We all really know this. Talk to any smoker, and he/she will tell you that they always drink more in a bar. The physiology makes sense. Habits: A Smoke Much Sweeter

A new study has found that alcohol, even in very small amounts, appears to enhance the pleasurable effects of nicotine.

At the same time, the researchers say, nicotine may counteract some of the effects of alcohol, like drowsiness.

"It may be kind of a balancing act in the brain ? that you're taking one substance to balance the effects of another substance," said Dr. Jed E. Rose of the Nicotine Research Program at Duke University and the lead author of the study, which appears in the current issue of Nicotine & Tobacco Research.

The link between alcohol and tobacco is strong and complex. According to the researchers, as many as 90 percent of alcoholics smoke. And alcoholism is much more likely to occur among smokers than among nonsmokers, they said.

But while there has been a longstanding cultural marriage between drinking and smoking, scientists have had trouble explaining the physiological relationship. Some have theorized that alcohol lowers the ability of nicotine receptors in the brain to respond to the drug, creating a desire for more cigarettes.

While this may, in fact, occur in some receptors, the new study reports, over all, alcohol makes nicotine more pleasurable.

If researchers can better decipher this interaction, we might gain some treatment ideas. It does explain an interesting phenomenon, and provide some useful information for counseling patients.

As one commenter suggested, I have really enjoyed the comments on my paternalism rants. They have help inform my conceptualization about this subject.

If one takes a libertarian viewpoint in our society one must still understand that the limits of ones freedom end when another is harmed. The common shorthand expression - The freedom of your fist ends just short of my nose.

So the first test for restricting a medication must involve potential costs to society of improper use. Certainly all antimicrobials fit into that paradigm. The huge problem of MDR-TB (multidrug resistant tuberculosis) stems from unrestricted access and distribution of TB drugs. You may want to take your medications as you choose (or even think you have researched). However, your knowledge lack can lead to my worse illness. In fact, we take a very paternalistic view of TB in this country requiring DOT (directly observed therapy) give through public health departments.

One can certainly extend this concept to all antimicrobials - the good of many others should outweigh your desire to buy antibiotics without seeing a physician.

Admittedly, the philosophical position gets more complex when discussing cardiac medications. However, your illness improperly treated (because you chose your meds rather than having a trained physician choose those meds) costs society significant dollars - from hospitalizations, lost productivity, etc. That decision also has a significant impact on your loved ones.

Critics argue against licensing physicians and requiring proper training. I have a difficult time understanding that position. Medical care has advanced dramatically over the past 50 years. This care advances because of our training and research. We do need standards for the public good.

You can choose care from a non-physician - e.g. chiropractic care. That certainly gives you freedom. You can go to a health food store and self treat with supplements and herbs. That gives you freedom. In my opinion that also gives you substandard care.

Like many such arguments, one can take a highly controversial position and incite everyone. However, as I read the comments, that highly controversial position does not withstand careful scrutiny for our society.

Our current medical system is not perfect, but it is very good. We do improve the quality of lives. We do lengthen life spans. We cure many infections. I cannot believe that a call for anarchy will help society. Thus, your freedom to buy any medication that you desire without medical consultation could lead to societal harm. And that should be the main concern.

EKR at Educated Guesswork writes about my paternalism rant - When is paternalism justified?

I think DB is missing something important here. Sure, if you want high quality medical care and you're not medically sophisticated you want to be under the supervision of a doctor. The problem is that it's legally mandated. There's no law against me working on my own car, but when I have a transmission problem, I don't drop the tranny in my garage--I take it to a mechanic. (To tell the truth, I take it to a mechanic to have the wiper blades changed). So, I think if you want to have mandatory paternalism, you really have to explain why people aren't able to decide for themselves whether they want close monitoring. In my view, DB doesn't do that satisfactorily.

Let me try again. Many patients make their own decisions regardless of our recommendations (and remember, we prescribe we do not force feed medications). I guess a well educated patient might be able to figure out a complex medication regimen. But it really is unlikely. I guess I could treat myself - but we do have a saying about that - "The doctor who treats himself has a fool for patient".

So I must endorse this form of paternalism. Physicians have the training and experience to juggle the multiple conditions and disease manifestations. We should include the patient in our decision making - but we should recommend and recommend strongly a treatment course that best fits the available evidence. For that I do not apologize!

Paternalism In Medicine - Part II: Gatekeepers

Trent McBride writes a long rant about the influence of prescription drugs on the doctor patient relationship. First, I love the blog's title - I love renal physiology. Maybe I should rename my blog the Countercurrent Mechanism. Or that could be a great name for an alternative band!

Trent hypothesizes that making patients come to the doctor for prescriptions represents the ultimate form of paternalism. I will disagree to some extent on his proposed solutions.

Yes, prescribing medications is paternalistic. But then I do not assume that all medical paternalism is bad.

If you have congestive heart failure, I have a complex drug regimen to prescribe. Adjusting these medications requires repeated visits. I must understand the side-effects of each medicine, alone and in combination. I must consider your renal function, and your electrolytes. Finally, I must prescribe the medications with an understanding of your other medical problems (and few patients have CHF alone).

So to provide the highest quality care, I believe that I must be paternalistic. In that sense paternalism is not a bad attribute.

Narcotics might be the exception. I do not really know how much pain a patient suffers. How can I judge the best method for treating that pain? Should I worry about narcotic abuse? Wouldn't we be better off if we just let patients buy their own pain meds and suffer their own consequences?

Trent does mention antibiotics - and he is correct. But I will gladly argue that many conditions which I treat require complex decision making and adjusting of multiple medications. I accept that paternalism and I believe the great majority (>90%) of patients want that paternalism.

Caveat ahead - even when one must take a paternalistic stance, one should still discuss the rationale for each medication with the interested patient. When choices are available for treatment, we can and should discuss those choices with the patient.

So as usual, I am a bit wishy washy. I agree with some of the Tubule's argument. But I believe he goes overboard. But after all, that is what blogs are for - to stimulate our thinking and challenge accepted thinking. And therefore he succeeds.

A New Era in Treating Imaginary Ills

They make frequent doctors' appointments, demand unnecessary tests and can drive their friends and relatives — not to mention their physicians — to distraction with a seemingly endless search for reassurance. By some estimates, they may be responsible for 10 to 20 percent of the nation's staggering annual health care costs.

Yet how to deal with hypochondria, a disorder that afflicts one of every 20 Americans who visit doctors, has been one of the most stubborn puzzles in medicine. Where the patient sees physical illness, the doctor sees a psychological problem, and frustration rules on both sides of the examining room.

Recently, however, there has been a break in the impasse. New treatment strategies are offering the first hope since the ancient Greeks recognized hypochondria 24 centuries ago. Cognitive therapy, researchers reported last week, helps hypochondriacal patients evaluate and change their distorted thoughts about illness. After six 90-minute therapy sessions, the study found, 55 percent of the 102 participants were better able to do errands, drive and engage in social activities. Antidepressant medications, other studies indicate, are also proving effective.

"The hope is that with effective treatments, a diagnosis of hypochondriasis will become a more acceptable diagnosis and less a laughing matter or a cause for embarrassment," said Dr. Arthur J. Barsky, director of psychiatric research at Brigham and Women's Hospital in Boston and the lead author of the study on cognitive therapy, which appeared in the March 24 issue of The Journal of the American Medical Association.

If these patients do not induce "heart sink" then you are a different physician than me. These patient's name on your daily list causes anxiety, depression and thoughts of illness.

The biggest challenge is sorting out their hypochondriacal complaints from real disease, because even a hypochondriac can get sick.

I once had a patient who came to me after having 17 negative HIV tests. He had not had any sexual relations in over 6 months, yet thought he needed another test.

I saw this patient for around 9 months. My greatest feat was getting him back to see his psychiatrist, as he also had major depression. Over time with reassurance, calm, scheduled appoints and medication he was able to regain a productive life.

As I read the article this morning, I saw most of his personality and problems. We (physicians) would all like a consultant who wanted to see these patients, as most physicians and psychiatrists shun them. I certainly hope that these initial positive reports are confirmed.

Wow - sometimes research provides good news. FITNESS: Study finds no evidence stretching prevents injuries

People who stretched were no more or less likely to suffer injuries such as pulled muscles, which the increased flexibility that results from stretching is supposed to prevent, researchers found. And the injuries found in the study typically happened within the muscle's normal range of motion, so stretching them would not have made a difference, Thacker said.

Other research has found that warmups, which increase blood flow through the muscle and make it more ready to respond to exercise, can reduce the risk of injury, Thacker said. Being in good shape also helps. Strength and balance training reduced injuries as well, he said.

Sounds good - warm up, stay in shape, do not worry so much about stretching.

The Limits of Opening Arteries

Experts agree that artery-opening methods ? like bypass surgery, or insertion of a balloon to mash down plaque and a wire-cage stent to keep the channel open ? can alleviate crushing chest pain and save some lives. But patients should not assume that their cardiovascular problems are "fixed" by such procedures, and patients without symptoms whose arteries are narrowing should be wary about undergoing these procedures to ward off a potential heart attack. They may have hundreds of vulnerable plaques elsewhere that are more apt to burst and trigger a heart attack than are the more stable plaques in the narrow section. Most such patients might better be treated with drugs to lower their cholesterol levels, control their blood pressure and prevent blood clots, or should adopt a healthier life style by giving up smoking, eating heart-healthy foods and exercising.

What follows represents the implications of this essay and the accumulated data that I teach on rounds. I have tried to interpret the original data and read about the theories.

Procedures - CABG and stenting - are still very important in 2 scenarios. First, patients who have just had an acute coronary syndrome, especially a small heart attack (which we call either NSTEMI or non-Q wave MI), clearly benefit from immediate intervention. Second, patients who have extensive disease (usually 2 or 3 vessels with severe narrowing) and problematic symptoms have their symptoms improved with interventions. Choosing an intervention must take into account the lesions, their location and availability of good artery past the obstruction. One must also consider current cardiac function (e.g., 3 vessel disease with a decreased ejection fraction has better results from surgery).

One should not go looking for disease to "repair" in asymptomatic patients. One might want to diagnose disease in patients with mild or equivocal symptoms - but not to "repair" the disease.

Regardless of whether patients do need a procedure, they need good medical management. I have written often about this issue. To reiterate:

We clearly know that coronary artery disease patients benefit from 4 drug classes

• Platelet inhibitors - aspirin, clopidogrel (in certain circumstances)
• Beta blockers
• ACE inhibitors or ARBs
• Statins

So the article and this editorial describe the current thinking of coronary artery plaques as fragile changing lesions. Understanding the dynamic nature of plaques gives us a broader understanding. This concept explains much current clinical trial and epidemiologic data. It drives current therapy.

Most important it should give hope to patients. As patients we can take some responsibility for our hearts. Exercise, weight control, and - when indicated - medications can modify coronary artery plaques, leading to regression and stabilization. Patients can often prevent coronary artery disease, but when they cannot (bad genetics especially), physicians can help greatly by prescribing the right drugs. Of course, the responsibility quickly reverts to the patient who then must take those medications.

Listening to philosophy tapes certainly gives me a different perspective on medicine. Currently I am listening to Will to Power: The Philosophy of Friedrich Nietzsche. This morning on the way to working out and then to work I was lietening in particular to: Lecture 11: Nietzsche on Truth and Interpretation. This lecture expands on the quote you see on the right of this blog: There are no facts, only interpretations. - Nietzsche .

As the lecturer expands on this discussion, I started to understand why yesterday's rant created such interest (8 comments by this morning). As I personally rate my rants, the number of comments provides me a good indicator of their effectiveness in stimulating thinking and interest.

Reading the comments, and then rereading Sydney's column, I realize that I am working from a different context. Nietzsche would argue (or at least the lecturer is arguing for him) that we only have interpretation in our attempts at truth. All interpretations depend on the context in which one views the data.

Our friend and frequent poster Bernie lives in a different contextual framework than I do. Thus, he views the same data but interprets it differently.

Now unlike many politically correctness advocates today, Nietzsche does not assume that all viewpoints have equal value (of course, he is judging from his own context). I believe that the bio-medical model is the superior model for judging medical data. (Bernie might disagree - but then I should not speak for Bernie).

As I read Sydney's column, she alludes to an important point. We must take all new data and put those data into our underlying context. What do we already know? Can we reconcile these new data with previous data?

I believe that the best way to interpret new data uses the principles of evidence based medicine. One should not discount previous knowledge or expert opinion (I am a Bayesian, and therefore adjust my probabilities based on prior information).

However, we should not ignore new data just because it does not fit current expert opinion. When the major study examining anti-arrhythmic therapy after MI came out - we all changed our context and practice - FINAL REPORT FROM THE CAST STUDY . The study results were unexpected and counter to expert opinion. The study had such compelling results that it overcame previous expert opinion and changed expert opinion.

As one studies the precepts of evidence based medicine, one first learns the hierarchy of research designs. The randomized double blind controlled clinical trial is the epitome of research. Epidemiologic studies represent an excellent method for generating hypotheses.

Perhaps my disagreement over Sydney's column involve shades of interpretation. I know many physicians who teach and practice evidence based medicine. They strive to interpret data in the context of previous knowledge and the quality of the new data.

I agree that often the popular press does not hold the same high standard. Autism and MMR attracts headlines, and headlines sell papers. Even if most medical reporters understand the evidence and avoid the article, some other reporter will see this as a quick easy controversial piece to publish.

So I would probably have written a similar article, but shaded it differently. In my mind we must remain skeptical of all new data and wait for the accumulation of supporting data prior to changing our contextual model. As a physician and scientist this seems natural. Perhaps Sydney's underlying message is that patients should remain just as skeptical.

Medpundit (Sydney Smith) and I often disagree on issues. We have communicated and agree that our public disagreements (on our respective blogs) advance thinking. Only when we have polite yet spirited debate can our readers be stimulated to think carefully about issues.

In this spirit I wish to disagree with her latest Tech Central column - Medical "Truths"

And medical science has continued to march on, or so we like to think. Discriminating doctors of the early twenty-first century, unlike the doctors of the early twentieth, pride themselves on practicing "evidence based medicine." Unless there's a paper and statistics to back up a theory, we don't put it into practice. We like to think of medicine as a hard science, as dependent on the observable and quantifiable as chemistry, or some branches of physics. But, the truth is, in many respects medical science has devolved into a science as soft as economics or sociology.

Sydney does a nice job in this article of creating a straw man argument. She reasons that when she can show examples of incorrect analyses, that we can discard all analyses. She argues (I believe) that evidence-based medicine is futile because the studies are so often flawed.

There's nothing wrong with putting forth a hypothesis. That's what science is about, coming up with and disproving hypotheses. But not all hypotheses are created equal, and this one was based on particularly shoddy science -- a very small study, and the confusion of association with causation. Yet, for some reason The Lancet found it worthy of publication, well aware of the potentially devastating effects its poorly thought out conclusions could have on public health. At the time of publication, the article was accompanied by a prescient guest editorial from an official at the CDC that warned that "passion would conquer reason and the facts" if the study's conclusions were taken at face value by the media and the public. And that is just what happened. Blessed with the imprimatur of a world renowned medical journal, and a subject enticing to the media, the lead researcher was treated to a press conference at which he suggested that parents should avoid the MMR vaccine. MMR vaccine rates in Great Britain, where the story got much play, plummeted, and the incidence of measles rose. Within two years of the study's publication, there was a measles outbreak in Dublin that killed two children and hospitalized hundreds more.

She makes an interesting point about the article which supposedly linked MMR and autism. However, I believe that she targets the wrong group with her criticism. Certainly the Lancet editors made a mistake here. However, I am not aware of physician groups who endorsed this study as "evidence based medicine". Rather, "advocacy" groups of parents made this study a reason to avoid MMR. Most experts disagreed with the study at the time of publication.

Sydney finishes with:

These are but two of the most recent and glaring examples of just how soft medical science has become, or perhaps remained. There's no shortage of marginal hypotheses that appear in the medical literature and are passed on to the lay press as solid fact. That's why one day hormone replacement therapy is good for you and the next it's bad. Why one day fish is a health food, and the next it's a toxin. We may have better technology, better drugs, and a better understanding of many disease processes than our forefathers did a hundred years ago, but we're no more sophisticated than they were in sifting the bad science from the good.

Wow! This sentence insults the entire field of evidence based medicine and medical research. What a powerful sentence! But the sentence is incorrect and an example of hyperbole.

Those of us who try to practice evidence based medicine (and we freely admit when the evidence is not satisfactory to use) work hard to carefully evaluate the data. We rarely change our practice on a single study, unless it is a large, carefully done randomized controlled trial. One great web site for evidenced based medicine: Bandolier. The Cochrance collaboration provides outstanding reviews (requires a subscription).

The advances in medical treatment over the past 25 years are incredible. 25 years ago we had no way to modify lifespan in CHF. Now we can greatly increase life expectancy for those patients. Similar stories exist in diabetes mellitus, coronary artery disease and many cancers.

One should never regard a single study as the answer to our questions. However, as data accumulate we often can provide better care to our patients. We need more critical inquiry concerning published articles. We must put each new piece of information into context. If we do not do that, then we resemble ostriches.

We have made much progress both in scientific inquiry and the careful criticism of published articles. Medicine progresses not in a straight line, but rather through fits and starts, in a jagged line. But it does progress, and our patients benefit regularly from that progress.

Now this represents an interesting problem. Justices Hear Arguments About H.M.O. Malpractice Lawsuits

With the debate over patients' rights stalled in Congress, the issue moved to the Supreme Court on Tuesday in an argument about whether patients can invoke state law to sue managed-care companies for medical malpractice when treatment recommended by their doctor is withheld.

The federal law that governs the health insurance that millions of people receive through their workplace does not authorize such lawsuits. The question for the court is whether that law, the Employee Retirement Income Security Act of 1974, or Erisa, pre-empts the growing number of state laws that do.

The ability of patients to sue health maintenance organizations for damages for the denial of needed care is one of the most contentious issues in the health care debate, and this case has drawn intense interest from the industry and consumers alike.

Two managed-care companies, Aetna Health Inc. and Cigna HealthCare of Texas, are appealing a federal appellate decision that permitted patients' lawsuits to proceed under the Texas Healthcare Liability Act. President Bush was governor of Texas when the measure became law in 1997, without his signature, and he embraced the law during his last presidential campaign.

Now, however, the Bush administration is supporting the managed-care companies in arguing that the Texas law and others like it are invalid. Nine other states — Arizona, California, Georgia, Maine, New Jersey, North Carolina, Oklahoma, Washington and West Virginia — have enacted similar laws. These laws threaten to upset the "very careful balance" that Congress struck in the federal law, James A. Feldman, an assistant solicitor general, told the court.

As I consider this problem I do feel some conflict. I dislike legal solutions to these problems, but ... many managed care companies put physicians and patients into undesirable situations. While I understand the law, I disagree with the reasoning underlying the law. Thus, I must strongly disagree with the Bush administration on this issue.

Whenever I consider such a conflict, I try to consider first principles. In this case, patient care should trump everything. If that assumption is true (and I understand that some would debate that assumption), then it follows that managed care companies should not restrict necessary care.

First, I will start with an absurd hypothetical. A patient comes to the office with severe pneumonia. You calculate a pneumonia severity score - Improving Treatment Decisions for Patients with Community-Acquired Pneumonia - and determine that the patient needs hospital admission. The managed care company refuses admission and thus you try treating the patient as an outpatient. The patient dies. Who gets sued? Can the managed care company make this decision for financial reasons?

Now that example clearly rates as aburd, however, I have heard similar anecdotal stories over the years. What are the boundaries of medical decision making without liability for a managed care insurer?

I do not understand how I can be held liable for a decision for which I have incomplete responsibility. Thus, at least at the extremes, the insurer who refuses care must take some responsibility (and thus liability). I cannot understand any law which would prohibit this responsibility.

We will follow this decision with great interest.

Juan Davila, one of the two patients whose suits led to the Supreme Court case, was prescribed Vioxx by his doctor for arthritis but was required under his Aetna health plan to try two less expensive medications first. One of those drugs caused severe gastrointestinal bleeding that sent him to the emergency room.

The other patient, Ruby Calad, was hospitalized for a hysterectomy and other abdominal surgery under a Cigna HealthCare plan that authorized a one-day stay for those procedures. Though her surgeon recommended a longer stay, Cigna's hospital-discharge nurse refused to authorize it. Ms. Calad suffered complications at home and had to make an emergency return to the hospital several days later. The two cases, consolidated for the argument, are Aetna Health Inc. v. Davila, No. 02-1845, and Cigna HealthCare of Texas v. Calad, No. 03-83.

George P. Young, the patients' lawyer, said the inability of people like his clients to recover damages under federal law had necessitated the state's action. " What Texas has done is to fill a vacuum and say we are going to set out a professional medical standard of care when H.M.O.'s make medical necessity decisions," Mr. Young told the court.

He said that under the companies' position "they would be free to say we're going to use the medical-necessity standard of a witch doctor or whatever we decide it is."

The data continue to support moderate alcohol as cardioprotective. Study: Drinking May Help Heart Patients

In the study, men with high blood pressure who reported having about one or two drinks a day were 44 percent less likely to die of cardiovascular causes such as heart attacks than men with hypertension who rarely or never drank.

Alcohol is known to increase levels of good cholesterol and can thin the blood, warding off artery-clogging clots that can cause heart attacks.

A drink or two a day has been linked with reduced cardiovascular risks in healthy men and women. But many doctors are wary about alcohol use among people with hypertension because heavy drinking can increase blood pressure. For that reason, the American Heart Association generally advises patients with high blood pressure to avoid alcohol.

The latest findings suggest that moderate alcohol consumption offers the same benefits to hypertensive patients as it does to healthy people. But the researchers said the findings need to be confirmed in other large-scale studies.

They and other experts advised people with high blood pressure to remain wary about drinking.

"In light of major clinical and public health problems associated with heavy drinking, recommendations regarding alcohol use must be made on an individual basis," said the authors, led by Dr. J. Michael Gaziano, a researcher at Brigham and Women's Hospital and the Veterans Affairs hospital in Boston.

The findings appear in Monday's Archives of Internal Medicine.

Each study continues the general support for a drink or two each day. Clearly alcohol has a dose response curve. No alcohol or too much alcohol can harm us in different ways.

I continue to favor moderate alcohol unless the patient has a known alcohol problem.

What is malpractice? What are the costs of malpractice cases? Why does the legal system frustrate physicians so much?

One physician's malpractice battle: Dr. Diakos on trial

Despite the "win," Dr. Diakos said she didn't feel like celebrating. "I'm glad it's over," she said a few days after the trial. "But this was not a cost-free case for us."

The insurance company had to pay to defend the suit and Dr. Diakos lost about a week's worth of office time, using vacation days for the deposition and trial.

And she was clearly innocent.

Congress to look at Medicare pay formula

Physicians pushing for Medicare payment reform are hoping that Congress makes good on its intentions.

As lawmakers worked to finalize legislation laying out a fiscal year 2005 budget blueprint, the Senate Budget Committee attached a provision expressing the Senate's intent for Congress and the administration to correct "major flaws" in the formula used to determine Medicare payments for physician services. At press time, the Senate had not yet voted on the budget measure.

This intention is a "no brainer". Everyone knows that the current formula has major flaws. We need to fix the formula, not the payments.

Under the current payment formula, when spending for physician services exceeds an annual target, called the sustainable growth rate, future payments must be reduced to make up for the excess spending.

Physician groups, including the American Medical Association, argue that doctors have been held responsible for increases stemming from higher drug costs and new coverage mandates, despite having no control over this spending.

I certainly hope that Congress can pass a small bill to address this problem. But knowing Congress, they cannot think about one seemingly small problem at a time. Their effectiveness would increase if they did.

New Studies Cast Doubt on Artery-Opening Operations.

This important article does a very nice job of explaining our evolving understanding of CAD. Let me try to summarize the concepts - then go read the article.

CAD has two components, first the deposition of lipid laden atherosclerotic plaques. We used to think that these plaques were static, and grew over time. As they grew into the lumen, they eventually obstructed arteries leading to symptoms. However, several observations over the past 10-20 years have changed that thinking.

We now believe that plaques exist in a dynamic endothelium. Acute coronary syndromes occur when plaques rupture and release platelet aggregating factors. These PAFs attract first platelets - leading to the eventual development of clots - which cause acute vessel obstruction presenting as acute coronary syndromes.

This current theory (with much convincing data) stresses inflammation leading to plaque instability and the coagulation system.

We know that in acute coronary syndromes, opening the vessel helps in the short run. We also know that medication treatment remains very important. "Fixing the obstruction" does not cure the underlying disease.

We now have increasing evidence that patients with stable CAD need not have obstructions "fixed" with surgery or stents. Rather we should stress aggressive medical management with platelet inhibitors (esp aspirin), beta blockers, ACE inhibitors and statins.

This theory, which follows from available data, treats CAD as a dynamic disease which we can modify at the endothelial level.

Now for a few quotes from this well researched article:

But the new model of heart disease shows that the vast majority of heart attacks do not originate with obstructions that narrow arteries.

Instead, recent and continuing studies show that a more powerful way to prevent heart attacks in patients at high risk is to adhere rigorously to what can seem like boring old advice — giving up smoking, for example, and taking drugs to get blood pressure under control, drive cholesterol levels down and prevent blood clotting.

Researchers estimate that just one of those tactics, lowering cholesterol to what guidelines suggest, can reduce the risk of heart attack by a third but is followed by only 20 percent of heart patients.

"It's amazing and it's completely backwards in terms of prioritization," said Dr. David Brown, an interventional cardiologist at Beth Israel Medical Center in New York.

Heart experts say they understand why the disconnect occurred: they, too, at first found it hard to believe what research was telling them. For years, they were wedded to the wrong model of heart disease.

"There has been a culture in cardiology that the narrowings were the problem and that if you fix them the patient does better," said Dr. David Waters, a cardiologist at the University of California at San Francisco.

The old idea was this: Coronary disease is akin to sludge building up in a pipe. Plaque accumulates slowly, over decades, and once it is there it is pretty much there for good. Every year, the narrowing grows more severe until one day no blood can get through and the patient has a heart attack. Bypass surgery or angioplasty — opening arteries by pushing plaque back with a tiny balloon and then, often, holding it there with a stent — can open up a narrowed artery before it closes completely. And so, it was assumed, heart attacks could be averted.

But, researchers say, most heart attacks do not occur because an artery is narrowed by plaque. Instead, they say, heart attacks occur when an area of plaque bursts, a clot forms over the area and blood flow is abruptly blocked. In 75 to 80 percent of cases, the plaque that erupts was not obstructing an artery and would not be stented or bypassed. The dangerous plaque is soft and fragile, produces no symptoms and would not be seen as an obstruction to blood flow.

So for all those at risk for CAD and heart attack, we should follow a fundamental health prescription. Do not smoke. Keep our weight reasonable and exercise. Address hypercholesterolemia, especially with either a family history or diabetes mellitus. Treat hypertension.

Many experts worry about chronic mercury poisoning. An advisory panel has published new recommendations, with specific reference to albacore tuna. U.S. Issues Guidelines on Eating of Some Tuna

The Food and Drug Administration and the Environmental Protection Agency will recommend Friday that pregnant women, nursing mothers and young children eat no more than six ounces of albacore tuna or about one meal's worth each week, administration officials said.

As the article states, the recommendations differ according to the type of tuna, with light tuna having less mercury.

The new guidelines will say that young children and women who are pregnant, nursing or planning to become pregnant can eat up to 12 ounces per week of light tuna, which has less mercury and accounts for about 13 percent of the nation's seafood consumption.

The agencies will continue recommending that those groups limit their intake of shark, swordfish, king mackerel and tilefish, which can also have high levels of mercury.

Colon cancer screening works, but many patients reject current screening tests for a variety of reasons. "Virtual" colonoscopy sounds like a nice alternative. The prep is just as unpleasant, but the risks are significantly less.

Gastroenterologists will support this technology, as it will increase their interventional colonoscopy business. Moreover, we do not have enough gastroenterologists to perform all the needed screening colonoscopies. Here is another study reporting on the diagnostic test performance of CT colonoscopy. CT Colonography Helpful in Cancer Screening

CT colonography compares well with conventional colonoscopy in detecting polyps with a diameter of at least 10 mm, New York-based researchers report in the March issue of Radiology. They concede that performance is lower with smaller lesions but point out that if patients undergo 5-year screening, "missing small lesions is likely to be clinically insignificant."

"The examination is well tolerated, does not require sedation and can be certainly used in patients who are unwilling to undergo conventional colonoscopy or in patients with underlying medical conditions that make conventional colonoscopy risky," lead investigator Dr. Michael Macari told Reuters Health.

Dr. Macari of Tisch Hospital, NYU Medical Center and colleagues also note that use of the evolving CT technique may increase public acceptance and thus increase the number of patients who undergo colon cancer screening.

To compare the results of the two screening approaches, the researchers studied 68 asymptomatic men who were deemed to be of average risk and were aged more than 50 years. They underwent CT colonography followed by colonoscopy on the same day.

A total of 98 polyps were found in 38 patients by colonoscopy. Of these, 21 (21.4%) were detected by CT. All 3 polyps of 10 mm or larger were uncovered by CT. However, this was true of only 11.5% (9 of 78) of those of 1 to 5 mm and 52.9% (9 of 17) of those of 6 to 9 mm in diameter.

Not an overwhelming study, but another piece of data in the continuing story.

There are no facts, only interpretations.
from Nietzsche's Nachlass, A. Danto translation.

Having been an expert witness on 2 occasions, I have chosen to no longer participate in the process. I have had colleagues who do this frequently. Being an expert witness is financially lucrative.

Because of the financial benefits we have a class of expert witnesses for hire. Reforming the "expert witness" system.

Medical malpractice civil trials often involve so-called expert witnesses in order to provide testimony on the current standards of medical practice and whether they were adhered to in a specific case or whether the actions of the physician where likely to have contributed to or directly caused injury to the patient. Such expert testimony is needed because of the insane way our justice system organizes civil trials.

=================

Therefore both the plaintiff and defendant use "expert witnesses" to provide testimony that supports one side or another and it is here where the problems start. The irony is that the same bias that the court wants to avoid in jurors by excluding peers of the same profession is accentuated in the form of expert witnesses who are paid for their testimony. This has created an entire industry of "expert witnesses for hire", many of whom have highly questionable credentials and are too willing to "stretch the truth" or even simply state their "expert opinion" without any evidence to base such an opinion.

Such testimony enables their side to win the case and this may, in turn, lead to the witness being hired for more cases by the same law firm (it is considered unethical to pay expert witnesses based on the outcome of the trial). An example of such abuse of the system involves Jetta Brown MD who was hired by trial lawyer Ramon Garcia to provide "expert testimony" in a lawsuit involving cardiothoracic surgery;

Go read his entire rant. He highlights a feature of the malpractice problem on which we rarely focus. And that feature is very important.

I rarely rant about osteoporosis, yet I probably should. Osteoporosis remains a major cause of morbidity and mortality, especially in post-menopausal women, but also in older men and especially those men and women who take corticosteroids.

Thus, this report is very encouraging. Osteoporosis Drug Found Safe to Take for 10 Years

For millions of women who have the bone-thinning disease osteoporosis, researchers are reporting that Fosamax, the drug most commonly used worldwide to improve bone density and prevent fractures, can be taken safely and effectively for 10 years.

About three million Americans now take the drug, most of them postmenopausal women with osteoporosis, according to its maker, Merck.

The new study, the longest clinical trial ever conducted in osteoporosis, found that Fosamax enabled postmenopausal women to maintain or increase their bone density through 10 years of treatment, with no apparent ill effects. The improved bone density persisted even after the drug was stopped and diminished only gradually.

The study is being published today in The New England Journal of Medicine.

Yes this is important good news. One always worries about long term effectiveness. This study documents the answer to an important clinical question.

Home BP Measurement More Useful Than Office Measurement

Home blood pressure (BP) measurement has better prognostic accuracy than office-based measurement, according to the results of a cohort study published in the March 17 issue of The Journal of the American Medical Association.

"BP measurement in clinicians' offices with a mercury sphygmomanometer has numerous drawbacks," write Guillaume Bobrie, MD, from the Hôpital Europeen Georges Pompidou in Paris, France, and colleagues from the SHEAF (Self-Measurement of Blood Pressure at Home in the Elderly: Assessment and Follow-up) study. "In contrast, the use of home BP measurement improves measurement precision and reproducibility."

In a European cohort of 4,939 elderly patients (48.9% men) being treated by general practitioners for hypertension, mean age was 70 ± 6.5 years, and mean follow-up was 3.2 ± 0.5 years. Uncontrolled hypertension was defined as at least 140/90 mm Hg for office BP and 135/85 mm Hg for home BP.

At the end of follow-up, at least one cardiovascular event (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, transient ischemic attack, hospitalization for angina or heart failure, angioplasty, or coronary artery bypass graft surgery) had occurred in 324 patients.

For BP self-measurement at home, the risk of a cardiovascular event increased by 17.2% (95% confidence interval [CI], 11.0% - 23.8%) for each 10-mm Hg increase in systolic BP, and by 11.7% (95% CI, 5.7% - 18.1%) for each 5-mm Hg increase in diastolic BP. However, the same magnitude of increase in BP observed using office measurement was not associated with any significant increase in the risk of a cardiovascular event.

This study does make sense. We all know about white coat hypertension.

When I was seeing private outpatients, I generally involved them in their hypertensive management by having them check their BP several times each week. We would use those measurements (taken at home, at a pharmacy or at the fire station) as the data that we used to adjust their BP meds.

I always believed that this method had two positive outcomes. First, it helped the patient understand that BP control was their job, not my job. I can only help patients; I cannot take their medications, do their exercise or modify their diet. Second, the measured BP gave more and accurate data on their BP average (which isolated office BP did not do).

This article reinforces my belief that the office BP can be spurious.

"Home BP measurement has a better prognostic accuracy than office BP measurement," the authors write. "BP should systematically be measured at home in patients receiving treatment for hypertension."

The Flip-Flop Files

When the National Academy of Sciences (NAS) recently concluded that one's sense of thirst -- not a set number of glasses of water -- should determine the amount of liquid to drink each day, this respected scientific group overturned yet another widely held piece of health advice.

Add that to a growing list of recommendations that recently have been tweaked, changed or outright discarded. In addition to ensuring full employment for health journalists, this trend has left many consumers baffled, annoyed and discouraged.

From the finding that hormone replacement therapy doesn't help prevent heart disease in post-menopausal women to the news that we need more of certain kinds of fat in our diets, new and contrary findings are reported regularly. And consumers who thought the conclusions of medical research were ironclad often have their confidence shaken.

"We just have to accept the fact that something that is considered correct now, in a year or two there may be findings that show up to say this really isn't necessary," said Munsey Wheby, president of the American College of Physicians and professor of medicine at the University of Virginia School of Medicine. "I'm sure the public feels, 'Can't scientists just get a set of information and stick to it?' But I don't know of any way around it."

Blame can be assigned many places. Researchers and institutions often over-promote the importance of their work. Journalists, suspecting that editors and audiences don't like shades of gray, tweak findings into black or white. Consumers baffled by all the hype in the health care marketplace demand simple, unambivalent advice to act on.

Even physicians can be frustrated by the flip-flops. After giving a lecture on new guidelines for vitamin supplements during pregnancy a number of years ago, Wheby fielded a question from a physician in the audience. "Why do they keep changing these things?" the doctor asked.

As experts note, medical research and practice have never been static.

"People want science to be definitive, but anyone who has explored science knows that it is an evolving process," said Neal Kohatsu, president-elect of the American College of Preventive Medicine and an associate professor of epidemiology at the University of Iowa's College of Public Health. "Rarely is there a single definitive study. It's a matter of looking at patterns over time and seeing the results come up by different investigators."

I have ranted concerning this general issue in the past. Science demands that we test and revise hypotheses. As a physician we must search for the best data and make decisions based on those data, understanding that we may change as new data appear.

Read the long article for an update on a wide variety of interesting dietary, exercise, and even some medication issues.

Around the Globe, Drug-Resistant TB Is Rampant. TB was once known as the white plague or consumption. Literature abounds with characters who died of this scourge.

During my medical career, we have had great drugs to treat TB. Most patients have a quick and successful cure. However, due to a variety of factors, we now must once again worry about TB.

"The true burden is unknown," said Dr. Mohamed Abdel Aziz, the organization's tuberculosis expert and leader of the study. "The more we survey, the more multi-drug-resistant TB we find."

Despite 10 years of effort, the organization has examined only about one-fifth of the world's cases. Some countries have been reluctant to participate, and setting up regional laboratories, a worldwide effort led by the Prince Leopold Institute of Tropical Medicine in Belgium, is expensive and time-consuming.

In South Africa, only 1.6 percent of the cases are drug-resistant, said Abigail B. Wright, another author of the study, but the country's overall tuberculosis rate is so high that that translates into 6,000 cases. In India, which has a major TB problem, a survey limited to Tamil Nadu state found a 3 percent resistance rate.

The report highlights the need for new tuberculosis drugs, said a spokeswoman for the Global Alliance for TB Drug Development.

"The last new drug was introduced in 1963," said the spokeswoman, Gwynne Oosterbaan. Because tuberculosis is a bacterium, virtually all antibiotics attack it. But drug companies rarely test their new antibiotics against it because they might be pressured to limit the drugs' use to that disease, costing them billions.

Tuberculosis is common in very poor countries with many AIDS cases, because weakened immune systems allow the bacteria to grow. But drug-resistant cases are more common in moderately poor countries where patients receive inadequate treatment.

Many cases were found in Kazakhstan, Uzbekistan, Estonia, Latvia, Lithuania and parts of Russia, as well as in two Chinese provinces, South Africa and Ecuador. On a smaller scale, a high rate of cases per capita was also found in Israel, presumably through immigration from countries of the former Soviet bloc, the report said.

The situation in former Soviet Union countries is particularly bad because of the abrupt collapse of the bloc's economy in the 1990's, said Dr. Peter Cegielski, leader of the international multi-drug-resistant TB team at the Centers for Disease Control and Prevention in Atlanta who conducts studies in Russia.

Shortages forced many patients to cut back to one or two drugs "and that's what leads to resistance," Dr. Cegielski said. Also, a number of prisoners with TB were released in amnesties, spreading the disease. In addition, said Dr. John Jereb, a C.D.C. epidemiologist, Soviet bloc countries used unusual treatments.

In the West and in poor countries following World Health Organization recommendations, all patients are supposed to get a cocktail of four "first-line" drugs: streptomycin, isoniazid, rifampicin and ethambutol. The standard therapy, "directly observed treatment, short-course," or D.O.T.S., requires that a family member, a nurse, or even a traditional healer watch each pill swallowed every day for six months.

The first-line drugs are cheap and have few side effects. Resistance develops when patients skip pills. But researchers also suspect resistance is high anywhere that the same drugs are sold over the counter, as they are in Southeast Asia.

One of my colleagues studies this problem. Most strains are susceptible to more expensive medications. Someone must find the money to treat these patients properly. We in the US do a particularly good job at treating TB through our public health departments. For this disease we have model programs.

As this epidemic spreads, it may well once again become a major health problem. Some would argue that it already is.

Congress is trying to take preemptive action against obesity-food lawsuits (like the poorly conceived McDonald's lawsuits. The trial lawyers are screaming foul! Fast food and fat lawsuits

But now that Congress is considering a ban on lawsuits blaming food manufacturers or sellers for making people fat, Mr. Banzhaf is eager to contradict himself. In a press release issued the day before the House approved the Personal Responsibility in Food Consumption Act by a 2-to-1 margin, he said the bill "is surely premature, because there has been only one obesity lawsuit, and it was dismissed by a federal judge."

Before Congress passes legislation like this, Mr. Banzhaf said, "there should be a real history of abuse which must be corrected, not orchestrated panic based upon one failed lawsuit and some quoted-out-of-context rhetoric." Having orchestrated the panic and provided the rhetoric, he knows whereof he speaks.

Huh?

This proposed law is necessary to prevent a series of lawsuits, spending the courts money unnessarily. But then the trial lawyers would like to argue about everything.

Perhaps this law, and the movement behind it will start to help us develop a real sense of personal responsibility. Our country needs more personal responsibility and less blame. But perhaps the existentialism speaking. But probably that is me speaking!

Is a high HDL really protective? This article discusses the controversy about HDL - Scientists Begin to Question Benefit of 'Good' Cholesterol

But now, some scientists say, new and continuing studies have called into question whether high levels of the good cholesterol are always good and, when they are beneficial, how much.

While some heart experts are not ready to change their treatment advice, others have concluded that H.D.L. should play at most a minor role in deciding whether to prescribe cholesterol-lowering drugs. In the meantime, doctors are calling researchers and asking what to do about patients with high H.D.L. levels, or what to do when their own H.D.L. levels are high, and patients are left with conflicting advice.

"There is so much confusion about this that it is unbelievable," said Dr. Steven Nissen, a cardiologist at the Cleveland Clinic.

Medical advances occur because we (physicians and scientists) willingly challenge current dogma. We never assume that we know truth, but just that we function on our current best approximation.

Fortunately, we generally make most decisions based on LDL levels anyway. HDL has functioned as a minor issue for most physicians. It may decrease from mino.

One of my loyal readers writes:

The one my school district offers doesn't work that way it all.
It's completely independent of the insurance plan.
At the end of the year, you forfeit anything you didn't claim.
We also can only take out 2500.00 a year.
The good news, is that it is pretax dollars.

And that is the same plan that I currently have.

The article is referring to the new law. This creates an entirely new option. I suspect that more companies and even the public sector will start to offer these new plans. The rollover benefit makes them a wonderful choice.

They do require insurance with larger deductibles - thus you are expected to pay for the initial costs from your HSAs. I like the idea. Reread the money management article about them to pick up the nuances.

A Follow-Up on Health Savings Accounts

Thanks for the compliment! Health Savings Accounts are brand-new high-deductible health insurance accounts. Essentially, the insurance doesn't kick in until you've paid $1,000 worth of medical expenses out of your own pocket if you're single, or a total of $2,000 if you have family coverage. But you get to set aside the money to cover these out-of-pocket expenses via tax-deductible contributions. If you have individual coverage you can set aside as much as $2,600; the maximum contribution for a family is $5,150. These amounts will be adjusted every year for inflation.

Now here's where some folks get pretty jazzed about an HSA: If you don't spend all of the money you've set aside in your account, it remains there, growing on a tax-sheltered basis. In other words, as you clearly understand, Peter, these accounts can be a substitute retirement savings vehicle, similar to a nondeductible IRA.

Martha Priddy-Patterson, a director with Deloitte & Touche, says you're "absolutely right" to consider not dipping into your HSA to cover medical bills if you don't have to. "You're under no obligation to pay your medical bill out if the HSA account. If you can afford not to, it's smart." If nothing else, leaving the money in the account allows you to build up a kitty in the event you do have a major medical expense, whether planned (braces for your two kids) or unplanned (you're in a car accident).

Keep in mind that withdrawals before age 59 1/2 for expenses that are not health-related will result in a 10-percent penalty, plus ordinary income tax on the gains. However, provided the money is used for medical bills ? at any age ? your withdrawal is tax-free. And once you're past the 59 1/2 milestone, you can even take withdrawals for non-health expenses without a penalty (you'll still owe income tax on the gains, though). If you're planning to use your HSA for retirement purposes, stay abreast of current IRS regulations ? it is not inconceivable that the rules for these accounts could change once they come into widespread use.

Hopefully, this explanation will help clear some misconceptions about these accounts. I love the control that these accounts provide. They make sense financially.

They should also make many people think carefully about their health care expenditures. As I have said repeatedly, this thought process should lead to less demand for high cost procedures and medications. If that is true, we might actually get physicians and patients to become more cost effective.

Implementation of Guidelines Sharply Reduces Post-MI Mortality

A formal system designed to ensure implementation of standards of care can reduce 1-year mortality in Medicare patients admitted with myocardial infarction by 23%, researchers announced here Wednesday during late-breaking clinical trial sessions at the American College of Cardiology Annual Scientific Session 2004.

The results, from the ACC's Guidelines Applied in Practice (GAP) Project in southeast Michigan, were reported by Dr. Kim A. Eagle of the University of Michigan Health System in Ann Arbor.

The project findings included approximately 2800 Medicare patients admitted with acute MI and followed until discharge. The objective was to determine if the ACC's GAP guidelines were being implemented and how effective implementation would be. Average patient age was 76. The study group was roughly half men and half women. Between one third and one half had comorbidities on admission.

GAP tools included visible standard orders for the AMI patient, the use of pocket guidelines, patient information sheets and patient discharge contracts, among other tools to trigger GAP use.

During the study, use of the discharge tool increased from about 2% to more than 30%. As a result, a significantly greater number of patients were discharged on what Dr. Eagle called the "Fab Four," beta blockers, ACE inhibitors, lipid lowering agents and aspirin, all proven to improve survival after MI.

Changes in discharge practices as a result of GAP implementation resulted in a 26% reduction in mortality at 30 days and a 23% reduction in mortality at 1 year compared with pre-study rates.

Just another piece to the implementation puzzle. We know what to do for many conditions and many patients. Now we need to continue to study how to make certain that we give the most appropriate care to the most patients.

This study suggests a strongly positive result - good news for postmenopausal breast cancer patients. Research: Breast cancer drug switch cuts recurrence

A drug for advanced breast cancer prevents localized tumors from returning after surgery better than the current mainstay drug, according to a large, international study that promises new hope and treatment strategies for many patients.

Recurrence of such early cancer was reduced by one-third in women who started on the gold standard treatment, tamoxifen, then switched after 21/2 years to the newer drug, exemestane, compared to those who took tamoxifen the whole time.

The women switching to exemestane, a hormonal drug sold under the brand Aromasin, also had less serious side effects, were 56 percent less likely to get cancer in the other breast and were half as likely to develop unrelated cancer in other body areas.

Dr. Jeff Abrams, the National Cancer Institute's associate chief of clinical research, said a recent study on exemestane "cousin" letrozole showed important advantages over tamoxifen for their class of drugs, called aromatase inhibitors. Abrams was not involved in the new study.

Lead researcher Dr. R.C. Coombes, professor of cancer medicine at Imperial College School of Medicine in London, predicted doctors will give exemestane to many women at high risk for recurrence, such as those whose breast cancer spreads to multiple lymph nodes.

"More work needs to be done to understand what's going on" at the molecular level, he said.

The study, which included 4,742 postmenopausal women in 37 countries, focused on women with breast cancer in which the hormone estrogen fuels tumor growth -- the type causing about 70 percent of breast cancer. The results do not apply to premenopausal women or those with tough-to-treat breast cancer not driven by estrogen.

This study does give great promise to the majority of breast cancer patients. As scientists learn more about the biology of breast cancer, we may see even more advances. Great news!

Texas Company Removes Web List of Malpractice Plaintiffs

Yes I continue to listen to my tapes on existentialism. Currently, the lecturer is focusing on Sartre. Sartre's philosophy is quite complicated, but does include the concept of no excuses. I found this quotation particularly interesting.

"Freedom is what you do with what's been done to you."

Extra-Low Cholesterol

A cholesterol-lowering study whose results were announced this week has a wealth of important implications. The findings could certainly presage a significant change in the way heart disease patients are treated. It should also start a careful evaluation of whether normally healthy people could benefit from a sharp drug-induced reduction in their cholesterol levels. There may also be major side effects for the economy: the potential health benefits could drive up the use of high-cost drugs in a nation that is already struggling to pay its medical bills. Finally, the study should send a message to Congress and federal regulators about the value of comparative testing of prescription drugs.

The NY Times has a few issues right, and one or two that may not be right. Clearly, this study does make us reconsider how we treat coronary artery disease patients. The study does show that. My blogging colleague, Sydney Smith, disagrees - The Love Affair Continues. She and I have previously agreed that we can and should disagree on issues. I believe she is wrong on this one.

She minimizes the benefit

The results are more notable for what they don't tell us than what they tell us. Rather than following patients over a given period of time and tallying the number of events each group had, they stopped the study when they had 925 events, then relied on statistics to estimate the rates. As a result, the paper deals not with actual event rates but with Kaplan-Meier event rates. A far better study would have been to look at the actual rates. But then, the significance of the findings might not have been as impressive. That is, it would have been harder to present their statistically significant findings as equally clinically significant.

Sorry Sydney, but Kaplan-Meier event rates are actual event rates. Kaplan-Meier curves allow one to evaluate the entire curve over time, rather than just comparing rates at one arbitrary endpoint. Therefore they are much more informative. If anyone wants to read the nitty-gritty on this subject - Survival Curves: Accrual and The Kaplan-Meier Estimate. As I read this study, the results are dramatic (and just in the first 2.5 years). As I wrote yesterday, the curves suggest that the results would become even more dramatic over longer time frames.

The NY Times has no reason to suggest using higher doses as primary prevention. Primary prevention really is a different problem than secondary prevention. Extrapolating these data to the primary prevention problem does not make sense in 2004.

The NY Times suggests that the cost of the higher dose (a difference of ~$600/year) would "drive up the use of high-cost drugs in a nation that is already struggling to pay its medical bills". They should consider the possibility that the decrease in mortality and hospitalizations could overcome the medication costs. We err when we look at medication costs without analyzing the benefits of decreased hospitalizations, decreased development of congestive heart failure, decreased bypass surgery, and decreased mortality. These costs are all important.

Finally the NY Times is correct to point out the importance of head-to-head drug trials (a process which I have championed here over the past 2 years). Interestingly, and supportive of the results:

Bristol-Myers sponsored the study and expected it to prove that its drug was just as effective as Lipitor when it came to reducing disease and preventing deaths. Bristol-Myers was disappointed. But the effort did underline the great benefit in comparing the performance of two prescription drugs. Traditionally, drugs are only tested against placebos. From now on, the value of head-to-head competitions should be obvious to everyone.

Yes, Bristol-Myers makes Pravachol - not Lipitor. Kudos to Bristol-Myers for sponsoring this important study!!

Since posting last night, I have had a couple of interesting questions concerning this article. I would also like to link on today's news stories concerning this article. Finally, I would like to more explicitly give my own interpretation.

Who should receive the high dose strategy? Why not just use pravastatin (Pravachol) at a higher dose?

We must always remember that the patients in this study already had known, active coronary artery disease. This is a secondary prevention study. That being said, if one carefully reads the NCEP guidelines - Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) you will note that patients with adult onset diabetes mellitus are treated as if they already have coronary artery disease. One can (in my opinion) extrapolate the data to diabetic patients, but not patients with pure primary prevention (and no other major risk factors).

Reading the study carefully, they used the highest dosage of each medicine which currently has FDA approval. Certainly, pravastatin at 80 mg might work, but we have no data, either on efficacy or safety.

Today's news stories: New Conclusions on Cholesterol from the NY Times and Striking Benefits Found In Ultra-Low Cholesterol from the Washington Post.

My interpretation of the data at this time:

• This study, and its results are only definitely important for secondary prevention
• The results are, to me, striking at 2.5 years. Since atherosclerosis progresses over time, it seems logical that the benefits will increase over time (although that is theory).
• The costs for Lipitor 80mg ($3-4 per day) are significant, but given the benefits not unreasonable.
• I am converted, and plan to work on giving post ACS patients the new dose
• We have no data on Crestor at high doses. I would not use a new statin until I better know the risk profile

Study: Lower Cholesterol Helps Save Lives

Lowering heart attack victims' cholesterol to levels dramatically below current standards appears to be an important strategy for saving lives and preventing new heart problems, a major new study shows.

Drugs called statins are already standard medicine for people recovering from heart attacks. But the study suggests newer, more potent varieties work best for these high-risk patients.

``The message for these people going home from the hospital is they should be on a high-intensity regimen,'' said Dr. Christopher Cannon of Boston's Brigham and Women's Hospital. ``For everyone else, treating cholesterol and getting it down is very important.''

The much-anticipated study helps answer one of the most discussed questions in cardiology: How low should cholesterol go? For those getting over recent heart attacks, at least, the answer appears to be very low indeed.

Those who did best in this study saw their levels of LDL, the bad cholesterol, plunge in half to an average of just 62. The goal in current federal guidelines is to get LDL below 100.

The study was to be presented Monday in New Orleans at the annual scientific meeting of the American College of Cardiology. It also will be published in the Apr. 8 issue of the New England Journal of Medicine.

The latest work reinforces the conclusion of another head-to-head comparison of statin drugs released last November. In that study, doctors found the more intensive treatment resulted in less artery clogging. The new report is considered even more persuasive because it looks for differences in the risk of death and other clearly measurable misfortunes of heart patients.

Both studies compared 40 milligrams daily of Pravachol to 80 milligrams of Lipitor, the highest approved doses of both drugs when the research started. Pravachol is an older statin made by Bristol-Myers Squibb, while the newer and more potent Lipitor is made by Pfizer. Last fall's study was financed by Pfizer, and this one was paid for by Bristol-Myers Squibb. Lipitor came out on top in both comparisons.

For those who want to read the article from the NEJM - Comparison of Intensive and Moderate Lipid Lowering with Statins after Acute Coronary Syndromes and the editorial - Intensive Statin Therapy -- A Sea Change in Cardiovascular Prevention

Several caveats for everyone. First, they did use a higher dose in the Lipitor group - the group that we call intensive (rather than standard) therapy. Second, all patients had acute coronary syndrome. We should not extrapolate the use of intensive therapy to primary prevention. Third, we must understand cost (sentence quoted from the Wall Street Journal) -

Dr. Topol noted that the dose of Pravachol used in the study costs about $900 a year, while the dose of Lipitor costs $1,400.

Given all these caveats, I would take the higher Lipitor dose (@$4/day) if I had an acute coronary syndrome.

Whoever fights monsters should see to it that in the process he doesn't become a monster.

Friedrich Nietzsche

While most watchers have not picked this up on their radar, I have been ranting about this issue for months. We do not have enough physicians going into primary care - because primary care physicians are treated poorly, both financially and with relationship to worklife balance. Apparently DO students are figuring that out also. Fewer new DOs picking primary care

Tort reform debate best served by truth

Here's another e-mail: "Peer review may be one part of the solution, but it should be serious, responsible peer review of doctors and hospitals. ... Shining the light of investigation on negligence incidents would do more to reduce medical errors, thereby reducing malpractice claims."

The Institute of Medicine and the Health and Human Services Dept. say most medical errors are not failures of physicians, but failures of the system. Even when doctors do their jobs correctly, most errors would still occur.

A better approach to fixing the problem of system errors would be to dispel the fear of physicians, hospitals and nurses that open discussion on adverse events would be discoverable in lawsuits.

That's why we support the Patient Safety and Quality Improvement Act (S 720), a proposed federal law that would allow the voluntary, confidential reporting of errors to patient safety experts. The result would be advice on how to improve the system and therefore patient safety. This system fix would be shared with all in a de-identified manner. This model works for the Aviation Safety Reporting System. It would work in the health care field, too.

The AMA also helped launch the National Patient Safety Foundation in 1996 and has supported it since with more than $6.5 million dollars. Despite our repeated public challenges to match our donations, the Assn. of Trial Lawyers of America has not contributed a dime.

If this excerpt whets your appetite, go read the entire article.

Thanks for all the comments. As I have thought through the issues, I would like to be more explicit in my dislike of the web site.

My problem relates to diagnostic test performance. Of all the people (lawyers, unethical testifying physicians, and litigious patients) that one might conceivably like to exclude from ones practice, they would all be there. However, many people on the list do not deserve the scorn that one would give to anyone on the list. Thus, the list is sensitive, but not specific.

This listing sets a danger precedent. I am against similar lists of physicians have been sued, for exactly the same reason.

If one could look at each case, and classify the lawyer, testifying physician and patient as legitimate or not, then they might have a decent argument. However, in the absence of complete information this list does not meet my fairness test.

MDs Urged to Denounce Malpractice Site

Dan Lambe, executive director of Texas Watch, said the site is attempting to scare patients.

``This type of blacklisting runs counter to the Hippocratic Oath to the ethical and moral goals and obligations of medical professionals,'' Lambe said.

Dr. John Shannon Jones, a radiologist who created the database, could not be reached by The Associated Press for comment Friday. He told The Wall Street Journal that people who sue doctors are going to find their access to health care may be limited.

``That's a harsh thing to say, but this is a war,'' said Jones, who has settled two malpractice cases.

I understand it, but I cannot support it.

My colleague, Stef, wrote this important comment concerning my post on autopsies:

I would fault the NY Times article for failing to reference the autopsy review literature that supports the continued value of autopsies.

At least one or two papers a decade document the surprising effectiveness of autopsies at identifying clinically important (but unsuspected) diagnoses, despite our vaunted diagnostic technology. The most recent was published in JAMA (June, 2003) with Lee Goldman as senior author, reviewing 53 autopsy series articles published since 1966. Despite clearly documented improvements in premortem diagnoses over the decades, their data suggest that a contemporary US institution "could observe a major error rate from 8.4% to 24.4% and a class 1 error rate from 4.1% to 6.7%", where major errors involve the cause of death, and class 1 errors are such that the patient outcome would have been altered. Maybe some doctors prefer not to know about those missed diagnoses. I don't know for sure.

As a medical student pathology fellow at the original home of the "Black Crow Award," (an apocryphal legend about a contest in which a resident won a prize for obtaining the greatest number of autopsies, cf. House of Gods), I conducted about 17 autopsies. I scanned my notes from those cases this evening. Brief summary, of 15 adult autopsied, we found a fair number of unsuspected diagnoses and at least 1 or 2 that appeared materially related to the cause of death but were unsuspected by the physicians caring for the patient, a rate of Type 1 error which appears consistent with the findings of Goldman et al. At that particular hospital, housestaff came to a 20 minute autopsy conference once a week, and we reviewed the findings for them.

Beyond the turning up the occasional unexpected cause of death, the post-mortem examination does help physicians develop a clearer mental picture of the diseases we are called upon to diagnose indirectly, by hints and rumors.

These comments, while true, imply that we can extrapolate from these studies to all hospital deaths. That implicit assumption (which some may make explicitly) does not work.

We must remember that those patients who have autopsies are not representative of all hospital deaths. Most physicians push harder for autopsies when they do not really understand what happened to the patient. Thus, the probability of finding new information is enriched in the autopsied patients.

I favor autopsies in many patients. Usually I do not push for an autopsy in a patient who was terminal (i.e., receiving comfort care, managed by the hospice service). As this represents a large percentage of deaths on our services these days, we will have a lower autopsy rate than 50 years ago. I believe that many patients who had autopsies in the past do not receive them because we make more pre-mortem diagnoses, and thus treat patients appropriately, obviating the need for an autopsy. But then, I cannot prove that.

We have had excellent information on the pneumonia severity index in the past. This report re-emphasizes its usefulness. Tool Accurately Assesses Pneumonia Severity. If you want to use the index online, go here - Pneumonia Severity Index Calculator

In Texas, Hire a Lawyer, Forget About a Doctor?

For months, an obscure Texas company run by doctors has been operating a Web site, DoctorsKnow Us.com, that compiles and posts the names of plaintiffs, their lawyers and expert witnesses in malpractice lawsuits in Texas and beyond, regardless of the merit of the claim.

"You may use the service to assess the risk of offering your services to clients or potential clients," the Web site says.

For fees listed as low as $4.95 a month for the first 250 searches and thereafter 2 cents a search, subscribers are invited to search the database "one person at a time or monitor any sized group of individuals for litigious conduct." They can also add names to the database "from official and unofficial public records." Whether that could include a doctor's own files is not clear.

"They can sue but they can't hide," says the Web site.

So I ask, is this strategy akin doing a credit check, or is this an excuse to deny service. Some malpractice suits are legit.

I understand this strategy, but I do not think that I can personally endorse it. What do you think?

Go read our favorite surgeon (Bard Parker) - No Black Crow Award Here. I like his rant - of course we agree!

Interesting and well done study in today's NEJM. This report from Medscape describes the findings of a new COPD mortality risk index - Simple Grading System Predicts Mortality Risk in COPD

What the Body Knows

The NY Times has, in my opinion, used their editorial page irresponsibly (once again).

But autopsies have not declined because they're useless. In fact, most studies confirm that autopsies regularly turn up surprises, including mistaken diagnoses, undiscovered conditions and, in a small but steady number of cases, diagnosis and treatment errors that may have led to death. The numbers are not trivial. One study examined 1,000 autopsies between 1983 and 1988 and found that there were " `major discrepancies' between the autopsy findings and the clinical diagnosis" in 317 cases.

Autopsies have dwindled for a number of reasons. Hospitals were once required to perform them to be accredited, but that requirement ended in 1971. Insurance companies do not pay for autopsies. But the problem really lies in our attitude toward them. In recent years, families have become increasingly reluctant to authorize autopsies, and doctors too often believe that modern diagnostic tools like CAT scans and M.R.I.'s have made them obsolete. Yet underlying these reasons is another, more pervasive one: the risk of malpractice suits. An autopsy that uncovers an error in treatment also uncovers the potential for litigation. Never mind that it may improve subsequent diagnoses.

When our patients die, we frequently request autopsies, but rarely will the patient's family approve. I am probably naive or just not smart enough to consider that I could avoid malpractice through the deceit of not asking for an autopsy.

Most hospital deaths in 2004 are expected. Most dying patients are terminally ill.

Autopsies can give valuable information, but they are not as important an information source as they were in the 70s when I started training (nor as important then as they were in the 30s). I suspect that the NY Times editor has watched one too many episodes of CSI. Most autopsies show a few surprises, but rarely many that would change outcomes.

I favor getting more autopsies. They are instructive and help us understand medicine. They offer new important information less frequently than in the past.

The NY Times editors have, as I said before, overhyped this issue. But I must give them credit, they have taken a bold stance. Perhaps they understand our motivations better than we do. Thus I will finish this rant with an existential thought (yes I am still listening to the tapes) - does anyone really know our motivations for our actions - even ourselves? The NY Times editors have attacked the medical community because they believe that they can attribute motivation to us. I find that assumption arrogant.

Given the number of comments related to the MRSA article, I thought that I would provide a few thoughts.

MRSA refers to methicillin resistant staphylococcus aureus. For the non-physicians, that means that the old penicillin variants that we once use for staph infections (oxacillin, dicloxacillin, nafcillin) do no work to kill these staph. Staph infections commonly cause skin infections, like boils, but may cause even more serious infections.

Where did MRSA come from? Bacteria develop resistance by natural selection and mutation (the purest form of evolution). Bacteria naturally mutate. When we use antibiotics, we always have a probability that a mutant strain (starting with only 1 bacteria) will occur. If that mutant has resistance to the antibiotic, then it will multiply and become the prodominant infecting bacterial strain.

This process fits our understanding of natural selection perfectly. Unfortunately, staph infections spread easily between patients. Thus, once a mutant is selected and grows, it becomes capable of infecting other patients.

Some bacteria more often develop resistant strains (i.e., they mutate more often). Staph does mutate often.

Even with appropriate antibiotic use, the biology almost insures that resistance will develop. Over the past decade MRSA first became a problem in intensive care units, then hospital wards, and now the general community.

The cow is out of the barn. We now assume that staph are resistant (unless we prove otherwise with cultures and sensitivity testing).

Understanding how staph became methicillin resistant reemphasizes our need to use antibiotics prudently. They are great and powerful aids to treating serious infections. Whenever possible we need to use the most specific antibiotics possible. However, even with perfect antibiotic usage, we will still develop resistance organisms - genetics and evolution drive the development.

Continued research into the mechanisms of resistance will enable us to "defeat" the resistance - at least for a period of time. We can blame the emergence of resistance on many people and antibiotic uses. Our obligation though is to use antibiotics intelligently for clear indications. This will slow the emergence (not stop the emergence) of resistance and give research the opportunity to develop the next generations of antibiotics. We have an ongoing struggle against bacterial, viral and fungal infections. We can win battles, but will always lose some battles also.

This comment is placed with the wrong rant. Therefore I will quote the entire comment and respond.

Well there you go.

The "experts" believe the average citizen is too dumb to make healthcare decisions.

Let Daddy Government do it for you.

Or we will let the government delegate to self-appointed "experts" to decide for the people.

With government and agencies like AHRQ, heck with Hillary and her crowd...this is not about providing the most medical care, most appropriately, to the most people. People like Hillary don't care about the "little people". This is about their raw political power. They want to take your money and tell you how THEY will spend it on your behalf. The LAST thing they want is to let people decide for themselves, especially when so much money is at stake.

As has been said before, their fear is not that MSA's will not work.

The fear in government and their dependent private organizations like AHRQ......is that MSA's WILL work.

First I must defend AHRQ. AHRQ (Agency for Healthcare Research and Quality) is an important research agency. They have a meager budget (relatively) and deserve a larger budget since they fund studies which actually help us understand what works and what does not work in health care.

The article quoted an individual from AHRQ. He has an opinion with which I disagree. That does not invalidate the agency.

However, the commentor makes a very insightful point. We have advanced in medicine to patient focused decision making. Back in the 70s when I trained we generally functioned paternalistically. We rarely sought patient input into our decision making. Rather we told patients what to do.

Sharing decision making represents a major advance in health care. If we follow that logic, then HSAs extend that concept. We who favor HSAs see them as a way for patients to more actively participate in their medical care.

These plans increase patient's responsibility for their health care. As a physician I expect that patients will expect me to understand costs and explain advantages and disadvantages of differing strategies. As a patient, I should make medication decisions based upon knowledge of alternatives - especially generic alternatives.

Economically these plans should do much to control health care costs. They do require a belief in patients. That is a very libertarian concept.

Methicillin resistant staph will soon be the only staph that we see. Routine antibiotics just will not work against many minor abscesses anymore. Bacteria Run Wild, Defying Antibiotics

"Staph infections are such a common problem that the emergence of infections resistant to common antibiotics has important public health implications," said Dr. Daniel B. Jernigan, an epidemiologist at the federal Centers for Disease Control and Prevention.

But the infections are so common that they are not reportable to the local or federal public health authorities. Because of this, detective work to explain the appearance of the new resistant staph in this country and track its progress is just beginning.

The resistant staph was first recognized in the United States among children in Chicago in the mid-1990's. In 1999, the disease control centers reported that four children in the Midwest had died of infections with the new staph. Three of them had initially been treated with the wrong antibiotics.

In the last several years, clusters of infections with the resistant staph have been reported in jails and prisons in states around the country, including California, Texas, Pennsylvania and Georgia. Clusters of skin infections have also been reported among athletic team members and military recruits.

Clearly, we treat all suspected staph infections as MRSA until culture results prove otherwise. This has become the most prevalent and therefore the most important resistance problem.

Hospitals hang on to money-losing medical practices

A major problem in medicine stems from who gets paid and how much. Currently, the front line physicians (family docs, general internists) are struggling financially. They make significant money for everyone else in the health system. Some hospitals understand economics enough to support these groups.

Medical practices owned by hospitals or integrated delivery systems reported a median net loss of more than $82,000 per full-time physician in 2002, according to a survey published by the Medical Group Management Assn.

The report says the loss was 9.5% more than in 2001, when groups posted a median loss of just more than $75,000 per physician. The report highlights a trend that has been apparent to health systems for several years. Hospitals were selling practices back to physicians or anyone else that would take them more than four years ago because they already had been deemed a drain on finances.

Still, some hospitals have managed to mold thriving medical practices, while others have decided the losses are worth it to have a physician network.

"The philosophy is, 'We will make money off their referrals, even if we don't make money off their practice,' " said Janet Houser, PhD, associate professor of health services administration at Regis University in Denver.

Would it not make more sense for our system to reward these important physicians financially? We all know the answer to that rhetorical question. So why do we pretend that we cannot afford to pay these physicians?

Beat the clock: The new challenges to residents

Resident programs are taking the limits seriously, said David Leach, MD, executive director of the Accreditation Council for Graduate Medical Education, which accredits all residencies. But, he said, it is how they approach the task that makes the difference in the kind of education residents receive.

"There are early adopters and innovators who have shown you can improve patient care and [meet duty-hour limits]," he said. "The majority have shown you can do this, but in making do they've not redesigned clinical care as much as reacted to the requirements. In a few of our citations, programs have met the requirements but have weakened patient care and resident education."

The ACGME has reviewed 500 to 600 programs since July 2003 and has issued 79 citations related to duty-hour violations, Dr. Leach said.

Residents aren't completely happy with the new constraints either.

"You have to realize that the larger health care system is broken," Dr. Leach said. "Residents have lived in the cracks of that broken system for a long time, and they've been told that the system can and will kill your patient, and you need to make sure that doesn't happen. Residents have depended on vigilance, knowing that the system can't be trusted. Now we've reduced the availability of the residents, and they're worried. They want to stay [at the hospital] because they can't trust the system."

Here in our program, we are doing quite well. I have had to insist that interns leave a few times. They have a difficult dilemma. After admitting for 24 hours, then rounding for 3 hours, they only have 3 more allowed hours. If a patient has an interesting study scheduled, they really hate leaving until they know the results. They rarely want to stay for patient care (our system manages that quite nicely) but rather for their own education. So we have to say, sorry you must go home.

In talking with attendings at other institutions, they express the opposite problem. They have told me that their residents do not seem to take as much responsibility for their patients as residents formerly did.

The 24 + 6 rule is so arbitrary and without supporting data as to engender scorn from almost all of our residents and interns. How can we teach evidence based practice when our accredition body makes decisions without evidence?

But these are the rules and we do the best we can. I am proud of our residents who remain committed to outstanding patient care. They have developed a system which adheres to the most important principle - outstanding patient care - yet allows reasonable work hours. They are not always happy about the rules (and some will ignore the rules regardless of what the attendings say). Most important, our residents worry about the patients first, and the rules second. I think that should be the focus of ACGME evaluations.

HSAs (Health Savings Accounts) immediately push observers into one of two camps. Libertarians and free market economists believe that they will lead to better rationing of care - patient directed rationing. Others argue that patient care will suffer because patients do not understand enough to ration logically. Consumer-driven health care: Bush, GOP back HSA expansion

Businesses large and small are looking for ways to preserve employee health benefits without breaking the bank. Many have latched onto the concept of consumer-driven health care, which shifts more of the responsibility for health-spending choices onto the patient.

"We see a 15% reduction in drug spending right out of the chute within five to six months and a 6% reduction in physician visits," said Mike Parkinson, MD, chief medical officer for Lumenos, an Alexandria, Va.-based health insurance company offering consumer-driven plans across the country.

"You know that 20% to 25% of doctor visits are unneeded; 30% to 35% of all health care is ineffective or inefficient. How better to get at [that waste] than front-loading the consumer who says I want to get the care I want when I want it and from whom I want it," he said.

Consumer awareness of price and quality information will drive competition among physicians seeking to offer the highest value services, Dr. Parkinson said. Many physicians like consumer-driven plans because they emphasize preventive and behavioral services that support doctor-prescribed treatments and make for healthier patients, he said.

That is the argument in favor of HSAs. Others remain skeptical.

"What these plans are asking [patients] to do is to ration their own care," said Dwight McNeill, an expert in quality measurement and improvement at the Agency for Healthcare Research and Quality.

"The question now is, do consumers, as rationers or deciders of their own health care, have better or more useful information to make these decisions than doctors did" in managed care, he said. "The answer has to be, no, ... consumers just aren't ready for it, and they don't have appropriate information."

Gathering information on the efficiency, quality and value of health care services and procedures will take more time and money, McNeill said.

Republican lawmakers remain unconvinced by arguments that patients cannot make their own health decisions. Many want to move forward with legislation designed to encourage the trend.

People make bad economic decisions daily. This occurs through our economy. Those who favor HSAs (including this ranter) believe that patients will change their focus when asking for health care options. Most patients will listen to recommendations and be more likely to accept less expensive medications, rather than the newest medication advertised on television.

Our current system clearly does not work. We should collect data to understand the impact of HSAs. I have had them for several years - and am a major proponent.