Warning: file_get_contents(http://webbiscuits.net/images/blan.gif) [function.file-get-contents]: failed to open stream: HTTP request failed! HTTP/1.1 404 Not Found in /home/residenc/public_html/wp-content/themes/residencynotes/header.php on line 26

Archive for May, 2008

Thursday, May 29th 2008

Two Vioxx Verdicts Get Altered On Appeal

Two of the earliest Vioxx suits which went for the plaintiffs have been overturned or reduced. In Texas an appeals court overturned a twenty-six million dollar verdict. In New Jersey the court reduced the award for a plantiff who blamed his MI for a heart attack from fourteen million to nine million. Both were clients of Mark Lanier.

Mark Lanier, a plaintiffs’ lawyer who was involved in both cases decided Thursday, criticized the decisions and promised appeals. But plaintiffs face an uphill battle.

In the Texas case, three appeals court judges simply reversed the verdict of a jury that had spent six weeks hearing testimony from more than a dozen witnesses. Essentially, the appeals court threw out the views of the plaintiffs’ experts.

“The judges wrote a simple decision that defies medicine and the trial itself,” Mr. Lanier said. He said he would appeal the verdict “to the Supreme Court, if necessary.”

At this point, beyond the individuals seeking damages, these rulings have little impact. Merck has already reached a settlement. The appellate courts’ rulings do however continue the demonstration of the weakness of the plaintiff’s claims against Vioxx. As the NYT says,

The rulings on Thursday leave lawyers for plaintiffs with just three victories, all with relatively small verdicts, in the nearly 20 Vioxx cases that have reached juries.

Wednesday, May 28th 2008

Normalizing Obesity

“Weight bias”? Really? The political correctness is going to smother me.

Reported discrimination based on weight has increased 66% in the past decade, up from about 7% to 12% of U.S. adults, says one study, in the journal Obesity.

Lynn McAfee, director of medical advocacy at the non-profit Council on Size and Weight Discrimination in Mt. Marion, N.Y., is not surprised by the findings.

“Until we clean up language like ‘war on obesity’ and have authorities speak out about it, discrimination will continue to increase,” she says.

Despite comments to the contrary obesity is more than a choice in a vacuum; it is a burden on society and the populace as a whole. We need a war on obesity because I doubt even Ms. McAfee is comfortable with results like this.

True, we’ve grown into an “obesifying” world. I understand lifestyle options favor obesity. Indeed, much of that which is available for consumption in the modern society may actually be contributing to physiological changes in individuals which promote weight gain. But to ignore the play of individual choice in the growth of obesity in this country is foolish. My psychiatry team right now doesn’t excuse the responsibility of the heroin addict for picking up the needle; even though that is the only life he has known and the only escape readily available to him. I can’t imagine why we would excuse picking up that soda or that piece of pizza in the obese individual.

Doesn’t the choice behind it and the costs obesity burdens the rest of society with distinguish what is described in the study from ‘discrimination’? I am happy for those who are obese and comfortable with that (if disappointed they don’t take the health risks more seriously), but unless those same individuals are making efforts to minimize obesity’s extra burden on society then I am a little taken aback by their claims of ‘discrimination’.

To imagine we have come to a point of political correctness that rhetoric like “war on obesity” should be considered offensive to someone who chooses (through omission) to remain obese is alarming.

Wednesday, May 21st 2008

Google Health

I Don’t Know What This Has To Do With Google Health…Something Maybe…

The same company that brings you “real life” on the street with the street view service of Google Maps now wants to securely store your health care records. Google Health has launched and some big names have jumped on board including BIDMC, Cleveland Clinic, Wallgreens and Quest Labs.

A lot of questions about security. Still, I’d rather trust my records to Google than that entity further north.

Wednesday, May 21st 2008

DB Elected To The ACP Board of Regents

My favorite medical blogs were obviously one of my biggest motivations for starting my own. One of the first blogs I started reading after I had been admitted to medical school was DB’s Medical Rants. True, I’ve become increasingly critical of some of the arguments put forth by the primary care blogosphere concerning the ‘outpatient internal medicine’ crisis. But whether I agree with some of the arguments he makes or not Dr. Centor remains one of my favorite medical bloggers.

Well now he has been elected to the board of the American College of Physicians (see: ACP Board of Regents). This is a huge deal.


Tuesday, May 20th 2008

Ted Kennedy Has A High Grade Glioma

A Glioblastoma Multiforme

“Brain tumors” are pretty variable things.

True, it is never good to have something pathologically growing in your head, but if someone tells you they have a “brain tumor” that can mean many different things. Not all brain tumors are created equal and the outcome measures for various brain tumors can vary considerably. One of the cruel tricks of nature however is that the most prevalent types of adult brain tumors are the most aggressive ones.

Ted Kennedy had a seizure recently and has now been diagnosed with a ‘malignant’ (read: high grade) glioma following a biopsy. I should’ve featured that differential more prominently in my original post. Especially considering that in adults single seizure without other neurological deficits is apparently the most common presentation for these brain tumors.

The classification of gliomas is complex but we’ll keep it simple for this post. By the WHO classification, high grade means a tumor with a grade of 3 or 4 (on a 1 to 4 scale). The prognosis drops as the grade gets higher. Based on various characteristics, you can further classify these high grade gliomas. I’ll spare you the names. Let us just say that more than 75% of high grade gliomas are Grade 4 (aka glioblastoma multiforme).

Perhaps as no surprise advanced age typically means a worse prognosis and shorter life expectancy (versus the whole of HCG patients) with high grade gliomas. And that is on top of the fact that 5 year survival with grade 4 gliomas is probably less than 5% for all those suffering from them.

Senator Kennedy and his family have some tough decisions coming up which I cannot even imagine facing. I have no idea about his general health but consider his age and the fact that the treatment options can only marginally improve patient survival time and you can imagine it might actually be a challenge to risk the morbidity that comes with treatment versus merely taking only pallative care.

Many, many things will influence Senator Kennedy’s treatment course. Much more than we as the public know. Plus I’m just a medical student. In general however we can say that therapy, if undertaken, essentially always includes radiation therapy and often entails surgical debulking.

By definition high grade gliomas are impossible to cure by surgery as they are substantially, microscopically infiltrative to the white matter ‘under’ the outer layers of the brain. However gross debulking of certain high grade tumors does improve survival times, if just slightly. The risk however is for neurological deficit. You can imagine how poking and cutting around in someone’s brain could cause that.

Since most patients with brain tumors present as Senator Kennedy did (fully functional and with their ‘mind intact’ so to say) and since the gained survival is often relatively marginal, surgery can be a considerable risk. You do not want to cause a deficit that the tumor isn’t. In some cases the tumor is so close to “important” areas of the brain that the risk of neurologic morbidity is too high to even attempt significant radical resection.

There are other risks that come with brain surgery and many of them are increased due to the Senator’s advanced age.

Chemotherapy seems less likely, despite what Senator Specter threw out:

Sen. Arlen Specter (R-Pa.), who has struggled through Hodgkin’s disease, said he was optimistic.

“I know something about chemotherapy myself,” Specter said. “I’m in the middle of it right now for Hodgkin’s. But Sen. Kennedy is a real fighter, we all know that. And I’m betting on Sen. Kennedy.”

It is certainly a possibility and is used against high grade gliomas but it is less standard of care unless Senator Kennedy has one of a handful of specific, less common forms of tumor like a malignant oligodendroglioma with specific chromosomal mutations (1p deletion for instance). If Kennedy has, say a GBM, and gets the chemo it may just be a reflection of the “try anything”/keep fighting mentality that some seem to turn to when faced with these fatal diseases. The treatment efficacy is not likely to be very good.

I will keep praying for Senator Kennedy but if we judge the ‘success or failure’ of the rest of his life merely by its length I am afraid the odds are we will all be disappointed.

Sunday, May 18th 2008

All You Need To Know Of Human Anatomy

Seriously, This Would’ve Saved A Lot Of Time In Med School

Via Reddit

Sunday, May 18th 2008

Ted Kennedy Suffers A Seizure

Ted Kennedy Will No Doubt Entertain His Nurses

Ted Kennedy is 76 years old and apparently has suffered his first seizure. He’s at MGH recovering nicely from all reports. While we don’t know some of the specifics, new onset seizures at 76 don’t have a lot of differentials and this is somewhat odd. It may be that Kennedy didn’t suffer a ‘seizure’ in the traditional term at all. You’d want all the labs including the chem and CBC and TFTs and LFTs, a head scan, an EEG, an EKG.

In the differential (if it wasn’t caused by a metabolic disturbance) is a head bleed (i.e. an SAH), a tumor, an infection (i.e. meningitis), a viral encephalopathy. There are some others to consider yet new onset epilepsy (if this is actually his first seizure) is way, way down the list. I wouldn’t be surprised one bit, if this isn’t secondary to hypoglycemia or natremia or another metabolic disturbance, that the etiology of this seizure remains ‘idiopathic’.

In anycase, Godspeed to the Senator in his recovery.

Sunday, May 18th 2008

PBS Takes A Look At DTC

Bill Moyer takes a look at direct to consumer advertising and the video is on the PBS website.

Just an opportunity to reaffirm my opinion: restricting pharma advertising is wrong as long as what they’re saying about their drugs is factually correct (even if sometimes incomplete). Even if I didn’t believe that DTC served any purpose, it is not the government’s place to be making that kind’ve determination. Physicians must do more to say “no” to patients who see an ad and become convinced they need the drug being marketed. It isn’t the drug companies’ responsibility to tame their advertising just because some of the public are easily ‘swayed’ and (mis)diagnosis themselves. And the reimbursement system must change a bit to give physicians more time with patients…in part to explain the growing complexities of prescription medications.

Wednesday, May 14th 2008

Sorry Milton, Two Wrongs Make A Right

Come Down To My Basement…I’ve Got Candy Down There…

Organized medicine is certainly facing a little bit of a faith crisis. From those they’re supposed to represent come cries that the AMA, specialty and state societies do not do enough for [put individual specialty here]. From the interested public and other interest groups comes cries that the AMA, specialty and state societies move to benefit the physician over the patient.

Throw amongst those pragmatic concerns the intellectual and long held criticism that organized medicine suppresses the supply of physicians and the scope of non-physician practice and is thus inherently anti-free market.

I’ve ignored this topic for long enough considering my considerable involvement in leadership roles within organized medicine and my libertarian leanings.

The clamoring from far right wing free market speakers like the late Noble Laureate above (who I respect considerably, despite the little joke above) and crazy think tanks like the Ludwig von Mises Institute is that the AMA is essentially a guild whose will the government has succumbed to. In a publication titled “100 Years of Medical Robbery” the think tank has this to say about the history of the American Medical Association and its goals:

In the days of its founding AMA was much more open–at its conferences and in its publications–about its real goal: building a government-enforced monopoly for the purpose of dramatically increasing physician incomes. It eventually succeeded, becoming the most formidable labor union on the face of the earth.

To accomplish the twin goals of artificially elevated incomes and worship by patients, AMA formulated a two-pronged strategy for the labor market for physicians. First, use the coercive power of the state to limit the practices of physician competitors such as homeopaths, pharmacists, midwives, nurses, and later, chiropractors. Second, significantly restrict entrance to the profession by restricting the number of approved medical schools in operation and thus the number of students admitted to those approved schools yearly.

The emphasis is my own.

I’ll offer a candid response to this. Through it’s history the AMA appears to have focused largely on improving physician income. Perhaps not as single minded or nefariously as the Ludwig von Mises Institute would have you believe but it remains. And the AMA has had considerable success doing such. The allowance of self governance that medicine enjoys and the sway it holds over the scope of practice for other providers is incredible. I think there are some real issues of ‘patient safety’ buried in these efforts. Even so it is clear that the AMA has a vested interest in restricting what nurse practitioners or chiropractors or optometrists are allowed to do under the law thus maintaining the physician monopoly over some income streams.

Organized medicine was responsible for the Flexner Report and continues to hold the greatest sway over the number of physicians this country will (or will not) have by controlling the LCME and ACGME. To argue some conspiracy to suppress the number of medical students (and thus number of future physicians) through these entities is baseless. But the fact such control exists shows organized medicine’s influence. Combine such with the AMA’s success in limiting the practice of other health care providers and you can see why it draws the ire of some libertarians.

As another Ludwig von Mises paper, “Bring Back The Guild System?” says,

Government regulations on the chiropractic profession, lay midwifery, and on the freedom of nurse practitioners to offer services within their competence, all of which make perfect sense from the point of view of the medical guild that lobbied for them, make no sense at all from the point of view of consumer wishes (as repeatedly expressed in polling data) or from economic considerations. In many cases, such people can provide health services far more cheaply than can licensed physicians (or, in the case of chiropractors, can provide services that licensed physicians do not provide at all), but consumers are prevented from making their own decisions regarding their medical care. Given the logic of the guild structure, no one has the right to be surprised to find that the AMA has put so much effort into undermining its professional opposition.

There is nothing wholly unique about physicians’ efforts towards this. Other professions do the same and also limit their membership through limiting education spots (see: lawyers). It is just that medicine has been so successful at it.

I will accept the blows Milton Friedman lands against the American Medical Association but let me make an argument on why organized medicine’s actions are reasonable despite violating the libertarian ideal.

Let us call what the AMA and the rest of organized medicine does a necessary evil. It might not have been through all of its existence granted but today it is. It is because physicians are not playing on a level, free market playing field.

Read More »

Wednesday, May 14th 2008

GodTube Makes My Head Explode

I am a Christian. Jesus Christ is my personal savior. I can reconcile my faith with a host of scientific facts including evolution. But as we’ve seen, there are plenty of believers who apparently cannot.

It is distressing because it is difficult to view such individuals as anything but morons. The following is a video posted to GodTube, which is currently being (rightly) mocked on Reddit. You can use the terminology of evolution correctly all you want and create reasonably good looking CG models but it doesn’t make your points any more valid.

How Depressingly Off Base Can One Video Get?

The truth on radiometric dating is that it has been vouched for again and again. Virtually all dating strategies give relatively similar results. And the dismissal of macroevolution is similarly, fearfully inadequate.

Watch For Lightning When Making This Type of Mockery

Some people will tell you 2+2 = 5 and no amount of effort will convince them that their little closed definition is wrong. ‘Creationists’ have no place arguing the science of evolution. They’ve created their own rules, their own definitions which make debate or discussion impossible.

In the end you just gotta let some of them be. Sometimes it ain’t even worth taking a horse to water if you know it won’t drink.