These past few days at the AAPS meeting have been very interesting. We heard from Kelly Jones (the PharmD who worked with my mentor, Dr. Terrell), and many persecuted doctors, as well as MD politicians (Paul Broun, Tom Price, Rand Paul, Mike Ritze), and the superbly entertaining and challenging Ezra Lavant (who identified, as the worst consequence of socialistic medicine, the surrender of ourselves, body and soul, to the state).

What was most striking about this meeting was not the urgency to reverse the current situation, or the strategies mentioned, or the personalities and great talks. What was most striking was the exaltation of Jesus by a majority of members.

This organization has more punch than any in medicine. For its size, it out slugs the best. They sued and stopped the Clinton health care debacle. They have exposed the Texas medical board for corruption. And they are taking on the current federal administration.

The meeting was tremendous. Various doctors that have suffered at the hands of the bureaucracy told their stories, compelling stories that are not isolated instances. Others gave moral and philosophical arguments for independence, both from Scripture and from their experiences.

Those that have been active politically (whether as elected reps or stalwart individuals) gave updates on various legislation and areas to be vigilant. It was most impressive that they are not merely trying to stop the rot, but are offering positive ways to get government out of medicine, while solving the problems that initiated the wrong solutions.

I know that political action is not our salvation. But God uses means to work his will. We have an obligation to stand up to protect our patients and our neighbors. If there is a time when action is important, it is now.

If you are a physician, join AAPS and find out what you can do. If you know physicians, encourage them to join.

But it doesn't, at least any better than a sham procedure. And it is not cheap. Just like with the knee arthroscopy proved to be useless, do you think anyone will be reimbursed, or at least apologized to?

Previous studies have shown a statistically significant (but not meaningful) increase in dementia with increased pressure. This study does not even show statistical significance. Rather, the variability in pressure is statistically signficant (again, we do have enough information to say whether this is meaningful). But the ranges of variability are much wider than the difference between the ranges.

The big question is, clinically, does treating BP (or worse, attempting to treat) cause greater variability leading to greater dementia? Have we worsened the dementia problem with our treatements (of BP, or cholesterol, or whatever)? Have we first done harm?

In light of the constitutional prohibition on titles of nobility, Herb Titus has argued persuasively against state licensure. This concept of being society's agent is flatly unconstitutional.

Further, it is contrary to reason. What is society? If one means the civil government, than say so. But the civil government is force, not reason. If one means the local community, that is more reasonable, but contrary to the force of the state.

More importantly, this view ignores the fact that Jesus reigns in Heaven and on earth. I am obligated to obey him, to be his agent. That, of course, does not preclude a temporal authority as well. But that temporal authority must also be obeying Jesus. So it is not the desire of society, or the patient, or the doctor, that is the main consideration, but of Jesus.

It is no wonder that the ethicists and policy makers find confusion amongst the options of models. Only the model of mutual servanthood can solve these dilemmas. I am a servant of Jesus and of his creation. I advise and treat fellow servants (even those that rebelliously reject or deny the Master). There is no autonomy, there is no abstract justice, there is no way to determine good or harm apart from his standard.

This article deserves wide, careful and repeated reading by anyone who has medical problems, or in the medical fields.

In order to preserve primary care, it seems that Obama will be forced to make that final socialist step making all primary care doctors employees of the State. Hitherto, under our current fascist system, we are being made employees of corporations controlled by the State. Currently, that control is exercised by reimbursement, increasingly out of the hands of the patient. In order for a single payor system to work, these various responses to cramdown will have to be limited.

And how does one know if one has the flu? The Positive predictive value of the test is less than a coin toss. That is, even if one tests positive, one cannot be sure one has the flu. This is a result of the poor specificity (15% false positives) and the low prevalence. The Negative predictive value is much better. So why do the test? You tell me.

Apparently, the transition team gave a list of acceptable answers to each of seven questions. I suspect that the answer to the biggest problem question did not allow the answers "hubris" or "idolatrous expectations."

One professor highlighted in the article is quoted to summarize the article, "There's this fundamental metric that's missing from our discourse -- what do individual patients value in a health care setting? We need to shift perspectives; we assume to know what value is, what the patient wants, but we make that assumption without any data."

I might agree with Dr. Corvera, if she were to go on to say that such a metric is noncollectable, and that therefore government, or other third-parties have no right or responsibility to make such decisions. But if she presumes that such a metric can be obtained and systematized for a single or third party payor, she will top the hubris charts.

The study was stopped in 2005 due to the excessive number of deaths in the tretinoin-treated group. It was not published in the AD until January 2009. Why was it delayed and what was the point of publishing it now?

Secondly, it is not clear to my reading what they were treating and what they were expecting. It appears that they were treating a certain type of skin cancer which has responded to systemic (as opposed to topical) medicines like this one. There is evidence of increased deaths among smokers treated systemically. Yet they claim that death was not a contemplated end point, when they were evaluating the "relation of topical tretinoin... with all-cause mortality... ."

I am even more curious about the view of science exhibited herein. There was a clear and significant association between use of this cream and death, yet the authors are unwilling to infer a causal association. The endpoint they were studying was a type of cancer. If there had been that association, would they have published? If the trial had shown an association of desired benefit, would they have inferred causality? By what right do we decide when an association is causal?

Disclaimer: This does not constitute advice to anyone using this acne cream.

Dr. Hilton Pack Terrell

Florence, SC

Dr. Terrell was born in Fort Worth, TX, a son of the late Lake E. Terrell, Jr, and Alma Pack Terrell. He was raised in Sumter, SC. Dr. Terrell received a BS, MA, & PhD all from the University of South Carolina and a MD from the Medical University of South Carolina. He served three years in a residency program in a Family Practice in Anderson, SC, practiced for one year in St. George, SC, and six years in Sumter, SC, before coming to Florence in 1985 to be on the faculty at McLeod Regional Medical Center in the Family Practice Residency Program.

Dr. Terrell was the President-Elect of the Association of American Physicians & Surgeons (AAPS) and was the past editor of the Journal of Biblical Ethics in Medicine. He also was employed by Palmetto Infusion of Florence. He was a member of Faith Presbyterian Church (PCA) of Florence, where he was a Past Elder and Sunday School Teacher, and he taught Biology from 2007-2008 at The King's Academy.

Surviving are his wife of 42 years, Marcia Slagle Terrell of the home; three children, Dr. Timothy David Terrell of Greer, SC, Amanda T. (Deason) Smith of Piedmont, SC, Dr. Eric S. (Rebekah) Terrell of Florence; a brother, Lake Eric (Margaret) Terrell, III, Jacksonville, FL; a sister, Elaine T. (George) Goosmann of Asheville, NC; six grandchildren, Elizabeth Terrell, Julia Ruth Terrell, William Terrell, Alex Smith, Joshua Smith, and Benjamin Smith.

Funeral services will be held at 1:30 PM Thursday, February 5, 2009 in the First Presbyterian Church in Florence. Burial will follow at 3:30 PM Thursday in the Gable Cemetery near Gable, SC, directed by Stoudenmire-Dowling Funeral Home of Florence.

In Lieu of Flowers, memorials may be made to the McLeod Foundation, PO Box 100551, Florence, SC 29501 or to Faith PCA Church, 1800 Third Loop Road, Florence, SC 29501.

The family will receive friends from 7:00-9:00 PM Wednesday, February 4, 2009, at the funeral home.

My eulogy:
One of Dr. Terrell's heroes, R. L. Dabney, a theologian who served as Stonewall Jackson's chief of staff and biographer, wrote about his death before the end of the War that God had spared General Jackson the tragedy of seeing the defeat of the South. Perhaps Dr. Terrell has been spared seeing the final defeat of private medicine.

Dr. Terrell was a man of intensity, of intense love. He had an intense love for his God, whom He knew personally. He loved God and he loved God's Word, and he wanted others to share that love. He was a dedicated student of God's Word.

Dr. Terrell was a man of intense love for his family. He loved his wife and his children, and they sit here today as evidence of that love. He reared his children in the fear of God, and they are all successful in their walk with Jesus and in their accomplishments.

Dr. Terrell was a man of intense love for his work. He loved teaching and he loved practicing medicine. He was intense in his peculiar approach to the limitations of medicine, as many here can attest to.

He was a man of intense love for his State, for his boat and the sea, for his palms and citrus. On our last trip together last year, we stopped to visit a man in Louisiana with a large selection of citrus. He examined every leaf and every genealogy of those citrus trees.

But Dr. Terrell was also a man intense in his disdain, not for people but for false ideas. He disdained false views of medicine particularly. He restrained himself, but woe to the opponent who failed to notice the rising redness appear above his collar to cover his whole face, until he exploded with the attack, setting that barb right in the center of the false argument.

{[ Dr. Terrell had achieved a rare sense of peace about his work. He understood for years what I have only begun to understand: that medicine is no source of truth, that we are very limited in what we can do for a suffering person. He arrived at this conclusion because he was not content to limit his understanding of the good news of salvation to its initial acceptance but sought to bring every thought captive to Christ. He wanted to hear how God's Word governed our life and work. He bemoaned preaching that failed to spur us to better works and understanding.]}

We were to have gone together this weekend to the AAPS Board meeting. You have heard mention of this organization already from Dr. Payne. Dr. Terrell had the utmost respect for these people. They did not share his theological convictions nor have his comprehensive view of the limitations of medicine. He respected their patient persistence in fighting what to him seemed a hopeless battle for free medicine. They obviously respected him as he was president-elect.

I had thought to read or sing to you Psalm 90, a Psalm we discussed much for its implications for medicine. But as that has already been read, I will read Ps 15.

1

LORD, who may abide in Your tabernacle?
Who may dwell in Your holy hill?

2

He who walks uprightly,
And works righteousness,
And speaks the truth in his heart;

3

He who does not backbite with his tongue,
Nor does evil to his neighbour,
Nor does he take up a reproach against his friend;

4

In whose eyes a vile person is despised,
But he honours those who fear the LORD;
He who swears to his own hurt and does not change;

5

He who does not put out his money at usury,
Nor does he take a bribe against the innocent.
He who does these things shall never be moved.

Dr. Terrell was an immovable man.

As also mentioned in the previous post, I have avoided spending any precious time on the Statin studies, in large part because the basic premise and justification, upon which all these subsequent studies have built, is fatally flawed. There is perhaps a mild statistical significance in the decreased measures of heart or brain disease. But there is no meaningful improvement in these, and no improvement at all in overall mortality.

I will undoubtedly be challenged on that last statement. But I would refer you to Worried Sick or to Joel Kaufmann's articles and letters in JAPS especially this one.

Back to Jupiter. Basically, low risk patients older than 50 for men or 60 for women (why the difference? because that is the only way to make the results statistically significant) were screened for low cholesterol but elevated hsCRP (high-sensitivity C-reactive protein). Those qualifying (only 20% of those screened) were enrolled and put on very high doses of The Statin. (They knew from other studies with other statins that low doses would not show an effect.) These news items (I realize some of these links require a password, but you can't have opened your eyes in the last two months without seeing something about Jupiter) give a good idea of the significance of the study, which has been touted as "paradigm-changing" and "one of the most important clinical trials in the long history of statin studies."

But it rather is just another attempt in the long train of confused commercial/clinical jumbles. I do not fault the drug company in question for trying to create a new market for their very expensive drug. But when this is confused with good medicine, there are problems. The very minimal absolute risk reductions for so-called hard events (death, heart attack, and stroke) require treatment of 170 patients to prevent one yearly event.

At more than $100 per month, medication costs alone would exceed $300,000 per event per year (more than $500,000 to prevent a death). It is not that a price can be put on life. Rather, it is absurd to spend so much money for so little benefit. If you are spending your own money, you answer for that. If you are spending mine, quit.

Glossary: Expansion of Selected Trial Acronyms

CELESTIAL - Changes in ELEctrocardiographic Signs of Myocardial Ischemia: a TrIAL with rosuvastatin

COMETS - A Comparative study with rosuvastatin in subjects with METabolic Syndrome

DISCOVERY - Direct Statin COmparison of LDL-C Values: an Evaluation of Rosuvastatin therapY

LUNAR - Limiting UNdertreatment of lipids in ACS with Rosuvastatin

MERCURY I - Measuring Effective Reductions in Cholesterol Using Rosuvastatin therapY

MERCURY II - Measuring Effective Reductions in Cholesterol Using Rosuvastatin therapY

ORBITAL - Open label primary care study: Rosuvastatin Based compliance Initiatives linked To Achievement of LDL goals

STELLAR - Statin Therapies for Elevated Lipid Levels compared Across doses to Rosuvastatin

Notice that all the studies concern just one of the statins. The article also mentions other trials of different statins with less exciting names:

ENHANCE - Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression

SEAS - Simvastatin and Ezetimibe in Aortic Stenosis

The FPN Guidelines lay out some nice terminology distinguishing acuity (acute, subacute, chronic or recurrent acute) and source (bacterial or viral). The only point of value here is that 4 weeks is considered a normal duration for rhinosinusitis. Even up to 12 weeks doesn't earn you chronic status.

The big question here is whether antibiotics are helpful in purulent rhinosinusitis. It turns out that they are -- with an NNT of 15. Fifteen people have to be treated with antibiotics for one to be cured at 8 to 15 days after initiation of treatment. That means that 14 of those people receive no benefit from the time and expense of taking the antibiotics. Based on the risk of side effects, this PURL concludes that there is no indication for antibiotics in routine purulent rhinosinusitis. Which means that antibiotics are not helpful. (They do make an exception of course for those that are seriously ill.) However, there was a meta-analysis done the year before that shows an NNT of 7. The studies it was based on had advanced imaging and cultures to help distinguish viral from bacterial. Furthermore, the FPN Guidelines are based on the expert opinion, and no hard evidence, when recommending antibiotics if the patient doesn't improve in 7 days. The subsequent study by Young which the PURL evaluates trumps the expert opinion.

Another point that the PURL authors make well is that we have to know whether the study criteria apply to the patients we are treating. And that includes the question of how much work-up is reasonable for a common, irritating inconvenience like purulent rhinosinusitis.

Another very encouraging point is that there are FP researchers and editors who are not immediately taken in by an impressive sounding NNT, but will rather evaluate it in context.

For the sufferer, irrigation is recommended, as the best therapy to reduce the severity of the symptoms. And reassurance that it will get better. And an explanation that the reason the antibiotic did not work last time is that you were one of the 14, not the one.

Trouble is over 70% of patients still get the antibiotics.