Read Jane Galt on Dean’s health care proposals

Like Jane Galt, I am working through my thoughts on the Democratic health care proposals. In the meantime, read these two posts from her site – HillaryCare, Part II. In this post, she challenges readers

But here’s the thing: I’m unaware of any situation in which sick children go without seeing a doctor simply because their parents can’t afford it. Poor people have Medicare. Less poor, uninsured people have free clinics, out-of-pocket payments, or the emergency room. The only situation in which I can see this occurring — that a child goes without a doctor simply for lack of health insurance, rather than because of other parental dysfunction — is one in which a lower-middle-class family cares more about their credit rating than their child. In other words, it seems vanishingly unlikely.

But perhaps I’m wrong. Can anyone produce evidence — not anecdotal, “my cousin says. . . “, but real data consisting either of peer-reviewed studies not funded by single-payer advocates, or of personal experience in which you, or a member of your immediate family, did not take a sick child in need of medical attention to the doctor because of the expense? Children with the flu, or other non-fatal maladies for which the only treatment is rest and liquids, do not count. Perhaps in some theoretical medical textbook world, they should see a doctor to ensure that it’s nothing serious — but my mother didn’t take us to the doctor for those things, and we had perfectly good health insurance. The pain-in-the-ass factor is too difficult to separate from the expense factor in mild illnesses, so please — only serious cases.

So Jane instead gets an email example which proves her point. Wow. I just got this amazing response to my post on Dean’s health care rhetoric: The response is heartwrenching and finishes with this quote

I don’t know if anything I’ve written above might be of use to you in your coming “pungent words”. I have to admit, writing this was at least 20% therapy for me (I’ve wanted to say these things for some time now – your post just opened the door). But I have a very compelling reason for opposing anything resembling HillaryCare.

I’ve been through the worst case scenario most HillaryCare advocates like to use as a rhetorical bludgeoning tool – and it convinced me just how wrong they are.

Possible SARS drugs

Research on SARS continues to move at a rapid pace. This article suggests a possible treatment based on the biology of the virus – SARS drugs may already exist

German scientists announced Tuesday that they have isolated a key protein that the SARS virus needs to attack the body, and that drugs designed to inhibit the protein may already exist. Meanwhile, China eased some SARS quarantine orders in the hard-hit capital of Beijing, and Greece and Nigeria said they may have their first cases of the virus.

IN A STUDY appearing this week in the journal Science, the researchers say their study suggests an experimental common cold drug called AG7088 may be able to keep the SARS virus from replicating.

AG7088 was developed by Pfizer Inc. and is currently in clinical trials for the treatment of rhinovirus, a pathogen that can cause the common cold.

…

The protein in the SARS virus, called protease, snips up parts of the cells the virus attacks. Protease inhibitors are the most effective drugs used against the AIDS virus and may work in the same way against SARS.

As scientists learn more about the virus, they are more likely to find specific targetted treatments. The investments in HIV and hepatitis C research over the past 2 decades have given us great insights into viral workings. Hopefully, scientists will build on that knowledge to more quickly find specific treatments for SARS.

Exercise boosts mood

I think we know this. Somehow exercising improves our mood – Scientists have a good feeling about exercise

Physical activity is known to exert a powerful “feel-good” effect, brightening mood and enhancing mental health ? in fact, regular exercise may be as effective as medication for some people with depression.

A growing body of evidence supports this boost to psychological well-being, but the exact mechanisms are not completely understood.

“We know exercise makes people feel better, but we’re not exactly sure how,” says Patricia Dubbert, associate chief of mental health at the VA Medical Center in Jackson, Miss. Dubbert is one of a growing number of mental health professionals who are prescribing exercise as a way to relieve stress and lift spirits.

This makes sense to me. I work out 2 mornings a week, and get to work in a great mood!

COMET results previewed

Today’s theheart.org features an article on the COMET (Carvedilol or Metoprolol European Trial) study – “COMET: Carvedilol improves survival more than metoprolol in CHF“.

Results of the Carvedilol or Metoprolol European Trial (COMET)the first-ever head-to-head mortality study comparing two beta-blockers in patients with chronic heart failurehave shown a significant improvement in survival for carvedilol when compared with metoprolol.

COMET was designed to investigate whether differences in pharmacology between the two drugs would translate into differences in outcome in heart failure patients.

“COMET is the longest and largest study ever conducted in chronic heart failure, with more than 10 000 patient-years of follow-up,” commented Prof Philip Poole-Wilson (Imperial College, London, UK), chair of the COMET steering committee. “The significant survival benefits of carvedilol demonstrate a clear difference between the agents,” he added.

This report is apparently preliminary and does not include the percentages. I will follow this important story, as choosing the correct beta blocker for CHF has important patient implications, as well as cost implications (metoprolol is generic, carvedilol is only available as the trade drug Coreg).

This story is important, and I will revisit it with the data as they are released.

Women and knee injuries

Men and women have different athletic abilities and different injury susceptibilities. Muscle Groups: Women and the Susceptible Knee

Women who play sports like basketball that involve extensive jumping and pivoting are known to be much more susceptible to knee ligament injuries than men. A new report suggests some reasons and what women can do about the problem.

Writing in The Journal of Bone and Joint Surgery this month, researchers from the University of Michigan said men appeared better able to contract the muscles that support the knee and protect its ligaments.

Women involved in some sports are up to eight times as likely as men to rupture the ligament toward the front of the knee, the anterior cruciate ligament, the study said. But they should not feel discouraged from participating in the sports, the researchers said.

The researchers have nicely identified the problem. We always hope that identifying a problem allows us to design a positive intervention.

To test whether women are as able as men to stiffen the knee intentionally, the researchers used machines that assessed the knees of 12 men and 12 women, all college athletes, to see how they reacted to stress. The results showed significant differences in muscle responses.

Dr. Wojtys said women involved in sports like basketball should pay extra attention to strengthening the muscle groups that protect the knee ligaments, including the quadriceps, hamstrings and calves.

Sports medicine experts, he added, are close to devising training programs to reduce the injuries.

“For years,” he said, “we’ve been training female athletes just like men. Women have their own needs.”

These data could help many women athletes in the future.

Great summary on cervical cancer screening

Many readers know that I am a big fan of Jane Brody. Her weekly column often has a wonderful summary of a complex issue. This week is no exception – Pap Test: Champion Against Cervical Cancer

Cervical cancer has been perhaps the biggest success story in the long-running war against cancer.

Once the leading cause of cancer deaths in women, cervical cancer will this year account for 4,100 deaths, not even 1 percent of cancer deaths among American women. Credit for the progress goes almost entirely to the Pap smear, a test now administered to 50 million Americans a year.

Despite the excellent results we have achieved with routine Pap smears, we now can probably achieve even better results. The improvements take advantage of our growing knowledge of the cause of cervical cancer.

For many years before the discovery that viruses could play a major role in causing human cancers, it was obvious that cervical cancer was a sexually transmitted disease, little different in its pattern of transmission from syphilis and gonorrhea. The earlier a woman became sexually active and the more sexual partners she or her partner had, the more likely she was to develop this cancer.

This pattern clearly implied that something transmitted in sexual intercourse increased a woman’s risk of developing cervical cancer. That something, it is now known, is a very common virus called human papillomavirus, or HPV, the same virus that causes warts, including genital warts.

Scientists have also learned that HPV exists in more than 100 forms, but only 13 are considered likely to cause cancer. It is now possible to screen women for the presence of an infection with one of the high-risk strains.

This screening adds important information to the routine Pap smear. In fact, most practices now have adopted the new guidelines for cervical cancer screening.

Rather than having every woman tested every year, the new schedule has been changed to take into account age, medical and sexual history, presence of HPV infection, results of past Pap tests and even the type of Pap test used.

The new guidelines should greatly reduce the number of women who are told that their test is abnormal and thus requires further evaluation. (Most of these abnormalities cure themselves.)

Under the previous guidelines, 2.5 million to 5 million women a year were called in for more testing to find about 5,000 cancers, according to Dr. Carmel Cohen, the director of gynecologic oncology at the Mount Sinai Medical Center in Manhattan, who headed the committee that produced the revised guidelines for the American Cancer Society.

About half the 13,000 cases of cervical cancer that occur each year are found in women who have never been screened, Dr. Cohen said.

…

Rather than having every woman start screening at 18, the groups now recommend starting three years after the onset of sexual activity or by 21, whichever comes first. After that, screening should be done every year with the regular Pap test or every two years using the liquid Pap until age 30.

If a woman 30 or older has had three normal test results in a row, the interval can increase to every two to three years.

But there are important exceptions. Annual screening may still be recommended for women with certain conditions that increase their cancer risk like smoking; infection with a cancer-causing form of HPV; infection with the AIDS virus; chlamydia infection; poor diet; exposure to DES, a synthetic estrogenlike drug, in utero; treatment with immune-suppressing medication or a weakened immune system; and a personal or family history of cervical cancer.

Women 30 and older can have a Pap test and an HPV test at the same time. The double test is not advised for younger women because they are much more likely to be infected with HPV and also to eliminate the virus in a few months or a year. In older women, the virus infection is much less common but is more likely to be persistent.

This year, the Food and Drug Administration approved using the HPV test in conjunction with the Pap test for women over 30. Previously, it was used only when the Pap test showed abnormalities. If a woman over 30 has a normal Pap test and no viral infection, she may safely wait three years to repeat her exams, according to the new guidelines.

Woman 70 and older who have had three or more normal Pap tests in a row and no abnormal test in the last 10 years can stop cervical cancer screening. Also, screening is not needed for women who have had total hysterectomies, unless cervical cancer was the reason for the surgery.

These guidelines do represent a significant change which responds to our newer better data. Some physicians might want to make copies of this article to hand out to patients!

Poor choices of words

Occasionally I get caught up in my own hyperbole. Like all commentators, I should be careful in my choice of wordings. In this piece – A contrary view on Scully , I was wrong to use this language: “Well, Mr. Goldberg (the editorialist) knows a lot about politics and perhaps even economics, but he does not know medicine. He continues this harangue with a spirited defense of Nexium and Aranesp. I admire his hyperbole and obfuscation, but he clearly is writing as a shill for the pharmaceutical industry. ”

I should not have called Mr. Goldberg a shill. I still disagree with him strongly in how he defends Nexium and Aranesp. Nonetheless, I believe that he believes his arguments. Thus, I apologize for calling him a shill.

I do stand by my support of Scully. If we are to have a free market medical economy (which we do not), then each new drug requires debate and decision making based on benefit and price. I teach residents not to use Nexium for the same reasons that Scully argues against the high price of Nexium. This drug does not add to our therpeutic armamentarium. No reasonable cost-effectiveness analysis would argue for its use. The drug really is not different from omeprazole.

In a free market economy, we (physicians) should speak out against unnecessary costs for our patients. The newest drug is not necessarily better.

I do not want to destroy the pharmaceutical industry, rather I want to hold them to reasonable standards. I disagree with their marketing tactics, and believe it my right and duty to point out their deficiencies. I hope that Mr. Goldberg understands that point, and the medical judgement behind my beliefs.