S.

One bad development is the rise in type-II or adult-onset diabetes, which can be prevented with proper diet and exercise.

The report finds that 6.5 percent of American adults were diagnosed with diabetes in 2002 compared with 5.1 percent in 1997. Another recent study shows that about 12 million adults have been diagnosed with diabetes and an additional 5 million adults have it but do not know it.

Another 12 million adults have impaired fasting glucose tolerance -- meaning they will develop diabetes if they do not do something right away. That means losing weight, exercising and eating better.

"We are at the cusp of a problem that can even get much worse," Bernstein said.

The development affects not only patients themselves, but the health care system. Diabetes is the fifth leading cause of death among women and sixth among men. The condition is associated with heart disease, chronic kidney disease, blindness, and amputations.

"Almost one in five hospitalizations in people over 45 has a diagnosis of diabetes associated with it," Bernstein said.

As we worry about rising health care costs, we need to understand this component of prevention. If we would invest in exercise and weight loss, we would be healthier. Healthy people have lower health care costs.

Our genetics have not changed in the past 5 years. But our waistlines have. We can only blame ourselves. We must change. We must all take personal responsibility for our health.

Robert Prather understands that until each person understands the cost of health care, he/she will not have the motivation to act - Health Insurance Again But act we must.

We need a different insurance system. One which keeps patients in touch with costs. Read Prather and the linked article from Reason.

And by the way - eat smart, keep portions under control, and exercise. That plan really works.

Brain science reveals what men are really thinking

The male brain secretes less of the powerful primary bonding chemical oxytocin and less of the calming chemical serotonin than the female brain.

So while women find emotional conversations a good way to chill out at the end of the day, the tired male brain needs to zone out all that touchy-feely chatter in order to relax -- which is why he wants the remote control to zap through "mindless" sport or action movies.

His brain takes in less sensory detail than a woman's, so he doesn't see or even feel the dust and household mess in the same way. Anyhow, the male brain attaches less personal identity to the inside of a home and more to the workplace or the yard -- which is why he doesn't get worked up about housework.

Male hormones such as testosterone and vasopressin set the male brain up to seek competitive, hierarchical groups in its constant quest to prove self-worth and identity. That is why men, paradoxically (from a hormonally altered new mother's point of view), become even more workaholic once they have kids, to whom they must also prove their worth.

These concepts seem obvious to this product of X and Y chromosomes. Maybe this article (which refers to a book) will help some women understand the men in their life. Maybe it won't.

Puzzling study on breast implants, suicide: Rate triple that of general population, but reasons unclear

The latest study, published Wednesday, found that Finnish women who had cosmetic implants were more than three times more likely to commit suicide than the general population -- in line with findings from a similar study of Swedish women and one of American women conducted by the National Cancer Institute.

All three studies also found that women with implants had overall death rates the same or better than the general populations, suggesting that the implanted devices were not causing disease during the time period studied, as once feared.

But the studies all noted the suicide rate as significantly -- and at this point inexplicably -- higher than expected.

Right now, please stop reading, close your eyes and think. What might cause this finding? Clearly, the data do not come from randomized controlled trials. Therefore, we must consider two possibilities - cause-effect or a confounding variable.

I have difficulty imagining and cause-effect hypothesis (although someone may develop a reasonable one). I can more easily imagine a confounding variable.

Now we must consider ways in which women who get breast implants differ from those who do not. These are (it seems to me) very different groups. The article speculates.

Some researchers contend the high suicide rate is a result of the psychological makeup of the women choosing implants -- that they are, as a group, women with problems different from the general population. Others say, however, that the high suicide rates are a function of the difficulties and pain that sometimes crop up years after the surgery.

McLaughlin said the data did not confirm a cause-and-effect connection between breast implants and suicide, and said it may instead be related to the nature of the women who select them. "In fact," he said, "it could be that because of characteristics of women who get implants, it may be that women who get them may reduce their risk of later suicide."

So what do we do with this information? I suggest that we consider these important thoughts:

In an article accompanying the Finnish study, University of Pennsylvania professor David Sarwer argued that plastic surgeons should make greater efforts to understand the psychological and emotional state of women seeking implants. He wrote that if a woman shows signs of instability or a history of psychiatric care, mental health professionals should be contacted before any implants are approved.

Speaking at last month's meeting of the American Medical Association, Sarwer said that 7 to 15 percent of women having plastic surgery have dysmorphic disorder, a preoccupation with a slight or imagined defect in appearance. He said that these women in particular do not respond well to cosmetic surgery.

Periodically I do housekeeping. This morning I decided to update my blogrolls. I deleted a few and added two very important and well done blogs. If you do not already read them - check out GruntDoc and Cut-to-Cure. They are (as the British are wont to say) "spot on".

As we consider health care costs, we must understand the implications of cost saving measures. Our friends to the north manage some costs by delaying some elective surgery. Cholecystectomy is one such elective operation. This excellent article discusses the implications of delaying surgery - Risk of emergency admission while awaiting elective cholecystectomy

Background: There is uncertainty regarding the frequency of adverse events while on a surgical waiting list. We assess the relationship between the duration of wait for cholecystectomy and the risk of emergency admission.

Methods: We analyzed time to emergency admission in a group of 761 patients who underwent cholecystectomy after being seen in clinic for biliary colic and placed on waiting lists at 2 acute care centres in Ontario, from 1997 to 2000.

Results: Emergency admissions due to worsening symptoms occurred in 51 patients (6.7%) waiting for elective cholecystectomy. The weekly rate of emergency admission was low during the first 19 weeks on the list, but increased almost by a factor of 3 after 20 weeks (rate ratio 2.7; 95% confidence interval 2.0?3.7). Relative to the first 4 weeks on the list, the rate was 1.6 times higher after 20 weeks, 2 times higher after 28 weeks and 7 times higher after 40 weeks.

Interpretation: The probability that a patient on a waiting list will be admitted for emergency cholecystectomy consistently increases with the duration of wait, particularly after 20 weeks.

This research points out a danger of long waiting lists. Emergency cholecystectomy is more dangerous and therefore undesirable. Patients who required emergency cholecystectomy have, in my mind, suffered needlessly. We need to understand clearly the risks of waiting lists for various surgeries.

In this study we used emergency cholecystectomy for worsening symptoms as a readily identifiable consequence of delay in surgical treatment. This type of adverse event should be examined for other surgical procedures. Clinical conditions that may require emergency surgery while patients are on a waiting list include inguinal hernia, spinal cord conditions, abdominal aortic aneurysm or the need for coronary artery bypass grafting, among others. Our results have implications for developing waiting-time limits for elective surgery. The findings suggest that patients with biliary colic awaiting elective cholecystectomy for longer than 20 weeks have a substantially increased risk for development of acute symptoms that require an emergency operation.

The Health Insurance Crisis

Even most experts were surprised by the sharp jump in the number of Americans lacking health insurance last year. The latest Census Bureau figures show that the number of uninsured jumped by 2.4 million, the largest increase in a decade, bringing the national total to 43.6 million uninsured in 2002, or 15.2 percent of the population. The ranks of the uninsured have increased by 10 percent over the past two years, with the likelihood that things may get worse this year.

The lack of health insurance, a problem once confined mostly to the poor and nearly poor, has reached into the lower middle classes, most notably to those earning $25,000 to $49,999 a year, and even to some above $50,000. It is a problem that needs to be addressed by Congress and the administration, which have thus far sat mostly on the sidelines.

Several factors are driving the expanding crisis. The number of unemployed Americans keeps growing in this jobless recovery, thus depriving many people of the opportunity for employer-provided health insurance. Even many full-time workers ? an astonishing 20 million last year ? lack health coverage.

Many employers, both large and small, are cutting back on the health insurance they provide, either by dropping it entirely or by making it harder for employees to qualify. Some are requiring much higher contributions from workers, so many workers are dropping coverage rather than paying amounts they consider unaffordable.

Underlying the problem is the still-unsolved issue of escalating health care costs, which leave employers struggling to find a way out and individuals staggered by premium increases.

The NY Times takes the easy road - let big government provide a solution. As usual, those who favor big goverrment show little understanding of the crisis, they just want Congress to solve (put a bandaid on) the problem.

Health care costs may or may not be escalating out of proportion. We must relate cost to value. We need to understand where the money goes.

Health care costs increase for many reasons. Some costs increase because newer technology makes diagnosis more reliable. More reliable diagnoses allow us to better target therapies.

Some costs increase because new medications allow us to improve quality of life or even quantity of life. Some costs increase because patients demand more care. Some costs increase because the cost of doing business increases: government regulations always cost money, malpractice insurance costs, higher salaries for employees (supply and demand for nursing staff).

So the question we should ask as a society is what health care we want, and is it worth the money? Should we expect health care expenditures to increase or not? Can we develop more reasonable governmental regulations? Can we control liability costs?

Solving the health insurance problem should require a careful analysis of all costs. We should better understand why health care costs increase every year.

Unfortunately, I am skeptical that Congress will address this issue intelligently. They rarely show common sense when passing laws which have impact on health care. Why should we expect better now?

While the benchmarks used in this study are questionable, the article does highlight an important problem. States Fail to Meet No-Smoking Goals for Women

Tobacco-related diseases are still the leading cause of preventable death in women, and most states are not meeting the nation's goals to discourage women from smoking, according to a report released today by the National Women's Law Center and Oregon Health and Science University.

Thirty-nine states earned a failing grade when judged by a list of criteria from the Department of Health and Human Services and on the strength of their tobacco control policies. The nation over all also earned a failing grade.

"Where we are in the United States is pretty appalling," said Dr. Michelle Berlin, an author of the study with Oregon Health and Science's Center for Women's Health. "The link between smoking and lung cancer is one of the strongest we know of. Yet more women are dying from lung cancer each year than they are from breast cancer."

Lung cancer has been the leading cause of cancer death in women since 1987, when it surpassed breast cancer.

"This reminds us that we have a long way to go with regard to tobacco use among women," said Dr. Corinne Husten, chief of epidemiology at the office on smoking and health at the Centers for Disease Control and Prevention. "It reinforces the need for comprehensive state tobacco control programs."

Study: Fat or thin -one gene does it?

SCIENTISTS HAVE long suspected a genetic link in determining how our bodies regulate weight. Now Icelandic biotechnology company deCODE genetics Inc says it has isolated a specific gene which, in different forms, tends to make us either overweight or underweight.

The finding is the result of analysis of DNA from more than 1,000 Icelandic women.

"Obesity and thinness are two sides of the same coin," said deCODE Chief Executive Officer Kari Stefansson. "This is an important step towards developing new drugs that can treat obesity, perhaps by utilizing the body's own mechanisms for promoting and maintaining thinness."

This is an interesting claim. We need more information to evaulate the claim. Hopefully we will see more stories on this issue over the next few months.