Houston's Clear Thinkers
Longtime Houston attorney Tom Kirkendall's observations on
developments in law, business, medicine, culture, sports, and other
matters of general interest to the Houston business, professional, and
academic communities. 






March 28, 2010


A stroke of insight

This is one of the most fascinating TED lectures. Brain researcher
Jill Bolte Taylor describes the experience of having a stroke.   




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March  8, 2010


Making good on Baylor Med’s bad bet

 The Chronicle’s Todd Ackerman and Loren Steffy did a good job in
this weekend article of chronicling the series of bad bets that Baylor
College of Medicine’s Board of Trustee’s made in the wake of the
school’s unfortunate 2004 divorce from The Methodist Hospital.
Baylor Med’s travails have been a regular topic on this blog, most
recently here.  The elephant in the parlor of Baylor' Med’s
financial problems is the $600 million in bond debt that Baylor Med
incurred in connection with its currently mothballed hospital project.
Indeed, the difference between the total bond debt and the value of
the underlying collateral would gobble up a large chunk of Baylor’s
endowment, which is currently a tad under a billion dollars. That was
enough to scare off Rice University, although I question whether that
was the right long-term decision for Rice.  So, the future is bit
cloudy for Baylor. But what I’m wondering is whether there is a
local partnership that could bail Baylor out of most of current
problems while providing an essential benefit for the Houston
community?  The last time I look into the issue, estimates in the
Houston metro area has one of the largest percentages of uninsured
residents in the U.S. (over 30% versus a national average of about
16%). The Harris County Hospital District ultimately ends up with the
issues involved with financing indigent care as well as ensuring that
adequate medical facilities exist for local citizens.  Given the
HCHD’s projected need for facilities to keep up with the growth of
the Houston area, it makes sense for the HCHD to engage Baylor in
discussions over a partnership in which HCHD would make an investment
in the hospital in return for Baylor’s agreement to staff the
institution as its primary teaching facility.   Baylor and the HCHD
already work closely in connection with the staffing of the Ben Taub
Hospital trauma unit in the Texas Medical Center. A pure teaching
hospital for Baylor would provide a quasi-public, low-cost alternative
to the Med Center’s impressive but expensive array of private
hospitals.   Sure, the details would have to be worked out, such as
management of the facility. But doesn’t such an investment by the
county make sense, particularly when compared to ones such as this?




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February 26, 2010


David Agus on the state of cancer research

University of Southern California University professor David Agus
provides a particularly lucid 24-minute lecture for the TED conference
on the state of cancer research.  




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February 18, 2010


Jamie Oliver’s TED Nutrition Talk

Jamie Oliver eloquently discusses the dire impact of our abysmal
teaching about nutrition in the U.S. Check out also this lengthy Byran
Appleyard/TimesOnline article on Art DeVany’s continuing research on
the integration of good nutrition with sound exercise protocols. Good
information for increasing the chances of enjoying a healthy life.   




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February 16, 2010


How much is “affordable” health care?

 Uwe Reinhardt posted this insightful Economix post last week in which
he bores in on the key issue to be resolved in reforming the U.S.
health care finance system:     I could easily offer every American
family a health insurance policy it could afford, simply by varying
judiciously the annual deductible, the coinsurance rate, upper limits
on items ostensibly covered by the policy and exclusions from coverage
of sundry services or products — for example, mental health services
or certain specialty drugs.    The policy might be a sham; but it sure
would be cheap.    Health insurance is just a means by which needed
health care can be made “affordable” to Americans when they fall
ill. Therefore the proper target of health policy should be the
family’s total outlay on health care, including out-of-pocket
spending. That total outlay on “needed health care” should be made
“affordable.”    Which requires us to define concretely, for
practical purposes, what we mean by “health care” and
“affordable,” pedantic as that may sound. Politicians should be
forced to be utterly clear about it. [.  .  .]    President
Obama could make this idea practical by using a visual device such as
the table [above]. In that table “disposable income” is defined as
all personal income from whatever source minus all personal income tax
payments and other government deductions. The numbers are
annual.  .   .   .    Professor Reinhardt
makes a good point about the disingenuous nature of health insurance.
As I noted here, most forms of health insurance – particularly the
employer-based kind -- insulate consumers from understanding the truce
cost of their health care choices. As a result, most consumers – and
virtually all legislators in Washington – have no idea on what
amount of health care costs are “affordable.” Most insureds are
pleased that someone else is footing the bill and simply don’t want
to lose that perk.  Health insurance is largely the product of bad
governmental policy (wage controls during World War II) and, as is
often the case with such policies, there are unintended consequences
that are even worse than the misdirected governmental policy. In this
case, we have two generations of Americans who have been largely
insulated from needing to know the true cost of some of their most
fundamental choices and needs in life.  Such ignorance is now
hindering reform of the fractured U.S. health care finance
system.  But any health care finance reform that does not rely at
least in part on reigniting a consumer market to control costs will
likely be even more expensive and less satisfying than the current
system.




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February 11, 2010


Lifestyle Nutritionists

In this clever sketch, That Mitchell and Webb Look channel the
mentality behind the legislation discussed in yesterday’s post.  




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February 10, 2010


More misdirected Nanny energy

 Does anyone really think for a moment that this legislation is going
to have any meaningful impact on its intended purpose:     The Obama
administration will begin a drive this week to expel Pepsi, French
fries and Snickers bars from the nation’s schools in hopes of
reducing the number of children who get fat during their school years.
   In legislation, soon to be introduced, candy and sugary beverages
would be banned and many schools would be required to offer more
nutritious fare. [.   .   .]    The legislation
would reauthorize the government’s school breakfast and lunch
programs. It aims to transform the eating habits of many of the
nation’s children and teenagers,  .   .  
.     No word yet on whether the legislation is also going to
attempt to bar students from going to the neighborhood grocery or
burger stand after school and buy the Pepsi, French fries and Snickers
that the do-gooders won’t let them buy during school.  On the other
hand, an initiative that really might generate some beneficial health
changes – such as providing each student’s family lower health
insurance premiums in return for family members maintaining a
non-obese weight – remains illegal under applicable governmental
regulatory schemes.   We really do find creative ways to waste time
and energy, don’t we?




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January 19, 2010


Did Rice blow it?

 So, Rice University last week finally decided to pass on the
proposed merger with Baylor College of Medicine.  In theory, the deal
makes sense. Both are top-notch academic institutions with campuses
within a stone’s throw of each other. Each institution would have
given the other something that it needs. Baylor would have gotten the
financial support of Rice’s multi-billion dollar endowment, while
Rice would have landed a strong scientific research and clinical care
center in one of the nation’s leading medical institutions, the
Texas Medical Center.  Although Rice President David Leebron supported
the merger, large segments of the Rice faculty and alumni opposed the
deal, primarily on financial and cultural grounds. Indeed, my sense is
that Leebron quit pushing the Rice Board of Trustees to approve the
deal when it became apparent that a consensus of Rice constituencies
were opposed to the marriage.  And Baylor clearly finds itself in
precarious financial condition, not completely of its own doing. After
its 54-year teaching hospital relationship with Methodist Hospital
soured in 2004, and a subsequent deal with St. Luke’s Episcopal
Hospital did not work out, BCM decided on a plan to go it alone and
build its own teaching hospital.   However, the ambitious deal has
been pretty much a disaster from the start. After floating almost $900
million in bonds to finance construction of the hospital, Baylor
announced last year that it was temporarily suspending construction of
the hospital’s interior as it works through its financial problems. 
 Meanwhile, BCM has lost over $300 million since the split with
Methodist. Inasmuch as Baylor’s endowment is less than a billion,
those kinds of losses have placed BCM’s financial condition at risk.
Already in in technical default on multiple bond covenants, BCM is now
facing the prospect of hiring a bondholder-required “chief
implementation officer” to oversee an overall financial
reorganization. That would have been avoided if the Rice merger had
succeeded.  Thus, Rice certainly had understandable reasons for
passing on the deal.  Nevertheless, I wonder – did Rice make the
right decision?  Despite its financial woes, BCM remains one of the
elite medical and research institutions in the U.S. The merger would
have undoubtedly brought a substantial increase in research funds in
such fields as bioengineering, neurobiology, nano-biotechnology, stem
cell biology and gene therapy. Although Rice would have been
subsidizing BCM’s financial problems in the short term, my sense is
that the increase in research resources flowing to Rice over the years
would ultimately make that bailout well worth it.  But even more
importantly, Rice passed on an opportunity to take a calculated risk
that could well have elevated Rice, BCM, the Texas Medical Center and
Houston to the forefront of medical and scientific research in the
world.   Despite the risks, that kind of upside doesn’t come around
very often. Failing to realize that is one of the key reasons why
Texas has lagged badly behind states such as California and New York
in the development of Tier 1 research institutions and all the
benefits that such institutions provide to the state and its
communities.  Thus, Rice is keeping its chips and betting that it can
develop its scientific research just fine without BCM. But if I were
to place a bet on which institution is closer to the cutting edge of
such research after the next 25 years, I’m still putting my chips on
Baylor.




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January  7, 2010


What killed F.D.R.?

     This interesting Lawrence Altman/NY Times article examines the
theory that that an undiagnosed melanoma contributed to the death of
President Franklin Delano Roosevent in 1945.  Of course, regular
readers of this blog know that another killer disease -- the dire
implications of which were not well-known in 1945 -- was probably the
main cause of FDR's death.  But despite the historical curiosity, the
most important point to glean from FDR's demise is the importance of
continued investment in clinical and scientific research.  We
sometimes forget that it was the generation of doctors and researchers
who came of age after World War II who embraced the optimistic view of
therapeutic intervention in the practice of medicine, which was a
fundamental change from the sense of therapeutic powerlessness that
was taught to these men by their pre-WWII professors. In short, it has
not been that long since medical science has understood that it could
cure disease and prolong life.  For example, if FDR's doctors had
known in 1945 what specialists in hypertension discovered in the two
following decades, then those doctors would never have allowed FDR to
be subjected to the stress of the Yalta Conference that doomed Eastern
Europe to almost 50 years of totalitarianism and economic deprivation.
  Stated simply, earlier discovery of the research into the
implications of hypertension could well have changed the course of
human history.   In fact, we all tend to under-appreciate the
advancements in medicine since World War II. For male babies born in
the U.S. in 1960, the life expectancy was about 66.5 years and for
female babies a tad over 73 years. By 2005, the live expectancies had
increased to over 75 and 80 years respectively. Although medical
advances don't account for all of those gains, newly-discovered drugs
and medical devices -- as well as enhanced understanding of disease --
have had an enormous impact on improving the quality of life of most
Americans.  Thus, as Congress considers reforming the U.S. health care
finance system, it is important for citizens to understand that
American medical care and research remains the hope of the world. The
current health care finance system has generated enormous investment
in that medical innovation, which has been a crucial and treasured
export of America to the rest of the world.  Let's think hard before
radically changing a system that generated the investment that
produced those benefits for us and the rest of the world.




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December 16, 2009


Criminalizing the neighborhood pharmacist

 This blog has long addressed the enormous cost to American society of
overcriminalization generally and particularly with regard to business
and risk-taking.  But lest we think that the problem is limited to
such things as business and victimless crimes, think again says Bob
Wachter:     Along comes another case involving jail time for a
medical mistake, this one featuring an Ohio pharmacist named Eric
Cropp.       Eric was the lead pharmacist at Cleveland’s Rainbow
Babies and Children’s Hospital on February 26, 2006. The
pharmacy, understaffed that day, received a rush order for
chemotherapy for a 2-year-old girl, Emily Jerry, who was undergoing
treatment for a spinal malignancy.     An unlicensed and distracted
(by press accounts, she was planning her wedding on the day of the
event) pharmacy technician mistakenly mixed the chemo with 23% saline
rather than the intended 0.9%. Eric, working in cramped quarters and
rushed for time, gave final approval to the mixture, partly because,
after seeing a spent bag of 0.9% saline next to the mixed solution, he
assumed that it had gone into the solution.     In other words, the
case was a classic illustration of James Reason’s Swiss cheese
model, in which numerous safety checks failed due to a confluence of
systems and human errors. Tragically, little Emily died from the
hypertonic saline infusion.    On hearing of the error, a Cuyahoga
County DA decided that the case merited criminal prosecution, even
though Eric had no history of errors in his pharmacy career and root
cause analysis of the case confirmed that its cause was simple human
error compounded by systems problems. At trial, fearing even harsher
penalties, Eric pleaded guilty to involuntary manslaughter, and was
sentenced to 6 months in the state prison, 6 months of home
confinement, 3 years of probation, 400 hours of community service, and
a $5,000 fine. Moreover, the Ohio pharmacy board permanently stripped
him of his license, depriving him of his livelihood –
forever.  .  .  .    During last week’s webcast,
Mike Cohen described visiting Eric in prison. “Like a scene out
of a movie,” he recalled, with Eric in his orange jumpsuit,
speaking to visitors through a glass wall, other felons –
including violent offenders – milling about. As he related the
visit, Mike choked up with emotion, clearly seeing this tale as both
powerfully tragic and cautionary.   How has it come to the point where
the criminal justice system exacerbates the tragedy of a young girl's
accidental death by ruining a career and inflicting enormous damage on
an innocent family? At least the young girl's family recovered
substantial financial damages resulting from the pharmacist's
negligence. Where does the young pharmacist's family turn for help?  A
truly civil society would find a better way.




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October  7, 2009


Fat chance

 A couple of interesting health care-related items caught my eye
today.  First, I went by my internist's office for my annual physical
and noticed that another group of doctors had leased a much larger
office across the hall from my doctor's office.   I peaked inside the
new doctors' office window and noticed that the reception area was
nicely furnished with plush leather sofas and chairs, flat screen
TV's, handsome hardwood flooring and tasteful Persian rugs.  The
opulence of the office prompted me to find out what kind of doctors
were apparently doing so well, so I grabbed one of the doctor's cards
from the reception area. It read (not the real name):      "John
Smith, M.D., Laparoscopic Obesity Surgery"   Meanwhile, this NY
Times article reveals the utterly unsurprising fact that New York City
regulations requiring fast food restaurants to post the caloric
content of their food did not induce obese consumers from eating less:
    A study of New York City’s pioneering law on posting
calories in restaurant chains suggests that when it comes to deciding
what to order, people’s stomachs are more powerful than their
brains.    The study, by several professors at New York University and
Yale, tracked customers at four fast-food chains —
McDonald’s, Wendy’s, Burger King and Kentucky Fried
Chicken — in poor neighborhoods of New York City where there are
high rates of obesity.    It found that about half the customers
noticed the calorie counts, which were prominently posted on menu
boards. About 28 percent of those who noticed them said the
information had influenced their ordering, and 9 out of 10 of those
said they had made healthier choices as a result.    But when the
researchers checked receipts afterward, they found that people had, in
fact, ordered slightly more calories than the typical customer had
before the labeling law went into effect, in July 2008.    The
findings, to be published Tuesday in the online version of the journal
Health Affairs come amid the spreading popularity of calorie-counting
proposals as a way to improve public health across the country.   
“I think it does show us that labels are not enough,”
Brian Elbel, an assistant professor at the New York University School
of Medicine and the lead author of the study, said in an interview.  
"Labels are not enough?" Makes one wonder what regulation
Professor Elbel will suggest next -- maybe governmental rationing of
fast food?  The argument in favor of these types of absurd
governmental intrusions into our lives is that government subsidizes
medical insurance, so government should attempt through regulation to
decrease obesity, which unfairly heaps a portion of health-care costs
relating to obesity on tax-paying citizens who are not obese.  But
putting aside for a moment the debatable notion of whether obesity
really increases health-care costs all that much, the far more
effective regulation to decrease obesity would be to provide a
financial incentive for citizens to lose weight. Namely, reduce the
governmental subsidy of medical insurance for those who choose to
remain obese.  Fat chance of that happening.




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August 31, 2009


Rationing health care in a disaster

 If you read one article health care-related this week, make it this
extraordinary Sheri Fink/NY Times Magazine article on the impossible
choices that the heroic doctors -- including 


February 19, 2008


An emerging risk of youth sports

As youth sports become increasingly specialized, a family from The
Woodlands is the subject of this Gina Kolata/NY Times article on one
of the big risks to children of that trend -- increased torn anterior
cruciate ligaments ("ACL"), the main ligament that stabilizes the knee
joint:

The standard and effective treatment for such an injury in adults is
surgery. But the operation poses a greater risk for children and
adolescents who have not finished growing because it involves drilling
into a growth plate, an area of still-developing tissue at the end of
the leg bone.

Although there are no complete or official numbers, orthopedists at
leading medical centers estimate that several thousand children and
young adolescents are getting A.C.L. tears each year, with the number
being diagnosed soaring recently. Some centers that used to see only a
few such cases a year are now seeing several each week.

A friend of mine and I were discussing last week how unfortunate it is
that most children these days depend on their parents to organize
athletic activities for them rather than simply playing sports
informally with neighborhood friends. Increased specialization is the
natural evolution of organized sports, which means more games, more
practice and more pressure on growing muscles, joints and bones. Not a
particularly healthy risk in my book.




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February  3, 2008


WinkingSkull.com

Check out WinkingSkull.com, a worthy counterpart to the Visual Medical
Dictionary (noted earlier here) in better understanding anatomy and
medical conditions.

Along those lines, did you know that "the bacteria count in the plaque
on human teeth approaches the bacteria count in human feces?" (H/T
Kevin, MD)

Still biting those fingernails? ;^)




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January 30, 2008


Arnold Kling's Medicare experience

As I've noted many times, EconLog's Arnold Kling is doing some of the
best writing and thinking about health care and health care finance
issues in the U.S. right now. In his latest TCS op-ed, Kling describes
the care received recently by his elderly father (who sounds as if he
should have been a patient of my late father) and observes:

Medicare is wonderful for relieving the elderly from the burden of
worrying about health care expenses. By the same token, it is
wonderful for relieving doctors of the burden of worrying about the
elderly as customers. You get paid for understanding the billing
system, not for understanding your patients.

Read the entire op-ed. An update post is here.




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January 25, 2008


The vanishing primary care physicians

This earlier post on my internist's decision to adopt a concierge
health care model for his practice noted that the economic crisis
faced by most primary care physicians was one of the primary reasons
for the change in his practice. In this recent post, Kevin Pho passes
along the story of yet another internist hanging up the stethoscope as
a result of not being able to make ends meet within the frazzled U.S.
health care finance system:

"I am an Internist for over 20 years, and I recently closed my primary
care practice as I cannot make a living at it. I made $23K in the last
11 months. And, my departure from practice is only the beginning of a
tsunami of closures of primary care practices  .   .   .

Primary care is unraveling around us. Indeed, all of the articles
about the inordinate strain & crowding of emergency departments across
the U.S., overlook the obvious - the impending failure of primary care
is going to completely overwhelm emergency rooms. There is no way to
prepare for this other than to save primary care.

The whole house of cards has begun to collapse, and all the articles
and discussions fail to put it in terms with sufficient emphasis. All
of the 'universal' systems that actually work are built on very strong
and well-funded foundations of primary care. Everything else in health
care is built upon that foundation, and that is precisely what is
failing across the country. Why are emergency rooms overcrowded? Why
are the wait times increasing even for the seriously ill? Because
primary care is failing!

Just remember, I told you so."

And here is another primary care physician's analysis of why he turned
to the concierge model.




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January 21, 2008


Visual Medical Dictionary

This is quite interesting.





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January 17, 2008


The fascinating "Flea"

Eric Turkewitz interviews Dr. Robert Lindeman, the Boston-based
pediatrician who caused quite a stir last year when the Boston Globe
broke the story that he was the anonymous blogger nicknamed "Flea" who
was blogging a medical malpractice trial while participating as a
defendant. One of Dr. Lindeman's answers even has a Houston twist:

A hypothetical question: You've been called for jury duty and the case
involves a question of medical malpractice. What will you tell the
attorneys during the jury selection process about your ability to sit
impartially?

Answer: "I will tell them that Roger Clemens will admit to using
performance-enhancing drugs before I will able to sit impartially on a
malpractice jury."




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January 11, 2008


America's worst 20 fast food items

Most folks can get by quite well with eating less than 2,000 calories
per day. Each of these food items pretty well gets you there.

Caramel Banana Pecan Cream Stacked and Stuffed hotcakes?

By the way, just to show that you can find almost anything on the Web,
The Healthy Dining Finder can help you pick healthier choices from
standard restaurant menus by eliminating high-calorie add-ons. 




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January  9, 2008


No sympathy

This NY Times article from the other day reports on the increasing
numbers of lawyers and doctors who are plagued by self-doubt (who'd
have ever thought that?). Mr. Juggles over at Long & Short Capital has
no sympathy:

To the lawyers:

In case the Neiman Marcus purchases succeeded in lifting your morale
and left you with the impression that what you did counted for
something, please let me add some critical information: It doesn’t.
This is why you are paid, on an hourly-adjusted basis, like a recent
(2nd tier) college graduate.

To the doctors:

The fact that I was able to diagnose my own illness after 15 min on
WebMD speaks to the value of your knowledge. Perhaps our relationship
would be more productive if you would stop making me wait 3 days for
an appointment (and 90 minutes once I get to the office) to diagnose a
sinus infection that I already know I have. Give me the antibiotics
without the self-importance. I will come see you again when I have
something you can actually be helpful with. For instance, after I
break my arm trying to carry my bonus home, I will come see you and
you can set the cast. Until then, please stop whining.




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January  8, 2008


Dr. Pou's fog of Katrina

This Dr. Susan Okie/New England Journal of Medicine article (H/T
Kolahun) provides the most extensive analysis to date of the
circumstances surrounding the tragic deaths of the nine New Orleans
area hospital patients during the aftermath of Hurricane Katrina that
led to the egregious prosecutorial decision to bring criminal charges
against one of the treating physicians, former University of Texas
Medical School physician, Dr. Anna Pou (previous posts here). Dr. Okie
addresses the key question of why these nine patients died ".  .  . in
light of the eventual evacuation of about 200 patients from [the
hospital], including patients from the intensive care unit, premature
infants, critically ill patients who required dialysis, patients with
DNR orders, and two 400-lb men who could not walk." It's an important
question to address, but not in the context of a criminal case.

The fog of war analogy is certainly appropriate. Even with as good
information as we have about the horrific conditions at the hospital
in the aftermath of Katrina, it's still hard to imagine how difficult
it was making even basic decisions in the face of the breakdown of
civil society and infrastructure. What we do know is that Dr. Pou, who
was not experienced in providing emergency medical services in what
amounted to a heavy combat war zone, was no ethicist on mission to
make a political statement. Rather, she was simply a physician doing
the best she could to make the right decisions under the worst
circumstances imaginable. It should not surprise us if, with the
benefit of hindsight bias, some of those decisions would not have been
the ones that a reasonable physician would have made under better
conditions.




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December 21, 2007


Self-deception about calories

This Gina Kolata/NY Times article (previous posts here) explains how
many people continue to misconstrue exercise as a primary means of
weight-control by overestimating the number of calories they expend
during exercise. A well-structured exercise program can assist in
controlling a person's weight over the long term, but it really
doesn't have much effect on weight over the short term.

On the other hand, my anecdotal experience is that many of the same
folks who overestimate the amount of calories that they expend during
exercise dramatically underestimate the amount of calories that they
are consuming, particularly in regard to restaurant food.

I'm convinced that the combination of these misunderstandings -- along
with not having a clear understanding of the difference between
exercise and recreation -- has much to do with the obesity syndrome
that many Americans battle throughout their lives.




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December 19, 2007


The remarkable story of Kevin Everett

Three months ago, Kevin Everett, a tight end for the Buffalo Bills who
was born and raised in Port Arthur just east of Houston, suffered a
serious spinal cord injury during an NFL game. At the time of the
injury, there was grave doubt whether Everett would ever walk again.

As this Sports Illustrated article recounts, Everett's recovery from
his serious injury has been nothing short of amazing. One of the
interesting aspects of Everett's recovery is that it may have been
fueled by the gutsy call of a 45 year-old orthopedic surgeon on the
scene in Buffalo, but it was certainly facilitated by the remarkable
rehabilitation services of the Texas Medical Center's Institute for
Rehabilitation and Research (known as "TIRR") and the inspiring
resolve of the 25 year old patient. TIRR is regularly ranked as one of
the finest rehabilitation institutions in the U.S. and is one of the
many reasons that Houston is among the world's finest medical
centers.




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December 17, 2007


Satel on desperately seeking kidneys

Sally Satel, the receipient of Virginia Postrel's kidney (see also
here), authored this amazing NY Times Magazine article in which she
describes the overwhelming emotions that donors and would-be
recipients go through under the current system of donating organs:

A week after my 49th birthday in January 2005, half a year after being
given a diagnosis of renal failure, a friend and I were drinking
coffee at a Starbucks when I wondered aloud if I would find a donor
before I reached 50. I wasn’t hinting. I knew she would never offer
because she was so squeamish about blood and pain. My friend, whom I
met a decade before when we were both new to Washington and worked
together on an advocacy project, was a little older than I; she was
charming, stylish, smart — and a hypochondriac. 

Nor, to be honest, did I want her kidney. Anyone as anxious about
health as she was would surely view donation as a white-knuckle
ordeal. And the bigger the sacrifice for her, the heavier the burden
of reciprocity on me. The bigger the burden on me, the more I would
resent her. Then I would feel guilty over resenting her and, in turn,
resent the guilt. Who could survive inside this echo chamber of
reverberating emotions? Thank goodness my friend would be holding on
to her kidney. 

But then to my amazement, within a minute or so of my speculating when
or if a donor would ever appear, she offered to do it. Later that
night we talked on the phone and she rhapsodized about what a
“mitzvah” it would be. Yes, her sentiments were lovely, but I felt
secretly annoyed because I knew it was her habit to embark upon
grandiose plans; when they fizzled, she would just shrug. I told her
that giving me a kidney was out of the question — “It would be too
weird,” was what I kept saying — but she persisted. I couldn’t
quite believe it when she told her family of her decision (they were
graciously in favor) and then had blood tests and consulted with my
transplant team. 

Gradually, I began to believe that she meant it, and I decided to
embrace her just as you might accept an in-law, as someone who could
drive you a little mad but whom you loved because they were the source
of something very precious to you — in my case, not a spouse but a
kidney. But then after a few months she stopped talking about it. When
I finally broke the silence, she said her doctor had advised against
it. More likely, I thought, she was scared. I felt sorry to have put
her in this position, but I was also bitter: just when would she have
gotten around to telling me? 

Such near-transplant experiences are not uncommon. All of the
transplant candidates I spoke to, as part of my own small
nonscientific sample, mentioned at least one person who promised to
donate, had some tests done and then developed cold feet. Transplant
teams explicitly, and properly, offer face-saving “medical alibis”
to potential donors who don’t really want to go through with it,
which suggests that bailing out isn’t all that rare. They might tell
the person needing the transplant and the rest of the family, for
example, that additional tests on the prospective donor revealed a
compatibility problem or some evidence that the donor might be putting
her own health at risk.

Inasmuch as the supply-demand imbalance for kidneys and other organs
is well known, it seems obvious that the simple solution is to allow
markets to fix the problem. However, absent political leadership to
change the existing obsolescent system, many patients who need a
transplant will remain relegated to long waiting lists. Many of those
patients will die before their name is called. As Satel notes at the
end of her article:

"But unless we stop thinking of transplantable kidneys as gifts, we
will never have enough of them."



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December 14, 2007


More on the myth of beneficial long-distance running

The increasing evidence that long-distance running is not healthy has
been a frequent topic on this blog, and this Lou Schuler/Men's Health
article surveying the most recent research and expert opinions comes
to the same conclusion:

[No expert] today believes that endurance training confers immunity to
anything, whether it's sudden death from heart disease or the
heartbreak of psoriasis. Every time you lace up your running shoes,
there's a chance your final kick will involve a bucket, and every
expert knows this. [.  .  .]

The highest death rate is among the men who exercise long and hard,
and is much higher than that of the men who exercise short and hard. 

Schuler concludes that frequent, short exercise sessions that balance
strength-training with moderate aerobic exercise is probably the
healthiest approach. Read the entire article. 





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November  6, 2007


30 year anniversary of the first angioplasty

Angioplasty has been a common topic on this blog, so it seems fitting
to pass along this article and related video about Dolf Bachmann, the
first patient to undergo balloon angioplasty. Bachmann was 38 years
old when he underwent the procedure on September 16, 1977 and now is a
healthy and happy 68 year-old who enjoys an "excellent life" that
includes hobbies such as "hiking, Nordic walking, skiing, working in
my garden and playing cards."




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November  5, 2007


Risky business

The tragic death Saturday morning of 28-year-old veteran marathoner,
Ryan Shay, during the United States Olympic trials marathon in Central
Park in New York City reminds us of a very important health tip --
long-distance running is not particularly healthy.

Update: Another participant in the marathon died afterward.





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October 26, 2007


My concierge health care experience

Bill Lent is one of Houston's finest internists. How do I know this?
Well, because I know who trained him (my late father) and he has been
my personal physician for the past 15 years or so. Having been blessed
with good health, the only medical service that I buy from Dr. Lent in
most years is my annual physical, which I generally schedule for about
this time each year. I always enjoy catching up with Dr. Lent, who
provides me with "on the front line" information regarding the
horrific cost of health care regulations, which are literally
strangling the market for primary care physicians in the U.S. 

It's been particularly interesting watching the evolution over the
years of Dr. Lent's internal medicine practice, from one in which Dr.
Lent provided an unusually high level of personal care to his patients
(something my father emphasized in his teaching) to a high volume,
impersonal practice that virtually all primary care practices have
been required to adopt to remain even marginally profitable under the
present U.S. health care finance system. Over the past ten years or
so, Dr. Lent has continually confided to me during our annual visits
that he was uncomfortable with the direction of his practice.

So, I was pleased to learn when I scheduled my physical a couple of
weeks ago that Dr. Lent is doing something about it. Starting next
month, Dr. Lent is commencing a concierge health care practice,
administered by MDVIP out of Boca Raton, in which he is limiting his
practice to about 600 patients who will pay Dr. Lent $1,500 annually
for the benefit of receiving his personalized style of service.
Coincidentally, this Wall Street Journal ($) article earlier this week
described the proliferation of pre-paid health care plans, which is
sort of a lower-priced form of what Dr. Lent is doing. The WSJ article
essentially describes how many primary care physicians are simply
dropping out of insurance plans -- both public and private -- in favor
of prepaid plans that offer unlimited access to basic health care for
set monthly fees. 

Inasmuch as the employer-based health insurance system typically
offers low-copays and deductibles for the vast majority of health care
services, a substantial amount of the American health care finance
system is basically prepaid health care already. In order to maintain
profitability in a highly-regulated market, insurance companies
compensate for these low usage fees by charging higher monthly
premiums, lowballing doctors' fees, and challenging claims
continually. The result has been the evolution of a primary care
system that is incredibly bureaucratic (have you ever tried to figure
out how your insurance pays claims?) and literally breaking down.

The MDVIP model treats primary care service similar to a health club
membership. The model focuses on the delivery of relatively
inexpensive, protocol-driven care than can be offered at a relatively
low cost while still providing patients more overall access. MDVIP's
model is relatively expensive, so low-income patients will have a
difficult time affording the fee. However, providing a tax deduction
for individual health insurance would make such pre-paid plans more
affordable for low-income patients, while providing Medicaid patients
with vouchers for prepaid health care would have a similar impact.

Who will be threatened from the proliferation of these plans under the
current health care finance system? Well, it's a bit early to
speculate, but my sense is that insurance companies with big stakes in
employer-based health insurance will not enjoy the competition from
MDVIP-type practices. Similarly, speciality providers who depend on
state regulatory mandates in comprehensive insurance plans to
subsidize their practices will also feel the competitive pressure if
these types of plans catch on in a big way.

So, I'm going to enjoy learning about how Dr. Lent's practice changes
over the next year under the MDVIP structure. If it is successful, as
I suspect it will be, it makes you wonder -- if such entrepreneurial
spirit can be generated even in the current highly-regulated health
care finance system, then imagine what could happen if we unleashed
the power of the marketplace to reform the delivery of health care and
the health care finance system?




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October 19, 2007


The risk of witch doctors

It never fails to amaze me that seemingly rational people continue to
seek out witch doctor treatments for anything more complicated than a
massage:

On the same shift I saw two very sick patients, both of whom were
under the care of chiropractors before they decided to pay us a visit
in the Emergency Department. The first was an old woman with a one
week history of dyspnea, chest pain, and a cough.  Her chiropractor
had diagnosed her with a “displaced rib,” and had been dilligently
popping it back into place every day for the previous week.  After a
simple set of vital signs revealing low blood pressure, a slow heart
rate, and a slightly low temperature, not to mention a chest x-ray
which showed a huge unilateral pleural effusion, it was not hard to
come up with the diagnosis of pneumonia with sepsis.

“He [the chiropractor] said she didn’t have a fever and she
wasn’t coughing anything up,” said the sister. [.  .  .]

The second patient was a 70-year-old man who finally came in after a
week of ineffectual adjustments for “muscle aches” and general
malaise which had evolved, by the time we saw him, into a vague
intermittant chest pain related to exertion but which the chiropractor
insisted, apparently, was some kind of subluxation.  The EKG told the
true story, an evolving myocardial infarction.  My patient would have
probably died if his son hadn’t raised the alarm and insisted his
father see some real doctors.

Meanwhile, this article reports that researchers have determined that
acupuncture works. But the same research study concluded that fake
acupuncture, where the needles are inserted shallowly and in the wrong
places, also works:

The results suggest that both acupuncture and sham acupuncture act as
powerful versions of the placebo effect, providing relief from
symptoms as a result of the convictions that they engender in
patients.

My conclusion: On one hand, if you stick pins in people who are
complaining about something, then some of them will eventually quit
complaining. On the other hand, if you take pins out of some people
who were previously complaining, then some of them will also stop
complaining.




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October 18, 2007


The end of socialized medicine

Peter Huber is a Manhattan Institute senior fellow, an MIT-trained
engineer and a lawyer who has authored several books, including Hard
Green: Saving the Environment from the Environmentalists and
Galileo’s Revenge: Junk Science in the Courtroom. In this
provocative City Journal article, Huber observes that the complexity
of modern diseases virtually assures that a "one-size-fits-all"
socialized medical system will fail:

That is the real crisis in health care—not medicine that’s too
expensive for the poor but medicine that’s too expensive for the
rich, too expensive ever to get to market at all. Human-ity is still
waiting for countless more Lipitors to treat incurable cancers,
Alzheimer’s, arthritis, cystic fibrosis, multiple sclerosis,
Parkinson’s, and a heartbreakingly long list of other dreadful but
less common afflictions. Each new billion-dollar Lipitor will be
delivered—if at all—by the lure of a multibillion-dollar patent.
The only way to get three-cent pills to the poor is first to sell
three-dollar pills to the rich.

With almost $30 trillion under management, Wall Street could easily
double the couple of trillion it currently has invested in molecular
medicine. The fastest way for Washington to deliver more health, more
cheaply, to more people would be to unleash that capital by
reaffirming patents and stepping out of the way.

On the other side of the pill, molecular medicine can only be
propelled by the informed, disciplined consumer. Any scheme to weaken
his role will end up doing more harm than good. Foggy promises of
one-size, universal care maintain the illusion that the authorities
will take good care of everyone. They reaffirm the obsolete and false
view that health care begins somewhere out there, not somewhere in
here.

Neither Pfizer nor Washington can ever stuff health itself into a
one-price uniform, One America box—not when health is as personal as
ice cream, genes, and pregnancy, not when every mother controls her
personal consumption of carbs, cholesterol, Flintstones, and Lipitor.
But the thought that government authority can get more bodies in
better chemical balance than free markets and free people is more
preposterous than anything found in Das Kapital. Freedom is now
pursuing a pharmacopoeia as varied, ingenious, complex, flexible,
fecund, and personal as life itself, and the pursuit will continue for
as long as lifestyles change and marriages mix and match. Given time,
efficient markets will deliver a glut of cheap Lipitor for every glut
of cheap cholesterol. And given time, free people will find their way
to a better mix.

Read the entire article here.




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October 17, 2007


Immune to reason

Paul Howard is a senior fellow at the Manhattan Institute Center for
Medical Progress and the editor of the blog Medical Progress Today. In
this Washington Post op-ed, Howard addresses the potential danger to
public health of indulging in the current wave of trendy skepticism
toward vaccinations:

Sadly, too many parents have lost faith in vaccines. Partly, this is
because of a "generation gap." In 1940, U.S. infant mortality rates
stood at 40 deaths per 1,000 live births. Tens of thousands more
children would go on to be killed or maimed by measles, polio and
chicken pox. Today, infant mortality averages about 7 deaths per 1,000
live births, and those other diseases have been largely vanquished by
vaccines. A childhood free of serious illness is now taken for
granted.

When mysterious disorders like autism strike seemingly healthy
children -- at about the same age when childhood vaccines are
typically administered -- frustrated parents lash out at doctors and
pharmaceutical companies. And today's vaccine inventors must contend
with a powerful force that had yet to arise when Jonas Salk created
his revolutionary polio vaccine -- mass litigation. 

The birth of "liability without fault" in pharmaceutical litigation in
1958 -- captured in Dr. Paul Offit's riveting book The Cutter Incident
-- set the dangerous precedent that vaccine companies would be held
liable for side effects even when their products were made using the
best available science and according to government regulations. [.  . 
.]

The debate over vaccine litigation has thus shifted from a presumption
of innocence to a presumption of guilt. While the number of major
studies that have failed to find any substantive link between vaccines
and developmental disorders or autism is now in the double-digits
(including a September 27th CDC study in the New England Journal),
critics are effectively demanding that scientists prove that
thimerosal does not cause illness -- an impossible standard.

The very success of vaccines has become their downfall. As Dr. Offit
writes in Vaccinated, "When [vaccines] work, absolutely nothing
happens. Parents go on with their lives, not once thinking that their
child was saved." 

The entire op-ed is here. This earlier post addresses the devastating
impact that the Cutter Incident had on the production of vaccines and
public health.




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October  9, 2007


Kolata on Good Calories, Bad Calories

NY Times nutrition columnist Gina Kolata (previous posts here) reviews
Gary Taubes' new book, Good Calories, Bad Calories: Challenging the
Conventional Wisdom on Diet, Weight Control and Disease (Knopf
September, 2007), which was previewed earlier here. Kolata observes:

His thesis, first introduced in a much-debated article in The New York
Times Magazine in 2002 challenging the low-fat diet orthodoxy, is that
nutrition and public health research and policy have been driven by
poor science and a sort of pigheaded insistence on failed hypotheses.
As a result, people are confused and misinformed about the
relationship between what they eat and their risk of growing fat. He
expands that thesis in the new book, arguing that the same confused
reasoning and poor science has led to misconceptions about the
relation between diet and heart disease, high blood pressure, cancer,
dementia, diabetes and, again, obesity. When it comes to determining
the ideal diet, he says, we have to “confront the strong possibility
that much of what we’ve come to believe is wrong.” [.  .  .]

Taubes convincingly shows that much of what is believed about
nutrition and health is based on the flimsiest science. To cite one
minor example, there’s the notion that a tiny bit of extra food, 50
or 100 calories a day — a few bites of a hamburger, say — can
gradually make you fat, and that eating a tiny bit less each day, or
doing something as simple as walking a mile, can make the weight
slowly disappear. This idea is based on a hypothesis put forth in a
single scientific paper, published in 2003. And even then it was
qualified, Taubes reports, by the statement that it was “theoretical
and involves several assumptions” and that it “remains to be
empirically tested.” Nonetheless, it has now become the basis for an
official federal recommendation for obesity prevention.

But the problem with a book like this one, which goes on and on in
great detail about experiments new and old in areas ranging from heart
disease to cancer to diabetes, is that it can be hard to know what has
been left out. [.  .  .[

.  .  . I kept wondering how he would deal with an obvious question.
If low-carbohydrate diets are so wonderful, why is anyone fat? Most
people who struggle with their weight have tried these diets and
nearly all have regained everything they lost, as they do with other
diets. What is the problem?

On Page 446, he finally tells us. Carbohydrates, he says, are
addictive, and we’ve all gotten hooked. Those who try to break the
habit start to crave them, just as an alcoholic craves a drink or a
smoker craves a cigarette. But, he adds, if they are addictive, that
“implies that the addiction can be overcome with sufficient time,
effort and motivation.” 

I’m sorry, but I’m not convinced.

John Tierney comments, too.




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September 21, 2007


Coopertown?

Dr. Kenneth Cooper of Dallas may have oversold the benefits of aerobic
exercise, but will the same be true for his new real estate venture?:

Dr. Cooper is developing a $2 billion residential wellness community
here called Cooper Life at Craig Ranch that is going up on the first
51 of an eventual 151 acres on the Texas plains, north of Dallas.

Taking the concept of spa real estate into the medical realm, Dr.
Cooper’s community promises home buyers a life that sounds equal
parts Norman Rockwell and Olympic village: a small town where doctors
will make house calls and where every resident has a bevy of experts
close at hand for keeping in tiptop shape. 

It appears to be the first of its kind. .  .  . 

Included in the monthly residential fee ($1,041 for an individual to
$2,181 for a family of six) will be an annual physical and a six-month
follow-up, which Dr. Cooper calls key to his utopian vision of a place
where everyone can live in peak health. The fee also includes home
doctor visits, a fitness center membership, concierge services and
exterior home maintenance, lectures and social activities.

While a diverse mix of ages and fitness levels are welcome, Dr. Cooper
admits that many prospective residents may well be baby boomers with
cushy bank accounts. “They’ve got the money,” Dr. Cooper said,
“now they want to live long enough to enjoy it.”

I get exhausted just thinking about the thought of living there. ;^)




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Something ailing you?

If so, and even if not, check out these 100 Web Resources for Medical
Professionals.





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September 18, 2007


What makes us healthy?

Gary Taubes, a writer for Science magazine, is the author of the
soon-to-be-released book Good Calories, Bad Calories: Challenging the
Conventional Wisdom on Diet, Weight Control and Disease (Knopf
September 25, 2007). He provides a don't miss preview of his book in
this past Sunday's New York Times:

Many explanations have been offered to make sense of the
here-today-gone-tomorrow nature of medical wisdom — what we are
advised with confidence one year is reversed the next — but the
simplest one is that it is the natural rhythm of science. An
observation leads to a hypothesis. The hypothesis (last year’s
advice) is tested, and it fails this year’s test, which is always
the most likely outcome in any scientific endeavor. There are, after
all, an infinite number of wrong hypotheses for every right one, and
so the odds are always against any particular hypothesis being true,
no matter how obvious or vitally important it might seem. [.  .  .]

The dangerous game being played here, as David Sackett, a retired
Oxford University epidemiologist, has observed, is in the presumption
of preventive medicine. The goal of the endeavor is to tell those of
us who are otherwise in fine health how to remain healthy longer. But
this advice comes with the expectation that any prescription given —
whether diet or drug or a change in lifestyle — will indeed prevent
disease rather than be the agent of our disability or untimely death.
With that presumption, how unambiguous does the evidence have to be
before any advice is offered? [.  .  .]

Richard Peto, professor of medical statistics and epidemiology at
Oxford University, phrases the nature of the conflict this way:
“Epidemiology is so beautiful and provides such an important
perspective on human life and death, but an incredible amount of
rubbish is published,” by which he means the results of
observational studies that appear daily in the news media and often
become the basis of public-health recommendations about what we should
or should not do to promote our continued good health. [.  .  .]

All of this suggests that the best advice is to keep in mind the law
of unintended consequences. The reason clinicians test drugs with
randomized trials is to establish whether the hoped-for benefits are
real and, if so, whether there are unforeseen side effects that may
outweigh the benefits. If the implication of an epidemiologist’s
study is that some drug or diet will bring us improved prosperity and
health, then wonder about the unforeseen consequences. In these cases,
it’s never a bad idea to remain skeptical until somebody spends the
time and the money to do a randomized trial and, contrary to much of
the history of the endeavor to date, fails to refute it.

Read the entire article.




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August 31, 2007


Property rights, economics and AIDS

Peter F. Schaefer explains how economics and property rights in
African nations combine to facilitate the proliferation of the AIDs
virus:

However no one in the US government and few in the anti-AIDS community
are dealing with a major issue in the transmission of AIDS called
"property stripping." Since the cure for property stripping is cheap,
technically quite easy and would have an enormous secondary impact on
economic growth (poverty is a hidden vector of AIDS) it would seem
like a sure thing for attention. But it is virtually ignored.

On World AIDS Day two years earlier Dr. Jim Yong Kim - [head of World
Health Organization's HIV Division, Kevin] De Cock's predecessor -
said, 

"In sub-Saharan Africa almost 60 percent of AIDS sufferers are women
[and] in some settings ... we are finding ... that the number one risk
factor for women in becoming infected with HIV is marriage. [And]
married women have the highest rates of HIV infection. We have to take
on some of the most fundamental and difficult cultural and social
issues that are definitely affecting the way this epidemic is
spreading. And ... if we can take on things like for example, property
rights [so] women can inherit the property of their husband if [he]
dies, that really reduces the likelihood of them getting into sex work
for example. If we can ... change laws, change fundamental beliefs and
culture by [getting] people the right kinds of prevention messages we
will have done a lot not just for HIV AIDS but for issues like gender
equity that have been with us forever."

In the scholarly literature, the traditional practice of the husband's
family inheriting all his property after he dies is called "property
stripping." In normal times, this had some logic; the husband's family
had responsibility for the widow and her children, a brother often
taking her as a second wife and so assuming responsibility for his
nieces and nephews.

But things have changed. In the time of AIDS, the widow is likely also
infected with the HIV virus, though not yet sick since her husband
often gets it first and the disease is less advanced in her when her
husband dies. So even if her brother-in-law hasn't died from AIDS
himself, he is not willing to marry someone infected with HIV. And
often the brother-in-law himself is sick or dead. Nevertheless, the
family often still follows custom and seizes her house and farm and so
she has no recourse but to turn to menial jobs, begging or
prostitution. And since she was infected later, she may have years to
spread her illness to her sex partners which are commonly many a day.

[A] Washington Post editorial by Richard Holbrooke .  .  .  noted that
increased testing and detection efforts was the "only effective
prevention strategies can stop the spread of AIDS." He goes on to
point out that "...monogamous women [are] thrown out of their homes
for a disease they got from their husbands."

Read the entire article, which is another reminder that there are few
simple solutions to this terrible disease.




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August 28, 2007


What's ailing you?

Have you had a symptom of an illness or an injury that has bothering
you for awhile? Medgle allows you to click on the body part that's
bothering you and select the specific symptom from a list of possible
options. Then, Medgle asks how long the symptom has been apparent, as
well as th inquirer's sex and age. Medgle then returns a listing of
possible matches for the symptoms. 

Moreover, you can then take the result that Medgle generates and, on
the following page, provides you with a brief summary of the condition
and a Google search relating to treatment, prevention, drugs, tests,
research, diet, alternative medicine, and fitness. You can even refine
the search by changing the age or gender. 

This is never going to replace a visit to your doctor, but it sure
provides a handy way to increase the patient's knowledge and
understanding regarding diagnosis and treatment. Check it out.





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August 27, 2007


In Dr. Pou's words

Dr. Anna Pou (previous posts here), the former faculty member of the
University of Texas Medical Branch in Galveston, performed heroically
in the horrific aftermath of Hurricane Katrina. For her heroism, she
became the main subject of one of the most egregious examples of
prosecutorial misconduct in recent memory. In this extensive Newsweek
article, Dr. Pou finally tells her side of the story and it magnifies
the enormity of the injustice that a few irresponsible Louisiana state
officials have put her through. The following are a few tidbits:

What was it like after the levees broke?

Monday after the storm passed, we figured, ‘OK, minimal damage; we
began organizing how we were going to evacuate the hospital.’ We
didn’t have full power so we needed to move patients. Tuesday
morning we were planning our day and one of the nurses called me to
the window and said you’ve got to come see this. Water was gushing
from the street. So we all kind of looked in disbelief. What is this?
We could tell the city was flooding, you could see water down
Claiborne Street. It was rising about a foot an hour. Then the whole
mood at the hospital changed and what we were doing changed. We were
in hurricane mode and we had to go into survival mode because we knew
we had to be there for some time.

How did things change on Wednesday?

Tuesday night, we lost generator power, and that changed things a lot.
‘Til then we were on generator power so we did have some lights, and
we did have some water. Water wasn’t clean, but it was running. But
then we didn’t have water, we didn’t have any electricity,
commodes were backing up everywhere. Conditions in the hospital
started to deteriorate Tuesday night and early Wednesday. When that
happens it makes care a lot more difficult. I was called to help
suction a patient who had a tracheotomy but we had no suction running.
We were going down to very, very basic care. You try every old-time
method you can … [P]eople in charge were trying to get helicopters
to come, [but] at that time we were told we were low priority. There
were people on rooftops [who were going to get rescued first]. They
said … there’s not going to be a lot of help coming, [so] what we
decided [was] if helicopters were going to show up sporadically, we
have to have patients ready and waiting to go. [.  .  .]

The conditions were unbearable. Inside the hospital it was pitch
black, with odors, smell, human waste everywhere. It was very rancid.
You would take a breath in and it would burn the back of your throat.
The patients were very sick. That’s when we had to go from triage to
reverse triage because we came to realize if patients aren’t being
evacuated, [we had to deal with what we had]. Basically it was a
general consensus that we’re not going to be able to save everybody.
We hope that we can, but we realize everybody may not make it out. [. 
.  .]

By the time Wednesday evening came around, if you can imagine in our
mind, there is a central area that is a sea of people. A lot of very
sick patients in that central triage area. It’s grossly backed up.
Few patients had been evacuated. So there was just enough space to
walk between the stretchers. It is extremely dark. We’re having to
care for patients by flashlight. There were patients that were
moaning, patients that are crying. We’re trying to cool them off. We
had some dirty water we could use, some ice. We were sponging them
down, giving them sips of bottled water, those who could drink. The
heat was—there is no way to describe that heat. I was in it and I
can’t believe how hot it was. There are people fanning patients with
cardboard, nurses everywhere, a few doctors and wall-to-wall patients.
Patients are so frightened and we’re saying prayers with them. We
kind of looked around at each other and said, “You know there’s
not a whole lot we can really do for those people.” We’re waiting
[for help]. The people in that area could have [been evacuated] by
boat but no boats were coming. I would do what I could with the
nurses: changing diapers, cooling patients down with fanning. It
wasn’t like, “I’m a doctor, you’re a nurse.” We were all
human beings trying to help another human being, whatever it took.

What happened Thursday?

On Thursday morning we were told nobody was coming and we had to fend
for ourselves. Everybody was kind of like at a loss here. What is plan
B? Or plan C?

How did you come to be the one administering the injections? Louisiana
Attorney General Charles Foti made a point of saying you had
administered medication to people who were not your patients.

This was an emergency situation. There were no LifeCare doctors. In an
emergency situation, the patients become everybody’s patients. What
are you supposed to do if a patient needs to be cleaned and have IV
fluids, say, “You’re not my patient, good luck”? That’s
absurd. If that’s the case I dare say three-fourths of the
population of Memorial Hospital would have been left without a doctor.
We’re in medicine because we care about people. This is what we do.
We don’t run around murdering people. That’s why what he said is
so ludicrous.

When did you leave the hospital and who was still there when you
left?

I left Thursday around 6 p.m. in a helicopter. When I left no one was
in the hospital. There were a handful of patients on the helipad. I
went to [another hospital and then] on a bus to Baton Rouge because my
family was there.

How did you feel?

I was tired but I was more in total disbelief that the sick and the
poor could be abandoned the way that they were in the United States of
America. I never thought I would ever live to see that day. I was sad,
heartbroken, kind of amazed and shocked at the lack of
organization—the fact that there was no type of coordination. I have
friends who practice in the third world and this was less than third
world.

What was it like to be arrested in 2006?

I had [performed] surgery that Monday. It was bedlam in the medical
community after Katrina. I had surgery Monday, Tuesday, Wednesday,
Thursday and clinic on Friday. And the attorney general’s office
knew that. I was taking care of indigent patients. He put my patients
at risk. I am still angry about that. And then I was basically sitting
by myself eating a salad, still in scrubs. I was starving and really
dehydrated because I had been on call the weekend and been up 48 hours
before. There was a knock on the door. It was four agents from the
attorney general’s office.

The whole way [to jail] I was asking God to help my family get through
this. I have nieces and nephews, and my hospitalized patients, who
found out about this on the 10 o’clock news, which was heinous. Had
I known [about the arrest], I could have spoken to my patients.
Instead I just don’t show up and they see me on the news. There were
cancer surgeries that had to be rescheduled. These patients’
treatments were delayed because of what happened. I am still furious
about it. It just really makes me mad.

There is much more, so read the entire article. Again, I ask -- where
is the investigation of the public officials who are responsible for 
attempting to organize this lynch mob against this hero?



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August 18, 2007


A job well done

University of Houston student-athlete and football player Jerrod
Butler was stricken by sudden cardiac arrest on Monday during a
weightlifting session at the University of Houston. Butler passed out
and stopped breathing.

Members of the UH athletic training staff, led by Mike O'Shea and John
Houston, immediately revived Butler, performing CPR and using an
automatic external defibrillator. Butler was then rushed the short
drive to the Methodist Hospital emergency room at the Texas Medical
Center, where he was put on a ventilator and placed in the intensive
care unit.

On Thursday, Butler was moved out of the ICU and into a regular room.

It's easy in our busy lives to take professionals such as O'Shea and
Houston for granted, but they are the type of dedicated people who
make Houston such a special place to live. A tip of the hat to these
two fine professionals on a job well done.




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July 31, 2007


Endurance training to death

As noted in previous posts here and here, the myth that endurance
training and long-distance running are good for one's health remains
firmly entrenched among most Americans, despite sad reminders such as
this. In this timely article, Mark Sisson lucidly explains why
endurance training is hazardous to one's health. Here is a snippet:

The problem with many, if not most, age group endurance athletes is
that the low-level training gets out of hand. They overtrain in their
exuberance to excel at racing, and they over consume carbohydrates in
an effort to stay fueled. The result is that over the years, their
muscle mass, immune function, and testosterone decrease, while their
cortisol, insulin and oxidative output increase (unless you work so
hard that you actually exhaust the adrenals, introducing an even more
disconcerting scenario). Any anti-aging doc will tell you that if you
do this long enough, you will hasten, rather than retard, the aging
process. Studies have shown an increase in mortality when weekly
caloric expenditure exceeds 4,000. [.  .  .]

Now, what does all this mean for the generation of us who bought into
Ken Cooper’s "more aerobics is better" philosophy? Is it too late to
get on the anti-aging train? Hey, we're still probably a lot better
off than our college classmates who gained 60 pounds and can't walk up
a flight of stairs. Sure, we may look a little older and move a little
slower than we'd like, but there's still time to readjust the training
to fit our DNA blueprint. Maybe just move a little slower, lift some
weights, do some yoga and eat right and there's a good chance you'll
maximize the quality of your remaining years… and look good doing
whatever you do.




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July 27, 2007


Fit Nation Map

The map on the left purports to track the increase in the percentage
of obese persons in the U.S. over the past 20 years. I don't know
about the methodology of the statistical analysis, but the map is
pretty darn cool.





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July 25, 2007


Good news for Dr. Pou

An old saying in criminal defense circles is that a prosecutor could
persuade a grand jury to indict a ham sandwich if the prosecutor is
inclined to do so.

Fortunately, that was not the case in regard to former Houston area
resident, Dr. Anna Pou (previous posts here). Dr. Pou served on the
faculty of the University of Texas Medical Branch in Galveston from
1997-2004, where she was the Director of the Division of Head and Neck
Surgery from 1999 to 2004. Kevin, M.D. has been doing a good job of
tracking developments and comments regarding the case against Dr. Pou,
and here is the link to the website that has been established to help
raise funds for Dr. Pou's defense.

Following on this recent post on developments in Dr. Pou's case, a New
Orleans Parish grand jury today declined to indict Dr. Pou for
second-degree murder in connection with the deaths of several elderly
patients in the horrifying aftermath of Hurricane Katrina. The
decision ends a two-year long criminal investigation into Dr. Pou's
heroic treatment of patients at Memorial Medical Center in New
Orleans, which was turned into a sweltering, powerless hellhole on
Aug. 29, 2005 when the levees failed after the hurricane. Inasmuch as
the hospital was not evacuated until several days after the storm, 24
out of 55 elderly and infirm patients died.

The case against this distinguished academic had all the earmarks of a
political lynch mob from the beginning. It became quickly apparent
that Dr. Pou's arrest was the result of the highly questionable
accusations of three employees of LifeCare Hospitals, the company that
owned the hospital and whose top administrator and medical director
didn't even show up at the hospital during those chaotic days after
Katrina. Inasmuch as the accusing LifeCare employees made no effort to
evacuate the elderly and sick patients before or after the hurricane,
it quickly became clear to any reasonably objective observor that they
were attempting to divert attention (and perhaps prosecution) from
their own appalling inaction.

But the facts didn't matter to an elderly Louisiana attorney general
named Charles Foti, who had campaigned on a plank of "cracking down on
abuse of the elderly." Foti engineered the arrest of Dr. Pou and two
of her nurses while publicly referring to them as murderers, a charge
that he repeated in an episode of 60 Minutes several months later.
Although Dr. Pou's lawyer had told Foti that she would surrender to
authorities if an arrest warrant were issued for her, Foti had his
investigators arrest Dr. Pou and haul her into Orleans Parish Prison
on the evening of July 17, 2006, where she was booked on four counts
of second-degree murder. Thankfully, the decision on whether to
prosecute Dr. Pou was not Foti's, but that of New Orleans District
Attorney Eddie Jordan and the local grand jury, which was undoubtedly
persuaded by the New Orleans coronor's report that earlier this year
concluded that no compelling evidence of homocide existed. But that
did not stop Jordan from recently granting immunity to the two nurses
who were charged with Dr. Pou in an effort to induce them to testify
against Dr. Pou before the grand jury. Sheesh!

So, when does the investigation of the public officials begin who were
responsible for attempting to organize this lynch mob? 




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July 23, 2007


Dr. Pou's defense goes on the offensive

The state's threat to prosecute Dr. Anna M. Pou for murder is a sad
reflection of the incompetence in the Louisiana state government that
permeated the preparations for and the aftermath of Hurricane Katrina.
After almost two years now of legal limbo, Dr. Pou's defense team is
fighting back:

Dr. Anna Pou - the physician arrested in the deaths of four patients
at a New Orleans hospital after Hurricane Katrina - filed suit against
the Louisiana Attorney General on Monday, accusing him of using her
arrest to fuel his re-election bid.

The suit, filed in state court in Baton Rouge, also seeks to force the
state to provide a legal defense for Pou against civil lawsuits filed
by families of three of the patients.

Last year, State Attorney General Charles Foti claimed Pou and two
nurses killed four people with a ‘‘lethal cocktail'' at Memorial
Medical Center during the chaotic conditions after the August 2005
storm. The four were among at least 34 who died at the sweltering,
flooded hospital in the days following Katrina. Pou, who is free on
bond, has not been formally charged. A New Orleans grand jury is
looking into the case.

Foti had Pou arrested, ‘‘called an international press conference
the next day to announce the arrest, made extra judicial comments
totally contrary to the Rules of Professional Responsibility, and
culminated the week's activity with an attorney general fund raiser to
showcase his ‘achievements' in the arrest of Dr. Pou and the two
nurses,'' the suit says.

Foti was not immediately available for comment .   .   .

Go Dr. Pou!




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July  5, 2007


More on the myth of healthy long distance runners

This earlier post noted development of research indicating that long
distance running over a long term may be hazardous to your health.

Thus, this article from earlier in the week about arguably the
greatest American marathoner caught my eye:

Alberto Salazar, the former champion marathoner who collapsed over the
weekend, had his condition upgraded Monday from serious to fair.

A cardiologist at Providence St. Vincent Medical Center said tests now
indicate that Salazar had a heart attack while coaching distance
runners Saturday at the Nike campus outside Portland, said Lisa
Helderop, a hospital spokeswoman.

Salazar, who is alert and talking with his family, told a doctor at
the hospital that he has a family history of heart conditions,
Helderop said. [.   .   .]

Salazar, a University of Oregon graduate, won the New York City
Marathon three straight years (1980-82) and the 1982 Boston Marathon.
He has set six U.S. records and one world record. He is a longtime
Nike employee and consultant who trains elite distance runners and has
a building named for him on campus.

This recent University of Maryland Medical Center study addresses
another health risk of long-distance running. And none of the
foregoing even touches on the heightened risk of joint and ligament
damage that results from long distance running. Take note, runners.




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July  2, 2007


The search for a cure

Yale University School of Medicine neurologist Steven Novella, the
editor of the Scientific Review of Alternative Medicine, provides this
insightful NeuroLogica post that addresses the issue of why medical
research has not discovered a cure for cancer despite the enormous
resources dedicated to cancer research. In so doing, he clears up
several common misconceptions about cancer and the incentives involved
in finding a cure. He concludes as follows:

The overall reality is that the standard of scientific medicine is not
a monolithic entity, controlled by any one institution, agency, or
industry. It is a complex and dynamic set of many forces and
interests. It is ultimately driven by science, which is a transparent
and public process, and prevents any big brother type of control (this
is partly why it is so important that healthcare be based upon
science).

Cancer is a very difficult type of disease to treat, and the public
has a very distorted view of the nature of cancer and of medical
scientific progress in general. This has lead to unrealistic
expectations of progress in curing cancer, which then in turn leads to
thoughts that cancer research is somehow not working.

I find the same to be true in medicine in general – the public
thinks of scientific progress in terms of dramatic
“breakthroughs.” Media hype feeds this misconception. The reality
is that medical scientific progress is largely a series of very small
steps, with a cumulative effect of slow steady improvement in
treatments. We have not cured Alzheimer’s disease, ALS, Multiple
Sclerosis Parkinson’s disease, and many other diseases as well. But
treatments are slowly improving. Slow steady progress does not make
good headlines, however, so the myth of miracle medical breakthroughs
will likely continue to be promoted by the media.

Read the entire post. Hat tip to Sandy Szwarc.




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An important distinction in the health care finance debate

Clear Thinkers favorite Arnold Kling, who appears to be everywhere
these days in regard to discussions over reform of America's health
care finance system, reminds us in this Washington Times op-ed of an
important distinction in the health care finance debate -- despite the
problems in health care finance, American medical care and research
remains the hope of the world:

On one side of me at the graduation [of my daughter] sat [my wife], a
breast cancer survivor. On the other side was my father, whose heart
condition and blood pressure threatened to take his life before my
daughter was ready to graduate kindergarten, much less college.
Finally, there was my daughter herself, who since high school has had
a chronic intestinal illness sufficiently contained that she could
graduate on schedule.

None of these three stars would have been there without medical
treatments that only became available since my daughter was born. New
drugs played a significant role in each case. In fact, some
pharmaceuticals critical for my daughter only were approved for her
condition a few years before she was given them. Drugs in the pipeline
are likely to play an important role in her future.

In other countries, would the same state-of-the-art medicines and
equipment have been available to my father, my wife and my daughter?
Perhaps. But it is a safe bet these technologies were not invented
elsewhere.

Much of the medical innovation that the world enjoys comes from
America. While as an economist I find much to criticize about our
health-care system, America's role in medical innovation is crucial
not just for Americans, but for the entire world.

Read the entire op-ed.




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June 29, 2007


A primer on insulin, blood sugar and Type 2 diabetes

Mark Sisson (earlier post here) is now blogging on nutrition and
exercise issues, and one of his first posts provides this good
overview of the often misunderstood interrelationship between insulin,
blood sugar and Type 2 diabetes. As Sisson notes, "we are all, in an
evolutionary sense, predisposed to becoming diabetic."





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June 18, 2007


Steroids, home runs and variables

This post about Barry Bonds from a week or so ago prompted an
interesting exchange in the comments between me and Gary Gaffney, a
University of Iowa physician who blogs about steroid use over at
Steroid Nation. Following on that exchange is this Michael
Salfino/Grand Rapids Press article that raises questions regarding the
conventional wisdom these days that steroid use dramatically increased
home run totals in Major League Baseball:

Between 1995 and 2003, the era where, [steroids critics contend that]
home run totals were inflated dramatically by alleged steroid use,
each team hit, on average, 173 homers. 

Unfortunately for [the steroids critics' argument], home run totals
per team post-steroid testing are actually up, not down: 176 homers
for the average team in the average year. 

Leaguewide, there were 5,250 homers hit on average between 2001 and
'03; 5,290 between '04 and '06. 

One argument is that between '00 and '02, seven batters slugged 50 or
more homers. Between '03 and '05, just one did. 

But two batters, Ryan Howard and David Ortiz, hit more than 50 homers
last year, and another, Albert Pujols, just missed with 49. 

We again share the great insight by Art De Vany, professor emeritus of
economics at the University of California-Irvine, that hitting home
runs is an act of genius. 

So, De Vany concludes, we must expect wide variance in the best years
of athletes just like we accept wide variance in the best films of
directors, albums of musicians or books by authors relative to their
main body of work. 

De Vany also concludes that large swings in individual home run
performance are irrelevant to the steroids debate. 

This year, teams are hitting homers at a 4,632 pace, which would be
the lowest, by far, per team, in all the years cited by Kriegel except
for '95. The homer rate thus far could be a fluke that will correct
itself going forward. 

Still, it would be surprising if the year-end total cracked 5,000,
about where it stood in '02 and '05. Swings of 10 percent are common
in every era. In the modern context, that means a range of anywhere
between 4,800 and 5,800 homers should be considered normal.

Professor DeVany comments.




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June 15, 2007


Investing in fat people?

Following on earlier posts here and here on how the U.S. anti-obesity
industry often misrepresents the nature and extent of the health
problems related to widespread obesity in American society, Laura
Vanderkam reviews NY Times nutrition columnist Gina Kolata's new book,
Rethinking Thin: The New Science of Weight Loss--and the Myths and
Realities of Dieting (Farrar, Straus, and Giroux, 2007) in which
Kolata challenges the conventional wisdom that an obese person's
capacity to lose weight and maintain that reduced weight is merely a
question of an individual's willpower. 

Despite Kolata's book and a growing body of research that questions
the anti-obesity crusade, investing in anti-obesity appears to be a
potentially lucrative investment opportunity. A case in point is this
Merrill Lynch research report on how best to invest in "the emerging
obesity epidemic." Table 5 presents "stocks that represent the ML
Obesity Theme" which, by the way, includes Whole Foods and Wild Oats
Markets. 

"The developed world is getting older and fatter," writes ML analyst
Jose Rasco. "People are increasingly eating more proteins and
processed foods, leading more sedentary lives and gaining weight."
Inasmuch as ML projects that the number of obese people worldwide will
increase to 700 million in 2015 from 400 million in 2005, there's
money to be made in those companies that are fighting obesity or, as
ML might say, "why not monetize a trend of more fat people?"




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June  8, 2007


Snow Fall

Robin Moroney over at The Wall Street Journal's Informed Reader blog
picks up on this interesting Ken Dermota/Atlantic ($) article that
reports on the weird economics relating to the demand, the supply and
the price of cocaine:

Demand for cocaine stays steady, Colombia’s coca fields are
destroyed, yet the drug’s street price in the U.S. continues to fall
.   .    . [as] drug smugglers and dealers have eked out efficiencies
in their operations to keep their prices low. The U.S. Coast Guard has
been able to catch only a small percentage of the drugs entering the
country since President Nixon declared a “war on drugs” in 1971.
In 2000, the U.S. decided to switch tactics and take the fight to
Colombia, which produces 90% of the cocaine sold in the U.S. Since
then, it has spent $4.7 billion fighting rebels who grow and sell the
crop, as well as spraying coca fields from the air. 

The price of cocaine—the pure version, not crack—has kept falling.
In the early 1980s, the price of a gram of cocaine was about $600. By
the late 1990s the price had fallen to about $200. According to the
Drug Enforcement Administration, the street price of a gram of cocaine
in 2005 was $20-$25 in New York, $30-$100 in Los Angeles and $100-$125
in Denver. 

Some of the price decrease has come from more efficient distribution
networks. Some New York smugglers have chosen to eliminate the
middleman and pick up their drugs directly from Colombia, offering
“factory-to-you” prices. The surging trade with Mexico has
increased the nooks and crannies for drugs to be hidden as they cross
the border, making smuggling both safer and cheaper.

Labor costs also have decreased. Street vendors take a smaller cut of
the drug’s proceeds. A lot of the drug dealers who fell prey to an
aggressive imprisonment campaign in the 1990s are now leaving prison.
Their felony conviction and minimal job experience means they have few
other ways to make money and are willing to take a pay cut.

The falling street price also reflects the lower risk of handling the
drug. The violence of the 1980s crack boom has faded and, since 2001,
federal drug prosecutions have fallen 25% as agents get diverted to
the hunt for terrorists.

While the Atlantic article focuses on why the price of cocaine
continues to drop even though the supply sources are declining, what's
particularly interesting is that the demand for cocaine is not rising
dramatically as the price declines. Given its addictive nature, it
makes sense that the demand for cocaine would be somewhat price
inelastic, but it seems logical that demand would increase at least to
some extent as the price falls. This does not appear to be happening.
Sounds like a good exam question for an economics course.




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June  5, 2007


Texas' medical licensing logjam

The number of insurance companies offering medical malpractice
insurance policies has dramatically increased and malpractice
insurance premiums have substantially decreased since the 2003
legislation enacting medical malpractice caps in Texas, but the med
mal caps have contributed to at least one unanticipated problem:

.   .   . about 2,250 license applications await processing at the
Texas Medical Board in Austin. The wait could be as long as a year for
some of the more experienced doctors because it takes longer to review
their records. 

The fear is that some doctors will give up on Texas and go elsewhere
instead of waiting. A $1.22 million emergency funding request was
approved during the last days of Texas legislative session for the
Texas Medical Board, which licenses physicians. That is on top of the
$18.3 million regular biennial appropriation, said Jane McFarland, the
board's chief of staff. 

The board plans to add nine new employees to its 139-member staff,
seven of which will help chop away at the backlog of license
applications.




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May 24, 2007


Proof that Texas legislators don't have enough to do

The lead in to this Ft. Worth Star Telegram article is a dead giveaway
that Texas legislators are in a "throw the money around" mood as they
near the end of the legislative session:

Many Texas students are too fat, experts say, and face future health
problems because of their poor fitness. This week, the Legislature may
weigh whether a new annual fitness test can help whip them into better
shape. Fitness guru Dr. Kenneth Cooper of Dallas teamed up with Sen.
Jane Nelson, R-Lewisville, to author legislation that would require
schools to monitor students' health to prevent childhood obesity  .   
.   .

According to the bill, students in kindergarten through fifth grade
must have “moderate or vigorous" activity for 30 minutes each day.
Students in grades six, seven and eight must have physical activity 30
minutes a day for four semesters. Additionally, schools must annually
assess the physical fitness of students in grades three through eight.
Under the legislation, the Texas Education Agency would be asked to
adopt a testing tool that measures aerobic capacity, body composition,
muscular strength, endurance and flexibility.

According to the bill, the TEA must also analyze the data for a
correlation between physical fitness and academic achievement,
attendance, disciplinary problems and obesity  .   .  .

The wording in the bill that describes the required testing tool
mirrors language on the Web site for Cooper's FitnessGram, developed
in 1982 to measure health and fitness levels of children  .   .   .
The FitnessGram would cost about $230 for each child when purchased
from its distributor, Human Kinetics. The nonprofit Cooper Institute
receives $30 from each sale.

Sandy Szwarc nicely sums up the skimpy clinical evidence upon which
the above-described legislation is based:

The bottom line was that [Harvard School of Public Health] researchers
were not able to clearly establish a direction between fitness and
overweight. Meaning, the slightly lower levels of athleticism among
heavier children didn’t necessarily point to that as being the cause
for their size, nor that trying to turn them into better athletes will
make them slimmer.

There is no credible evidence that the levels of physical activity and
fitness among fat children are less than thinner kids to explain their
diversity in sizes. There is no credible evidence that school or
after-school physical activity programs reduce obesity among children.
The medical evidence long ago demonstrated that heredity and genes
account for aerobic capacity, upper body strength and athletic
prowess. Researchers have also found that different children have
different physical aptitudes, just like academic and artistic
abilities. Research, for example, in the journal of the North
Association for the Study of Obesity, Obesity Research, found that
“obese” and nonobese school kids had similar levels of physical
activity, while nonobese boys engaged in more sports. The fat children
did poorer on propulsion tasks, but showed greater grip strength and
similar scores with the other kids on overall fitness.




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May 16, 2007


Dubious Chronicle advertising

David Barron generally does good work for the Chronicle, particularly
in reporting on media developments relating to professional sports and
collegiate athletics. And this Barron piece in yesterday's Chronicle
about Waco chiropractor John Patterson's work on various professional
athletes is filled with all sorts of interesting anecdotes on the
miraculous results of Patterson's treatments on such professional
athletes as Tracy McGrady, John Smoltz, Earl Campbell and former UT
star pitcher and current Oakland A's closer, Huston Street, among
others.

But don't you think that any reasonably objective newspaper article
would at least mention the fact that there is substantial research
(see also here) that has concluded that what Patterson is doing is
quackery?

By the way, Street went on the disabled list yesterday with elbow
tendonitis.




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May 11, 2007


More on the futility of dieting

Earlier posts here, here and here discussed the general
ineffectiveness of dieting. Now, this Gina Kolata/NY Times article
reports that researchers at Rockefeller University are finding that
"it is entirely possible that weight reduction, instead of resulting
in a normal state for obese patients, results in an abnormal state
resembling that of starved nonobese individuals.” 

In other words, being fat may just be an inherited condition.




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May  3, 2007


Changing history

The NY Times' medical reporter, Lawrence Altman, M.D., tells the story
of how Houston's famed heart surgeon Michael E. DeBakey changed the
course of history by persuading the late Boris Yeltsin that he could
survive heart bypass surgery after the Russian president had suffered
a heart attack in the fall of 1996. The surgery saved Yeltsin's life
and allowed him to live for another decade.

Of course, there are some who would argue that Dr. DeBakey efforts did
not change history for the better.




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May  1, 2007


The Hurwitz conviction

You probably have already heard by now that Dr. William Hurwitz
(previous posts here) was convicted this past Friday afternoon on 16
counts of drug trafficking for prescribing opioid prescriptions to his
chronic-pain patients. The New York Times' John Tierney -- who
deserves an award for his coverage of the trial and the sad case of
Dr. Hurwitz -- interviewed three of the jurors after the trial and his
findings are disturbing: 

[The jurors] said that the jury considered Dr. William Hurwitz to be a
doctor dedicated to treating pain who didn’t intentionally prescribe
drugs to be resold or abused. They said he didn’t appear to benefit
financially from his patients’ drug dealing and that he wasn’t
what they considered a conventional drug trafficker. 

So why did find him guilty of “knowingly and intentionally”
distributing drugs “outside the bounds of medical practice” and
engaging in drug trafficking “as conventionally understood”? After
attending the trial and talking to the jurors, I can suggest two
possible answers: 

1. The jurors were confused by the law.
2. The law is a ass (to quote Mr. Bumble from “Oliver Twist”). 

I can’t blame the jurors for being confused, because that’s the
norm in trials of pain-management doctors. The standard prosecution
strategy is to charge the doctor on so many counts and introduce so
much evidence that the jurors assume something criminal must have
happened. Their natural impulse, after listening to weeks of
arguments, is to look for a compromise by digging into the mountain of
medical minutiae – and getting in so deep that they lose sight of
the big picture.

According to Tierney's inteview, the Hurwitz jury essentially
convicted Hurwitz of not examining his patients adequately.
Remarkably, the jurors were candid with Tierney that they did not
understand the legal standard of "outside the bounds of medical
practice." Rather, they just decided "to go with our gut." 

Sound familiar?

Dr. Hurwitz's conviction is troubling for medical professionals on
several levels, not the least of which is described by a doctor in the
following comment to Tierney's post:

The Hurwitz persecution scares the bejabbers out of me. If I refuse to
treat pain adequately that is a criminal offense. If I over treat pain
that is a criminal offense. If I cannot tell a smooth, practiced,
professional liar from real pain that is a criminal offense. I am
expected to be all things to all people, omnipotent and infallible -
and if I fail I will be stripped of my license or sent to prison. 

Just recently I received a phone call that one of my patients was
selling my narcotic prescription on the street. Was this real, a crank
call, or a sting operation by the prosecutor? My only avenue of
survival was to immediately file a complaint against the patient with
BAYONET (a narcotics strike force). Welcome to 1984, Hurwitz jurors.
So now that you have forced me to survive by turning people in to the
secret police, how do you feel about coming to me and discussing your
personal issues?

The message is clear. Pain specialists better be careful who they
treat -- and undertreat those patients who they elect to take on -- or
risk going to jail. The doctor-patient relationship has just become
much more complicated. And not for the better.




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April 30, 2007


Is it the farm subsidy? Or the processed food subsidy?

Michael Pollan, the Knight professor of journalism at the Cal-Berkeley
and the author of “The Omnivore’s Dilemma” (earlier post here),
has been writing a series of op-eds for the New York Times in which he
is addressing in an abbreviated manner various nutritional issues that
he covers in his book. In this recent piece, Pollan examines why
calorie-intensive processed foods have such a relatively cheap price
at the supermarket in comparison to fresh fruits and vegetables:

For the answer, you need look no farther than the farm bill. This
resolutely unglamorous and head-hurtingly complicated piece of
legislation, which comes around roughly every five years and is about
to do so again, sets the rules for the American food system —
indeed, to a considerable extent, for the world’s food system. Among
other things, it determines which crops will be subsidized and which
will not, and in the case of the carrot and the Twinkie, the farm bill
as currently written offers a lot more support to the cake than to the
root. Like most processed foods, the Twinkie is basically a clever
arrangement of carbohydrates and fats teased out of corn, soybeans and
wheat — three of the five commodity crops that the farm bill
supports, to the tune of some $25 billion a year. (Rice and cotton are
the others.) For the last several decades — indeed, for about as
long as the American waistline has been ballooning — U.S.
agricultural policy has been designed in such a way as to promote the
overproduction of these five commodities, especially corn and soy. 

That’s because the current farm bill helps commodity farmers by
cutting them a check based on how many bushels they can grow, rather
than, say, by supporting prices and limiting production, as farm bills
once did. The result? A food system awash in added sugars (derived
from corn) and added fats (derived mainly from soy), as well as
dirt-cheap meat and milk (derived from both). By comparison, the farm
bill does almost nothing to support farmers growing fresh produce. A
result of these policy choices is on stark display in your
supermarket, where the real price of fruits and vegetables between
1985 and 2000 increased by nearly 40 percent while the real price of
soft drinks (a/k/a liquid corn) declined by 23 percent. The reason the
least healthful calories in the supermarket are the cheapest is that
those are the ones the farm bill encourages farmers to grow.

Read the entire piece.




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April 27, 2007


What was Dr. Hurwitz's motive?

The NY Times' John Tierney, who has done an outstanding job of
covering the sad case of Dr. William Hurwitz, provides this insightful
post on the utter lack of a motive for Dr. Hurwitz to commit the crime
for which he is being prosecuted:

Prosecutors charged that Dr. William Hurwitz was in a conspiracy with
some of his patients to illegally distribute drugs, but there was no
evidence that the patients had shared the profits when they resold the
painkillers he prescribed. The only money he got was from the medical
fees he charged. The prosecutors tried to portray his practice as a
lucrative operation, and him as a doctor motivated by greed. This is a
bit hard to square with what the jury heard about his background.
which included stints in the Peace Corps and the Veterans
Administration. And it’s really hard to square with his bank
account.

In 2003, before the charges in this case had even been brought against
him, authorities seized Dr. Hurwitz’s assets. (That’s standard
procedure in drug cases like this, and one more reason why doctors
have such a hard time mounting a defense.) There wasn’t much to
seize. They took all his retirement savings — which amounted to less
than $250,000. He was at that point 58 years old and had been
practicing medicine for decades. .  .   .

“It’s so ridiculous to hear the prosecutor talk about this rich
doctor,” Mrs. [Nilse] Quercia [Dr. Hurwitz's former wife] told me.
“Except for that Keough account they seized, he had nothing but
debts and a 1990 Subaru.” His subsequent legal expenses, she said,
were paid by friends and relatives and by the law firms now
representing him pro bono.

In my experience, when a prosecutor must fabricate a motive for the
white collar criminal act that is being prosecuted, it's a pretty darn
good indication that a lack of prosecutorial discretion is behind the
decision to pursue the charges in the first place.




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April 10, 2007


Speedy treatment of heart attacks

This Gina Kolada/NY Times article examines one of the most
underappreciated aspects of treating heart attack victims -- the
importance of speedy treatment:

Studies reveal, for example, that people have only about an hour to
get their arteries open during a heart attack if they are to avoid
permanent heart damage. Yet, recent surveys find, fewer than 10
percent get to a hospital that fast, sometimes because they are
reluctant to acknowledge what is happening. And most who reach the
hospital quickly do not receive the optimal treatment — many
American hospitals are not fully equipped to provide it  .  .   . [. 
.  .]

What few patients realize .   .    . is that a serious heart attack is
as much of an emergency as being shot. 

“We deal with it as if it is a gunshot wound to the heart,” Dr.
[Elliott] Antman [director of the coronary care unit at Brigham and
Women’s Hospital] said.

Cardiologists call it the golden hour, that window of time when they
have a chance to save most of the heart muscle when an artery is
blocked.

But that urgency, cardiologists say, has been one of the most
difficult messages to get across, in part because people often deny or
fail to appreciate the symptoms of a heart attack. The popular image
of a heart attack is all wrong. [.  .  .]

[M]ost people — often hoping it is not a heart attack, wondering if
their symptoms will fade, not wanting to be alarmist — hesitate far
too long before calling for help.

“The single biggest delay is from the onset of symptoms and calling
911,” said Dr. Bernard Gersh, a cardiologist at the Mayo Clinic.
“The average time is 111 minutes, and it hasn’t changed in 10
years.”

Read the entire article, which is a good overview of the early warning
signs to look for in diagnosing a heart attack. Heck, even this cool
customer is at elevated risk of having one.




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April  5, 2007


The sad case of Dr. William Hurwitz

For you doctors out there who believe that what happened to Jeff
Skilling could never happen to you, take a moment to read the NY
Times' John Tierney's chilling opening blog post on the re-trial of
Dr. William Hurwitz, the Virginia doctor who is being prosecuted on
drug trafficking charges for prescribing pain medications that his
patients allegedly abused or sold without his knowledge:

Jonathan Fahey, one of the prosecutors in federal court in Alexandria,
Va., told the jurors in his opening statement that Dr. Hurwitz was a
drug trafficker — part of a drug-trafficking conspiracy, in fact —
because he prescribed large quantities of OxyContin and other pills
while ignoring clear “red flags” that his patients were misusing
and reselling the pills. The prosecutor said that Dr. Hurwitiz’s
prescribing was “without a legitimate medical purpose” and “in
its wake it left destruction, devastation and death.” [.  .  .]

[Defense attorney Richard] Sauber used his opening statement to tell
the jury over and over that the case boiled down to one question: Was
Dr. Hurwitz a doctor or a drug dealer? Calling him a “passionate
advocate for patients who had been unfairly treated,” Mr. Sauber
talked about Dr. Hurwitz’s work in the Peace Corps and in Veterans
Administration hospitals, and his belief that too many patients were
in pain because doctors were afraid to give them proper dosages of
opioids. Mr. Sauber also promised to do something that the defense
didn’t effectively do in the first trial: use expert testimony to
show that the dosages prescribed by Dr. Hurwitz were within the bounds
of legitimate medicine.

The Hurwitz case is an appalling reminder of how the Drug Enforcement
Agency has pursued a perverse agenda in its pursuit of pain doctors.
During Hurwitz's first trial, the DEA actually changed their own
guidelines during the trial and removed them from its website because
the defense was going to show that Hurwitz prescribed by those
guidelines. Meanwhile, DEA head Karen Tandy publicly stated that
Hurwitz deserved 25 years in the slammer because he “was no
different from a cocaine or heroin dealer peddling poison on the
street corner.” 

Sound familiar?





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April  4, 2007


Lessons of the Heart

Following up on recent posts here and here, don't miss this John E.
Calfee/American.com op-ed on how recent research into heart disease
treatments has not only changed medicine, but also basic science
research:

How do we know where heart attacks come from? The answer lies in
feedback from pharmaceutical clinical trials to basic research. Long
before the stent trials began to upset received wisdom, massive trials
of heart drugs had first validated previously controversial hypotheses
and then upset the next generation of hypotheses. Eventually, these
trials pushed basic research in unexpected directions. [.  .  .]

So there is a bit more to this week’s news about stents and heart
attacks than meets the eye or is described in the media. We are
witnessing another episode in the remarkable story of feedback from
drug and device development to basic science. And we can expect more
drug-tools to wreak more havoc in scientific understanding of human
biology.

Read the entire piece, which is an excellent summary on how clinical
research spurs development of better drugs, superior treatment and
even better-focused research. Check out the new design of
American.com, which has quickly developed into one of the most
interesting and insightful on-line magazines.




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March 12, 2007


Thinking about diet and exercise myths

One of my goals this year is to blog more on issues relating to
nutrition and exercise, which are two of the most myth-generating
subjects in American culture.

Along those lines, contrary to the information about the latest fad
diets that bombards most Americans on almost a daily basis, this Sandy
Szwarc post explains the reality -- diets do not work, at least for
most people most of the time.

Similarly, long cardio workouts are often recommended as a way to burn
calories for overweight folks, most of whom look absolutely miserable
doing them. As Art DeVany explains, too much cardio actually has the
opposite effect -- long workouts will likely make a person fatter.




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February 28, 2007


The remarkable evolution of open heart surgery

Given the importance of Houston's Texas Medical Center in the
development of open heart surgery (see here and here), a couple of
recent NY Times articles focusing on open heart surgery caught my
attention.

First, in this article, David Schribman compares his recent open heart
surgery to the heart surgery that a childhood friend endured 42 years
ago.

Next, following on this earlier post, this NY Times article reports
that safety concerns are increasing over the long-term risks of stents
used in angioplasty procedures. New data is indicating that the
sickest heart patients may actually live longer if they receive bypass
surgery rather than the angioplasty, which is prompting some
well-known heart surgeons and cardiologists to conclude that the
pendulum has swung too far away from bypass surgery.

Finally, the Times provides this extraordinary slide show of open
heart surgery. The slide show is a powerful reminder that -- despite
the now common nature of bypass surgery -- it is still not as routine
as changing a flat tire.




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February 27, 2007


The ruse of dieting

This earlier post made the point that a sound understanding of
nutritional principles and moderate eating habits are far more likely
to result in proper personal weight management than relying on the
dozens of fad diets that are available to the American consumer.

Along those lines, this Sandy Szwarc post reports on some rather
startling statistics relating to one such diet program:

A study on one of the largest commercial weight-loss programs was just
published in the International Journal of Obesity but has been ignored
by the press. Understandably, a major media campaign and flurry of
press releases have not trumpeted its findings. 

Researchers at four major research centers across the country followed
60,164 adults enrolled in the Jenny Craig Platinum program in
2001-2002 to evaluate how long people were able to stick with this
program and how much weight they lost. 

They found that a quarter dropped out the first month, 42% after 3
months, 22% after 6 months, and only 6.6% were able to stick with the
program for a year. 

Unlike Kirstie Alley, the weight loss among people not being paid as
celebrity spokespersons was considerably less notable. For a 200 pound
woman able to keep with the program an entire year, according to this
study, she would have lost half a pound a week....except fewer than 7
out of 100 were able to hang in for a full year. Hardly winning
endorsement for the success and palatability of the program.

Read the entire post. Research is increasingly concluding that being
overweight does not equate with increased mortality risk. Rather,
physical activity and fitness have a far greater impact on lowering
mortality risk than one's body mass index or waist measurements.
Despite our cultural stereotypes of what “fit” looks like,
research on obese adults has shown that about half rate highly fit on
maximal exercise testing, which is not much different from slender
people.

Thus, there is nothing wrong with wanting to lose a few pounds, but
forget about the latest fad diet. Instead, understanding nutrition and
modifying eating habits over the long-term is much more likely to
produce the calorie deficit that will eventually result in permanent
weight loss. But if the goal is to reduce mortality risk, the better
bet is simply to increase the exercise and recreation regimen, and
more exercise is not necessarily better — a couple of hours total
spread over 3-5 days a week is fine.




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February 24, 2007


Don't sweat the small stuff

Dr. Nortin M. Hadler is a professor of medicine and
microbiology/immunology at the University of North Carolina at Chapel
Hill, and attending rheumatologist at the University of North Carolina
Hospitals in Chapel Hill. He also sounds in this ABC News op-ed a lot
like my father:

To be well is not the same as to feel well. 

Being well requires some sense of invincibility. No one is spared
symptoms for long. 

It's abnormal to go one year without upper respiratory symptoms or
pain. 

Lurking in our future are heartache and heartburn, shoulder and knee
pain, headache, rashes and skipped heartbeats -- not to mention
bothersome fatigue, sore muscles, bowel irregularity, insomnia and so
much else to challenge our sense of well-being. 

Nearly all of these predicaments can go away as mysteriously as they
come about. To be well requires the wherewithal to cope with these
ailments for as long as that takes -- and it can take weeks. [.  . 
.]

We all need to get beyond the traditional complaint of "what's wrong
with me, Doc, that I have this symptom?" and move on to more rational
discourse, such as "is there any important disease that is causing my
symptom? If so, can it be treated? If not, can we discern why I can't
cope with this episode?"

Read the entire piece. And then get on with coping!




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February 21, 2007


The dark world of binge eating

Jane Brody is the longtime New York Times fitness and nutrition writer
and I have admired her writing for many years. Her column from
yesterday -- titled "Out of Control: A True Story of Binge Eating" --
is a must-read not only because it addresses an important health
problem, but also because it has a compelling personal touch:

It was 1964, I was 23 and working at my first newspaper job in
Minneapolis, 1,250 miles from my New York home. My love life was in
disarray, my work was boring, my boss was a misogynist. And I, having
been raised to associate love and happiness with food, turned to
eating for solace. 

Of course, I began to gain weight and, of course, I periodically went
on various diets to try to lose what I’d gained, only to relapse and
regain all I’d lost and then some.

My many failed attempts included the Drinking Man’s Diet, popular at
the time, which at least enabled me to stay connected with my
hard-partying colleagues. 

Before long, desperation set in. When I found myself unable to stop
eating once I’d started, I resolved not to eat during the day. Then,
after work and out of sight, the bingeing began.

I learned where the few all-night mom-and-pop shops were located so I
could pick up the evening’s supply on my way home from work. Then I
would spend the night eating nonstop, first something sweet, then
something salty, then back to sweet, and so on. A half-gallon of ice
cream was only the beginning. I was capable of consuming 3,000
calories at a sitting. Many mornings I awakened to find partly chewed
food still in my mouth. 

And, as you might expect, because I didn’t purge (never even heard
of it then), I got fatter and fatter until I had gained a third more
than my normal body weight, even though I was physically active.

My despair was profound, and one night in the midst of a binge I
became suicidal. I had lost control of my eating; it was controlling
me, and I couldn’t go on living that way. 

Fortunately, I was still rational enough to reach out for help, and at
2 a.m. I called a psychologist I knew at his home. His willingness to
see me in the morning got me through the night.

Read the entire column. Brody's honest and forthright story of how she
finally came to terms with her obsession and addressed it --
abandoning diets and embracing sound nutritional principles for her
life -- provides a hopeful and practical guide for those who are
afflicted with this disorder. It is a stark reflection of the state of
nutrition in the U.S. today that most of us know someone who is
currently grappling with the same problem that Brody overcame.




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February 14, 2007


Five big health care issues

EconLog's Arnold Kling, who is doing some of the best thinking these
days on reforming America's dysfunctional health care finance system,
identifies in this TCS Daily op-ed the five big questions in health
care:

1. What will we do about the large projected deficit in Medicare?

2. What can we do to reduce government subsidies for extravagant use
of medical procedures with high costs and low benefits?

3. What should we do about the health care needs of the very poor?

4. What should we do about the health care needs of the very sick?

5. What should we do about a scenario in which both income inequality
and the share of average income devoted to health care rise sharply?

Kling goes on to discuss our social fetish with health insurance,
which is really not insurance at all:

If you ask me what kind of health insurance I would like for my
family, my instinct is to answer, "None." The only reason we have
health insurance now is to avoid the stigma of being called
"uninsured." 

Somehow, health insurance has become a social fetish. I could travel
to the far reaches of the globe, and almost everywhere I would find
merchants where my credit is good and my dollars are welcome. But here
at home, trying to enter a local hospital with nothing but a wad of
cash and a credit card would be like urinating on the sidewalk.

Read Kling's entire piece. As the WSJ's ($) Holman Jenkins pointed out
awhile back, government policy has exacerbated these issues and is
unlikely to solve them through greater involvement in the system:

The tax code is the original hectoring mommy behind our health-care
neuroses. It gives the biggest subsidy to those who need it least. It
pays the affluent to buy more medical care than they would if they
were spending their own money. It prompts them to launder our health
spending through an insurance bureaucracy, creating endless paperwork.
It prices millions of less-favored taxpayers out of the market for
health insurance. It fosters a misconception that health care is free
even as workers are perplexed over the failure of their wages to
rise.




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February  9, 2007


Trying to get in shape the hard way

Sandy Szwarc makes sense while expressing skepticism about the FDA's
decision to approve an over-the-counter version of Xenical (orlistat)
for sale, the first prescription weight loss drug to be available
without a prescription:

Even the FTC’s scientific expert panel reviewing the evidence for
weight loss advertisements, .  .  . determined that any claims that a
weight loss product will cause weight loss by blocking the absorption
of fat or calories were false and fraudulent advertising. .  .  .
[E]ven with the prescription strength Xenical, people can’t
malabsorb enough fat a day to lose a pound a week and there are limits
beyond which significant gastrointestinal problems occur. The
panel’s scientific analysis stated: “The biological facts do not
support the possibility that sufficient malabsorption of fat or
calories can occur to cause substantial weight loss.”

Meanwhile, this NY Times article reports that one of the formerly most
popular ways to attempt to lose weight has fallen out of favor: 

[I]f current trends continue, aerobics will be as rare as, .   .   .
those vibrating belts that were supposed to jiggle away fatty hips and
gravity boots that were supposed to — what was it they were supposed
to do? For now, the popularity of aerobics is sharply down from when
it was “the mainstay of fitness in America,” said Mike May, a
spokesman for the Sporting Goods Manufacturers Association. 

It’s why you may have noticed — if you have shown up at your gym
attired in your best leg warmers with a sweatshirt off one shoulder
— the lack of aerobics classes on the menu. Fewer than half of the
300 gyms and health clubs recently surveyed by IDEA offered aerobics
classes, a number that is “continuing to decline,” according to
the summation of the report. 

At its peak in the mid-’80s, an estimated 17 million to 20 million
did aerobics, Mr. May said. But only five million did in 2005,
according to a report by the sporting goods association. “We expect
the 2006 numbers to be significantly lower,” Mr. May said.
“Aerobics are increasingly out of favor.” 

The legacy of injuries is one reason. Many of the original instructors
like Mr. Blahnik won’t teach aerobics — because they can’t.
“Those hardest hit by all those aerobics were often the teachers,
because they were pushing harder than anyone else and doing the
classes a dozen times a week,” Dr. Metzl said. “Our bodies just
weren’t meant to withstand all that pounding.”


By the way, Art DeVany has compiled this category of blog posts that
explores the damaging physical effects of distance running and
endurance training. More exercise does not always equate with better
health.




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February  5, 2007


Update on the case of Dr. Pou

Speaking of prosecutorial excess, the case of Dr. Anna Pou -- the
former University of Texas Health Science Center professor and
physician who was arrested last year in Louisiana on wrongful death
charges for her actions in attempting to save lives during the chaotic
aftermath of Hurricane Katrina -- was back in the news last week. The
New Orleans coronor announced that he had not found evidence that
would show that the cases were homicides, although he noted that he
was continuing to gather evidence and had reached no final
conclusion.

Dr. Pou's case was transferred to Orleans Parish after Louisiana
Attorney General Charles Foti had labeled her and two nurses who were
assisting her during the chaos as murderers. Just to make sure he got
the most publicity possible for his lack of prosecutorial discretion,
Foti repeated those charges on 60 Minutes several months ago.
Ultimately, the decision on whether to prosecute will come down to
Eddie Jordan, the District Attorney of New Orleans, who is still
planning on presenting evidence to a grand jury. With the the
coroner’s current classification, what on earth is there to present
to a grand jury?




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January 30, 2007


Food myths

Americans love their myths and their food, so it makes sense that some
of our most active myth-making occurs in the realm of eating and
nutrition.

Michael Pollan, author of "The Omnivore’s Dilemma," (Penguin 2006) 
provides this excellent NY Sunday Times magazine piece in which he
reviews the food and nutrition myths that have been developed and
dispelled over just the past two decades in America. It's a
fascinating story, particularly how Americans' willingness to accept
the latest food or nutrition fad co-exists with a huge fast-food
industry that is largely based on high-calorie processed food of
dubious nutritional value.

Pollan is spot on in his observation that most Americans know just
enough about nutrition to be dangerous, which is also the case with
medical matters generally. Few people can accurately recount how many
calories they consume in a day, and even fewer still can tell you how
many calories they need to consume to lose weight or maintain their
optimum weight (do you know what 200 calories looks like?). Similarly,
few of those overweight folks torturing themselves on the treadmills
or stationary bicycles at the local gym have a clue of how long they
would need to exercise to work off the excess calories that they have
consumed. Despite their tenacity, most of those overweight exercisers
almost always overestimate the amount of calories expended during
exercise. 

As my wise father used to say: "What would you rather do? Eat one less
helping of mashed potatoes? Or go ride the stationary bicycle for an
hour?"

By the way, the following are a couple of terrific resources on
nutrition that approach the subject from very different, but quite
insightful, perspectives -- Junkfood Science by nutritionist Sandy
Szwarc, who exposes many food myths that are based on studies of
questionable merit, and Art De Vany's  blog, where he frequently
explores the physiological impact of diet, obesity and exercise.




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January 25, 2007


Thinking beyond the UH Medical School

BlogHouston.net's Kevin Whited notes this Chronicle/Todd Ackerman
article about the University of Houston floating a proposed new Texas
Medical Center-based medical school in a collaborative project with
The Methodist Hospital and Cornell University's Weill Medical School.

Unfortunately for UH, the proposal has zilch chance of floating for
much more than a few minutes amidst the shark-infested waters of Texas
educational politics. Heck, the political forces in Texas cannot even
agree to provide adequate funding of UH's uncriticizable goal of
becoming the state's third tier I research university. The University
of Texas, Texas A&M University, and Baylor College of Medicine --
Methodist's former longtime partner -- are just a few of the powerful
political forces that would almost certainly line up against the
UH-Methodist proposal.

Yet, the UH-Methodist proposal has merit, so here's a proposed
modification. Rather than start another medical school from scratch,
let's merge the University of Houston system with the Texas A&M system
and have A&M expand its fledgling medical school into the Texas
Medical Center from its current central Texas outpost. From a broader
standpoint, the merger makes sense because it gives the A&M system
something that it desperately needs -- a major urban presence -- while
also giving UH something that it has always lacked -- that is, access
to adequate endowed capital. Such a merger would also provide A&M with
the law school that it has always coveted and would greatly facilitate
UH's elevation into a tier I research institution, which is something
that would substantially benefit the Houston area. 

While the University of Texas would almost certainly oppose such a
merger, perhaps a deal could be struck at the same time to merge the
Texas Tech University system into the UT system while organizing the
remainder of Texas' non-affiliated public universities into a third
university system for funding and administrative purposes. Such a
structure would give Texas a similar structure to that of the
reasonably successful California model, which has generated far more
first rate, tier I research universities (10) than the current
dysfunctional Texas system (2). Indeed, almost anything would be a
huge improvement over the current Texas system, which allocates a
disproportionate amount of endowed capital to the UT and A&M systems
while starving the remainder of Texas' public universities.

Make sense? You bet. Chances of happening? Probably not much. But just
as UCLA and Cal-Berkeley co-exist productively in the same university
system in California, UH and A&M could do the same in Texas. And just
as two major university systems work side-by-side together to educate
Californians, a similar structure would be a substantial improvement
in the educational system of Texas.




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January 12, 2007


The myth of healthy marathoners

The Chevron Houston Marathon takes place Sunday morning, and this Dale
Robertson/Chronicle article tells the story of Dolph Tillotson, the
Galveston Daily News publisher who almost died of a heart attack while
training at Memorial Park in preparation for the 2004 marathon.
Tillotson has now recovered to the extent that he is going to try and
complete the marathon on Sunday, which is certainly a remarkable
comeback.

But is Tillotson's long-distance running making him healthier? Art
DeVany argues that it does not and, in this recent post, notes a study
from the Annals of New York Academy of Sciences that indicates that
long-distance running is more dangerous to one's health than
conventional wisdom suggests:

Ann N Y Acad Sci. 1977;301:593-619.
Related Articles, Links

Coronary heart disease in marathon runners.

Noakes T, Opie L, Beck W, McKechnie J, Benchimol A, Desser K.

Six highly trained marathon runners developed myocardial infarction.
One of the two cases of clinically diagnosed myocardial infarction was
fatal, and there were four cases of angiographically-proven
infarction. Two athletes had significant arterial disease of two major
coronary arteries, a third had stenosis of the anterior descending and
the fourth of the right coronary artery. All these athletes had
warning symptoms. Three of them completed marathon races despite
symptoms, one athlete running more than 20 miles after the onset of
exertional discomfort to complete the 56 mile Comrades Marathon. In
spite of developing chest pain, another athlete who died had continued
training for three weeks, including a 40 mile run. Two other athletes
also continued to train with chest pain. We conclude that the marathon
runners studied were not immune to coronary heart disease, nor to
coronary atherosclerosis and that high levels of physical fitness did
not guarantee the absence of significant cardiovascular disease. In
addition, the relationship of exercise and myocardial infarction was
complex because two athletes developed myocardial infarction during
marathon running in the absence of complete coronary artery occlusion.
We stress that marathon runners, like other sportsmen, should be
warned of the serious significance of the development of exertional
symptoms. Our conclusions do not reflect on the possible value of
exercise in the prevention of coronary heart disease. Rather we refute
exaggerated claims that marathon running provides complete immunity
from coronary heart disease.

DeVany -- who has been studying physiology and exercise protocols for
years --  has accumulated a series of posts regarding the unhealthy
nature and outright dangers of endurance training. The reality is that
many endurance runners are not particularly healthy people, suffering
from lack of muscle mass, overuse injuries, dangerous inflammation and
dubious nutrition.

Tillotson obviously has great desire and discipline to be able to
return to marathon running after almost dying of a heart attack. But
his judgment in doing so is open to serious question.




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January  4, 2007


The unintended consequences of the anti-steroids crusade

As noted in this earlier post, I have long had reservations regarding
the anti-steroids campaign that is promoted by various regulatory
bodies and the media. As Peter Henning noted over the holiday season
in this extensive post, the Ninth Circuit Court of Appeals recently
issued an important decision in the Balco case in which the appellate
court overturned three lower court orders that had declared government
searches unconstitutional and directed the government to return the
drug tests to the businesses that were searched. In United States v.
Comprehensive Drug Testing, Inc., a divided Ninth Circuit panel
reversed the lower court rulings and upheld the search warrants,
including seizure of computer records, and ordered the lower courts to
segregate records that fall outside the scope of the warrants so that
they can be reviewed by a federal magistrate. The appellate decision
also reversed the district judge's order quashing the subpoena issued
after the search, and went on to declare that the government may issue
a subpoena for documents held by a third party even after a search for
the same records.

In this lucid ReasonOnline op-ed, Jacob Sullum sums up why all of this
is quite troubling:

The 9th Circuit's loose treatment of "intermingled" data allows
investigators to peruse the confidential electronic records of people
who are not suspects, hoping to pull up something incriminating. It
replaces a particularized warrant based on probable cause with a
fishing license.

The mob believes that the athletes who use steroids are cheating
criminals who should be punished. Let's just hope that the laws that
protect us from government's overwhelming prosecutorial power aren't
trampled in the process of upholding the myth of fair play in
professional sports.




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The epidemic of diagnosis

Following on the strong NY Times medical-related stories of Lawrence
K. Altman (here, here and here) over the holiday season, Drs. H.
Gilbert Welch, Lisa Schwartz and Steven Woloshin contribute this op-ed
to the Times in which they make the salient point that the American
health care system is a hypochondriac's dream:

For most Americans, the biggest health threat is not avian flu, West
Nile or mad cow disease. It’s our health-care system. 

.   .   . The larger threat posed by American medicine is that more
and more of us are being drawn into the system not because of an
epidemic of disease, but because of an epidemic of diagnoses. 

Americans live longer than ever, yet more of us are told we are sick.


How can this be? One reason is that we devote more resources to
medical care than any other country. Some of this investment is
productive, curing disease and alleviating suffering. But it also
leads to more diagnoses, a trend that has become an epidemic.[ .   . 
.]

.   .   . the real problem with the epidemic of diagnoses is that it
leads to an epidemic of treatments. Not all treatments have important
benefits, but almost all can have harms. Sometimes the harms are
known, but often the harms of new therapies take years to emerge —
after many have been exposed. For the severely ill, these harms
generally pale relative to the potential benefits. But for those
experiencing mild symptoms, the harms become much more relevant. And
for the many labeled as having predisease or as being “at risk”
but destined to remain healthy, treatment can only cause harm.

Read the entire article. Then take a chill pill! ;^)




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January  2, 2007


Reviewing medical advances

Fresh off his fascinating article on Dr. Michael DeBakey's
confrontation with death (here and here), the NY Times' Lawrence K.
Altman reminds us in this article that -- despite the dysfunctional
U.S. health care finance system -- medical advances are continuing at
an increasing rate:

As a reporter for The New York Times for 37 years, I have witnessed
many important medical events, from new treatments to new diseases. In
reflecting on that panorama, it is clear that technology has accounted
for the greatest changes in medicine. Technology has improved
laboratory testing; allowed for the development of CT scans, magnetic
resonance imaging exams and positron emission tomography, or PET,
imaging to improve diagnostic accuracy; and produced new drugs and
devices. Basic science, too, has deepened our understanding of
disease, and much of that work depends on technology.

At the same time, the care for many ailments has been greatly improved
by ancillary developments like better nursing care, newer antibiotics,
transfusions of platelets to prevent bleeding, the insertion of
monitoring tubes in major veins, and better organization of some
services. [.  .  .]

Few people appreciate that medicine has advanced more since World War
II than in all of earlier history. Newer drugs and devices and better
understanding of disease mechanisms have vastly improved the care of
patients. For male babies born in this country in 1960, the life
expectancy was 66.6 years; for female babies, it was 73.1 years. In
2004, the figures, respectively, were 75.2 and 80.4. Medical advances
account for much, though not all, of the gain.

Altman's point regarding the importance of medical advances reminds me
of a similar one that Donald J. DiPette, the chairman of the Texas A&M
Internal Medicine Department, made while giving the Walter M.
Kirkendall Lecture at the University of Texas Health Science Center
this past spring. Given the advances in treatment of hypertension over
the past 60 years, Dr. DiPette noted that President Franklin D.
Roosevelt would have never been allowed to participate in the Yalta
Conference at the end of World War II had his doctors known then what
doctors knew a decade later about the traumatic implications of acute
hypertension. In short, a better understanding of hypertension at the
time of Yalta almost certainly would have changed the course of human
history.




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December 30, 2006


Reacting to the DeBakey surgery story

The reactions to last weekend's fascinating story about the surgery to
repair a dissecting aortic aneurysm in 97-year old Medical Center
icon, Dr. Michael DeBakey, are as interesting as the story itself. The
following are a few comments selected from letters to the NY Times
regarding the story:

"Dr. Michael E. DeBakey’s surgery may have been a technical advance
of heroic and dramatic proportions, but it was a setback for
patients’ rights. Dr. DeBakey is the epitome of the informed
patient, and a document evidently existed that said he did not want
surgery for his disease.

Progressing into a coma as one dies is a normal part of the terminal
stages of many illnesses. Directives exist to prevent such an
incapacitated patient from becoming a victim of the grieving spouse or
the frightened caregiver.

Because of Dr. DeBakey’s stature and publicity about his case, this
surgery may decrease patients’ right to die in a manner they desire,
an unfortunate result of a remarkable feat."

"Your article about Dr. Michael E. DeBakey’s aortic aneurysm
operation was described as emblematic of the difficulties of
end-of-life care, but it is as much or more emblematic of the
difficulty patients encounter in having their wishes to forgo
treatment respected. No one in the world had better capacity to refuse
this operation than Dr. DeBakey, and he did.

.   .   .After the world’s best medical care, months in the hospital
and a million dollars, Dr. DeBakey and his family had a happy
outcome.

But for those thousands of ordinary patients who must struggle against
family, church and state to refuse invasive, risky, experimental or
simply unwanted care, it is not necessarily a happy ending."

"I wonder if Katrin DeBakey would have been so eager for her
husband’s surgery if she had had to provide all the postoperative
care herself as the rest of us have to do.

Almost any elderly patient with good insurance and an educated and
younger spouse making decisions can get good high-tech surgery, but
the system fails when the hospital dumps the patient back home on the
spouse after only two days of postoperative hospital care.

In Mrs. DeBakey’s case, her husband received months of in-hospital
intensive care, emergency care, more surgery, physical therapy and
psychological support.

The rest of us caregivers would have long since passed the breaking
point from dealing on our own with medical emergencies, unavailable
doctors, no home nurses, no respite time and the psychiatric problems
of many elderly male patients — rage and depression."

"The article about Dr. Michael E. DeBakey illustrates many central
issues that arise in determining types of care for gravely ill
patients and whether to perform a risky but potentially lifesaving
procedure.

The case exposes the standards of patient autonomy and informed
consent — foundational principles of ethical medicine — to be
impossible ideals. Even Dr. DeBakey, likely the person most thoroughly
informed about the procedure, regretted his prior decision to forgo
the surgery.

Another problem exposed by this case is the persistent misuse of the
do-not-resuscitate order, interpreting it to signify more general
wishes about less aggressive care instead of its actual, more
restricted meaning: not resuscitating in the event of cardiac
arrest."

As one of the other letter-writers pointed out, the story also
reflects that Dr. DeBakey is the consummate educator, using his
experience to prompt consideration and discussion of important medical
and ethical issues in caring for patients who are close to death. He
is truly one of Houston's treasures.




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November 16, 2006


Re-thinking angioplasty in certain situations

Following on a trend noted in previous posts here and here, this NY
Times article (see also here) reports that findings from a major new
study suggest that noninvasive treatment with beta-blockers and other
heart drugs turns out to be at least as good as angioplasty for
patients whose arteries remain blocked at least three days after a
heart attack. The findings -- which were presented earlier this week
at the annual scientific meeting of the American Heart Association and
published simultaneously online by the New England Journal of Medicine
-- supplement an increasing body of research that is indicating that
heart-attack patients whose disease is stable and whose symptoms are
under control should be wary of taking the risk of invasive treatment,
which can result in infection and bleeding.

Over the past 20 years or so, treatment of heart attacks has been
transformed by the ability of doctors to break up blood clots that
cause the heart attacks with clot-busting drugs and angioplasty
procedures. By quickly restoring blood flow to the heart muscle
following an attack, doctors have been able to save lives and minimize
damage that can lead to total heart failure. However, a nagging
problem has been that about a third of the million or so Amerians who
suffer a heart attack each year do not arrive at a hospital within the
12-hour window after the attack during which the patients are most
likely to benefit from these techniques. In those patients who
stabilize on their own after an attack and then are not diagnosed with
blocked arteries until days after the attack, the conventional wisdom
has been to go ahead and perform the angioplasty, anyway.

The trial, which was funded by the National Heart, Lung and Blood
Institute, involved about 2,200 men and women who had a totally
blocked artery three to 28 days after suffering a heart attack. They
were assigned randomly to receive either just the best-available drug
therapy or drug therapy plus angioplasty and stent treatment. Blocked
arteries were opened successfully in about 90% of the angioplasty
patients and they opened spontaneously in about 25% of the patients
taking just medication.

After four years, 17.2% of patients in the angioplasty group had died,
suffered another heart attack or developed serious heart failure. In
comparison, 15.6% in the group on medication alone had the same
results. Although the relatively small difference could have resulted
from mere chance, researchers suggest that the findings do not support
the the higher risk of aggressive intervention in such patients.

The bottom line: People with chest pains should get to the hospital as
soon as possible because quick application of clot-busting drugs and
angioplasty remains the best way to preserve the heart muscle. But if
the patient fails to do so and stabilizes on their own, then the
benefit of an angioplasty later may not be worth the risk.



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October 31, 2006


Calorie restriction and longevity

All the rage these days in longevity circles is calorie restriction,
so this Julian Dibbell/New Yorker article reports on Dibbell's
two-month test on the the ultra-extreme Calorie Restriction Diet -- an
1,800 calorie daily diet:

I’ve been starving for the past two months, actually, and that’s
precisely what the party is about: My dinner guests—five successful
urban professionals who for years have subsisted on a caloric intake
the average sub-Saharan African would find austere—have been at it
much, much longer, and I’ve invited them here to show me how it’s
done. They are master practitioners of Calorie Restriction, a diet
whose central, radical premise is that the less you eat, the longer
you’ll live. Having taken this diet for a nine-week test drive,
I’m hoping now for an up-close glimpse of what it means to go all
the way. I want to find out what it looks, feels, and tastes like to
commit to the ultimate in dietary trade-offs: a lifetime lived as
close to the brink of starvation as your body can stand, in exchange
for the promise of a life span longer than any human has ever known. 

Seat belts, vaccines, clean tap water, and other modern miracles have
dramatically boosted average life expectancies, to be sure—reducing
annually the percentage of people who die before reaching the maximum
life span—but CR alone demonstrably raises the maximum itself. In
lab studies going back to the thirties, mice on severely limited diets
have consistently lived as much as 50 percent longer than the oldest
of their well-fed peers—the rodent equivalent of a human life
stretched past the age of 160. And it isn’t just a mouse thing:
Yeast cells, spiders, vinegar worms, rhesus monkeys—by now a
veritable menagerie of species has been shown to benefit from CR’s
life-extending effects.

The WSJ chimes in with this article ($), which focuses on a group of
scientists who are attempting to mimic calorie restriction's antiaging
effects with medicines. At the same time, this NY Times article
reports on a Wisconsin-based research project that indicates that
rhesus monkeys on a calorie restricted diet are much healthier than
their counterparts that are eating a normal diet. Meanwhile, this NY
Times article reports on a researcher's work that indicates that the
65% or so of Americans who are overweight or obese got that way, in
part, because they didn’t realize how much they were eating.

After all this, please excuse me while I go get a gelato. ;^)




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October 25, 2006


A fascinating peek at the descent into Alzheimer’s

When he learned in 1995 that he had Alzheimer’s disease, William
Utermohlen, an American artist based in London, began his final
project -- drawing self-portraits during his descent into dementia and
ultimately Alzheimer's. This NY Times article reports that
Utermohlen's work is being exhibited this week by the Alzheimer's
Association at the New York Academy of Medicine in Manhattan:

The paintings starkly reveal the artist’s descent into dementia, as
his world began to tilt, perspectives flattened and details melted
away. His wife and his doctors said he seemed aware at times that
technical flaws had crept into his work, but he could not figure out
how to correct them.

“The spatial sense kept slipping, and I think he knew,” Professor
[Patricia] Utermohlen [William Utermohlen's wife] said. A
psychoanalyst wrote that the paintings depicted sadness, anxiety,
resignation and feelings of feebleness and shame. [.  .   .]

Mr. Utermohlen, 73, is now in a nursing home. He no longer paints. 

His work has been exhibited in several cities, and more shows are
planned. The interest in his paintings as a chronicle of illness is
bittersweet, his wife said, because it has outstripped the recognition
he received even at the height of his career. 

Colleen Carroll Campbell, who has written extensively about
Alzheimer's, observes that the disease "embodies everything we fear
most about aging -- weakness and dependence, humiliation and
oblivion." Nearly half of Americans over the age of 35 know someone
personally who is at some stage of dementia, and as Americans are
living longer, Alzheimer's is claiming more victims. About 4.5 million
Americans suffer from Alzheimer's today, which is more than double the
number who had the disease just 25 years ago. Utermohlen's paintings
provide us with an important perspective on this insidious disease as
we confront the difficult issues that result from it.




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August 18, 2006


Merck's bad day

As with the baseball season, Merck & Co.'s defense of the Vioxx
litigation is a marathon and not a sprint (previous posts here).
Yesterday's sprint was not good for Merck, but my sense is that it's
still way too early to write off Merck's defense strategy as a failure
at this point.

The bad news for Merck was that a federal jury in New Orleans awarded
$51 million to a former FBI agent who was taking Vioxx when he
suffered a heart attack, while a New Jersey judge threw out a verdict
in Merck's favor from a trial there last fall. The NJ judge has a
reputation of being plaintiffs-friendly, so that ruling was not all
that much of a surprise and, despite the federal venue of the New
Orleans trial, New Orleans is still a plaintiffs-friendly environment.
After a year of Vioxx trials, the scorecard reflects that Merck and
the plaintiffs each have four victories, and there are at least
another eight or so Vioxx trials scheduled in both state and federal
court through the end of this year.

Ted Frank, who has been following the Vioxx litigation closely, has
the best analysis of yesterday's developments in the overall context
of the Vioxx litigation (see also here and here). Peter Lattman also
has an interesting post in which he includes an email exchange with
Houston plaintiff's lawyer, Mark Lanier, who was the first lawyer to
hammer Merck in a Vioxx trial.




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August  1, 2006


The story behind the arrest of Dr. Pou

As noted in this previous post, the arrest in Louisiana of former
University of Texas Health Science Center professor and physician Dr.
Anna Pou on wrongful death charges for her actions in attempting to
save lives during the chaotic aftermath of Hurricane Katrina is an
egregious example of prosecutorial misconduct.

As is typical in such cases, word is now filtering out about the real
motivations for the prosecution. Not only is an elderly Louisiana
attorney general who campaigned on a plank of "cracking down on abuse
of the elderly" at the center of the dubious decision to arrest, this
NY Times article reports that Dr. Pou's accusers are three employees
of LifeCare Hospitals, the company that owned the facility where 24
out of 55 elderly patients died in the aftermath of Katrina and whose
top administrator and medical director didn't even show up at the
hospital during those chaotic days. It turns out that the accusing
LifeCare employees didn't make any effort to evacuate the elderly and
sick patients, either. Does this have the smell to you of someone
attempting to distract attention (or perhaps avoiding prosecution)
from their own indiscretions?

Dr. Kevin Pho of Kevin, M.D. is doing a good job of keeping up with
the reactions and commentary around the web to the case against Dr.
Pou and the nurses. The case against Dr. Pou is the other side of the
same coin that the government flips when it criminalizes risk-taking
by businesspersons, so stay tuned to developments in this troubling
prosecution.




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July 25, 2006


Thinking about progress in health care

This NY Times article tells the fascinating story about the
assassination of President James A Garfield back in 1881 while noting
an exhibit commemorating the 125th anniversary of Garfield’s
assassination at the National Museum of Health and Medicine on the
campus of the Walter Reed Army Medical Center.

President Garfield was shot on July 2, 1881 in Washington by a
disgruntled federal job-seeker, Charles J. Guiteau, who made his move
while Garfield was waiting for a train. What is not as well-known is
that neither of the shots that hit Garfield should have fatal even by
the more primitive medical standards of the 1880's. As my late father
once observed to me while discussing Presidential assassinations,
"Garfield's assassin just shot him. Garfield's doctors killed him."

The Times article reminds me of another interesting medical case that
Dr. Donald J. DiPette, chair of the Department of Internal Medicine at
Texas A&M University Medical School, presented earlier this year
during the Walter M. Kirkendall Lecture that the University of Texas
Medical School conducts annually in honor of my father. 

Dr. DiPette's subject was how advances in clinical research on
hypertension had contributed to our understanding and knowledge of
related medical problems that are related to high blood pressure, and
he used a case study of a man in his mid-50's in the late 1930's who
was showing signs of acute hypertension as an example of how that
understanding can change the world.

The negative impact of hypertension on an individual's health was not
well-understood in the late 1930's and 40's, and Dr. DiPette showed
how the patient's health in the case study deteriorated at an
accelerated rate as his blood pressure readings increased markedly
from 1937 to 1945. One evening in early 1940, he collapsed unconscious
at the dinner table. The patient's doctors at the time were unsure
why.

By 1945, the patient -- who was still working in an important and
high-pressure job -- had blood pressure that was off the charts and
was experiencing a combination of associated medical problems that
would have landed him in a hospital these days. Nevertheless, the
patient continued to work and, about a month after a particularly
important work-related meeting, the patient died of a massive stroke.

Only at the end of his lecture did Dr. DiPette reveal the name of the
patient in his case study -- President Franklin D. Roosevelt. 

Dr. DiPette's point was that President Roosevelt's acute hypertension
clearly affected his performance at the Yalta Conference, and his
doctors would likely have never allowed FDR to participate in that
history-changing event had they known what we know now about the
effects of hypertension. Thus, lack of knowledge about hypertension --
which finally began to be understood less than a decade after FDR's
death -- literally changed the course of the 20th century.

Remember that as you contemplate the negative impact on clinical
research of this, this and this.




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July 20, 2006


The doctor at the center of the Hurricane Katrina wrongful death
prosecution

Dr. Anna Pou, the New Orleans doctor who heroically served
severely-ill patients during the chaotic aftermath of Hurricane
Katrina last summer, is at the center of the highly-publicized and
controversial decision of Louisiana criminal authorities earlier this
week to arrest Dr. Pou and two assisting nurses and charge them with
second-degree murder in the deaths of four patients who died during
that horrible time. She is also a former Houston-area resident, having
served on the faculty of the University of Texas Medical Branch in
Galveston from 1997-2004, where she was the Director of the Division
of Head and Neck Surgery from 1999 to 2004.

Today, this excellent NY Times article places in perspective the
arrest and prosecution of this outstanding physician, who is a
diplomate of the American Board of Otolaryngology, Fellow of the
American College of Surgeons, and a member of the American Head and
Neck Society. Dr. Pou has authored more than forty publications, has
also served on multiple committees of the American Academy of
Otolaryngology, and has lectured in national and international forums
on topics in otolaryngology, head and neck oncology, and microvascular
reconstructive surgery.

In short, Dr. Pou is no murderer. This prosecution has all the
earmarks of yet another lynch mob that is more interested in myths
than reality, so watch it closely.




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May 25, 2006


Thinking about heroin addiction

Theodore Dalrymple -- the pen name of British psychiatrist and author,
Anthony Daniels (previous posts here) -- has written a new book,
Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy
(Encounter 2006) in which he challenges the conventional medical
wisdom regarding opium addition. In this Wall Street Journal ($)
op-ed, Dalrymple provides interesting insight into the nature of
addiction:

I have witnessed thousands of addicts withdraw; and, notwithstanding
the histrionic displays of suffering, provoked by the presence of
someone in a position to prescribe substitute opiates, and which cease
when that person is no longer present, I have never had any reason to
fear for their safety from the effects of withdrawal. It is well known
that addicts present themselves differently according to whether they
are speaking to doctors or fellow addicts. In front of doctors, they
will emphasize their suffering; but among themselves, they will talk
about where to get the best and cheapest heroin.

When, unbeknown to them, I have observed addicts before they entered
my office, they were cheerful; in my office, they doubled up in pain
and claimed never to have experienced suffering like it, threatening
suicide unless I gave them what they wanted. When refused, they often
turned abusive, but a few laughed and confessed that it had been worth
a try. Somehow, doctors -- most of whom have had similar experiences
-- never draw the appropriate conclusion from all of this. Insofar as
there is a causative relation between criminality and opiate
addiction, it is more likely that a criminal tendency causes addiction
than that addiction causes criminality.

Furthermore, I discovered in the prison in which I worked that 67% of
heroin addicts had been imprisoned before they ever took heroin. Since
only one in 20 crimes in Britain leads to a conviction, and since most
first-time prisoners have been convicted 10 times before they are ever
imprisoned, it is safe to assume that most heroin addicts were
confirmed and habitual criminals before they ever took heroin. In
other words, whatever caused them to commit crimes in all probability
caused them also to take heroin: perhaps an adversarial stance to the
world caused by the emotional, spiritual, cultural and intellectual
vacuity of their lives.

It is not true either that addicts cannot give up without the help of
an apparatus of medical and paramedical care. Thousands of American
servicemen returning from Vietnam, where they had addicted themselves
to heroin, gave up on their return home without any assistance
whatsoever. And in China, millions of Chinese addicts gave up with
only minimal help: Mao Tse-Tung's credible offer to shoot them if they
did not. There is thus no question that Mao was the greatest
drug-addiction therapist in history.

Substitution of one drug for another is at best equivocal as a means
of treating drug addicts. No doubt if you gave every burglar $10
million, each would burgle far less in the future; but this treatment
of the disease of burglary would scarcely discourage burglary as a
social, or rather antisocial, phenomenon. And the fact that there
would be a dose-response relationship between the amount of money
given to burglars and the number of burglaries they subsequently
committed does not establish burglary as a real disease or money as a
real treatment for it.

Why has the orthodox view swept all before it?  .  .  . [A]ddicts and
therapists have a vested interest in the orthodox view. Addicts want
to place the responsibility for their plight elsewhere, and the
orthodox view is the very raison d'être of the therapists. Finally,
as a society, we are always on the lookout for a category of victims
upon whom to expend our virtuous, which is to say conspicuous,
compassion. Contrary to the orthodoxy, drug addiction is a matter of
morals, which is why threats such as Mao's, and experiences such as
religious conversion, are so often effective in "curing" addicts.



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May 21, 2006


A real hero's story

Following on this post from a couple of months ago on Virginia
Postrel's donation of a kidney to a friend, don't miss Virginia's
inspiring Texas Monthly ($) article on the experience.

Interestingly, the most important part of Virginia's successful
donation was her stubborness in going through with it:

Most important, it turned out, I had the right personality. Donating a
kidney isn’t, in fact, a matter of just showing up. You have to be
pushy. Unless you’re absolutely determined, you’ll give up, and
nobody will blame you—except, of course, the person who needs a
kidney. When I went to see my Dallas doctor for preliminary tests, the
first thing she said was “You know, you can change your mind.”

To me, giving Sally a kidney was a practical, straightforward solution
to a serious problem. It was important to her but not really a big
deal to me. Until the surgery was scheduled—for Saturday, March
4—and I started telling people about it, I had no idea just how
weird I was.

Normal people, I found, have a visceral—pun definitely
intended—reaction to the idea of donating an organ. They’re
revolted. They identify entirely with the donor but not at all with
the recipient. They don’t compare kidney donation to other risky
behavior, like flying a plane or running 31 miles to the bottom of the
Grand Canyon and back, as my brother did last summer.

What a gal!




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April 20, 2006


Diet and Alzheimer's

A new Annals of Neurology study headed by Nikolaos Scarmeas of the
Columbia University Medical Center in New York has found that people
who followed a Mediterranean-style diet were up to 40% less likely
than those who largely avoided it to develop Alzheimer's during the
course of the research study. Previous posts on Alzheimer's research
are here.

The study evaluated about 2,200 elderly residents of northern
Manhattan every 18 months for signs of dementia over a four years
period. None showed any dementia at the start of the study, but by the
end of the study, 262 had developed Alzheimer's. The researchers gave
each participant a score of zero to nine on a scale that measured how
closely they adhered to a Mediterranean-style diet. Compared to those
showing the lowest adherence, those who scored four or five on the
diet scale showed 15% to 25% less risk of developing Alzheimer's
during the study and those with higher scores had about 40% less risk.
Prior research suggested that certain components of the Mediterranean
diet can reduce the risk of developing Alzheimer's, but the research
focused on specific nutrients (such as vitamin C) or foods such as
fish. By incorporating an entire diet, the new study addresses
possible interactions between specific foods and nutrients.

The diet tested in the study included primarily vegetables, legumes,
fruits, cereals and fish, while limiting intake of meat and dairy
products. The diet also included drinking moderate amounts of alcohol
and emphasizing monounsaturated fats, such as in olive oil, over
saturated fats. Previous research has suggested that such an approach
also reduces the risk of heart disease, and the new study is
additional evidence that certain conditions that are associated with
heart disease -- high cholesterol, high blood pressure, obesity,
smoking and uncontrolled diabetes -- may also contribute to
Alzheimer's.




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April 11, 2006


Houston's Bubble Boy

You may want to set your Tivo to this Friday at 1 p.m. when local PBS
channel KUHTDT-TV (check your local PBS station for the time) will
rebroadcast the excellent PBS American Experience series segment that
ran last night entitled The Boy in the Bubble, which focuses on the
difficult ethical issues raised by the medical treatment of the late
Houstonian David Vetter (a/k/a  the "bubble boy"), who had severe
combined immunodeficiency and lived inside a sterile plastic chamber
for his 12 year life:

When David Vetter died at the age of 12, he was already world famous:
the boy in the plastic bubble. Mythologized as the plucky, handsome
child who had defied the odds, his life story is in fact even more
dramatic. It is a tragic tale that pits ambitious doctors against a
bewildered, frightened young couple; it is a story of unendingly
committed caregivers and resourceful scientists on the cutting edge of
medical research. This American Experience raises some of the most
difficult ethical questions of our age. Did doctors, in a rush to save
a child, condemn the boy to a life not worth living? Did they, in the
end, effectively decide how to kill him?

Here is a Steve McVicker/Houston Press story from nine years ago that
raises many of the same questions as those addressed in the PBS show.





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March 16, 2006


Inhibiting the production of vaccines

The ever-observant Walter Olson points us to this interesting Theodore
Dalrymple review of the new book The Cutter Incident: How America’s
First Polio Vaccine Led to the Growing Vaccine Crisis (Yale University
Press 2005) by Paul Offit, a professor of pediatrics at the University
of Pennsylvania. 

Dr. Offit's book tells the story of how a heartbreaking disaster
caused by mass immunization during research — a disaster that helped
lead to the major medical and scientific breakthrough of virtually
eliminating polio from much of the world -- led to a legal ruling that
has subsequently inhibited pharmaceutical companies from developing
and manufacturing vaccines. During the early stages of polio
immunization, the Cutter Company followed the then-imperfect
instructions regarding production of the vaccine to the letter, but
those instructions -- together with the then-imperfect scientific
knowledge regarding the vaccine -- proved inadequate to guarantee the
vaccine’s safety.  As a result, the live polio virus survived in
some of the company's vaccine, which was distributed to a large number
of people. Seventy thousand of those immunized by the faulty vaccine
experienced the transient flu-like symptoms of mild polio, 200 wound
up being paralyzed by polio, and 10 died from the disease.

Some of the victims then hired the most flamboyant plaintiffs’
lawyer of the time, Melvin Belli, who proceeded to sue the Cutter
Company for all that it was worth. Although the trial was essentially
a draw, the outcome nevertheless established a principle that would be
nearly fatal to the production of vaccines in America:

The trial established beyond reasonable doubt that Cutter had not been
negligent. But the judge stated—as a matter of law, so that the jury
was powerless to disagree—that the company was liable for damages,
even if it had done nothing wrong, simply because its product had
harmed its recipients. This principle of absolute liability soon found
itself defended in legal journals on the grounds that a large company
was best able, via its insurance, to distribute the costs of risks
among all the relevant parties, and society as a whole would benefit
from the arrangement.

Quite apart from its repugnance to natural justice, this principle has
been disastrous to the manufacture of vaccines. It opened the way for
huge claims against the manufacturers. Since the courts are often
cavalier in their complete disregard of scientific evidence, awarding
huge damages against companies not only innocent of any negligence but
whose products have done no objectively demonstrable harm, it is not
surprising that pharmaceutical companies have largely withdrawn from
the vaccine market. For them, the potential profits are small, and the
risks great. SmithKlineGlaxo, for example, one of the world’s
largest vaccine producers, withdrew its safe and effective vaccine
against Lyme disease because of the expense of defending it against
speculative tort actions of no merit. One almost wishes that an
epidemic of Lyme disease would strike the whole tribe of tort
lawyers.



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March 10, 2006


A real hero

While enduring Andy Fastow's explanations this past week on how he was
a hero at times while working at Enron, I've been meaning to note the
story of a real hero, Dallas-based blogger and writer, Virginia
Postrel. 

Check out Virginia's posts here, here and here for the story.

What a gal!




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January  5, 2006


Belly to Hip Ratio more important than BMI?

This Washington Post article reports on a new study published in The
Lancet that indicates the relationship between belly size and hip size
is more useful measure of health risk than the commonly-used body mass
index (BMI):

According to a study published in The Lancet, a calculation comparing
waist circumference to hip circumference is a better predictor of
heart attack risk than .   .   . [b]ody mass index, [which] is often
used to screen for obesity and to assess risk for a variety of
diseases and conditions, including diabetes, metabolic syndrome and
heart attack.

[T]he Lancet study, described by the authors as the largest and most
conclusive to date, found that "BMI is a very weak predictor of the
risk of a heart attack," said Salim Yusuf, lead author and director of
the Population Health Research Institute at McMaster University in
Hamilton, Ontario. "Measuring the girth of the waist and [the] girth
of the hip is far more powerful."

The authors suggested people forgo calculating BMI. "I'd say just do
the waist-to-hip ratio," Yusuf said. "There really is no additional
value [in] doing the BMI."

The study indicates that even relatively lean people with a BMI that
is quite low still have increased risk for heart attack based on the
presence of abdominal fat. It remains unclear why location of fat in
the abdominal area poses a greater health risk than fat carried around
the hips, but recent studies have also linked waist-to-hip ratio to
increased risk of diabetes and hypertension. The findings reported in
Lancet study indicate that men with waist-to-hip ratios greater than
0.95 are at heightened risk for a heart attack and that females with
ratios above 0.8 are at increased risk, and that the the risk "rose
progressively with increasing values for waist-to-hip ratio, with no
evidence of a threshold." 

Speaking of health-related matters, the Chronicle has added a
health-related blog by medical reporter Leigh Hopper to its growing
list of weblogs. Chronicle technology reporter Dwight Silverman
spearheaded the Chronicle's blog initiative last year, and now other
prominent newspapers are emulating the Chronicle's blog idea. Kudos to
Dwight and the Chronicle for contributing greatly to this productive
trend of enhancing communication between media and its customers.




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December 15, 2005


New study links Alzheimer's to diabetes

A new Brown University Medical School study published in the Journal
of Alzheimer's Disease supports a growing body of clinical evidence
indicating that Alzheimer's may be a new form of diabetes. The study
found that brain levels of insulin and related cellular receptors fall
precipitously during the early stages of Alzheimer's and that insulin
levels continue to drop progressively as the disease becomes more
severe. Previous posts on Alzheimer's-related matters are here.




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November 28, 2005


Aspirin as Vioxx?

In one of my earlier posts about the Merck/Vioxx case, I observed
somewhat facetiously that the risks associated with aspirin would
probably deter any pharmaceutical company today from making the
investment necessary to bring the drug to market. In this Medical
Progress Today piece, pharmaceutical expert Derek Lowe confirms that
my speculation is almost certainly correct:

[I]f you were somehow able to change history so that aspirin had never
been discovered until this year, I can guarantee you that it would
have died in the lab. No modern drug development organization would
touch it.

Thanks in part to advertisements for competing drugs, people know that
there are some stomach problems associated with aspirin. Actually, its
use more or less doubles the risk of a severe gastrointestinal event,
which in most cases means bleeding seriously enough to require
hospitalization. Lower doses such as those prescribed for
cardiovascular patients and various formulation improvements (coatings
and the like) only seem to improve these numbers by a small amount.
Such incidents, along with others brought on by other oral
anti-inflammatory drugs, are the most common severe drug side effects
seen in medical practice.

It doesn't take too long to see these effects in a research program.
Aspirin causes gastric lesions in rats and dogs, which are the
standard small and large animal models for drug toxicity. This side
effect occurs at levels which would raise red flags for any new
compound. What would a present-day research organization do about it?
If we stipulate that they could determine that aspirin worked by
inhibiting cyclooxegenase enzymes, they would surely try to break the
vascular effects of the drug apart from its anti-inflammatory effects.
They would try to find new compounds that selectively inhibited only
one of the enzyme subtypes. They would, in other words, produce Vioxx,
and Celebrex, and the other COX-2 inhibitors, and this is just why
these drugs were developed.

Read the entire piece. By the way, the third Vioxx trial against Merck
cranks up this week in Houston federal court. And Ted Frank wonders
why Mark Lanier has still not moved for entry of a judgment on the
$253 million jury verdict in the Ernst case?



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November 10, 2005


Sleep apnea and strokes linked

A Yale University study of 1,022 patients over the age of 50 published
in this week's New England Journal of Medicine concludes that
obstructive sleep apnea more than doubles the risk of a stroke or
death and that severe cases of sleep apnea more than triple the risk,
even after even adjustment for other stroke-risk factors such as
diabetes, hypertension and obesity.  A number of previous studies have
found links between sleep apnea and serious cardiovascular disease,
but a link between sleep apnea and strokes had not yet been
established. Strokes are the third leading cause of death in the U.S.
after heart disease and cancer.

About 20% of American adults suffer from at least some form of sleep
apnea, although physicians generally do not recommend treatment unless
the condition involves five or more pauses in breathing per hour of
sleep along with other symptoms, such as daytime drowsiness. Although
only about a fifth of sleep apnea cases are considered severe,
researchers and physicians estimate that more than half of the
severest cases in the United States still go undiagnosed. Obstructive
sleep apnea involves the muscles in the throat becoming so relaxed
that the airway becomes all or partially closed, and with regard to
the rarer central sleep apnea, the body temporarily stops making any
effort to breathe. Common symptoms include daytime drowsiness and loud
snoring, choking or gasping during sleep, although the episodes often
fail to wake the person suffering from the condition. 

Interestingly, one question that the Yale study does not answer is
whether treating sleep apnea will reduce the incidence of strokes. In
the Yale study, of the 72 sleep apnea patients who died of strokes,
many of these patients were undergoing various forms of treatment for
the condition. However, even with treatment, the group still had an
elevated risk of stroke and death, which raises the question of
whether treating sleep apnea will actually decrease the stroke risk
measurably.



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November  9, 2005


The anti-obesity industry

Coming off his Texas barbeque excursion, Marginal Revolution's Tyler
Cowen notes that J. Eric Oliver, a political science professor at the
University of Chicago, has entered the debate a new book called Fat
Politics (Oxford 2005), in which Professor Oliver argues that a
handful of doctors, government bureaucrats and health researchers --
funded by the drug and weight-loss industry -- have campaigned to
classify more than sixty million Americans as "overweight," to inflate
the health risks of being fat, and to promote the idea that obesity is
a killer disease. The Publishers Weekly review of the book notes the
following:

It's not obesity, but the panic over obesity, that's the real health
problem, argues this scintillating contrarian study of the evergreen
subject of American gluttony and sloth. Political scientist Oliver
condemns what he feels is a self-interested "public health
establishment" -- obesity researchers seeking federal funding,
pharmaceutical and weight-loss companies peddling diet drugs and
regimens, bariatric surgeons and other health-care providers angling
for insurance reimbursement -- for spuriously characterizing fatness
as a disease. He debunks the dubious science and alarmist PR that
fuels their campaign, taking on arbitrary Body-Mass Index standards
that slot even Michael Jordan in the overweight category,
state-by-state maps of obesity rates that make fatness look like a
contagion spreading over the countryside, and flimsy research studies
that vastly exaggerate the danger and costs of weight gain. Oliver
also examines American attitudes towards obesity, probing the
abhorrence of fatness implicit in the Protestant ethic and, less
plausibly, tying our contemporary feminine ideal of the emaciated
supermodel to a confluence of sociobiology and the economics of the
urban sexual marketplace. Arguing that fatness is perfectly compatible
with fitness, he contends that scapegoating obesity drives Americans
to experiment with dangerous crash diets, appetite suppressants and
weight-loss surgeries, while distracting us from underlying harmful
changes in the American lifestyle -- mainly our incessant snacking on
junk food and shunning of exercise and physical activity, of which
weight gain is perhaps merely a "benign symptom." Oliver provides a
lucid, engaging critique of obesity research and a shrewd analysis of
the socioeconomic and cultural forces behind it. The result is a
compelling challenge to the conventional wisdom about our bulging
waistlines.

Here is also an LA Times review of the book and several prior posts
that have examined the issues relating to the increasingly obese
nature of America's population. 

As several of the earlier posts note, Professor Oliver's thesis has a
ring of truth to it, although most of us are conflicted by our
anecdotal experiences in which we notice large numbers of overweight
and out-of-shape people in the course of our daily lives. In many
respects, the core problem is widespread ignorance about nutrition,
the difference between exercise and recreation, and the fact that
exercise is a poor means of weight-control, at least in the short
term. My late father used to comment that, if you are riding a
stationary bike for an hour to lose weight, then you could achieve the
same benefit in terms of reducing calories for a lot less effort by
simply eating one less helping of mashed potatoes at dinner. 



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October  6, 2005


And you thought the recent hurricanes were bad?

As the U.S. goes about recovering from the double whammy punch of the
two hurricanes that hit the Gulf Coast region over the past month or
so, this NY Times article reminds us that a potentially much more
serious threat to our well-being is looming on the horizon:

"Two teams of federal and university scientists announced today that
they had resurrected the 1918 influenza virus, the cause of one of
history's most deadly epidemics, and had found that unlike the viruses
that caused more recent flu pandemics of 1957 and 1968, the 1918 virus
was actually a bird flu that jumped directly to humans.

The work, being published in the journals Nature and Science, involved
getting the complete genetic sequence of the 1918 virus, using
techniques of molecular biology to synthesize it, and then using it to
infect mice and human lung cells in a specially equipped, secure lab
at the Centers for Disease Control and Prevention in Atlanta.

The findings, the scientists say, reveal a small number of genetic
changes that may explain why the virus was so lethal. The work also
confirms the legitimacy of worries about the bird flu viruses that are
now emerging in Asia. 

The new studies find that today's bird flu viruses share some of the
crucial genetic changes that occurred in the 1918 flu. The scientists
suspect that with the 1918 flu, changes in just 25 to 30 out of about
4,400 amino acids in the viral proteins turned the virus into a
killer. The bird flus, known as H5N1 viruses, have a few, but not all
of those changes."

Here is a companion NY Times article on the growing political concern
in Washington over the prospects of an epidemic. The 1918 flu pandemic
killed an estimated 25 to 50 million people and, as the articles
report, we are not much better protected from the virus now as the
world was then. Even the mere reconstruction of the virus for research
purposes has raised concerns:

Richard H. Ebright, a molecular biologist at Rutgers University, said
he had concerns about the reconstruction of the virus and about
publication of procedures to reconstruct the virus. "There is a risk
verging on inevitability, of accidental release of the virus; there is
also a risk of deliberate release of the virus," he said, adding that
the 1918 flu virus "is perhaps the most effective bioweapons agent
ever known."

During a closed door Senate briefing last week, Secretary of Health
and Human Services Michael O. Leavitt and other senior government
health officials warned of the implications of such a flu pandemic in
the U.S.:

Mr. Leavitt warned in the briefing last week that an outbreak could
cause 100,000 to 2 million deaths and as many as 10 million
hospitalizations in the United States, one person who was present
said. Those numbers have been presented publicly many times before.
But hearing them in closed session gave them urgency, some who were at
the meeting said.

Since 1997, avian flu strains have infected thousands of birds in 11
countries, primarily in Southeast Asia. So far, it is probable that
virtually all of the 100+ people who have been infected with the
disease (about 60 of whom have died) received the virus directly from
infected birds. Thus, at least to date, there has been no or very
little transmission between people, which is a requirement for an
epidemic. Moreover, if the virus does begin being transmitted between
humans, then there is a possibility that the mutated virus may be
weaker and less lethal than the viral strain contracted directly from
birds.

However, this remains a huge potential public health problem and not
one that should be ignored merely because the pandemic may not occur
or may be years away. Here's hoping that the federal government does a
better job planning for this potential problem than it did for a
direct hit by a category 4 hurricane on New Orleans.

Update: Eric Berger chimes in with this informative post over at his
very smart SciGuy blog.



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September 29, 2005


A key tip for dealing with rattlesnakes

One of the best parts of the Houston Chronicle for many years has been
the newspaper's Hunting and Outdoors section of its sports section.
Inasmuch as my reaction to finding a rattlesnake would have been the
same as the fellow's reaction as described in the following Chronicle
article, I was glad to learn something from the Chronicle piece about
dealing with dead rattlesnakes:

Even a dead rattlesnake can hurt you. Just ask Trey Hanover of College
Station.

On Labor Day weekend, Hanover and his father, Tommy Hanover, were
working on their deer lease when they killed a big rattler. They shot
the snake's head off with a shotgun and loaded the carcass in the
truck to show other hunters on their lease that they needed to be
careful.

"We hung the snake on the fence at the camphouse," Tommy Hanover said.
"When we got ready to leave, Trey picked up the snake and threw it out
in the pasture for the buzzards to eat."

By the time he'd driven to College Station, Trey Hanover's eyes were
very irritated. By the next morning, his eyes were swollen shut. The
doctor who examined Hanover said it looked like he'd suffered a
chemical burn.

It took them a while to figure out that the shotgun load that
vaporized the rattlesnake's head splattered the snake's venom over its
body.

When Hanover handled the snake, he got the venom on his hands and
later rubbed it in his eyes, made itchy by dust and ragweed. Sixteen
days later, the vision in his right eye was back to normal. His left
eye was still a little cloudy, but the doctor thought it would return
to normal as well.

"We learned a valuable lesson about handling rattlesnakes — even
dead ones," said Tommy Hanover.



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August 24, 2005


Stop daydreaming!

According to this Washington Post article, now daydreaming may be
hazardous to your health:

The brain areas involved in daydreaming, musing and other
stream-of-consciousness thoughts appear to be the same regions
targeted by Alzheimer's disease, researchers are reporting today in an
unusual study that offers new insights into the roots of the deadly
illness.

While some unknown third factor may be responsible for triggering
daydreaming as well as Alzheimer's, .  .  . a causative link between
the two would explain a mystery that has long bothered scientists: why
Alzheimer's generally affects memory first.  .  . [T]the undirected
thought patterns that most people slip into readily may result in the
kind of "wear and tear" that ends in Alzheimer's disease, .  .  .

This theory, however, clashes with the evidence that intellectual
activity plays a protective role against Alzheimer's disease. Far from
the "wear and tear" model, other research has suggested that the brain
runs on a "use it or lose it" system.

The best observation in the article is from a scientist who cautions
that the findings are preliminary and should be taken with a grain of
salt:

"I look forward to the public health campaign to stop people from
engaging in these dangerous, risky behaviors," he quipped. "Maybe we
can equip ourselves with anti-daydreaming monitors that shock us when
we slip into reverie."

Read the entire article.




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August 19, 2005


Merck gets hammered

As anticipated by this prior post, a Brazoria County jury found that
Merck & Co. was liable for $253 million in damages ($24 million in
actual damages, plus $229 million in punitive damages) as a result of
its negligence in the death of a 59-year-old Robert Ernst, who at the
time of death was taking Merck's prescription painkiller Vioxx that
over 20 million Americans took regularly before it was pulled from the
market last year over concern that it might cause increased risk of
strokes and heart attacks. The prior posts on the Merck/Vioxx trial
are here, here, and here.

Inasmuch as Merck is currently facing another 4,200 Vioxx lawsuits,
the verdict is not exactly a rousing start for Merck in the defense of
the lawsuits. Merck's defense in the lawsuit seemed to be reasonably
strong -- that is, Mr. Ernst, who had only taken Vioxx for eight
months, died of arrhythmia that Vioxx has not been shown to cause.
However, the Brazoria County coroner testified -- over Merck's
strenuous objection because of the plaintiff's failure to designate
the coroner as an expert prior to trial -- that Mr. Ernst's arrhythmia
could have been caused by a heart attack. That testimony seemed to
hurt Merck badly, as the Chronicle interviewed an alternate juror who
had been dismissed from the trial immediately before deliberations
began who remarked that Merck "wasn't doing the right thing by
marketing the drug the way they were." Plaintiff's lawyer Mark Lanier
accused Merck of dragging its feet after the Food and Drug
Administration told it in late 2001 to put a label on Vioxx warning of
potential heart risks, and during closing arguments, Mr. Lanier
contended that Merck saved $229 million by waiting months to add the
warning label. Not surprisingly, that's the amount of of punitive
damages awarded by the jury. 

Estimates of Merck's potential liability in the Vioxx cases range from
$4 billion to $20 billion, which could be as large as a third of
Merck's market capitalization. Although the price of Merck's shares
dropped 8% today on the news of the verdict, that's not as bad as the
25% plus decline that occurred last September on the day Merck
withdrew Vioxx from the market. Moreover, media reports on the jury's
verdict have not differentiated between the plaintiff's economic and
non-economic damages, but that distinction will be important to
Merck's ultimate liability in this case when the court applies Texas'
statutory cap on punitive damages to the jury verdict. You can be
reasonably certain that the ultimate amount recovered will be far less
than the jury verdict. Given that, and in view of the fact that
Brazoria County is going to be one of the more plaintiff-friendly
jurisdictions for a Vioxx trial, the market may be overreacting a bit
to the verdict, although that's about the best spin that Merck can put
on this result.

As usual, Professor Ribstein has insightful comments on the absurdity
of all this, as does Ted Frank, Professor Bainbridge, Kevin M.D.,
Derek Lowe, Jonathon Wilson, and Walter Olsen.



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August  4, 2005


Brain dead woman gives birth

Don't miss Tom Mayo's interesting analysis of the difficulty that the
mainstream media has in explaining the context under which Susan
Torres, a brain dead Virginia woman, gave birth to a baby girl this
past Tuesday. Tom observes about the headline for the AP/Yahoo story:

Once dead, a patient can't die again.  But, amazingly, 37 years after
the Ad Hoc Harvard Medical School report on "irreversible coma," the
public's resistance to the notion of neurological criteria for death
is curiously persistent.




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July 12, 2005


Strong medicine with serious side effects

This post from yesterday made the point that that most medications are
toxins that often have serious side effects, but that the risk of
those side effects has to be weighed against the benefit that patients
derive from the medications. However, the side effect noted in this
article is, might we say, a bit difficult to weigh:

A Mayo Clinic study published Monday in Julys Archives of Neurology
describes 11 other Parkinsons patients who developed the unusual
problem [of becoming compulsive gamblers] while taking Mirapex or
similar drugs between 2002 and 2004. Doctors have since identified 14
additional Mayo patients with the problem, .  .  . 




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July 11, 2005


The first Vioxx trial

Jury selection begins today in Angleton, Texas in the first personal
injury/wrongful death trial against Merck & Co. for alleged
non-disclosure of the risks of taking the pain relieving drug Vioxx.
Angleton is a small town in a plaintiff-friendly county about an hour
south of downtown Houston. Talented Houston-based personal injury
trial lawyer Mark Lanier has been receiving quite a bit of free
publicity about the upcoming trial (here is the NY Times article and
an earlier WSJ ($) article is here),  and here are several previous
posts on Merck and Vioxx.

Mr. Lanier's effectiveness as a trial lawyer is in no small part
attributable to the fact that he is a devout Christian who regularly
teaches a Bible Study class at his church in Houston. Such familiarity
with the Bible typically resonates with jurors in small Texas towns,
who often rationalize tenuous liability and damage issues through
Biblical associations. 

Curiously, as Professor Ribstein has pointed out, Mr. Lanier's case
against Merck is based largely on the very un-Biblical concept of
resentment and not the truth. Merck pulled Vioxx from the market in
October, 2004 after a study showed that it increased the risk of heart
attack or stoke, but not necessarily the risk of death. That move
prompted Cleveland Clinic cardiologist Eric Topol to go postal over
Merck's handling of the drug, contending that Vioxx resulted in 15
cases of heart attack or stroke per 1,000 patients.

Unfortunately, what Dr. Topol failed to mention is that the foregoing
number of cases relating to Vioxx was precisely seven more cases of
heart attack or stroke per 1,000 patients taking the similar
medication, Naprosyn. Moreover, as MedPundit points out, Dr. Topol
neglected to mention that aspirin -- which is regularly prescribed
without controversy for heart attack and stroke prevention -- results
in a clinically significant case of bleeding in every 3 out of 1,000
patients. Thankfully, aspirin has not been pulled from the market, at
least yet.

Moreover, the statistical bungling got even worse. David Graham, the
associate director for science in FDA's office of drug safety, took
the results of these studies and without any sub-group analysis
calculated that 27,785 heart attacks may have occurred between 1999
and 2003 as a result of Vioxx use based on the number of Vioxx
prescriptions. That was music to the ears of the plaintiffs personal
injury bar, but the music was a bit tinny given that his conclusion
was not based on the number of Vioxx users who truly should have been
counted. Rather, it is based on the the number of patients who were on
Vioxx continuously for more than 18 months as indicated in the studies
that showed an increased risk of cardiovascular problems. Thus, the
statistical evidence is quite shaky that short-term or periodic use of
Vioxx contributes to an increase risk of cardiovascular problems. Not
surprisingly, the initial trials of Vioxx were all shorter than 18
months and they did not find any meaningful evidence of increased
risk.

As my late father often observed, the truth is that medicines are
toxins that have side effects that sometimes kill people. Vioxx was 
developed to address the problem of patients who regularly die as a
result of the use of non-steroidal anti-inflammatory medications for
chronic pain. Studies reflect that about 16,500 patients die and
another 100,000 are hospitalized annually as a result gastrointestinal
bleeding from the use of these NSAID medications for chronic pain. The
number of people who have suffered heart attacks and strokes as a
result of the long-term use of Vioxx pale in comparison to these
numbers.

The foregoing is not meant to be a defense of Merck or other drug
companies. It's simply to point out that Vioxx is not unusual -- most
medications have potentially serious side effects. Perhaps there
should be more rigorous FDA approval process for new drugs and maybe
the FDA should be given the power to require drug companies to fund
research to evaluate possible side effects that emerge after a drug is
approved and large numbers of patients begin using it. However, those
moves are more likely to result in a longer approval process for new
drugs and even higher cost for most medications than better patient
safety. Moreover, increased regulation raises the sticky issue of
establishing parameters to decide if and when a certain side effect in
a new drug would require pulling that drug from the market. Stated
another way, just when do the risks of a medication outweigh the
benefits of the drug in treating a certain disease or medical
condition?

Thus, these are the issues that we need to be discussing in regard to
medications such as Vioxx. However, the reality is that analysis of
such issues is unlikely to be anywhere near as appealing to the jury
in Angleton as Mr. Lanier's morality play. Where is the Biblical
justification for that?



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July  1, 2005


Piling on Merck

Texas attorney general Greg Abbott announced yesterday that he has
filed a lawsuit against Merck & Co. in state court alleging that the
company bilked Texas out of about $170 million in Medicaid payments by
misrepresenting the safety of its Vioxx painkiller. Although a flurry
of personal injury lawsuits have been filed against Merck throughout
the country after the company pulled the Vioxx drug late last year,
Texas is apparently the first state to file such a suit against the
company. 

A one-time popular arthritis drug, Merck voluntarily withdrew Vioxx
from the market last fall after a study of cancer patients correlated
use of the drug with an increased risk of heart attack and stroke. As
is typical in such situations, the numerous private lawsuits that have
been filed against Merck allege that the company knew of potential
problems with Vioxx, but disregarded them and marketed the profitable
drug anyway.

Greg Abbott is one of the genuine good guys in Texas politics, but he
is wandering far afield with this latest salvo against Merck. As Dr.
Rangel has noted here and here, lawsuits such as this follow a
troubling pattern of attempting to feed off of the sensationalism and
publicity of a side effect of a new and popular drug. It's not at all
clear that Merck did the right thing in pulling Vioxx off the market,
but the mainstream media and plaintiffs' personal injury lawyers have
seized on the company's removal of the drug from the marketplace by
drumming the theme that Vioxx is an excessively dangerous drug that
could kill you. Not mentioned in such propaganda is the fact that
there are plenty of other medications on the market that have side
effects that are more common and worse than those of Vioxx, but those
drugs remain on the market for patients who are willing to risk the
side effects of the drugs to obtain the benefits from them.

As one doctor observed in the Wall Street Journal awhile back, given
the known side effects of aspirin, that drug "probably couldn't gain
FDA approval today."




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June 23, 2005


New study promotes change in treating lung cancer

This NY Times article reports on a new research study to be published
today in the New England Journal of Medicine that is strong evidence
that chemotherapy greatly improves the chances of survival for
early-stage lung-cancer patients. Lung cancer is by far the leading
cause of death from cancer, exceeding annual deaths from colon,
breast, pancreatic and prostate cancer combined.

Lung cancer has long been one of most difficult cancers to treat. A
high percentage of lung cancer victims are are smokers or former
smokers, and because there is no systematic screening process for lung
cancer, almost half of the 175,000 annual lung cancer cases are not
discovered discovered until the cancer is metastatic (i.e.,
spreading), which makes survival unlikely. Currently, only about 15%
of lung cancer victims survive beyond five years.

The standard treatment for early-stage lung cancer has long been
surgery to remove the lobes containing the tumor, but that treatment
has resulted in only a 54% survival rate beyond five years. Until this
new study, no published research studies had shown a substantial
benefit from chemotherapy after surgery for early-stage lung-cancer
patients, who represent nearly a third of all cancer cases.

The results of the 10-year trial of 482 patients with early-stage lung
cancer show that intravenous chemotherapy drugs improved five-year
survival rates to almost 70%. That 15-point improvement will make
doctors and patients much more willing to consider follow-on
chemotherapy, which sometimes requires hospitalization. "There's never
been a lung-cancer trial that showed this benefit of treatment in any
stage of disease," commented Katherine M.W. Pisters, M.D., an
oncologist at Houston's M.D. Anderson Cancer Center in the Texas
Medical Center, who has an op-ed on the study in the current issue of
the Journal. In response to the findings, the American College of
Clinical Oncology and the American College of Chest Physicians are
currently rewriting their official guidelines to physicians to
recommend chemotherapy for early-stage lung-cancer patients.

The study was funded by the American and Canadian governments'
National Cancer Institutes, and received $1.6 million from
GlaxoSmithKline PLC.




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June 18, 2005


New Chron blog reports on medical research funds

The Houston Chronicle has added another blog -- Eric Berger's SciGuy
-- to its impressive and expanding Chronicle bloglist that Chronicle
tech writer Dwight Silverman has spearheaded. Kudos to Dwight and the
Chronicle editors for being pioneers in this emerging method of
delivering their product to customers.

In this post, Mr. Berger notes the National Institutes of Health
annual ranking of U.S. medical schools by the amount of research
funding, which is a key indicator of a medical school faculty's
research capabilities. Here is a listing of medical schools of local
interest:

1.  John Hopkins University, Baltimore, Md., $449 million
11. Baylor College of Medicine, $248 million
21. UT Southwestern Med. Center, Dallas, $172 million
35. Cornell Univ. Medical School (Methodist Hospital) $124 million
39. UT Medical Branch at Galveston, $104 million
48. UT Health Science Center at San Antonio, $80 million
64. UT Health Science Center at Houston, $51 million

In addition, although not a medical school, UT's M.D. Anderson Cancer 
Center in the Texas Medical Center generated another $145 million in
research last year. Consequently, as Mr. Berger notes, the
institutions in the Texas Medical Center pump almost half a billion of
research funds into the local economy.

By the way, the NIH list dovetails nicely with the ranking of
university endowments that was noted in this earlier post. Given the
size of Baylor Medical School's endowment and annual research funding,
one has to respect the risk that Baylor took in ending its longtime
partnership with the even better-endowed Methodist Hospital ($2.3
billion endowment). Hopefully, the competition between the two
institutions for research funds will enhance the amount and quality of
research being performed at the Texas Medical Center.




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May 26, 2005


Study favors bypass surgery over angioplasty

The New England Journal of Medicine yesterday published the findings
of a large-scale study that indicate that angioplasty -- an
increasingly popular invasive procedure for patients with blocked
coronary arteries -- carries a higher risk of death over the long term
than open-heart bypass surgery. The researchers were led by Edward L.
Hannan, chairman of the Department of Health Policy Management and
Behavior at the University at Albany School of Public Health.

The study is particularly significant because it raises questions
regarding the shift in treatment for blocked coronary arteries over
the past decade or so -- the shift away from coronary bypass surgery
in favor of angioplasty, which involves sliding a balloon into an
artery through a small incision and then propping it open with a
wire-mesh stent.

Inasmuch as angioplasty procedures require a far shorter recovery time
and lower risk of in-hospital complications than bypass surgery, it is
currently performed more than one million times a year in the U.S.,
which is about three times the rate of bypass operations. Bypass
surgery generally costs between $25,000 to $35,000 while angioplasties
run from around $10,000 to $15,000.

The study involved a review of almost 60,000 patients from 1997
through 2000 with serious heart disease in two government databases in
New York state. Researchers concluded that those with three blocked
arteries who received stents were 1.56 times as likely to die within
three years as those who had bypass surgery. Similarly, those with two
blocked arteries who got stents were 1.33 times as likely to die as
those who had bypass surgery. Finally, over a third of the angioplasty
patients required either surgery or additional stents within three
years, while only 5% of the bypass surgery patients required either
angioplasty or further surgery within the same period. The researchers
note that the study does not include findings on the newer generation
of drug-coated stents, which some cardiologists believe will improve
the outcome for angioplasty. 

This large scale study adds to an increasing number of smaller studies
finding advantages of bypass surgery over angioplasty for long-term
survival. Last year, a Cleveland Clinic study that followed 6,000
patients found that the risk of death over time was more than twice as
high in the angioplasty group of relatively high-risk patients.

Both the Cleveland Clinic and New York studies involved review of
registry data and not the controlled clinical trials that scientists
consider the best form of evidence. In registry studies, researchers
must adjust existing data for various factors, which can lead to
debate and criticism over the effect such adjustments have on the
ultimate findings of the study. Nevertheless, registry data studies
allow the reearchers to involve much larger patient groups than
clinical trials and to evaluate medical practices that are being most
commonly performed in the medical marketplace.




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May 10, 2005


Did you remember the Doctor's note?

Michael Alcott was charged with bank fraud in September 2004 relating
to a $2.5 million line of credit for his now defunct employment
placement firm. The indictment alleges that he submitted a fraudulent
audit opinion to the bank on the letterhead of a local auditing firm
with the name of a fake partner.

Nevertheless, Mr. Alcott was free on bail pending trial. A couple of
weeks ago, Mr. Alcott submitted a letter to the court in his case from
a doctor at Masschusetts General Hospital. The doctor's note stated
that Mr. Alcott was being treated at the hospital for terminal
cancer.

Yesterday, Mr. Alcott was arrested pending trial because the letter is
a fake and he is not suffering from cancer.

H'mm, I don't think Mr. Alcott should testify at his upcoming trial on
that fake audit opinion. ;^)

Hat tip to the White Collar Prof Blog for the link.




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April 14, 2005


It's time for the MS 150

This Chronicle article reports on the 20th anniversary taking place
this weekend of the two-day, Houston to Austin, 186 mile bicycle
excursion known in these parts as the "MS 150."

In the first event 20 years ago, 237 riders braved the ride and raised
$117,000 for research into Multiple Sclerosis. Incredibly, the event
has now grown to over 13,000 riders who will raise about $10 million,
which is the largest event by far of this type of event organized by
the National Multiple Sclerosis Society. Check out the MS 150 website,
which allows you to donate money in the name of any of the riders in
the event.




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New study on drinking water while exercising

This New York Times article reports on a just released New England
Journal of Medicine study that indicates athletes who drink as much
liquid as possible during intense exercise to avoid dehydration face
an even greater health risk than dehydration. 

The study reports that an increasing number of people who engage in
intense exercise or recreation are severely diluting their blood by
drinking too much water or sports drinks, risking serious illness and,
in some cases, death.

The condition -- called Hyponatremia -- occurs because, during intense
exercise, the kidneys cannot excrete excess water. Accordingly, as
intense exercisers continue to exert themselves and drink more fluid,
the extra water moves into their cells, including brain cells. The
expanded brain cells eventually have no room to expand further and
press against the skull and compress the brain stem, which controls
vital functions such as breathing.

Indeed, the mantra from docs to intense exercisers over the past
generation -- i.e., avoid dehydration at any cost -- may be part of
the culprit. As the Times article notes:

"Everyone becomes dehydrated when they race," [said one of the
researchers involved in the study]. "But I have not found one death in
an athlete from dehydration in a competitive race in the whole history
of running. Not one. Not even a case of illness."

On the other hand, he said, he knows of people who have sickened and
died from drinking too much.

To make matters even more complicated, Hyponatremia can be treated, 
but doctors and emergency workers often pressume that a person feeling
ill after intense exercise is simply suffering from dehydration. Thus,
they give the exerciser intravenous fluids, which makes the
Hyponatremia worse and can kill the patient.

I guess those old high school football coaches of mine back in the
late 1960's who didn't allow my teammates and I so much as a drink
during two-a-days in the summer heat knew more than they were letting
on? ;^)




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April  7, 2005


Possible relief from the worst television commercials ever?

This BBC News article reports on a University of Minnesota Medical
School study that links use of Viagra to vision loss: 

[Researchers at the University of Minnesota Medical School] writing in
the Journal of Neuro-ophthalmology, said it brought the total number
of reported cases to 14. But Pfizer, the makers of the drug which has
been used by more than 20m men since its launch in 1998, said the
cases were a coincidence. The seven men, aged between 50 and 69 years
old, had all suffered from a swelling of the optic nerve within 36
hours of taking Viagra for erectile dysfunction. 

If the plaintiffs' lawyers can use this information to prompt Pfizer
to use Viagra's advertising budget for defense costs rather than
advertising, then I will be strong advocate of the plaintiffs' bar in
this case. Hat tip to the HealthLawProf Blog for the link to the BBC
News article.




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April  6, 2005


Promising new drug to treat alcoholism

A new Journal of the American Medical Association ($) article
(abstract here) described in this summary reports on a once-monthly,
injectable medication that has been shown to reduce heavy drinking
substantially among alcoholics.

The drug is a formulation of naltrexone, a drug that is currently
approved to treat alcohol dependence. However, the drug is currently
rarely prescribed because it must be taken daily, which most
alcoholics simply will not do. Cambridge, Mass.-based Alkermes Inc.
filed an application with the Food and Drug Administration earlier
this month to approve the drug, which will be known under its brand
name of Vivitrex. According to the study, Vivitrex -- which must be
taken only monthly -- has the "potential to improve intervention
strategies for alcohol dependence." Alkermes funded the JAMA-Vivitrex
study and the development of the drug was supported by a grant from
the National Institute on Alcohol Abuse and Alcoholism, a unit of the
National Institutes of Health.

The NIAAA estimates that up to 18 million Americans have an
alcohol-related disorder. Alcohol dependence is defined as women who
consume four or more drinks a day on a regular basis and men who
consume five or more drinks, which researchers used to define a "heavy
drinking" day in the JAMA study involving Vivitrex.

James C. Garbutt of the University of North Carolina at Chapel Hill
headed up the study, which involved 624 alcoholic adults. The patients
received either an intramuscular injection of 380 milligrams of
Vivitrex, 190 milligrams of Vivitrex, or a placebo (i.e., a fake
injection), and all of the patients received counseling. Overall, the
study showed that the number of "heavy drinking" days was cut by 25%,
a drop that researchers deemed "significant" among those using the
highest dose of the drug. 




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March 24, 2005


The Schiavo case

A number of friends have asked me why I have not blogged on the Terri
Schiavo case, to which I have stolen Eugene Volokh's reply that "I
know nothing about the Schiavo matter, and -- despite that -- have no
opinion." 

As we have seen with the Enron case, when a case becomes as
sensationalized in the MSM as the Schiavo case has over the past
several weeks, battle lines get drawn politically, increasingly shrill
views compete for the public's limited attention, and wise
perspectives tend to get lost in the shuffle. Bloggers can find
thoughtful views -- such as those of Professors Bainbridge and
Ribstein -- but, let's face it, the vast majority of the public do not
read blogs.

At any rate, I wanted to pass along a couple of informative articles
on the Schiavo case that will appear in next month's New England
Journal of Medicine. Timothy Quill, M.D. is a nationally-recognized
expert in palliative care and end-of-life issues who is a professor of
medicine, psychiatry, and medical humanities at the University of
Rochester, School of Medicine and Dentistry. In this article, Dr.
Quill dispassionately reviews what has occurred in the Schiavo case,
and then makes the following observation:

In considering this profound decision, the central issue is not what
family members would want for themselves or what they want for their
incapacitated loved one, but rather what the patient would want for
himself or herself. The New Jersey Supreme Court that decided the case
of Karen Ann Quinlan got the question of substituted judgment right: 

If the patient could wake up for 15 minutes and understand
his or her condition fully, and then had to return to it, what would
he or she tell you to do?
If the data about the patients wishes are not clear, then in the
absence of public policy or family consensus, we should err on the
side of continued treatment even in cases of a persistent vegetative
state in which there is no hope of recovery. But if the evidence is
clear, as the courts have found in the case of Terri Schiavo, then
enforcing life-prolonging treatment against what is agreed to be the
patients will is both unethical and illegal.

In the same issue, George P. Annas, J.D., the Edward R. Utley
Professor and Chair Department of Health Law, Bioethics & Human Rights
at Boston University School of Public Health, pens this article in
which he reviews the legal precedent relating to the Schiavo case and
criticizes Congress for ignoring it. In so doing, Professor Annas
observes the following:

There is (and should be) no special law regarding the refusal of
treatment that is tailored to specific diseases or prognoses, and the
persistent vegetative state is no exception. "Erring on the side of
life" in this context often results in violating a persons body
and human dignity in a way few would want for themselves. In such
situations, erring on the side of liberty  specifically, the
patients right to decide on treatment  is more consistent with
American values and our constitutional traditions.

Hat tip to the HealthLawProf blog for the links to these articles.




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March 17, 2005


The Texas Children's case

This HealthProfBlog post provides an insightful analysis of the legal
issues raised by the decision of Texas Children's Hospital earlier in
the week to take Sun Hudson, the nearly 6-month-old who had been
diagnosed and slowly dying from a rare form of dwarfism (thanatophoric
dysplasia), off the ventilator that was keeping him alive. A Houston
state district court had authorized the hospital's action, and Sun
died shortly after being removed from life support.




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March  8, 2005


Dr. DeBakey: Health model

Dr. Michael DeBakey is Houston's most famous physician and one of the
most reknowned of the post-World War II generation of doctors who
changed the way medicine was practiced in the world. But in this Wall
Street Journal ($) article, Dr. DeBakey is something entirely
different -- a model for longevity and good health:

[L]ong a role model for physicians, [Dr. DeBakey] now can serve as a
role model for another group: anyone turning the corner on what used
to be called old age. In 1965, Dr. DeBakey appeared on the cover of
Time magazine. He was 56. Almost 40 years to the month later, the
96-year-old remains a player in the field of medicine, his most recent
article ("Kismet or assiduity?") having appeared only last month in
the journal Surgery.

Entering the room, Dr. DeBakey looked only slightly older than he did
in photographs taken decades ago. Sitting down, he poured himself a
cup of coffee with a steady hand. For anyone who wrestles with the
health implications of caffeine, this gesture might have borne
significance, except that during the two hours we spoke Dr. DeBakey
barely took a sip of it. "This will be my only cup of the day," he
says, touting moderation.

His hearing was sharp; I never repeated a question.  .  .

His personal habits largely parallel what doctors order. He always has
been a light eater, and on most days takes only one meal, dinner,
often consisting of a salad. "My wife is a great salad maker," he
says. Though he doesn't take vitamins or engage in what he calls
"formal exercise," he walks from place to place, putters around the
garden and chooses stairs over elevators. He is on no medications,
doesn't drink and never smoked. His military uniform still fits him
perfectly.

Interestingly, Dr. DeBakey views the key to his longevity and health
to be something that the medical profession often characterizes as
damaging to health -- hard work and stress:

But here is what Dr. DeBakey sees as the real secret to his longevity:
work. He rises at five each morning to write in his study for two
hours before driving to the hospital at 7:30 a.m., where he stays
until 6 p.m. He returns to his library after dinner for an additional
two to three hours of reading or writing before going to bed after
midnight. He sleeps only four to five hours a night, as he always
has.

But isn't stress harmful? In the Time magazine article of 40 years
ago, Dr. DeBakey expressed scorn for the alleged ill effects of
stress: "Man was made to work, and work hard. I don't think it ever
hurt anyone," he said then. Now, that quote elicits a sheepish smile
from him. "I was being provocative," he says.

Although he concedes now that stress can be damaging, he also believes
that work is underrated as a health tonic. "What we call stress is
sometimes stimulating and can bring out the best features in our
makeup," he says, adding that no vacation spot could ever prove as
relaxing for him as did the operating room. "Work can block out the
unpleasant things we have to deal with every day. When you
concentrate, you are not distracted by the things that are bothering
you."

My anecdotal experience with my late father -- Dr. Walter Kirkendall
-- certainly supports Dr. DeBakey's views. Walter worked as a
professor of medicine at the University of Texas Medical School in
Houston literally up to the day he died suddenly of a heart attack in
1991. Although stress arguably played a role in his sudden death,
Walter's work during his final years was a large part of what
sustained him, giving him the focus and purpose of a much younger man.
Walter would not have wanted to live his life in any other way.

The examples of Walter and Dr. DeBakey remind us that the motivation
to excel in what we do is inextricably tied to our will to live.




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March  7, 2005


An alternative to heart bypass surgery

This Washington Post article reports on drug-coated stents, which are
allowing an increasing number of people to avoid having heart bypass
surgery. The new generation of tiny, drug-coated metal scaffolds prop
open arteries and slowly release medication that prevents the arteries
from from reclogging. Check it out.





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February 22, 2005


Novartis rocks medical community with $8.4 billion expansion of
generic drug empire

Swiss pharmaceuticals giant Novartis AG announced over the weekend an
$8.4 billion expansion of its generic drug holdings in a move that is
widely viewed in the drug and medical communities as the continuation
of trend toward consolidation in the generic drug sector. As a result
of the deal, Novartis will become the world's largest seller of
generic drugs at a time when it is already the top seller of branded
drugs. Novartis had total world-wide sales last year of just under $30
billion.

Novartis will pay $7.4 billion to buy Hexal AG of Germany and 68% of
Eon Labs Inc., which are two generic-drug makers that are controlled
by Germany's wealthy Strngmann family. As a part of the deal,
Novartis will also launch a tender offer to acquire the balance of Eon
shares for about another billion.

The generic drug industry has exploded in growth since the 1980s when
U.S. law was modified to make it easier for drug companies to copy
successful branded drugs. As a result, the generic drug industry
became increasingly aggressive at challenging the legality of branded
drug patents in court, which has often resulted in patents being
overturned years ahead of the normal term.

Nevertheless, the sector has always been highly fragmented and now its
profits are being squeezed by brutal price competition. Thus, these
difficult market conditions are prompting consolidations in the
generics business, and the Novartis deal reflects that the branded
drug companies are going to be involved in the consolidation in a big
way.




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January 26, 2005


Second Circuit reverses "Super Size Me" lawsuit dismissal

Super Size Me is the Morgan Spurlock documentary that chronicled
Spurlock's health as he as he ate nothing but McDonald's food at least
three times a day for a month. Although certainly not a balanced
treatment of the fast food industry, Super Size Me is quite clever and
certainly worth watching. Last week, the film was nominated for an
Academy Award in the best Documentary Feature category.

One of the criticisms of Super Size Me was that it was a transparent
attempt to promote frivolous lawsuits against the fast food industry,
although the onslaught of such litigation has not occurred.
Nevertheless, such lawsuits received a glimmer of light yesterday from
the Second Circuit Court of Appeals. In this decision, the Second
Circuit reinstated part of a highly publicized lawsuit that accused
McDonald's of misleading young consumers about the healthiness of its
products.

The Second Circuit's decision concluded that the trial judge in the
case incorrectly dismissed parts of the lawsuit brought on behalf of
two New York children on the grounds that the lawsuit complaint failed
to link the children's alleged health problems directly to McDonald's
products. For the trial court to dismiss the case on those grounds
without a trial, the Second Circuit essentially held that such a
ruling could only come in summary judgment proceedings after discovery
and presentation of summary judgment evidence. Thus, the decision at
least opens the door a crack for the plaintiffs' lawyers to demand in
discovery from McDonald's the type of previously secret documents
regarding the company's promotion of unhealthy products that
ultimately led to a string of multi-billion dollar verdicts against
Big Tobacco companies.

John F. Banzhaf III, a George Washington University professor of
public-interest law who has advised plaintiffs in the big tobacco
cases, is an unpaid adviser to the McDonald's plaintiffs in this case.


Despite McDonald's protestations to the contrary, Super Size Me has
already had an effect the way in which McDonald's promotes its menu.
In early 2004, McDonald's removed the "super size" option from the
menus of its 13,000 U.S. restaurants and it began promoting a new line
of premium salads. The company also began promoting milk as an
alternative to soft drinks and sliced apples as a substitute for
French fries in its famous Happy Meals for children.

I suspect that those apples have not competed particularly well
against McDonald's French fries. ;^)




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December 24, 2004


Is your surgeon a "Nintendo surgeon?"

Following on this earlier post about video games being used as
anesthetia for young patients, several of my surgeon friends, nephews,
and my two sons are going to enjoy this latest finding:

Surgeons who play video games three hours a week have 37 percent fewer
errors and accomplish tasks 27 percent faster, . . [based on]
observation on results of tests using the video game Super Monkey
Ball.

Link hat tip to Tyler Cowen, who hilariously suggests that maybe the
surgeons and the patients could play each other?




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December  2, 2004


The Myth of Vioxx

Dr. Rangel analyzes in posts here and here the dilemma raised by
Merck's decision to pull Vioxx from the market. Definite clear
thinking. Check his thougts out.




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November 30, 2004


K-rations and dieting

Ancel Benjamin Keys, PhD., the inventor of the K-rations that  kept
Allied troops alive and reasonably well fed on the battlefield during
WWII, died last week at the age of 101. 

But the greater contribution of Dr. Keys is even more interesting. As
Sandy Szwarc notes in this TCS op-ed, Dr. Keys' greatest scientific
contributions are to our understanding of the human body and eating.

Inasmuch as the mainstream media in America is obsessed with dieting
and a svelte figure, few Americans who read Dr. Keys' obituary know
that, over half a century ago, he conducted the soundest clinical
studies ever done on the adverse effects of dieting. His findings --
which have been confirmed many times since -- proved that dieting can
actually cause severe physiological and psychological harm, often
results in people becoming fatter, often leads to eating disorders,
and even increases the risk for heart disease and life shortening
illnesses.

As Ms. Szwarc notes:

The extreme physical and mental effects [of restricted diets that]
Keys observed led to his famous quote:

"Starved people cannot be taught democracy. To talk about the will of
the people when you aren't feeding them is perfect hogwash."

Read the entire article.




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November  9, 2004


Could you pass a maggot, please?

My late father -- Dr. Walter M. Kirkendall -- was a master internist
who was a legend among his students for his diagnostic skills and
conservative views toward use of many medicines. For one of the
reasons supporting his skepticism regarding the use of clinically
untested medicines, take a look at Alex Tabarrok's post over at
Marginal Revolutions on Jerry Avorn's new book, Powerful Medicines.




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November  6, 2004


The Disease of the Century

Colleen Carroll Campbell, a fellow at the Ethics and Public Policy
Center, is the author of The New Faithful: Why Young Adults Are
Embracing Christian Orthodoxy (Loyola, 2002). She is working on a book
based on her father's experience of Alzheimer's disease, and this New
Atlantis article provides an outstanding overview of her research into
the subject. There is no question that Alzheimer's is becoming an
increasingly important health care issue:

.  .  . [E]very once in awhile, we face a situation that forces us to
collectively consider what it means to be human persons who grow old,
suffer, and die.

The looming Alzheimer's epidemic is just such a situation. This
disease embodies everything we fear most about aging -- weakness and
dependence, humiliation and oblivion. Its insidious onset and
relentless progression have penetrated our collective consciousness,
and nearly half of Americans over the age of 35 know someone
personally whose brain has been ravaged by it. As Americans are living
longer and more physicians are recognizing dementia as a disease to be
diagnosed, Alzheimer's is claiming more victims. Some 4.5 million
Americans suffer from Alzheimer's today, more than double the number
who had the disease in 1980. Alzheimer's has become the eighth-leading
cause of death in America, and its impact is expected to mushroom as
77 million Baby Boomers head into retirement. By 2050, if no cure is
found, 16 million Americans could have Alzheimer's. As they bid their
long goodbye -- Alzheimer's can take up to 20 years to run its
devastating course -- we will no longer be able to ignore the human
questions raised by this disease. Such questions, about the basis of
our human dignity and our identity as persons, cannot be answered by
science or technology. We must grapple with them the old-fashioned
way, drawing on both reflection and lived experience to find the
meaning in this way of dying.

For anyone dealing with the onset of dementia in a loved one, this
piece is essential reading. Read the entire article.




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September 27, 2004


The decision to die

THis long NY Times article about end-of-life decision making provides
an excellent overview of the issues that confront families and health
care professionals in making those decisions. Check it out.




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September 16, 2004


Fat but fit

Sandy Szwarc is an editor and a prolific writer on food, health and
science issues for various print and internet media. She is also a
registered nurse with a science degree from the University of Texas at
Austin, and over twenty years in critical-care nursing, emergency
triage, and medical outreach education with a focus on nutrition,
weight and eating issues, and preventative health. Ms. Szwarc is a
leading advocate in debunking junk science as it pertains to food and
health, and she is currently completing an upcoming book entitled "The
Truth About Obesity and Dieting-Dangers and Good News We're Never
Told."

In this Tech Central Station op-ed, Ms. Szwarc takes dead aim at the
junk science industry and the mainstream media for providing muddled
information to the public regading the health risks of obesity:

Consumers were left more confused than ever when the media reported on
two obesity-related studies from the Journal of the American Medical
Association last week. One seemed to find it was more important to be
fit than thin for your heart health; the other that it was more
important to be thin than fit to prevent diabetes .  .  . 

But in fact, the controversy has already been repeatedly answered in
the scientific literature. The trouble is, it's not what a lot of
people want to hear...and others without science backgrounds don't
realize.  

These side-by-side JAMA studies provided an invaluable opportunity for
the media to help consumers sort through medical information and come
away with a very important message: not all studies are created equal.


Ms Szwarc goes on to explain how some medical researchers are
misleading the public with spurious conclusions drawn from "dredge
data research," and that the conclusions of such studies are of
dubious merit:

Sadly data dredge studies are increasingly being misused and
misinterpreted. Most noteworthy is that [the Weinstein study
correlating obesity with diabetes] findings contradict many stronger
clinical and epidemiological studies that have found that exercise
reduces type 2 diabetes and improves insulin resistance, unrelated to
weight.

For example, researchers at the Cooper Institute in Dallas, Texas led
by Timothy S. Church, MD, PhD, followed over 2,000 diabetics for 25
years, using a range of health assessments, including treadmill tests
to gauge their fitness levels. They found that premature deaths from
all causes were significantly lower among the fit. Weight was
irrelevant. Researchers at the Veterans Affairs, Palo Alto Health Care
System, Stanford University studied over 6,000 men for six years and
found exercise capacity was more important in risks of dying than
"known" risk factors including obesity, cholesterol, hypertension,
smoking and even diabetes. Even a small clinical study at Queen's
University, Kingston, Ontario, Canada following 54 obese women found
daily exercise, without dieting or weight loss, substantially reduced
insulin resistance in just 14 weeks.

In the mainstream media's rush to embrace the American delusion that a
svelte physique equates with good health, Ms. Szwarc points out that
the media ignores scientifically proven reality:

Most significant, [another recent study] is just one of dozens of
clinical studies over decades which have found the exact same thing in
men and women: when fitness is considered, weight is irrelevant to
long-term health, heart disease, diabetes or premature death from all
causes. 

The list is too extensive to cite here, but clinical studies
concluding 'fitness not weight is what counts' include the Harvard
Alumni Health Study of 12,516 men followed for 16 years; the St. James
Women Take Heart Project of 5,721 women studied for 8 years; and the
Aerobics Center Longitudinal Study, an ongoing study that includes
25,389 patients examined at the Cooper Clinic in Dallas from 1970 to
1989. Even the Women's Health Study published findings in 2001 that
found merely light to moderate activity was dramatically associated
with lowered heart disease in women, including those who were
overweight, had high cholesterol or smoked.

Ms. Swzarc concludes by pointing to a recent op-ed by two researchers
at the Dallas-based Cooper Institute, which has an outstanding record
of performing landmark research on fitness and preventative health:

[Drs. Blair and Church, the Cooper researchers] chastised today's
obesity researchers, saying that "failure to adequately quantify
physical activity when examining the risks of obesity is similar to
exploring risk factors for cancer and misclassifying tobacco use." 

Drs. Blair and Church emphasized that death rates and heart disease
among obese people, with just moderate fitness, are half that of
"normal" weight people who aren't fit. The amount of exercise to
attain this health-giving level of moderate fitness isn't much,
either, and has been proven in 24 clinical studies: it's merely 150
minutes of moderate-intensity activity a week. They say that's
equivalent to 30 minutes, 5 times a week of: walking, gardening,
housework, bicycling, swimming or other activities enjoyed in daily
life.

Read the entire article.











 




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August 31, 2004


Merck reels from Zocor study

This Wall Street Journal ($) article reports on the reaction of
pharmaceuticals giant Merck & Co. to the disappointing study involving
Zocor, its top-selling cholesterol drug.

The study found that high doses of the drug did not benefit patients
at high risk of a heart attack compared with both placebo and
less-aggressive Zocor treatment. Researchers presented the
4,500-patient Zocor study at the annual meeting of the European
Society of Cardiology in Munich, Germany, and it also was published
online by the Journal of the American Medical Association.

Even before this news, Merck had been losing in the competition with
Pfizer's Lipitor, which is the world's biggest-selling statin drug
with sales of $9.2 billion in 2003. A clinical trial reported earlier
this year that Lipitor was was much better than another statin --
Bristol-Myers Squibb Co.'s Pravachol -- at reducing the risk of death,
heart attack or other serious complications within two years of
treatment. Here is an earlier post on that study.

The 4,500-patient study tested an aggressive cholesterol-lowering
strategy compared with a moderate approach for patients hospitalized
with severe unstable chest pain. The aggressive treatment was 40
milligrams of Zocor for a  month followed by 80 milligrams for the
next 23 months. The moderate approach was four months of a placebo
followed by 20 milligrams of Zocor.

In the earlier Lipitor/Pravachol study, Lipitor at a dose of 80
milligrams proved significantly more effective in reducing LDL and the
risk of serious heart problems than Pravachol at 40 milligrams. The
benefit for Lipitor was evident within 30 days of starting the drug
and the study was an important reason why cardiology experts are now
recommending that doctors consider aggressive therapy with statins to
enable patients at very high risk of a heart attack to reduce their
levels of LDL to below 70. Previously, the target for such patients
was below 100. 

Cardiologists expected aggressive treatment with Zocor to reflect the
Lipitor findings, especially because the control group was treated
with a placebo during the first four months of the two-year trial. But
even though their LDL levels fell to 62, aggressively treated patients
at the end of four months had no difference in heart attacks, death
from heart attacks, or strokes for heart problems than patients on
placebo whose LDL was twice as high. After two years, 14.4% patients
on aggressive therapy had suffered negative outcomes compared with
16.7% on the moderate regimen, but the difference was not considered
statistically significant.




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July 26, 2004


Addressing the obesity epidemic

Clinical psychologist Gerard Musante was the first person to adapt the
principles of behavior modification to the eating habits of
significantly overweight people. For the past 30 years, Dr. Musante
has taught these principles at Structure House, the residential weight
loss facility he founded in Durham, N.C.

In this Tech Central Station op-ed, Dr. Mustante addresses that the
national debate over responsibility for our society's obesity
overlooks the effect that the debate has on how individuals perceive
their personal battles with being overweight or obese:

[O]ur national debate on obesity is evolving into two camps. One
emphasizes that obesity results from such factors as genes, a disease
state or physiology. The other focuses on the role personal
responsibility plays and possibly defines obesity as a personal
failing. 

While the first camp paints the individual as a victim of forces
beyond his control, the latter argues from a moral or social
viewpoint. While I strongly support personal responsibility, even the
discourse to this effect fails to address the most critical reason for
espousing such a perspective. What is too often absent from both
viewpoints is a direct consideration of the ramifications these
arguments themselves can have on how individuals view their personal
battles with overweight and obesity. 

Dr. Mustante points out that the biggest problem is defining the issue
as being out of an individual's control:

If one defines a problem as out of his control, then he remains
powerless to influence it. However, nearly all experts acknowledge
obesity ultimately results from violating a simple principle: calories
consumed should equal calories expended. The idea that individuals are
victimized by their own bodies or a toxic environment is problematic.
For starters, it's untrue. But as importantly, it stymies their
motivation and perceived ability to control their weight loss. 

The key lies in a related psychological concept called self-efficacy,
which was defined by Albert Bandura, a noted Stanford University
psychologist, in 1977. He theorized that people's expectations of
their ability to be effective influence whether and how they will act.
It will affect how much effort they expend, and how long they will
sustain their efforts in the face of challenges. If a person believes
he lives in a "toxic food environment" or is suffering from a disease
state, how can he have confidence in his ability to change his
predicament?

Dr. Mastante then points out that "quick fix" diet plans are usually 
counterproductive to obesity because the personal sense of failure
that an individual experiences triggers a false sense that the
individual is powerless to overcome the problem. And that false sense
of powerlessness is becoming more popular:

Worsening the problem, we now are seeing efforts to sue food
establishments, to demonize various industries, and to rid schools of
vending machines. By blaming industries and products, society only
makes individuals feel increasingly powerless about their ability to
lose weight, and that perceived lack of control makes them less likely
to attempt or experience success. Frivolous lawsuits against the food
industry and the classification of obesity as a disease only reinforce
the idea that obesity is something people cannot control. 

Read the entire article, and then take a look at this piece in which
the authors point out that the obestiy epidemic is partly the
unintended consequence on the anti-smoking campaign over the past
generation.




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July  5, 2004


Ken Klee, Energy Healer?

Many Houston business litigation attorneys know Ken Klee as a Los
Angeles-based corporate reorganization and bankruptcy law expert, as
well as a UCLA Law School professor. However, this LA Times article
reports that Ken is also up to something completely different from
representing parties in reorganizations or teaching students the
intricacies of bankruptcy law:

Brentwood real estate broker Joan Gardner was suffering such
excruciating pain with a swollen knee, months after a fall, that she
was homebound, depressed and unable to work. Her doctor and orthopedic
physical therapist encouraged her to have surgery, but Gardner
declined because, "I'm stubborn and vain." Instead, she decided to try
something different.

Digging up a number her grocery clerk had given her, Gardner dialed
Ken Klee, a UCLA law professor and prominent corporate bankruptcy
lawyer who practices energy healing on the side. A seven-year student
of more than half a dozen healing methods including reiki's radiance
technique, pranic healing and Theta Healing, Klee practices eight
hours a week out of his Brentwood home office, stacked high with
stones and crystals, massage table at the center.

Without touching her body or charging her a fee, Klee waved his hands
over Gardner for three hours last December, channeling divine healing
energy and helping her clear out anger and other blocks. The next day
the swelling in Gardner's knee was gone.

"I was in shock. It sounds probably crazy, but it's the truth," she
said. "I feel like a million dollars, and I have since that day."

Stories like Gardner's raise eyebrows among those in the medical
establishment and Klee's academic colleagues. Once the provenance of
faith healers, shamans, ancient and New Age mystics, however, energy
healing is increasingly going mainstream.

And what on earth is energy healing?

Methods vary, but principles generally stem from ancient concepts of a
life force  called chi or qi in traditional Chinese medicine (prana
in Indian medicine)  that moves through pathways called meridians.
Acupuncture, qigong, tai chi, yoga and shiatsu massage are all based
on the idea that free-flowing energy throughout the body leads to
optimal health.

Energy healers contend that people have an etheric, or energy, body,
often called an aura, surrounding and penetrating the physical body,
and energy fuel centers inside the body called chakras.

Because bodies are made up of subatomic particles in constant motion,
many physical ailments manifest first in this energy body, like a
blueprint, healers say. Stress and painful emotions, for instance, can
cause energy to get stuck or depleted, inhibiting the body's natural
healing processes.

Healers claim to be able to detect and repair these problems with or
without touching the body, sometimes from great distances. "All we are
at our essence is vibration, and all disease is dissonance in
vibration," Klee says. "If we alter the vibration through crystals,
color, sound, prayer or bringing energy through the hands, it all has
to do with vibration."

By harnessing the power of the mind-body connection, many energy
healers say they are simply promoting the innate ability to heal
oneself, meaning receptivity can affect whether it works, as can the
intent and state of mind of the healer.

The line between energy healing and faith healing can get blurry. Some
practitioners invoke a higher power, while others align cosmic healing
symbols or gather and project healing energy from nature. Some tout
extraordinary gifts; others say they are simply conduits, and anyone
can learn to heal themselves and others with a little practice.

Altough the article notes that some clinical research into energy
hearling is underway, the medical community retains a healthy dose of
skepticism regarding the benefits of energy healing:

Stephen Barrett, a retired psychiatrist and founder of the health
fraud guide Quackwatch, holds the "sheer quackery" point of view. He
dismisses such research, saying, "There is nothing there."

Barrett is coauthor of an article published in the Journal of the
American Medical Assn. in 1998 debunking the effectiveness of
Therapeutic Touch, an energy healing method often used by nurses.

"They claim they can, by concentrating, feel a person's energy field
and go through certain maneuvers to modify it and create a healing
force," he said. "We feel that's preposterous. It's a figment of their
imagination."

Barrett's JAMA article publicized the results of a science fair
project of a 9-year-old girl named Emily who tested Therapeutic Touch
practitioners' ability to detect her energy field. The experiment was
similar to Schwartz's, but the practitioners correctly guessed which
of their hands the girl's hand was hovering over only 44% of the time,
less than chance would suggest.

Barrett, one of the nation's most outspoken critics of alternative
medicine, says energy healers and those who bolster them through
studies are delusional or dishonest.

But Mr. Klee remains a true believer:

"If I can do it, anybody can do it. I'm a conservative guy, a lawyer,
a skeptic. I believe in verifying things. Seven years ago, I would
have thought this was completely nuts. Now I'm convinced science is
going to validate this. It's going to happen in my lifetime."

Hat tip to Professor Bainbridge for the link to this story.




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July  3, 2004


Do artificial sweeteners make us fat?

Dr. Rangel has insightful comments on the recently published study
linking artificial sweeteners with obesity in rats.




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June 29, 2004


Promising new approach to treating Alzheimer's

This Wall Street Journal ($) article reports on a significant
advancement for the next generation of Alzheimer's treatments,
Neurochem Inc says it will begin recruiting patients for a large
efficacy trial of its drug Alzhemed in the next few weeks.

Unlike current drugs that generally treat the symptoms of Alzheimer's,
the new drugs target the underlying illness itself. The goal of these
new these new medicines are to halt the devastating progression of the
disease or prevent it entirely. Alchemed is at the cutting edge of the
new medicines that offer hope to the 4.5 million Americans struck with
the memory-robbing illness. 

Alzhemed, which helps prevent the formation of the plaques many
scientists believe are the culprit in Alzheimer's disease, could be on
the market within four years. The new study will enroll 950 patients
over 18 months at 70 sites in the U.S. and Canada.

For a long time, Alzheimer's research was a depressing area that
simply was not producing any insights to a possible cure for the
disease. That is changing, as the clinical trials described in this
article appear quite promising.




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May 10, 2004


M.D. Anderson fat pill research

Both the Chronicle and the Wall Street Journal ($) have front page
stories on the research project that Dr. Wadih Arap, a cancer
biologist at the University of Texas M.D. Anderson Cancer Center in
Houston's Texas Medical Center, is leading a study that offers a
potential new approach to treating obesity and is also showing promise
in cancer treatment. The results are being published in the June issue
of the journal Nature Medicine.

Such research is becoming increasingly important because several
recent studies are revealing that many of the improvements in health
that medical advances have bestowed upon middle-aged and older
Americans will likely be effectively erased over the next 20 years if
Americans' weight continues to increase.

The researchers said they melted away body fat in laboratory mice by
cutting off the blood supply to fat cells. The agent is a drug the
researchers designed to home in on blood vessels cells linked to fat
tissue and then deliver an agent that induces the cells to
self-destruct. As the blood vessel cells died, the fat tissue
essentially vanished.

Weight-loss drugs typically seek to suppress appetite or increase the
body's metabolism to make it burn more calories. However, the body can
quickly compensate for the effects of such drugs, making it difficult
to lose and keep off weight. Accordingly, the new research is
important because it could decrease the amount of fat in a completely
novel way.

Dr. Arap cautions that only mice have been studied so far and that
what works in mice often fails in people. Even if additional research
goes well, it would probably be several years before any treatment
could reach the market.

No corporate sponsors were involved to date in the study. The research
has been funded with grants from the National Institutes of Health and
several philanthropies. M.D. Anderson has filed patents related to the
approach, and its institutional policies enable Drs. Arap and other
researchers in the project to benefit financially if the strategy is
commercially developed.

As far as potential corporate sponsors go, I recommend highly that the
researchers get in touch with a certain doughnut makere. 




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April  8, 2004


Increasing good cholesterol

This NY Times article reports on a preliminary University of
Pennsylvania and Tufts University study that found that an
experimental drug can sharply increase levels of H.D.L. -- the
so-called "good" cholesterol -- and, thus, potentially offer an
entirely new way to help prevent heart attacks. The new drug -- called
torcetrapib -- also reduced low density lipoprotein, or L.D.L. in the
tests. 
 
Doctors currently concentrate on lowering bad cholesterol by giving
patients statin drugs, which are researchers believe have reduced
heart attacks in Americans by about one-third. This new study is a
part of an initiative to reduce heart disease further by increasing
good cholesterol.

This related Wall Street Journal article relates how Pfizer Inc. is
investing $800 million on human tests of torcetrapib, which is the
most that any drug company has ever committed to spend on a clinical
test in an effort to obtain regulatory approval of a drug.





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April  6, 2004


Oops!

Emergency workers are sometimes lowering the chances that heart attack
victims will survive by improperly administering CPR.




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Health care industry eschews new technology

On virtually every visit to a private doctor's office, I am amazed at
the amount of clerical staff that even relatively small offices
employ. Having run a law office for many years, I understand that the
amount -- and productivity -- of clerical staff is an important
component in the overall profitibility of the office. There is no
discernible reason why that principle should be any different in most
doctors' offices.

This NY Times article may explain a part of this phenomenom. Despite
pressure from an array of interest groups, only a few dozen medical
centers across the country are making full use of the latest
computerized patient safety systems. Hospitals and doctors contend
that they have good reason to be cautious about the new technology
because they believe that the computerized systems will never repay
their multimillion-dollar cost, or will be outmoded or cost much less
in a few years. Moreover, many doctors complain that using the systems
to write prescriptions and order tests diverts them from patient care 
and running their offices on already stressful workdays.

The coordination of technology with patient care and medical practice
business operations is one of the most challenging problems in the
complicated field of health care finance at this time. This is an
issue that we all need to follow closely.




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March 23, 2004


Allergies? Sinusitis? How to Tell the Difference

It's springtime in Houston. You need to know the difference.




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March 21, 2004


Rethinking how best to prevent heart attacks

This NY Times article reports on new studies that increasingly
indicate that coronary bypass opearations and angioplasty procedures
are not as effective in preventing heart attacks in high risk patients
than non-invasive treatments such as giving up smoking and taking
drugs to control blood pressure, reduce cholesterol levels, and
prevent blood clotting. The research reflects that that just one of
those treatments -- lowering cholesterol to what guidelines suggest --
can reduce the risk of heart attack by a third. However, only 20% of
heart patients follow that approach. As the Times article notes:

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.

That is why, heart experts say, so many heart attacks are unexpected 
a person will be out jogging one day, feeling fine, and struck with a
heart attack the next. If a narrowed artery were the culprit, exercise
would have caused severe chest pain.

Heart patients may have hundreds of vulnerable plaques, so preventing
heart attacks means going after all their arteries, not one narrowed
section, by attacking the disease itself. That is what happens when
patients take drugs to aggressively lower their cholesterol levels, to
get their blood pressure under control and to prevent blood clots. 

Yet, researchers say, old notions persist.

"There is just this embedded belief that fixing an artery is a good
thing," said Dr. Eric Topol, an interventional cardiologist at the
Cleveland Clinic in Ohio. 




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March 19, 2004


The Health Care Market

Arnold Kling at EconoLog carries on an interesting discussion of
health care finance with Steve Verdon  in which Arnold makes the
following common sense observation:

A free-market but compassionate health care system would provide
vouchers for catastrophic insurance coverage, but eliminate all other
subsidies, including the tax-advantages for employer-provided health
insurance.




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March 18, 2004


The poor health of Russians

Tyler Cowan over at Marginal Revolutions has this interesting post
about the Russian health care system, which has been in the news
because of recent reports regarding the decreasing life expectancy of
Russian men. Tyler's post contains several good links and solid
analysis of the reasons for this crisis in Russian health care.




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March 15, 2004


Doc, Let me get this straight .   .   .

This NY Times article delves into the confusion among doctors
regarding HDL -- the so-called "good" cholesterol. Doctors have been
saying that patients should pay attention to both the so-called bad
cholesterol (LDL), and the good cholesterol (HDL) to prevent
cardiovascular disease. As a general proposition, the doctors believed
that the good cholesterol counteracted the bad.  But now, some
scientists say, new and continuing studies have called into question
whether high levels of the good HDL cholesterol are always good and,
when they are beneficial, how much. As the Times article relates:

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.

In the meantime, as noted in this earlier post, the pharmaceutical
companies are watching this development closely.




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March  9, 2004


Obesity becoming major public health issue

This Rand Corporation study concludes that many of the improvements in
health that medical advances have bestowed upon middle-aged and older
Americans will likely be effectively erased over the next 20 years if
Americans' weight continues to increase.

The proportion of health care expenditures associated with treating
the consequences of obesity would increase from 14 percent in 2000 to
21 percent in 2020 for 50-69 year-old men, and from 13 percent to 20
percent for women in the same age group, according to the study to be
published in the March/April edition of Health Affairs ($).  

Absent changes in health behavior or medical technology and assuming
obesity trends continue through 2020, the study predicts that the
proportion of people 50-69 with disabilities (those who are limited in
their ability to care for themselves or perform other routine tasks)
will increase by 18 percent for men and by 22 percent for women
between 2000 and 2020.

These statistics -- coupled with America's broken health care finance
system and accelerating Medicare costs -- indicate that health care in
America is headed for a day of reckoning soon. In my view, one of the
Bush Administration's biggest political problems in the upcoming
election is the perception of many Americans that the administration
ignores major domestic issues such as these. 




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Pfizer's Lipitor pummels Bristol-Myers' Pravachol in study

Both the NY Times and the Wall Street Journal ($) have extensive
articles about the results of a Bristol-Myers Squibb sponsored study
that compared high doses of Pfizer's most powerful
cholesterol-lowering drugs, Lipitor, with Bristol-Myers Squibb's less
potent drug, Pravachol. Both drugs are statins, a class of medications
that block a cholesterol-synthesizing enzyme and are often prescribed
for patients with heart problems.

Much to Bristol-Myers' dismay, the study concluded that the patients
taking Lipitor were significantly less likely to have heart attacks or
to require bypass surgery or angioplasty than those taking Pravachol.
The study is spurring discussion among cardiologists and the medical
community that lowering cholesterol far beyond the levels that most
doctors currently recommend can substantially reduce heart patients'
risk of suffering or dying of a heart attack. This could greatly
change how doctors treat patients with heart disease and will likely
result in re-evaluation of how low cholesterol levels should be even
for people without heart problems.




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March  5, 2004


Interesting use of a website relating to medical malpractice defense

This NY Times article discusses a doctor-owned Texas company that 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. The Times article attempts
to place a political spin on the service indicating that the website
provides information on cases regardless of the merit of the
underlying claim. However, plaintiffs' lawyers in medical malpractice
cases have used the Internet for years in coordinating cases and
expert witnesses, and there is nothing wrong with the defense teams in
such litigation attempting to use the Web for similar information
sharing.




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February 28, 2004


Guys, we tried, but we failed

Pfizer announced that it has given up on developing a drug that many
males were following closely.




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February 22, 2004


President Bush names fellow Texan to run Medicare and Medicaid

President Bush announced that Dr. Mark B. McClellan, the food and drug
commissioner, will be named to run Medicare and Medicaid, the health
insurance programs for more than 70 million Americans. Dr. McClellan,
40, is a graduate of The University of Texas at Austin, the brother of
the White House press secretary, Scott McClellan, and a son of the
Texas comptroller, Carole Keeton Strayhorn, who has been carrying on a
public spat with Governor Perry and has hinted that she might run
against Governor Perry in the 2006 Republican Primary. 





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February 19, 2004


UT-Houston Docs get back to correct research

The Chronicle reports that the FBI has investigated The University of
Texas Health Science Center at Houston and found no evidence that
employees regularly accessed child pornography websites. The
investigation was commenced after a UT-Houston auditor expressed
concern last fall that a number of employees, including physicians,
might have violated child predator laws when they visited porn sites
on UT Houston computers. An earlier post about this matter is here.




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February  3, 2004


Health Care Finance Concerns Continue

The New York Times carries a front page story today regarding the
increasing trend of employers to restrict health insurance coverage
for their retirees. In my view, the failure of the Bush Administration
to address the spiraling problems in the health care finance system in
the United States is an issue that will cause President Bush trouble
in the upcoming Presidential Campaign. 





Posted by Tom at  7:54 PM
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Wrong Type of Research, Docs

The Houston Chronicle reports today that the FBI has commenced an
investigation into teen porn websites that certain individuals at the
University of Texas Health Science Center at Houston apparently
visited on a regular basis. The UT Health Science Center is home to
the University of Texas Medical School, one of two medical schools
(Baylor Medical School is the other) in Houston's famed Texas Medical
Center.

The Kirkendall family has long and deep ties with the UT Health
Science Center. My late father--Dr. Walter M. Kirkendall--was a
longtime and loved Professor of Medicine at the UT Medical School at
Houston from 1972 until his death in 1991, and the school still holds
an annual lectureship in his name. I also have a brother (Matt of
Dubuque, Iowa) and sister (Mary of Boerne, TX) who graduated from the
UT Medical School at Houston.




Posted by Tom at  8:11 AM
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