Dr. Andy

Reflections on medicine and biology among other things

Friday, March 31, 2006

The power of prayer

Does praying for a sick person's recovery do any good? In the largest scientific test of its kind, heart surgery patients showed no benefit when strangers prayed for their recovery.

And patients who knew they were being prayed for had a slightly higher rate of complications. The researchers could only guess why.

Several scientists questioned the concept of the study. Science "is not designed to study the supernatural," said Dr. Harold G. Koenig, director of the Center for Spirituality, Theology and Health at the Duke University Medical Center.
Honestly, my first reaction to this is what a waste of $2.4 million (and parenthetically, how expensive has biomedical research become? They randomized 1800 patients to be prayed for or not and it cost 2.4 million? I wonder how much they paid the prayers?). Abstract of original article is here(no free full text).

Hopefully, further research funding can concentrate on interventions likely to actually, you know, benefit patients. I don't mean to disparage prayer and religion (especially given that I attend church regularly), but I agree with this editorial that describes prayer as
widely practiced . . . with no plausible mechanism
at least biologically. I don't think you are going to learn much about divine intervention doing clinical research

Thursday, March 30, 2006

Doctors telling all

Should physicians reveal how they are paid? A new study suggests disclosing this information increases trust:
Disclosing how physicians are compensated may increase patient loyalty, and does not appear to undermine patients' trust in their doctors, a new study shows.

"This study suggests that regulators, policy makers, and physician groups themselves should renew their consideration of disclosure as an instrument to advance the best interests of patients and physicians," Dr. Steven D. Pearson of Harvard Medical School in Boston and colleagues conclude.
Sounds good, and I agree that patients should have access to the information.

An important caveat is that all the doctors in the study were paid by a combination of salary and bonus with the bonus based on a rather nebulous formula, so these doctors weren't conflicted in giving impartial advice. Patients who learned their surgeon derived 80% of income from operating might be less trusting of his or her advice to undergo an operation; of course, in the global scheme that is probably a good thing.

Project retrains prostitutes as caretakers

A new project in Germany is retraining prostitutes to become care workers for elderly people.

The state of North Rhine-Westphalia is using {euro}1m (£0.7m; $1.2m) of local and European Union money to try to get sex trade workers off the street and into care homes
Seems like a good idea; I wonder if they could get Viagra to sponsor it. This quote from Rita Kuehn, one of the people behind the scheme is even better.
She believes that prostitutes make excellent carers as they have "good people skills, aren't easily disgusted, and have zero fear of physical contact."

"These characteristics can set former prostitutes apart from trainee nurses," she said

She added, "However, nursing home bosses will have to be discreet so that elderly men don't try to get more than they are paying for."

Tuesday, March 28, 2006

Three good days in NYC

I'm back from a brief mini-vacation in NYC.

Here are some of the highlights

1. Visitng Liberty and Ellis islands. I was completely against this, figuring it would be too crowded and touristy. It was, we waited more than an hour for a ferry. And the Statue of Liberty was cool, but not that cool. Ellis island, however, was awesome. It's been converted to an immigration musuem which was fabulous. It is hard to imagine giving up everything where you are to come to a new country sight unseen. And kids and wives often followed with just a train ticket pinned to their coats to direct them where they were going.

My favorite was asking my kids the questions the examiners asked the immigrants. I asked my son if he was a polygamist. He didn't know what that meant, so I asked if he wanted to have more than 1 wife. "Not at this time" he replied.

2. The NY Public Library. Beautiful building, free and the map collection room is great. For a time it was believed California was an island, disconnected from the rest of North America. The main reading room is also wonderful

3. Ice skating at Rockefeller center. A Mastercard moment: you can't believe the price, but my daughter's smile was priceless

4. The Lion King. Tremendous, especially the costumes and sets. I thought it would be smarmy Disney, but it was wonderful. Yesterday, I mentioned that I'd seen it to one of my pateint's parents who is a theatre professional and she said she'd cried during the show because it was so wonderful. Appropriate for almost anyone (Isabel, who is 5 sat throught it, mesmerized)

5. The Intrepid. A converted aircraft carrier with lots of planes, helicopters, etc. including a Concorde. My son loved it and it had lots I was interested in as well+

6. American Museum of Natural History. This was okay but overrun by schoolkids and the "space show" was not much better than what you can see for free elsewhere (like the Carnegie Science Center in Pittsburgh).

7. Books on tape. We drove the 6+ hours both way and listened to Harry Potter and the Order of the Phoenix. It makes the time fly, yet doesn't really distract you from driving

Tuesday, March 21, 2006

Another reason

not to marry your cousin, especially if you are already a member of an inbred population:
In a sky blue bedroom they share but rarely leave, a young sister and brother lie in twin beds that swallow up their small motionless bodies, victims of a genetic disease so rare it does not even have a name.

Grand Rounds 2:26

is here

Monday, March 20, 2006

No symptoms, no asthma

It is widely recognized (at least by physicians and scientists) that asthma is a chronic disease. In a simplified view, ongoing inflammation in the lung underlies contraction of smooth muscle which causes symtpoms. Blocking or treating the underlying inflammation, by means such as allergen avoidance and use of inhaled steroids, helps prevent exacerbations triggered by things like exercise, viral infections and exposure to allergens (think cat).

Patients, however, may not share this view, believing instead that they only have asthma when they are having symptoms. Thus one of the hardest things asthma doctors face is convincing patients (or thier parents) that they need medicine everyday when they only have symptoms intermittently. Even when we think we've explained ourselves, patients often returns saying they stopped the medicine because they were all better.

Halm et al. have now shown just how prevalent that belief can be; more than 1/2 of patients HOSPITALIZED with asthma at Mt. Sinai in New York City believe that they only have asthma when they have symptoms. This even though 1/4 of the sample has been intubated for an asthma exacerbation in the past.

This helps explain why many patients are resistant to use of daily controller medications to prevent asthma flares.

They authors identify the question "Do you think you have asthma all of the time, or only when you are having symptoms?" as an effective means of identifying patients who need further education.

My only criticism of the study is that it doesn't tell us much about the level of persistent symptoms the patients have. If you have symptoms most or all days, which many of these patients presumably do, the idea that you only have asthma when you have symptoms may not be relevant. The authors do show that among patients with daily symptoms, the "no symptoms, no asthma" belief is less common.

Friday, March 17, 2006

2 more deaths with mifepristone

The FDA has issued an alert to medical providers that an additional two deaths coinciding with use of mifepristone to induce abortion. Previously, 4 women died of overwhelming infection with an unusual bacteria Clostridium sordellii but it isn't clear yet what the cause of death in the additional cases was.

Not good

Not good at all
Four men left seriously ill after taking part in a drug trial have regained consciousness, say doctors.

Another two are in a critical condition and under sedation but have shown early signs of responding to treatment, said Dr Ganesh Suntharalingam.

The men suffered multiple organ failure within hours of taking the TGN1412 drug at a research unit based at Northwick Park Hospital in north-west London.
TGN1412 is an antibody that blocks a key molecule on the surface of T-cells called CD-28, thereby causing changes in the immune system which can apparently be either pro or anti-inflammatory (as evidenced by it being studied for both cancer and rheumatoid arthritis).

Usual protocol for new drugs is to administer them to healthy volunteers after extensive animal testing, which was apparently done in this case and showed no evidence of toxicity. Why the medicine caused such a violent reaction when given to humans is unclear, but it sounds like it was horrible.

I would not discount the possibility that the medication given was somehow adulterated. If not, it is probably just an example of very bad luck.

That said, why 6 people were given the medicine simultaneously is not clear. It would seem safer to give it to one at a time, so at least 5 of the 6 might have been spared. Additionally, the practice of testing new drugs first on healthy volunteers seems odd; wouldn't it make more sense to test it on someone suffering from one of the diseases for which the med is being studied? I know that might confuse the outcome as for some adverse outcomes it might be unclear whether it was the medicine or the underlying condition that was causitive. That said, at least the participants would have an incentive beyond money.

Wednesday, March 15, 2006

Ethics of conscientious objection

In the February 4th British Medical Journal, one Julian Savulescu, director of the Oxford Uehiro Centre for Practical Ethics argues that there is little if any room for autonomy by physicians in deciding not to provide certian kinds of care
A doctors' conscience has little place in the delivery of modern medical care. What should be provided to patients is defined by the law and consideration of the just distribution of finite medical resources, which requires a reasonable conception of the patient's good and the patient's informed desires. If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors. Doctors should not offer partial medical services or partially discharge their obligations to care for their patients.
Certainly once can't accuse Savulescu of pulling punches.

I see a number of problems with this sort of reasoning, not least that the pool of potential physicians might be signficantly limitied if every medical school applicant had to be prepared to offer any medical service that was currently legal or might be legal in the future. I don't think breast augmentation should be illegal, but I don't see any problem with not doing them myself.

Now, in a letter responding to the original article, Vaughan Smith, powerfully points out the flaws in Sauvescu's "public servants must act in the public interest, not their own" line of reasoning:
Since visiting Auschwitz, I have grappled with the question of how I would have behaved as a doctor in Nazi Germany or Stalinist Russia. I hope I would have had the moral courage to refuse to participate in the various perversions of medicine that these regimes demanded—for example, respectively, eugenic "research" and psychiatric "treatment" of dissidents.

I hope, but not being a very courageous person, I'm not at all sure. My chances of behaving honourably would have been greatest if I had felt part of an independent medical profession with allegiance to something higher and more enduring than the regime of the day.
which puts it more eloquently than I ever could. And points our the obvious problem that what is "legal" can vary immensely from time to time and society to society. One can of course object that conscientious objection by physicians hasn't been very effective, but that is an entirely different issue. I suspect that Savulescu wouldn't be impressed with US physicians who participated in mistreatment and torture of prisoners at Abu Ghraib and Guantanomo because it was "legal."

Note that I'm pro-choice, although not necessarily pro-abortion. I don't currently face the issue commonly, but would refer any pregnant patient who desired an elective abortion to a qualified provider. So it's Savulescu's reasoning I object too.

Tuesday, March 14, 2006

Grand Rounds 2:25

is here at Geeknurse. What a great name for a blog

Sunday, March 12, 2006

Two girls named Sam

This week's grand rounds at Geek Nurse will feature a "glass half-full/glass half-empty" theme. I don't generally try to post to conform to specific criteria, but I've been mulling over this post for some time.

The first Sam came to me while I was still in Boston. She had egg allergy. On her first bite of scrambled eggs at age 2 she had gotten classic symptoms of anaphylaxis: hives, swelling and shortness of breath. Her pediatrician had gotten the labs to prove that it was egg, prescribed an Epi-pen and told her parents to have her see an allergist. Her parents brought her all the way from New Hampshire. She was precocious, although I soon learned that some of that was that she was extremely small for her age, well under the 3rd percentile for both height and weight. Otherwise everything was straightforward.

I asked about her size, but the parents assured me neither they or her pediatrician were worried. As a specialist, you always face the question of how much to just focus on your area (her egg allergy) and how much to worry about other problems. With Sam apparently healthy and thriving, albeit small, and both parents and pediatrician seemingly on the ball and unconcerned, I figured there wasn't much to add.

I saw her several more times, before the parents told me they were moving back to Tennesee, where they were from. Two weeks after they moved I got a tearful call from the mother. Sam had been diagnosed with cystic fibrosis. Their new pediatrician was worried about her size and checked a sweat test, standard protocol for failure-to-thrive. Ouch. Massachusetts screens newborns for CF, so most kids I saw had already been screened; of course Sam wasn't from Massachusetts.

I still think about Sam frequently, still kick myself for not picking up her CF. From then on, I vowed I would do what I thought best for my patients, even if it meant stepping on a pediatrican's toes. Luckily, Sam saw a better doctor than me before any serious damage occurred.

The second Sam is the worst asthmatic I follow here in Pittsburgh. I first met her when she was 18 months and intubated in the ICU secondary to a horrible asthma exacerbation. She had coded in a small ER in a small town way north of Pittsburgh and been life-flighted in. They lived on a farm, far from good medical care.

She was lucky, the outside ED doc had intubated her quickly, she had avoided prolonged hypoxia and fully recovered. I saw her and started her on an aggressive regimen to control her asthma, but it didn't help much. She had two more hospitalizations that winter along with a couple more courses of oral steroids. 98% of asthmatics I can make better, if they take their medicines; Sam I couldn't. I tried treating her for gastroesophageal reflux, looked for sinustis, even though she was young but couldn't find anything. I sent her to pulmonary for a sort of "second opinion" but they didn't have any brilliant ideas, either. Sam's mom would call me when she was sick to get advice, and we'd discuss if she just needed to see the pediatrician or go to the hospital or even come straight to Pittsburgh. I was afraid she might have another horrible attack and die.

The parent's best friend was a chiropractor so they'd also take Sam there to get "adjustments." They claim it really helps, although I'm skeptical. I told them it is okay as long as they also give the medicines that really do help, which they do

A few weeks ago I realized I hadn't heard from Sam's mom in several months. I'd been wondering what had been up. So I called up mom, who told me she was doing great, and thanking me for making her better. I pointed out that Sam had mostly gotten better on her own, maybe with a little help from me. We see that sometimes; the young asthmatics get better as they get older, probably because the airways get a bit bigger, less prone to close off. Either way, we are both thrilled with how well she's doing and I sleep a little bit better at night, not so worried about getting awoken about Sam.

Thursday, March 09, 2006

Bird flu miscellany

Baxter has shown that it's plasma derived products (such as clotting factor for hemophiliacs and IVIG for patients with immune deficiency) are safe from avian flu. Given that the properties of the avian flu aren't significantly different from the usual influenza virus, at least in a chemical sense. Still good news for patients who depend on these products, particularly given how many hemophiliacs got HIV.

Also, Britian has announced it will reserved the avian flu vaccination for health care workers. This may sound unfair, but given how hard it will be to keep the health care system working in case of a pandemic, it makes sense. Hopefully, others can stay home and avoid exposure, but health workers will be needed to care for patients.

Kissing and peanut allergy

I missed this while I was away, but apparently Christina Desforges didn't actually die of peanut allergy.
A 15-year-old Canadian girl with a peanut allergy did not die because of kissing her boyfriend who had eaten peanut butter, a coroner has ruled.

But Saguenay coroner Michel Miron did not reveal why Christina Desforges died last November because he has yet to make his final report.
According to another article, she died of cerebral anoxia or lack of oxygen to the brain. I hate to speculate, but there was recently a tragic case in Pittsburgh where a pediatrician's son died of asphyxia. Apparently, some kids play a game called "knock out" where they strangle themselves near the point of passing out to get a high as bloodflow returns. I'm tempted to make fun of this as natural selection at work, but I'm sure many of us did things as teenagers that seem crazy in retrospect.

As I pointed out at the time, the timing of the death would have suggested that very little peanut protein was left in the boyfriend's mouth. At the AAAAI meeting I just got back from, a group presented a study of how long saliva contains peanut protein:
The new study, presented at the American Academy of Allergy, Asthma and Immunology's annual meeting in Miami Beach, involved 10 people and found that the peanut allergen was detectable in a majority of subjects after eating but left the saliva after several hours.
This seems like reasonable advice, although I'd consider avoiding peanut altogether. So as of now there are again no documented cases of deaths from food allergies after kissing.

Wednesday, March 08, 2006

Brokeback marriages

On the whole these are not marriages of convenience or cynical efforts to create cover. Gay and bisexual men continue to marry for complex reasons, many impelled not only by discrimination, but also by wishful thinking, the layered ambiguities of sexual love and authentic affection.

"These men genuinely love their wives," said Joe Kort, a clinical social worker in Royal Oak, Mich., who has counseled hundreds of gay married men, including a minority who stay in their marriages. Many, he said, considered themselves heterosexual men with homosexual urges that they hoped to confine to private fantasy life.

This will sound terrible, but I'd recommend that women ask prospective husbands what kind of porn they look at (or sneak around and figure it out themselves). I suspect that most of the gay men who get married look at gay porn, much as they want to believe they can have a successful heterosexual marriage.


I'm back from Miami. I have some good posts coming, but without easy free full text access to most journals at home, you'll just have to wait. My flight didn't arrive until 11:30PM last night so I didn't get into bed until after 1. Spent the day revising dictations, following up labs and phone calls etc. But now I'll be set tomorrow.

A couple notes. One while I find David Irving deplorable, putting him in jail is preposterous. As my former neighbor, Jeff Jacoby puts it:
But as a matter of law and public policy, Irving's sentence is deplorable. The opinions he expressed are vile, and his arguments about the Holocaust are ludicrous. But governments have no business criminalizing opinions and arguments, not even those that are vile or ludicrous. . . . . But free societies do not throw people in prison for giving offensive speeches or spouting historical lies.
Well said.

More trivially, I was glad to see Trader Joe's make the NYTimes today. Allegedly they are coming to Pittsburgh this fall, which should greatly improve my wife's opinion of the city. The only downside is that whenever I go there, everyone thinks I work there (I like to wear Hawaiian shirts).

Friday, March 03, 2006

It can always get worse

or so we told ourselves during residency. That said, I hope not to have many more weeks like this one.

First, I realized that the protocol I've been working on was the WRONG VERSION. I'm not sure how exactly this happened (either the sponsor sent us the wrong one or my boss didn't pass on the correct one to me) and in any case I get a large share of the blame for not paying more attention and noting that the title was different.

Then yesterday someone from outside my section contacted me about a handout I'd spent a fair amount of time working on, saying her section wanted to do something similar and could she look at ours. 4 hours later she e-mailed back saying our sucked (in slightly different words) and she couldn't believe we were using it. Funny, I didn't remember asking her opinion.

For whatever reason this really pissed me off. I'm not sure why. I didn't even originate the handout, I just adapted it. I did spend a fair amount of time on it, not least sitting through meetings endless discussing it.

Luckily, I think, I'm currently in the Pittsburgh Airport surrounded by college students heading to Spring Break, waiting for my flight to Miami. Not vacation, but the annual allergy meetings, which will at least give me some time to read, relax and decompress.

Thursday, March 02, 2006

Misleading graphs

I want to call attention to a graph I published yesterday (source here) showing the relationship between asphalt use in Finland and asthma rates.

There is something very misleading, even wrong, about this graph: the asthma rate is plotted for 20 years longer than asphalt use. This causes several problems.

1. It tricks you into thinking that the asthma/ashphalt correlation has gone on much longer than it really has.

2. It makes the correlation look much tighter. Cover up the area of the graph from 1990 on and the dip in asphalt use between 1980 and 1990 is much more prominent.

Why would you ever present data like this? I can think of no reason to continue graphing one variable and not the other, especially for a period taking up 1/4 of the whole graph. The relationship is a good one without the extra data and this just blows your credibility in the eyes of a careful reader. I also can't help but wonder what asphalt use really was in 1995 and 2000. Maybe it plateaued?

Wednesday, March 01, 2006

Eat dirt, prevent asthma!

Why have asthma and other allergic diseases gotten so much worse in the last 50 years? No one knows for sure. A leading hypothesis is called the “hygiene hypothesis,” which states that we are too clean. Initially the idea was that we got fewer infections than we used to before immunizations, antibiotics, antimicrobial soaps and gels, etc. However, studies haven’t been able to show, for example, that kids who get antibiotics earlier or more frequently are more likely to get allergic diseases than those that don’t

A new modification of the hypothesis suggests that it isn’t lack of exposure to microorganisms that cause infections that is the problems, but lack of exposure to harmless bacteria and fungi, particularly those that live in the ground. Studies clearly show that growing up on a farm is protective against allergies (as shown in the first graph) and that the more rural the environment the better.

One problem is that measuring the extent of urbanization is difficult. Now, 2 Finnish researchers writing in this month’s Journal of Allergy and Clinical Immunology have come up with a good proxy, use of asphalt. As this graph shows, the increase in asthma in Finland closely parallels use of asphalt.

So if you want to avoid asthma, allergies, etc. eat dirt.

UPDATE: added link to original article. Link to criticism of second graph as misleading.