March 05, 2008
vaccination pain overload
A new study released in Pediatrics compared a sucrose solution to water placebo as anesthesia two minutes prior to the routine 2 and 4 month immunizations. Responses were measured on a pain scale at 2, 5, 7, and 9 minutes. There was a 78% (relative) reduction in mean pain score for the sugar group. (The absolute reduction was approaching 3 points on their pain scale.)
I am not sure of the pain scale used, or how accurate it is. But this seems to be a clear case of data overload. Besides the confusion of using the term "anesthesia" for this response to sugar, there is the issue of whether water is an adequate placebo. What baby wouldn't cry if given water instead of sugar?
But knowing this much information about the (presumed) pain response of infants after immunizations (and they received DTaP, IPV, Hep B and Hib over the several minutes) assumes that the vaccines are worth it, an assumption that has been significantly challenged, both on these pages and elsewhere. But even assuming they are worth it, does it really help us to have this much information about the relatively minor pain of what the advocates consider to be worth any risk or cost? Couldn't any grandmother have told us that an infant is happier with a sugar tit? Is this not yet another attempt to shepherd the wind?
Posted by Robert Maddox at 01:10 PM | Comments (0)
January 24, 2008
Pediatric OTC cough and cold
The battle is proceeding apace. The Baltimore Health Commissioner is pushing the issue of safety and efficacy of the OTC cough and cold preparations in children before the FDA. Doctors are elated on the one hand that they have found a voice in the drug process. OTOH they are assailed by parents who "know better about their own kids." I had a mother the other day assail me because she "didn't want her child to ever be sick" so she had hoarded quantities of these medicines. I heard a poll mentioned on the radio last week in which the majority of parents "thought" the medicines worked and were safe. So evidence to the contrary, we are to make decisions based on the anecdotal whims of individuals. (Not that I am against anecdotal whims entirely, when there is no good evidence.)
But most interesting is the response of the drug companies. They emphasized the safety of these drugs when used as directed. They failed to mention the lack of efficacy when used as directed. Which may be why parents don't use them as directed.
Posted by Robert Maddox at 01:35 PM | Comments (0)
June 19, 2007
mammograms
Please remember that I am not giving advice. Rather, I am recording information and trying to think through these issues.
Mammograms are one of the givens of modern medicine. A recent review in American Family Physician states correctly, "Breast cancer is one of the most significant health concerns in the United States. It is the most commonly diagnosed cancer in women and the second leading cause of cancer death in women." (So it is madness for me to challenge this sacred cow. But mad I am and challenge I must.)
Over the past few decades, several methods of screening have been advocated. Screening makes prima facie sense. Find the cancer early and you can prevent more significant problems. With this reasoning, any screening method is better than none. So we have the options of Breast self-examination (BSE), clinical breast examination (CBE), mammography, ultrasonography, MRI, scintimammography, PET and ductal lavage.
Compared to other conditions for which one might screen, at least breast cancer is relatively common. A woman has a one in 11 risk of developing breast cancer, so the saying goes.
Posted by Robert Maddox at 10:32 PM | Comments (0)
May 29, 2007
Properly evaluating Health care systems
David Hogberg, Ph.D., an analyst for the National Center for Public Policy Research, has an interesting article analyzing the reliability of life expectancy and infant mortality for comparing the US Health Care system to that of other countries.
It is a good analysis, which of course has sparked some debate. In it, he makes this observation: "... a health care system has, at most, minimal impact on longevity." Ignoring the fallacy of asserting the consequent (or its negative), he does provide good support for the assertion from the CEDP's own table. This is Leonard Sagan's claim from the 70's in his book Health of Nations, which was also influential in my education.
He also discusses the question of how we should measure a health care system. Unfortunately, he can only give some general principles. The OECD is working on such measures. However, the measure they appear to be using, such as vaccination rates, cancer screening rates, mortality rates, etc. are of questionable value. They are of value for comparing health systems, granted. And public policy writers may need such. But in the general scheme of life, they are not very meaningful. Rather, they are the hubris bringing nemesis.
Posted by Robert Maddox at 06:30 PM | Comments (0)
May 22, 2007
mumps outbreak
The mumps outbreaks are confusing the experts. The outbreaks are concentrated in the Midwest. Very few involved unvaccinated people. Almost half had received the two doses of vaccine.
Overall, between 2 and 66/100,000 were affected, usually white college students. The problem, we are told, is that the case definition and reporting forms and systems differ in different states. So at the beginning of outbreaks cases were ignored, and at the peak, cases were overcounted.
How many died? Very few. How many hurt in places they wished they didn't? A few. Less than 6,330 in 2006.
Is this a reason to be immunized against mumps? If you plan to go to college in Kansas or Iowa and haven't had it and don't want it, maybe. Otherwise, what is the point?
Posted by Robert Maddox at 08:19 PM | Comments (0)
Hormone Therapy
Female Hormone Replacement Therapy continues to take a bad rap. The Million Women Study has released a follow-up showing women who use HRT are at increased risk for ovarian cancer. The study has a number of flaws, which the critics are quick to point out.
And there is some clinical iatrogenesis proven, if the flaws are not fatal to the study. But even at its worst, the 20-60% relative risks of cancer or death in varying circumstances are actually much smaller absolute risks of 1/2500 to 1/3300. One or two women out of a thousand die of these cancers in 5 years. (Again, I do not mean to downplay the difficulty of such a condition.)
But the biggest problem is that this is old news. For two or three decades, we have been medicalizing menopause, and then seeking benefits to that medicalization. These drugs (not natural hormones for humans) are foisted on women, not just for symptoms of menopause (where they might be helpful for a short period of time), but for many conditions. There should be no surprise that there is conflicting data, or detrimental effects, when we create disease in order to destroy it.
Posted by Robert Maddox at 07:42 PM | Comments (0)
Walmarting health
Wal-Mart plans to open about 2,000 in-store clinics by 2012. Maybe you don't, but when I go shopping, I fall for the prominently displayed items. And many ED visits are "convenience" driven (because they happened to be in the area, or brought a relative or neighbor, and just figured they would get checked out). How many more unnecessary visits will be generated by these convenience clinics, to the detriment of our health?
Posted by Robert Maddox at 06:54 PM | Comments (0)
Wasting more money
President Bush as agreed to extend an early detection program for breast and cervical cancer. We looked at the relative uselessness of Pap smears. Mammograms are subject to the same analysis. Now the funding for the NBCCEDP will increase to $275 million by 2012.
About 341,000 women were screened for cervical cancer through the program, and almost 5000 cervical lesions were found. Interpret this information correctly. Ask how many of these women actually had cancer and how many would have regressed to normal. Ask how many needless procedures were done on these histological lesions with no meaningful significance. Ask how many women were harmed by this pogrom.
Continue reading "Wasting more money"
Posted by Robert Maddox at 05:12 PM | Comments (0)
May 14, 2007
Who can change the Future
Back in March, business professors from Harvard and UVA wrote a special communication in JAMA (March 14, 2007) basically summarizing their book, Redefining Health Care, which I am hoping to obtain so I can examine their thesis more closely. The article was entitled, How Physicians Can Change the Future of Health Care. They are very thoughtful and well-spoken professors who make the point that health care is not only a poor value for the money, but the system is fatally flawed, preventing any increase in value. They address the increasing value in telecommunications, for instance. No one complains about the cost of a cellphone because of the ever-increasing value purchased. Medicine is a zero-sum, cost-shifting competition. Their criticism is right on the mark. But their solution is reorganizing practice around medical conditions and care cycles, with risk-adjusted outcomes and costs carefully measured for comparison.
So their solution appears to be more of the same social iatrogenesis, compounded and re-organized. Any solution based on increased data will certainly improve results on an individual level, if the data is more accurate and applicable. But as clinical iatrogenesis improves, unless there is increased focus on the individual person's autonomy (according to Illich), social iatrogenesis will increase. And I would add to Illich that not only must the patient's autonomy increase, but the relationship between the doctor (teacher/advisor) and the patient must intensify. Porter's proposal speaks of value for "patients" but the focus shifts from the individual patient to "conditions and care cycles," the very shift started by Sydenham and intensified by Descartes. And the shift from individual to "disease" must be a shift of decreasing value for the patient, ultimately.
Posted by Robert Maddox at 11:55 AM | Comments (0)
May 08, 2007
marriage
Marriage is contranemesis. I haven't accumulated all the evidence. But it is pretty clear that marriage is healthier than singleness, and certainly the case that marriage is healthier than divorce. A married man with heart problems can expect to live 4 years longer than an unmarried healthy man. And a smoker is as well off married than a non-smoking divorcee.
Now there are many factors here that bear examination. And RAND is attempting to do that.
Posted by Robert Maddox at 02:48 PM | Comments (1)