There are strong psychosocial components to pain syndromes. That isn’t a disparaging statement or a claim that pain is anything but real and each individual patient’s unique experience. But I feel that sometimes recognizing that major psychological component of pain and putting it into the decision algorithm for or against surgery is taboo.
Strong independent associations were seen between depression burden (the sum of preoperative, 3-month and 6-month BDI scores) and 2-year disability, symptom severity, and poor walking capacity.
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Depressive symptoms interfere strongly with the ability of patients to obtain an optimal surgery outcome. Treatment models including the assessment and treatment of depression are encouraged.
This is a tough decision, you’re playing with the chicken and the egg here seeing as it is often a difficult assessment how much a patient’s pain syndrome is contributing to their mental health issues. But the fact is back surgery is major surgery with many, many serious risks and you should want the risk/benefit from the surgery to strongly favor the latter.
Greek hospitals have large debts to many drug companies, according to the Hellenic Association of Pharmaceutical Companies, or SFEE. As of June 30 this year, Greek’s state-financed hospitals had paid for just 37% of the €1.9 billion ($2.62 billion) worth of drugs delivered by SFEE member companies in the 18 months to June, 2011, the organization said in a recent report.
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Early this year, Greece tried to clear some of its pharmaceutical debts by giving companies government bonds. “We didn’t have a choice. Everybody got government bonds. The question was, you got nothing or you got government bonds,” Mr. Schwan said, adding that Roche sold the bonds immediately.
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Patients at some hospitals now must take their prescriptions to a local pharmacy, and, in the case of intravenous or injected cancer drugs, bring them back to the hospital to be administered, he said.
Mr. Schwan said patients haven’t been deprived of their medication as a result of the new measures, which he said Roche may need to adopt in Spain, as well. Some state-funded hospitals in Portugal and Italy have also fallen far behind on payments, he said.
There are hospitals “who haven’t paid their bills in three or four years,” Mr. Schwan said. “There comes a point where the business is not sustainable anymore.”
I can’t say, the little I know, I blame the big pharmacutrical companies. I know their margins worldwide, but why, as a for profit enterprise, would you continue these hand outs? For instance Novo Nordisk recieved significant criticism last year when it pulled the FlexPen from the Greek market over a unilateral move by the Greek government to start paying less for medicines. As the Eurozone crisis widens however I’m not sure how far we should expect healthcare corporate compassion and loss to extend.
Groups of people with unique environmental exposures create a place for politics and science to clash. Perhaps the most famous modern example is the long slow march towards government recognition of health problems associated with Agent Orange exposure during the war in Vietnam or, more recently, the debate over environmental factors in Autism.
The unique environmental public health issue for mine and just older generations however may be the exposures of September 11th first responders and clean up crews. Outrage over the lack of government response, foresight and funding for presumed health issues associated with exposure at Ground Zero seems to be a popular news focus, especially as we honor the tenth anniversary of that terrible day.
Over the past decade, most of the millions of dollars spent on helping treat sick Ground Zero workers has been focused on respiratory problems and mental health issues such as post-traumatic stress disorder.
Cancer treatment has been specifically excluded from federal health funding, with officials arguing there has been insufficient evidence to prove any direct link between the toxins present at the site and the disease.
But last week the results of the first large-scale study, published in the Lancet, found that firefighters who were involved on the day of the attacks and in the weeks that followed had a 19% higher risk of contracting cancer.
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“People all around us are getting sick and some are tragically dying. For those who are sick with cancer it’s infuriating to see the foot-dragging in making the link between Ground Zero and the disease.”
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Patrick Lynch, who heads a New York police officers’ union, said: “On September 11, we rescued you. Now it’s your turn to rescue us – New York city police officers who are sick and dying.”
Compared with the general male population in the USA with a similar demographic mix, the standardised incidence ratios (SIRs) of the cancer incidence in WTC-exposed firefighters was 1·10 (95% CI 0·98—1·25). When compared with non-exposed firefighters, the SIR of cancer incidence in WTC-exposed firefighters was 1·19 (95% CI 0·96—1·47) corrected for possible surveillance bias and 1·32 (1·07—1·62) without correction for surveillance bias. Secondary analyses showed similar effect sizes.
Impressive in the abstract and worthy of outrage from first responders, friends and family who anecdotally are struggling with cancer diagnoses. However, the story isn’t so clear on further inspection. Indeed the data from the abstract above are firefighters who served at Ground Zero as compared to other New York City firefighters who did not serve at Ground Zero. When the firefighters who served at Ground Zero are compared to a random cohort of American males however the SIR is just 1.02. A 2% increase in cancer findings and, more importantly, not statistically significant.
One of the problems, as the great blog The Incidental Economist points out, is that the cancer incidence amongst the control group of New York City firefighters who did not serve at Ground Zero was much lower than expected for men (and women) their age. That makes the SIR larger and statistically significant. However, perhaps a better comparison is against an average cohort of American males and in such a case there is no increase in cancer incidence.
All-cause SMRs were significantly lower than that expected for rescue and recovery participants (SMR 0·45, 95% CI 0·38—0·53) and non-rescue and non-recovery participants (0·61, 0·56—0·66). No significantly increased SMRs for diseases of the respiratory system or heart, or for haematological malignancies were found…In rescue and recovery participants, level of WTC-related exposure was not significantly associated with all-cause mortality (adjusted hazard ratio 1·25, 95% CI 0·56—2·78, for high exposure and 1·03, 0·52—2·06, for intermediate exposure when compared with low exposure).
Rescue and recovery workers who served at Ground Zero have had lower all cause mortality over the past 10 years as compared to a random cohort of Americans.
I’m not saying that there aren’t real and terrible diseases associated or potentially associated with exposures at the World Trade Center site. Because there are.
9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), and gastro-oesophageal reflux disease 39·3% (5650).
Those are incredible incidences as compared to expected. Those responders served incredibly that day and in the months that followed and deserve our attention and focus. But, at a minimum, we need further studies looking at specific cancer incidences for those serving at Ground Zero, before we race to condemn the lack of support they’re received for diseases dubiously linked to their incredible service
Understandably patients and families and friends of patients can become strong advocates for the disease community of those who suffer from a condition.
In unique circumstances that advocacy stretches into the science behind the condition. Consider Jenny McCarthy’s promotion of the discredited tie between vaccines and autism. Indeed advocacy and researchers seem to cross paths and sometimes butt heads the most when we’re dealing with disease for which the pathophysiology is poorly understood. Along with autism other examples might include fibromyalgia or chronic fatigue syndrome. Some though carry their well ingrained beliefs into the interaction, attempting to intimidate research into directions in line with those beliefs. Consider this story from The Guardian on threats made against chronic fatigue syndrome researchers,
Chronic fatigue syndrome – also known as myalgic encephalomyelitis (ME) – is common and debilitating. A recent BMJ (formerly the British Medical Journal) feature suggested that as many as one in 250 people in the UK suffers from it. Patients are sometimes unable to move and become bedridden, occasionally having to be fed through a tube. For more than 20 years, scientists have struggled to find the cause, with some pointing to physiological reasons, in particular viral infections, while others have argued that psychological problems are involved.
It is the latter group that has become the subject of extremists’ attacks. The antagonists hate any suggestion of a psychological component and insist it is due to external causes, in particular viruses. In the case of [Professor Myra] McClure, her “crime” was to publish a paper indicating that early studies linking the syndrome to the virus XMRV were wrong and the result of laboratory contamination. So furious was the reaction that she had to withdraw from a US collaboration because she was warned she might be shot.
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“The tragedy is that this tiny group of activists are driving young scientists from working in the field,” said Sharpe. “In the end, these campaigns are only going to harm patients.”
Unfortunately anecdotal experiences with poorly understood diseases, no matter how life altering or personal, give poor insight into etiologies and such. Ignoring the science, or worse trying to alter the science with intimidation, is reproachable and indeed in the examples listed in The Guardian article downright disgusting.
The Food and Drug Administration says that some 180 medically important drugs have been in short supply, many of which are older, cheaper generic drugs administered by injection that have to be kept sterile from contamination.
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Although there is limited data on how many patients have been harmed, a survey of 1,800 health care practitioners last year by the Institute for Safe Medication Practices found that a third of the physicians and a fifth of the pharmacists knew of adverse patient outcomes because of shortages, including some deaths from microbes resistant to the backup drugs. Cancer patients receiving less effective drugs may well face increased risks in the future.
Nobody is sure just what is causing the shortages because drug manufacturers are not required to report any reasons to the F.D.A. But several factors are likely to be involved…[including] reluctance to invest in production-line improvement for low-profit generics when high-priced brand-name drugs bring in far higher profits. Sweeping consolidation in the generic drug industry means that fewer companies are left in that market to make up for a shortage.
Certainly my primary training facilities have experienced impressive shortages, everything from steroids to sedatives to paralytics to electrolyte replacement solutions and likely a host of others I’m not privy to. And at least partly the focus is on the profit margins afforded some of these drugs as compared to others. It certainly seems, by anecdote, that the vast majority of the shortages involve relatively cheap generic pharmaceuticals. Which makes the pharmaceutical companies current villains in some eyes as they focus on drug development, and more importantly production, for biotech and other “profit” drugs.
The industry is pouring money into clinical trials for cancer drugs (see chart).
This is part of a shift in how big drug firms do business. For years they have relied on blockbusters that treat many people. Now they are investing in more personalised medicine: biotech drugs that treat small groups of patients more effectively.
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The snag, from society’s point of view, is that all these drugs are horribly expensive. Last year biotech drugs accounted for 70% of the increase in pharmaceutical costs in America, according to Medco, a drug-plan manager. This trend will continue as drug firms develop new ways to treat, for example, multiple sclerosis and rheumatoid arthritis.
Indeed, spending on pharmaceuticals in total, and as a percentage of all therapies actually, continues to rise well past inflation even as we struggle currently to supply effective, very necessary generic drugs in enough quantity. That wouldn’t be so remarkable if we were making remarkable advancements in treating patients but that doesn’t appear to be borne out on large scale. What it takes to get a drug to market and then push physicians to use it is remarkably skimpy on evidence. PLoS Medicine’s most downloaded paper ever is titled, “Why Most Published Research Findings Are False.” In profiling the author of that paper The Atlantic points out something I agree with,
Doctors may notice that their patients don’t seem to fare as well with certain treatments as the literature would lead them to expect, but the field is appropriately conditioned to subjugate such anecdotal evidence to study findings. Yet much, perhaps even most, of what doctors do has never been formally put to the test in credible studies, given that the need to do so became obvious to the field only in the 1990s, leaving it playing catch-up with a century or more of non-evidence-based medicine, and contributing to Ioannidis’s shockingly high estimate of the degree to which medical knowledge is flawed. That we’re not routinely made seriously ill by this shortfall, he argues, is due largely to the fact that most medical interventions and advice don’t address life-and-death situations, but rather aim to leave us marginally healthier or less unhealthy, so we usually neither gain nor risk all that much.
[O]f all the 197 new drugs approved in the past decade, only 70% had data to show they were better than other treatments (and that’s after you ignore drugs for conditions where there was no current treatment).
But the problems go beyond just using the wrong comparator: most of the trials we rely on to make real-world decisions also study drugs on highly unrepresentative, freakishly ideal patients. These patients are younger, with perfect single diagnoses, fewer other health problems, and so on.
This can stretch to absurd extremes. Earlier this year, some researchers from Finland took every patient who’d ever had a hip fracture and worked out if they would have been eligible for the trials that have been done on fracture-preventing bisphosphonate drugs, which are in wide use.
Starting with all 7,411 fractures, 2,134 patients get excluded straight off, because they’re men, and the trials have been done on women. Then, from the 5,277 remaining, 3,596 get excluded again, because they’re the wrong age: patients in trials had to be between 65 and 79. Then, finally, 609 more fracture patients get excluded, because they’ve not got osteoporosis.
This leaves 1,072 patients. So the data from the trials on these fracture-preventing drugs are only strictly applicable to about one of every seven patients with a fracture: they might still work in those who’ve been excluded, though that’s not a judgment call you should have to make; and one problem, in particular, is that the size of the benefit might be different in different people.
Dr Leemon McHenry, a medical ethicist at California State University, says nothing has changed. “They’ve just found more clever ways of concealing their activities. There’s a whole army of hidden scribes. It’s an epistemological morass where you can’t trust anything.”
Alastair Matheson is a British medical writer who has worked extensively for medical communication agencies.
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“The whole thing is a big lie. They are promoting a product.”
Matheson expects an article he wrote about a new cancer treatment to appear in print later this year, with an oncologist considered a “key opinion leader” (KOL) by planners listed as the author in his stead. “You’d do the same thing if you were selling cornflakes,” Matheson told me. “It’s no different.”
In reviewing a book for the New York Review of Books the former editor-in-chief of the highly respected medical journal The Lancet had this to say about the current state of medical publishing,
[J]ournals have devolved into information laundering operations for the pharmaceutical industry.
When the pharmaceutical companies can’t supply the drugs in part because they’re peddling much higher margin drugs on flimsy evidence, packaged as solid, then perhaps such criticism is fair enough.
Now excuse my ignorance on the subject but it appears the major offenders in this piece had experiences that pre-dated their availability in the United States without incidence. What I mean is that it appears the high rate of complications and failures is limited to the United States as compared to, say, Europe. That may reflect some clinical difference such as surgeon training or patient selection or something along those lines.
But I wonder how much the litigious culture of the United States works to either:
One, bring these issues truly to light so that perhaps the complications with these hips happen just as frequently elsewhere but it goes under reported without the culture of broad civil court
or
Two, how much these problems are made hyperbolic by the same culture.
There are literally dozens of these videos on YouTube. Is there something comparable in say, Germany?
I remember back in 2004 when a Wisconsin girl became one of the singular, confirmed and well documented cases of an individual surviving rabies without the vaccine.
Tests in early May revealed she had the disease after Precious’s grandmother took her to the doctor because of flu-like symptoms that grew so serious her grandmother said they began to resemble polio.
The hospital said doctors followed the protocol first established [in Wisconsin]. Precious was placed in a drug-induced coma as she received anti-viral medications.
She spent two weeks in intensive care undergoing the treatments, and immediately showed that her immune system was strong. She was then moved to the hospital’s general pediatric unit, where she remained Sunday.
Although rabies claim only approximately a dozen people in the United States a year it is a terrifying disease. Failing the vaccine, even best care, the “Wisonsin protocol,” bodes for a poor prognosis. Anyone with open skin exposure to feral or suspicious mammals, including bites or scratches, should certainly seek immediate care.
The 2004 reported survival with coma is found in NEJM.
I recently talked about what changes came into effect on the New Year under the Affordable Care Act. One of the tangential things I didn’t comment on was an executive Medicare regulation running parallel to congressional efforts which came into effect January 1st and promised to pay providers for any time spent discussing end of life issues with patients.
The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.
Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves.
Section 1233 of the bill passed by the House in November 2009 – but not included in the final legislation – allowed Medicare to pay for consultations about advance care planning every five years. In contrast, the new rule allows annual discussions as part of the wellness visit.
The proposal for Medicare coverage of advance care planning was omitted from the final health care bill because of the uproar over unsubstantiated claims that it would encourage euthanasia.
The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.
Critics decried the new rule as taking control away from patients and devaluing life and setting up death panels.
There is…something at least vaguely disturbing about a government incentivizing doctors to [discuss end of life issues] as part of an expansive regulatory program that has, as one of its primary goals, cost reduction.
At least the linked to criticism at Hot Air,
There is nothing wrong with patients planning for contingencies through advance directives. There is also nothing wrong with doctors discussing those options with patients ahead of those decisions. As the spouse of a patient who has faced life-threatening circumstances on more than one occasion, I certainly understand why these conversations need to take place before the pressures of acute circumstances come into play. This new regulatory effort at least puts the conversation where it belongs, in routine wellness visits, rather than as a five-year set conversation. It also appears to make this a voluntary conversation (at least for now), one the patient can decline without any repercussions.
I couldn’t agree more but I would argue that there should be reimbursement for it at anytime, anywhere.
Lacking a pallative care team there may be no one outside my team, the neurosurgery service, who sees as much end of life issues. Neurotrauma, aneurysmal bleeds, primary central nervous system cancer, bad things. And the choices family have to make in the heat of the moment are gut wrenching and painful and full of angst.
Patients and their physicians need to have conversations with families present concerning end of life issues well before anything happens. The young and the old need to have the conversation. In some ER with a loved one with a massive subdural on Coumadin, with me, is not the place to have the conversation for the first time.
The best way to promote people discussing end of life issues with their physicians is to pay physicians for such discussions. Too bad the political establishment on the right has a problem with that.
I have a strong desire to give a significant amount of my time post training. And maybe the sad thing is the more specialized you are the less you have to offer out in the developing world. Maybe I picked the wrong specialty.
That said, there are wonderful examples of specialist surgeons doing international humanitarian work.
My mother is part of a group that does congenital heart defect work at a number of locations around the world. It’s incredible to have her as an example. For her life in general, but for her dedication in this regard in particular. Below is an incredible video of some of the work the group she is a part of does:
The intersection of social media and privacy has made an older generation, and even some of my own generation, incredibly uncomfortable. There is talk of present and future consequences. Lost jobs, lost income, civil judgments, loss of respect/embarrassment, even criminal penalties for all that you put online. There is an idea that the blurring of intimate boundaries will come back and bite a whole generation.
Being online has responsibilities and consequences, no doubt. But Facebook isn’t going to cost most people a future job or a future election. The social rules are, as we speak, changing in terms of how we judge people for their private lives that they make public. The whole world is using social media and putting themselves out there. Tough to judge someone for your same acts.
Because those involved in health care and social media have the often near unique oppurutinities to not only dismiss their own privacy online but to do so for others. Horrific stories are rife. Take this one for example,
William Wells arrived at the emergency room at St. Mary Medical Center in Long Beach on April 9 mortally wounded. The 60-year-old had been stabbed more than a dozen times by a fellow nursing home resident, his throat slashed so savagely he was almost decapitated.
Instead of focusing on treating him, an employee said, St. Mary nurses and other hospital staff did the unthinkable: They snapped photos of the dying man and posted them on Facebook.
It is unfortunate if such scares providers and health systems away from social media like blogs, Facebook and Twitter.
As Ed Bennett comments,
“We already have guidelines; social media is simply another form of communication. It’s no different from e-mail or talking to someone in an elevator,” Bennett said. “The safe advice is to assume anything you put out on a social media site has the potential to be public.”
It’s a form of communication with the potential, as all others, to be abused. But more importantly, it has great potential to further provider-patient discourse and aid in health.
No patient privacy protections will ever be perfect. No patient-provider communication rules will ever absolutely guarantee professionalism and accurate information at all times. But guidelines and rules can limit such problems while furthering patient’s access. That holds no matter the medium.
The proliferation of easy mass communication tools should be embraced by health care, not cowered from. As always there are appropriate and inappropriate uses which health care providers should be counseled on and which should carry rewards and penalties. But just because social media is new shouldn’t make it scary.
