Cynicism

I post this link primarily to create controversy! Health Check: ‘During the doctors’ strike in the 1970s, death rates fell’

Deaths from heart disease have fallen by more than a third in the last decade, which is a matter for celebration, as a paper on the extensive Grace study, involving 31,000 patients in 14 countries, pointed out last week. But nobody knows quite why. No single factor can account for the size and speed of the fall.

Improved treatment has certainly helped. One finding in the Grace study is that though we are not bad at treating people who have had heart attacks (to prevent a recurrence) we are much less good at treating those about to have one, which looks very like shutting the stable door after the horse has bolted.

But the real puzzle is that we do not know what caused the heart disease epidemic, which began in the 1940s and peaked about 1970. Its subsequent fall is equally mysterious. There has been a sharp decline in smoking and limited dietary changes, which account for some of the fall. History will tell how much medicine has contributed, but it is unlikely to be a great deal.

Treatments come at a price. That is spelt out in a sobering report, also published last week, by the American Institute for Cancer Research, an independentbody that advises the US public on medical issues. It notes that the giant advances in treating childhood cancer, with cure rates now at 78 per cent, are not an unsullied success.

Two thirds of children suffer later complications, often as a result of the radiotherapy or toxic drugs they are given to deal with the cancer, and in a quarter of cases they are severe or life-threatening. The international survivors network for childhood cancer sufferers is about to establish a branch in Britain.

In medicine, the greater the advance, the more it becomes clear how far there is still to go.

The risk of renal dysfunction

Most generalists do not pay enough attention to renal function. Most cardiologists do not pay enough attention to renal function. We should consider renal function as an important risk factor in cardiovascular disease. Mild Renal Dysfunction an Emerging Risk Factor in Cardiovascular Disease

Using the Global Registry of Acute Coronary Events (GRACE), his team assessed the prognostic importance of admission serum creatinine values (and hence estimated creatinine clearance) on outcome in nearly 12,000 patients hospitalized with ST- and non-ST-segment elevation acute MI and unstable angina.

“Confirming our hypothesis, we found a direct relationship between creatinine clearance values estimated by using the Cockcroft-Gault formula and in-hospital adverse outcomes,” Dr. Santopinto said.

For patients with moderate renal failure (creatinine clearance 30-60 mL/min), the risk of in-hospital death was twofold greater (adjusted relative risk 2.01) than for patients with normal or minimally impaired renal failure (creatinine clearance > 60 mL/min). Patients with severe renal failure (creatinine clearance <30 mL/min) were nearly four times more likely to die in the hospital (odds ratio 3.71).

“A 10 mL/min decrease in creatinine clearance had the same adverse impact on hospital death rates as a 10 year increase in age,” the researchers note.

The risk of major bleeding episodes increased as renal function worsened and there was also a trend towards a higher rate of in-hospital stroke in patients with impaired renal function.

It is noteworthy, Dr. Santopinto told Reuters Health, that before hospital admission, patients with renal dysfunction were, for the most part, properly medicated with antiplatelet drugs, statins, ACE inhibitors, and beta-blockers.

But “surprisingly during hospitalization and at hospital discharge (and paradoxically because it was a high-risk group), they were less likely to be medicated with drugs of proven efficacy,” Dr. Santopinto said.

They were also less likely to undergo diagnostic and therapeutic interventions like coronary angiography, percutaneous coronary procedures or coronary revascularization. “We think that this could be one of the major determinants for their worse outcome,” the researcher said.

This issue requires more study and more attention.

A Kentucky paper editorializes on the oxycontin problem

Oxycontin (aka, redneck heroin) is a major problem in certain states. This editorial addresses the problem directly. Shifting the blame

Imagine the reaction if this corporate announcement were ever made:

“Wonder Drugs Inc. has decided to restrict distribution of its new and highly effective painkiller in rural Kentucky. Unlike the rest of America, Kentucky remains too backward to handle a powerful narcotic like ours.

“The state’s rural doctors, pharmacists and law enforcement agencies are not up to meeting their professional responsibilities or providing the public protections our medication requires and receives elsewhere. Thus, our only choice is to protect Kentuckians from themselves by restricting access to the proven pain relief that other Americans enjoy, and we urge all other manufacturers of pain medications susceptible to abuse to do the same.

“Wonder Drugs will henceforth withhold from rural Kentucky our normal marketing, informational and distribution efforts. Corporate policy will be to treat the family physicians and community druggists of rural Kentucky not as the competent professionals the state’s licensure boards claim they are, but as the clueless pill pushers the state’s record of prescription drug abuse shows them to be.”

Kentuckians would rightly be outraged. But this is the logical conclusion of the continuing effort to shift the blame for Kentucky’s illicit trade in and deadly abuse of OxyContin onto the marketing practices of the narcotics’ manufacturer, Purdue Pharma Inc.

Otherwise serious people continue to ignore Kentucky’s long history of widespread abuse of prescription medications and to portray the OxyContin disaster as a sinister corporate plot.

Strong words! This editorial makes it clear that Kentuckians should accept the blame for their drug abuse and not shift the blame to the pharmaceutical industry.

The state’s Prescription Drug Abuse Task Force is on the verge of recommending that an electronic prescription monitoring system already in place should be used to initiate investigations of possible abuse and that the reporting of drug sales by pharmacies should be speeded up.

That the state has been collecting this information for years, but doing so little proactive with it is the real negligence Kentuckians should be focused on.

In a state where sheriffs are being killed over drug corruption and doctors were able to operate a regionally famous pill outlet, Purdue Pharma’s sales tactics rank low on the list of public outrages.

Several observations are needed. First, thanks to the reader who sent me this link. The article does provoke much thought about prescription drug abuse.

Second, oxycontin is a very good pain reliever. It has an important role in palliative care. Efforts to totally restrict this drug make no sense.

Physicians who dispense large amounts of such painkillers should quickly lose their licenses and DEA numbers. Computers can identify these abusers.

Finally, I am sure glad to read about this as a Kentucky problem and not an Alabama problem.