Archive for November, 2007

Big Pharma I

Sunday, November 25th, 2007

Prescription drug costs, already astronomical, continue to rise into the stratosphere. Americans now spend a staggering $250 billion a year on drugs, and that figure is growing at a rate of about 12 percent a year. According to a revealing article by Marcia Angell, former Editor of the New England Journal of Medicine, prescription drugs are the fastest-growing part of the health care bill—which itself is rising at an alarming rate. “The increase in drug spending reflects … the facts that people are taking a lot more drugs than they used to, that those drugs are more likely to be expensive new ones instead of older, cheaper ones, and that the prices of the most heavily prescribed drugs are routinely jacked up.”

The U.S. Senate recently passed the FDA “drug safety” bill today (S.1082) with a 93-1 vote. A key amendment that would have called for genuine drug safety protections for consumers — the Grassley amendment 1039 — was defeated by a single vote (47 to 46). Senators who received substantial donations from pharmaceutical companies were instrumental in making the new drug bill more industry-friendly. The new law deepens financial ties between “Big Pharma” (2 million hits on Google) and the FDA, doubling the amount of money directly paid to the regulator by drug companies, “but fails to protect foods and nutritional supplements from overreaching FDA regulation efforts. The new law also failed to end Big Pharma’s monopoly stranglehold on American consumers, further blocking the ability of citizens, …to import equivalent and often (safer) medications from countries like Canada.”

Dr. Paul Rosch, President of The American Institute of Stress, discusses Big Pharma in his outstanding publication, Health and Stress. He documents multiple examples of “misleading drug promotion, overpricing, and the corruption of the medical and Governmental establishment by the pharmaceutical industry in a pattern of widespread abuse.” Dr. Rosch also reports that two years ago 94% of the more than 5,000 scientists at NIH were engaged in lucrative conflict of interest activities, and that top officials had received over $2.5 million in fees and stock options from drug companies over the past decade. “In 2002, the pharmaceutical industry spent $91.4 million on federal lobbying activities, and at least another $50 million was spent to influence Congress and others through advertising, direct mail, telemarketing, and grants. Drug companies had 675 registered lobbyists and 26 of these were former members of Congress.” This, according to other articles quoted by CNN and appearing in The New York Times, The New Yorker, Time, The Nation, and other publications, is only the tip of the iceberg.

Another shocking issue I hope to discuss in later blogs, is the employment by pharmaceutical companies of large numbers of practicing physicians in the “detailing” of drugs to fellow professionals and advertising hundreds of drugs to patients through the media, a practice illegal in the European Union.

The science fiction writer, Neal Stephenson, author of Snow Crash (1992), the three part trilogy The Baroque Cycle, and other philosophical-historical novels, offers an intriguing name to current medical economics. He describes how the political system has always been subject to “power disorders,” sudden deviations or disequilibria in which “certain groups or persons suddenly concentrate a lot of power and abuse it.” Does this phenomenon describe what is happening to medicine today? Or is it perhaps only one of many pathologies afflicting our present system of health care?

Thanksgiving for Everyone

Wednesday, November 21st, 2007

Part of the secret of success in life is to eat what you like and let the food fight it out inside.

Mark Twain

Being of sound mind, and though not of Mark Twain’s generation, I still tend to agree with the great man. Eat what you like on November 22, but beware of the Food Police and the “Coronary on a Plate” crowd: A good average American dinner on this holiday would include the usual turkey and “fixin,”that is, stuffing, cranberry sauce, potatoes (the regular white or yellow, sweet variety) veggies, salad, pumpkin or apple pie, (possibly) washed down with a glass or two of wine. I’m not necessarily counting appetizers or soup. Depending on serving size this meal might entail the consumption of anywhere between 900-1,800 calories, loads of trans fat, and, God forbid, three or more “starches” (read “loaded with carbs”).

On the other hand, if you’re really worried about your “health,” stick with low carbs, low cals, low fat, including low transfat. The perfect meal would then consist of 7 grain whole wheat bread, no butter, please, organic white meat turkey (no more than 90 grams or three ounces), salad, two green and one yellow vegetable, and fresh fruit for dessert. .

What you choose to eat the rest of the month is entirely up to you. At the very least, sleep 8 hours a night, take plenty of exercise, drink lots of fluids, and don’t forget to floss.

The Undercounted:Head Injuries in Iraq

Thursday, November 15th, 2007

The roadside bomb or improvised explosive device (IED) is the signature enemy weapon in Iraq, and the number one killer of troops. When any high explosive charge is detonated, very hot, expanding gases are formed in millionths of a second. These gases can exert pressures up to or beyond 700 tons per square inch surrounding the explosion, and rush away from the point of detonation at velocities of up to 7,000 miles per hour, thus compressing the surrounding air. The entire blast pressure wave, because of its two distinct phases, a positive and negative or suction wave as the air rushes back, delivers a one-two punch to any object in its path. Depending on the size of the charge and surrounding conditions, these blast effects, whether from an IED, a car bomb, surface mine, or suicide bomber, may cause serious brain injury hundreds of feet or more from the detonation.

When troops are wounded in the field they are evacuated immediately if they have any obvious wounds. But though thousands of troops in Iraq have felt the blast of an IED, and those knocked unconscious are evacuated to a field hospital for evaluation, those who appear uninjured or do not complain of a problem remain on duty.

As specialists in brain injury know all too well, the human brain is the consistency of gelatin and any external force from an explosion shakes it violently; people can suffer brain problems without losing consciousness. Troops with closed head injuries may show no external signs of injury, and appear to be normal. One of the most frightening aspects of brain injury is that brain-injured people often lose the ability to know something is wrong.

Dr. Harriet Zeiner, a brain injury specialist at the VA recently commented on a conference call she had with medical officials at several military facilities including hospitals in Iraq: “One of the things commanders are trying to determine,” she says, “is that after someone has been exposed to five and six concussive blasts are they still battle ready? Frankly, that floored us. You could have very significant effects from one exposure, and now they’re trying to figure out if people who’ve been exposed five and six times should be going back into battle.”

Compared to previous wars in Korea, Viet Nam, World War II, the toll of brain injuries in this war thanks to roadside and car bombs, is astounding. According the Department of Defense, almost 18,000 troops have been wounded. VA doctors say that two-thirds of them have been injured by IED blasts and two-thirds of those exposed to blasts, suffer some brain injury, ranging from a mild concussion to permanent damage. Thousands of unsuspected as well as suspected brain injuries will be one of the major legacies of this war.

Subtle personality changes that may occur as a result of such injuries “would only be noticed by relatives or close friends who know the patient well, and other symptoms could take years to develop. The effects of such injuries may therefore go unnoticed for years or even decades. The difficulty in diagnosis is further compounded by the fact that many of the symptoms of closed head injuries overlap with, or sound similar to those of post-traumatic stress disorder (PTSD).”

A recent JAMA article reports results of combined screening for PTSD, mental impairment, alcoholism, major depression, and other mental disorders of more than 88,000 soldiers returning from Iraq. If I decode the conclusions correctly, the study by physicians in the Division of Psychiatry, Walter Reed and Army Institute of Research, revealed 20% of active and 42% of reserve component soldiers requiring mental health treatment.

Reducing Hospital-Acquired Infections

Tuesday, November 6th, 2007

Some hospital officials object that, since the average hospital infection adds $30,000 to a patient’s bill, this is simply the “cost of doing business.” But this attitude is disingenuous, since the biggest push for more effective methods to combat hospital-acquired infections (HAI) may come, sadly, from the threat of huge lawsuits. Many of these cases have been settled with hospitals in which HAI have resulted in patient deaths. Moreover, as Allen observes, while hospitals have traditionally passed on their costs to other payers, Medicare—which sets reimbursement standards—is starting to curtail payments to cover hospital errors, and may eventually stop paying to treat infections that could have been prevented. Some private insurers may ultimately follow suit.

Disclaimer: Don’t let me Frighten You

All of the above facts about HAI have been in the news for some time. Some physician friends, including a medical director of a major health insurance company, have warned, “Whatever you do, stay out of the hospital,” Such radical advice is obviously not to be taken literally, especially if one recalls that the hospital is the only place where major surgical procedures are performed, and where life-saving high level medical care is administered to seriously ill patients. My purpose here is to inform without alarming, and to make the reader a more skeptical patient, one who asks:

1.”Could I be treated as an outpatient rather than be admitted to a hospital?”

2.”Why should I go into the hospital just for tests if I’m not sick?”

3.”How soon can I get out of here?,” and to the nurse, doctor, or person who brought in the lunch tray:

4. “Have you washed your hands in the last five minutes?”

Things are changing for the better. A growing number of physicians and health care experts say patients have the right to know a hospital’s infection rate before being admitted-and before long this information will be available in 28 more states. Many hospitals have launched efforts to reduce infection rates which can immediately be lowered by such simple steps as hand-washing between patients by all personnel, sterilization and following rigorous practices during procedures with a high risk of infection. In 2002, Rhode Island Hospital in Providence began search and destroy, and the MRSA infection rate at the hospital has dropped 43 percent. The University of Virginia Hospital in Charlottesville imposed the same system in 1980, and has maintained lower rates of MRSA and other infections. Thanks to increasing public pressure, other institutions are following suit. Don’t be afraid to add your voice to the crowd.

Copyright 2006, Mathemedics, Inc.

Why We Keep Getting Bugged, II

Saturday, November 3rd, 2007

Why do the Centers for Disease Control, which recently listed guidelines to prevent hospital infections, conspicuously omit universal testing of patients for methicillin-resistant Staph (MRSA), one of the most common causes of hospital-acquired infections? As a typical example of Government groupthink, the CDC continues to call for voluntary AIDS blood testing while hospital-acquired infections cause five times as many deaths as AIDS in this country.

Among developed countries, the United States has one of the worst records for curbing, not only MRSA, but other drug-resistant infections. The CDC itself noted a 32-fold increase in MRSA hospital infections between 1976 and 2003. 25 years ago Denmark, Finland, and the Netherlands faced similarly soaring rates of MRSA, but have nearly eradicated it. How was this accomplished?

Hospital Infections in Europe and Canada

In an eye-catching article in the online magazine, Slate, “Europe is killing off hospital infections. Why isn’t the United States following suit?”, Arthur Allen writes, “If you are an American admitted to a hospital in Amsterdam, Toronto, or Copenhagen these days, you’ll be considered a biohazard. Doctors and nurses will likely put you into quarantine while they determine whether you’re carrying methicillin-resistant staph…If you test positive for MRSA these European and Canadian hospital workers will don protective gloves, masks, and gowns each time they approach you, and then strip off the gear and scrub down vigorously when they leave your room. The process is known as “search and destroy.”

After five years of deliberation, the CDC continues its refusal to endorse search and destroy. Allen adds, “…This is a bitter pill for many infectious-disease experts, who have been joined by the relatives of dead patients, Consumers Union, and even a few Congress members in pressing the CDC.” “Why are we spending millions if not billions on bird flu, a ghost that might not happen, when you have thousands being colonized by MRSA and dying of it?” asks Dr. William Jarvis, a top CDC hospital-infection expert until he resigned in 2003.