A Brief History of Time: CPR (Cardiopulmonary Resuscitation)

In April, my good friend the cardiologist in California received an email from one of his friends on the subject of “New AHA rules for CPR finally released to the general public”.

It read:

“Thanks to you, I'd had a two year head start on this subject that's only this week published in the popular press. When you first advised me on it, I'd forwarded that info to all my friends. Believe it or not, a GI friend of mine actually saved a life at a wedding last year. Some elderly gent at his table suddenly collapsed to the floor without a pulse. He remembered the article I'd forwarded him and began vigorous CPR without giving mouth to mouth. That gent survived to thank him. Indirectly, of course, he's thanking you.”

My good friend has been interested in the subject of CPR for many years and provided me with some interesting material on the history of CPR, which I share with you below.

History in the Western World

1891: The first external cardiac massage in the Western world was reported to be done successfully by Friedrich Maass.

1960: Kowenhoven and Knickerbocker reported their method in JAMA that chest compression was accepted as a method of resuscitation for cardiac arrest.

1966: The first guideline for CPR was published.

1970: Teaching the lay public to do CPR was started.

1974: American Heart Association (AHA) formally promoted the practice involving the combination of rescue breathing and external cardiac massage for cardiac arrest in a ratio of 2:15.

2005: Ewy in Arizona showed that hands-only CPR, at a rate of 100 per minute until the emergency crew armed with automated cardiac defibrillators arrive, was superior to the traditional method of CPR.

My friend immediately drew the attention of his colleagues in Hong Kong to Ewy's work and suggested that the lay public should be taught this simplified method of CPR to encourage bystanders to give aid to victims of cardiac arrest. Many bystanders would otherwise be reluctant to help for fear of contracting AIDS through traditional mouth-to-mouth resuscitation to these strangers.

The AHA was hesitant to accept Ewy's idea in their new guidelines for CPR in 2005, but as a compromise, recommended a ratio of 2 breaths to 30 chest compressions instead.

2007: In March The Lancet reported a Japanese study on a series of over 4000 cases in Tokyo, comparing traditional CPR to hands-only CPR by bystanders. The results showed that the latter was more successful in the resuscitation of cardiac arrest with preservation of neurological function.

2008: In April, the AHA finally gave its approval on hands-only CPR from bystanders. The link has a video demo.

To date I could not find any hands-only CPR in NICE and the St John’s Ambulance site is still in the 2/30 era.

Luckily for the wedding guest, his friend did not wait for the AHA recommendation nor any British ones.

History in Traditional Chinese Medicine

403-221 BC: (Warring Kingdoms period) External cardiac massage was practised as a method of resuscitation for victims of suicide by hanging. Some credited this to Bian Que.

6 BC - 221 AD: (Eastern Han Dynasty) The first description of CPR for resuscitation of victims of hanging came from Zhang Zhongjing.

In his Essence of the Golden Chest, miscellaneous therapy #23, he described the method as follows: "Lower the victim gently, don't just cut the rope, and lie him on the blankets. One person should put his feet against the shoulders of the victim and pull on his hair, rendering it taut (to open the airway). One person should put his hands on the victim's chest and compress rhythmically (external cardiac massage). One person should flex and extend the victim's limbs (to promote venous return). One person should press on the victim's abdomen (to enhance intrathoracic pressure during external cardiac massage). ....This method is the best and usually successful."

Zhang Zhongjing's writings were handed down and read by Chinese physicians through the centuries.

1186-1249 AD: (Sung Dynasty) The above passage in Essence of the Golden Chest was cited by Sung Ci in his book on forensic medicine “Washing Away of Wrongs (Xi Yuan Ji Lu)”, which is recognized as the first book of forensic medicine in the world and has been translated into many languages both in Asia and Europe.

There is much we can learn from the past. One may even save a life.

Popular Posts:
Picasso and Tradition?
Teratoma: One Patient One Disease?
Teratoma: An Extract,
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
House M.D.: Modern Tyranny
House M.D. : 95% vs 5%

Golf Tour’s New Rule: Speak English to Stay in Play

The New York Times headline:

Golf Tour’s Rule: Speak English to Stay in Play

“Concerned about its appeal to sponsors, the women’s professional golf tour, which in recent years has been dominated by foreign-born players, has warned its members that they must become conversant in English by 2009 or face suspension.”

With 43 of the top 100 players in the LPGA from Korea, Taiwan, Japan and other countries in Asia, the LPGA must have employed some great lateral thinker.

If you cannot beat them in golf, make sure you can with a new rule.

The Cockroach Catcher checked the latest version of Rules of Golf from the Royal and Ancient and the USGA. Not there.

LPGA is different, my golfing partners told me this morning.

The trouble is that most of these young girls move to Florida anyway and in less than six months they can speak better English than any American player can speak Korean, Japanese or Mandarin.

Canada's Lorie Kane does not think LPGA's English rule is the answer:

"Right now we have an awful lot of tournaments internationally and a lot of them are in Asia. I don't speak any Asian languages. If we continue to play over there, are they going to require me to speak Korean?"

Luckily they did not have such rules in Psychiatry otherwise I would not have had the pleasure of listening to Anna Freud and a number of others with their heavy Viennese accent.

I can see that there will be a number of English language coaches prospering in Florida. What if you speak Scottish? Even I find that hard to understand sometimes.

What about Padraig Harrington?

Harrington is not playing in the LPGA.

Golf Posts:

Golf and Disability
Golf, Cholera and Tiger Woods
Ancient Remedy: Modern Outlook
Golf and Health
Tiger Woods and Breathing
Autism, the Brain and Tiger Woods

Psychiatry and Religion

The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers.

“According to old Chinese advice, it is wise never to discuss politics or religion even amongst best friends. Religious belief can often blur judgment in the wisest of people. In psychiatry it is sometimes not easy.”

I had this patient who was referred because the paediatrician thought she was catatonic. I admitted her to the paediatric ward of our cottage hospital.

“I was asked very early on by mother, although father did try to stop her, if this might be the work of the devil. She heard that the devil was always trying to do nasty things to anyone who had just become a Christian although she also heard that it could sometimes be God himself wanting to test her faith.

“When I reached the ward after my day’s clinic, Sister took me to the nursing station. She said the girl was either pregnant or she had a full bladder. A quick examination revealed a soft mass up her umbilical level.

How stupid of me. Remember: every female of child bearing age is pregnant until proved otherwise. Mother’s reassurance that she was not like the other girls fooled me. She must have found it difficult to tell her parents and therefore was in such a difficult psychiatric state. Faking mental illness would be one good way out.

I thought: great! At least I could deliver. Pregnancy test and OB consult and that would be it.

But hang on. Would mother not notice her sickness if she was this big? Would she not have complained about other symptoms? Something was not fitting in. And she still looked pre-pubescent.”

To cut the long story short she had a massive Teratoma which was removed. I thought she might have toxic psychosis secondary to the Teratoma.

“Neither of us knew what was to hit us next.

At 2 A.M. I had a call from my new junior.

“Your patient – I mean our patient could not be aroused after the operation. Yes they removed the Teratoma, complete and intact. It is bigger than any specimen I have seen but she could not be aroused. Any ideas?”

“Call the paediatrician on call in the regional paediatric unit and I will be in.”

What happened? I asked myself as I drove to the hospital.

What had we done? This was fast becoming a nightmare situation.

What was I going to say to the parents?

Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.”

We sent her to Great Ormond Street, arguably the best Children’s hospital in England if not the world.

Mother and her church were going to hold a vigil until she recovered.

“I was back at the hospital to deal with an overdose case. The junior was there and we had a chat in Sister’s office.

They had to ventilate her. That was the first thing she told me. I thanked her for going up there and she said it was scary but she felt important and the mother who was in the ambulance could not thank her enough.

She was impressed with mother’s faith and trust in God.

She said mother was near to tears. It was bad enough to have such a large Teratoma and then to have the patient unconscious with no one knowing what was going on was very frightening.

“I have seen some deaths as a medical student but never since I was registered. I do not want this to be my first.”

I knew the feeling well but what could I say? A doctor has to face it some time.

“Do you believe there is God?” She asked

“Do you really think I can answer that one?”

“Well, you have more experience.”

“To me it is like reading a good book. You would not know until the end.”

“So you mean I am not going to know until then.”

What can I say?

“Well. My view is this. We are here. We live. We help others to live and maybe we do not ask too many questions and we might or might not in the end know the answer.”

I left the hospital feeling slightly strange. I just had a philosophical encounter with a young doctor. How strange it is that threats of death always get one thinking about these things.”

Did she die?
“By the 23rd day, as my optimism was about to give in, word came from the hospital that she became conscious. It became big news in the papers.”

Post Script:
“Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.

I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often.”

Grand Rounds (4) 48, 49

Rural Doctoring Grand Rounds (4) 49

Shakespeare's Seven Ages of Man was the theme of this week's best medical blogs from around the world!

The blog is on Small-town Medicine in the Internet age and the Rural Doctor can really write. A lot of thought was indeed put into fitting in the best Medical Blogs around the globe.

Here is the quote from her Grand Round:

"The lean and slippered pantaloon should watch out for slubs in the carpet, because as he ages he's at more risk of slipping and breaking a bone, and the resulting MRSA osteomyelitis might just kill him. Read the Cockroach Catcher's take on the scenario."

Six Until Me: Grand Rounds (4) 48

A really good Diabetes Site. This week she uses a traditional library catalogue to present the best of Medical Blogs around the globe.
Mine is listed under 600: Technology and Applied Science.

"The Cockroach Catcher gives us a post about lithium to treat bipolar disorder, and how only time will tell if this is the best method."

Grand Rounds

OTHERS►►►

Anorexia Nervosa: Bach

In under an hour, Chinese cellist Jian Wang takes the stage of the Royal Albert Hall for the first three of Bach's six solo suites, works of towering technical accomplishment as well as intellectual and spiritual nourishment.

• Suite No.1 in G major for solo cello
• Suite No.2 in D minor for solo cello
• Suite No.3 in C major for solo cello

“Jiang Wang comments that 'Bach's music has a lot of qualities that appeal to the Chinese philosophy of life: to be humble, to wish but not desire, to love but not own. This is all in Chinese philosophy, and because I grew up with those values, these things are dear to me. When I listen to Bach's music, it confirms all of that.'” From the BBC website.

In The Cockroach Catcher Dr Zhang got his Anorectic patient to play the cello that was banned by the “weight gain contract”:

“She missed the cello too, the only thing she could use to shut out her worries.

Fourteen and carrying the burden of the world.

She played a couple of scales and we made some fine tuning. It was not quite the same as the violin, but at least I knew not to overdo the pegs. Then she started playing.

“Ah. The Bach G-major”

“So you know it”

Of course I do. The hours I spent listening to Yo Yo Ma and it was such amazing music, melancholic and uplifting at the same time. For a moment I forgot that I was her psychiatrist and she forgot she was my patient.

“My grandma gave me Casals.”

I knew Casals was even more emotional than Ma, but Ma is Chinese and he was less affecting, allowing the listener to tune in to his own mood.

She played from memory. What talent! What went wrong?”

Other Posts:
Anorexia Nervosa: Olanzapine (Zyprexa)-Veganism
Anorexia Nervosa: What If!
A Brief History of Time: Anorexia Nervosa
Anorexia Nervosa: a cult?

Hospital Infection: Quorum Sensing

This is the story of a much respected retired professor. As he celebrated his 82nd birthday, we have to be thankful that he must have some strong genes to have survived the last eight months. An unfortunate slip at home fractured one of his ankles, and as a pin was needed a surgical procedure was performed in a local hospital by the Orthopaedic surgeon. For the following eight months an otherwise independent and healthy eighty one year old had to suffer the indignity of many more hospital procedures because of a lingering infection.

“I don’t know” was his answer when we visited him and asked if it was the dreaded MRSA.

He was never tested!

Nearly 15 years since the discovery of Quorum Sensing by Nottingham University the topic seemed to be shrouded in some mystery. The Cockroach Catcher read about it by chance in an airline magazine and his own survey of some recent medical school graduates from Cambridge and Southampton indicated that this was not in their curriculum and they had never heard of it.

There is of course a Nottingham Quorum Sensing website and certainly Cambridge produced some research papers.

Why?

Bonnie Bassler said that all we knew about bacteriology in the last 300 years is all wrong. Strong words indeed. So are we still teaching medical students all the wrong stuff?

Is professional jealousy at work here? Surely not. But Quorum Sensing will itself lead to other exciting findings about the world of the microbe that has so far got the upper hand on the ever so clever Homo sapiens.

Think MRSA and C.difficile and I am sure you will agree.

I know that it is a new field and much of it theoretical and conjectural but I was a medical student once and the greatest buzz for me then was Heart Transplant, and VAMP treatment for some kind of leukaemia. So could we not let the future doctors have some excitement other than the 3G iPhone?

Surely we need to inspire some great brains to go where no men have gone before.

It is now well established that in France and Holland where hospitals do not run to capacity, they do not have the level of MRSA and C. difficile problem that we have here.

I do not think that is the result of them using some of the methods we have been known to use here, i.e. not testing the patients. Their standard of care is probably different and their wards are not as crowded.

We do seem to have lots of “good” lateral thinkers working in the NHS. In the meantime, our well loved professor has decided to move to sheltered housing. Months of struggling with his immobility and inability to go walking, swimming, shopping and getting on with his daily chores robbed him of his desire to be independent. But at least he survived.

What about his hospital manager? Did he or she get the bonus?
Popular Posts:
Picasso and Tradition?
Teratoma: One Patient One Disease?
Teratoma: An Extract,
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
House M.D.: Modern Tyranny
House M.D. : 95% vs 5%

To Ban Or Not To Ban: BPA

In an earlier POST I noted:
“Bottled water had an average 160 ppt of antimony when opened immediately after bottling. But ground water stored in a PET plastic bottle had 630 ppt of antimony when opened six months later.”

Globe and Mail

In April the Canadian Government moved to ban BPA (Bisphenol A) in all baby bottles. A first step by any government to do so and now the first State in the US to do this might well be California as the LA Times reported:

"Californian lawmakers weigh ban on chemical found in baby bottles, although danger is in dispute."
Now the BPA coating is also used in canned food for sometime and there were concerns it might be implicated in prostate cancer especially for babies exposed to BPA (a long lead time, you might think). Perhaps having baby food with lids lined with BPA is not such a clever idea after all.

“Wal-Mart Stores Inc. and Toys ‘R’ Us Inc. say they will stop selling baby bottles made with the chemical next year, and the maker of the hard-plastic Nalgene water bottles announced in April that it would stop using the chemical."

At least 11 other states have considered bills to restrict it.

“California's bill was approved earlier this year by the state Senate and it is awaiting a vote by the Assembly. It's not yet clear whether Gov. Arnold Schwarzenegger will sign it if the Legislature sends it to him.”

In the latest twist the Associated Press reported:

“FDA scientists said the trace amounts of bisphenol A that leach out of food containers are not a threat to infants or adults."

It is interesting that the evidence is supplied by the industry:
"'It's ironic FDA would choose to ignore dozens of studies funded by NIH(the National Institutes of Health) — this country's best scientists — and instead rely on flawed studies from industry,' said Pete Myers, chief scientist for Environmental Health Sciences." AP continued.
I wonder if FDA's Acting Commissioner Andrew von Eschenbach will be following Daniel Troy, (a former chief counsel at the FDA, as Glaxo’s new general counsel as reported by the the WSJ) and move to American Chemistry Council?
Or will the Terminator ban BPA anyway? Lets wait and see.

Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here.      It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.

The following is an extract from The Cockroach Catcher:

“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”

“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”

Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.

“Get him admitted and I shall talk to the doctor there.”

He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.

He had one of the worst encephalitis they had seen in recent times and they were surprised he survived.

Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.

Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.

I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.

Some parents question the wisdom of using a toxic drug for a condition where suicide risk is high. My answer can only be that lithium seems inherently able to reduce that desire to kill oneself, more than the other mood stabilizers, as the latest Harvard research shows.

Lithium has its problems – toxic at a high level and useless at a low one, although the last point is debatable as younger people seem to do well at below the lower limit of therapeutic range.

Many doctors no longer have the experience of its use and may lose heart as the patient slowly builds up the level of lithium at the cellular level. The blood level is a safeguard against toxicity and anyone starting on lithium will have to wait at least three to four weeks for its effect to kick in. In fact the effect does not kick in, but just fades in if you get the drift.

Long term problems are mainly those of the thyroid and thyroid functions must be monitored closely more so if there is a family history of thyroid problems. Kidney dysfunction seldom occurs with the Child Psychiatrist’s age group but is a well known long term risk.

Also if there is any condition that causes electrolyte upset, such as diarrhea, vomiting and severe dehydration, the doctor must be alerted to the fact that the patient is on Lithium.

Could Lithium be the Aspirin of Psychiatry? Only time will tell!

Latest: British Journal of Psychiatry

Related Posts:

Chile: Salar de Atacama & Bipolar Disorder.

Lithium Bipolar and Nanking
Bipolar Disorder in Children
Bipolar and ADHD: Boys and Breasts
Bipolar Disorder: Biederman Einstein God.
Antipsychotics: Really?
Bipolar and ADHD: Boys and Breasts

NHS: The Way We Were! Free!
FREE eBook: Just drop me a line with your email.

Email: cockroachcatcher (at) gmail (dot) com.

Medical Humanities Grand Rounds (4) 47

This week's selection of the best in Medical Blogs around the world is at Medical Humanities Blog.

The BMJ unfortunately came in for some satirical plod in EBM.
"We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute."
Would NICE people like to participate, I wonder.

A Better Alternative would be Science-based medicine (SBM), wherein basic science is placed a lot higher on the food chain of evidence. What would our Prince think!

The Cockroach Catcher details some of the latest goings-on in the Alaska-Zyprexa litigation. There's also good coverage of this over at the Clin Psych Blog, and at Furious Seasons.

The always-interesting Dr. Rich assails the use of guidelines in clinical practice. Of course, the many problems with guidelines hardly suggest that practitioners ought to eschew trying to understand what the best evidence is in formulating interventions. These problems do suggest some important considerations in thinking about what constitutes good evidence. The trouble is they cannot take money out of it in the US.

The Olympics is happening now so Jolie Bookspan talks about performance enhancement, and performance in general. James Logan addresses the complicated issue of doping in international sports. How many Canadian gold medals will there be with such medical support?

Happy reading.

Grand Rounds

OTHERS►►►

Maggots vs Superbugs

The Cockroach Catcher caught maggots this time.

Swansea University

Maggots live in some of the most disgusting conditions imaginable and never get ill. Nobody ever asked why until these scientists in Swansea University in Wales decided to have a look.

Surprise, surprise they produce an antibiotic that halts the growth of bacteria or even kills them.

From the Swansea University Press Release:

“Using live maggots on infected wounds is an age-old method of tackling infection and they work with amazing speed. It’s not uncommon for someone to suffer from chronic infected wounds for 18 months, despite all sorts of conventional treatment, but when maggots are applied to the same wound they can often begin to clear infection in just a few days. They have even been known to save people from having limbs amputated.

“The antibiotic, named Seraticin™, is derived from the maggot secretions of the common green bottle fly (Lucilia sericata) and scientists hope to develop it into an injection, pill or ointment.”

Right now Seraticin™ can tackle up to 12 different strains of MRSA, as well as E. coli and C. difficile

“Maggots are great little multi-taskers. They produce enzymes that clean wounds, they make a wound more alkaline which may slow bacterial growth and finally they produce a range of antibacterial chemicals that stop the bacteria growing.”

In my book The Cockroach Catcher I lamented:
".......Nearly all Medical Schools in England no longer specify biology as a prerequisite subject for anybody who wishes to embark on the study of the human body. As we are so intertwined with the rest of the living biological world I find this policy quite extraordinary....."
On the other hand, Johns Hopkins Medical School still requires Biology so did the majority of US medical schools.

Perhaps some Medical Schools will now change their requirements. Go easy with the pesticide spray too.

Global Warming: Wine

Ch. Lynch Bages Web Site

The 2005 Ch. Lynch Bages is now commanding a very high price for good reasons. There are rumours that 2005 may well be one of the best vintages in recent times for that part of the world.

Good French Wine is still the favourite of the Cockroach Catcher and his family.

There is a need to find some good value wines.

Global warming may indeed be offering some help here.

I do not propose to argue if humans are the only culprit in causing climate change. It is now common knowledge that most governments have a vested interest and will promote a theory that will let them collect more money, or one that will avoid them large expenditures.

Science in the modern era no longer comes under the control of the Church, not in the way it was in Galileo’s days anyway. Unfortunately money is the new religion and many have questioned the claims by scientists working in the field of climate change.

From the little I know, sun activity is still the dominant influence of planet temperature. Pluto, despite moving away from the sun, has been noted to be warming. The major contribution by humans is in fact nuclear bomb testing. Earth’s own natural contribution is of course volcanic activities.

Before we become the next Dinosaur on the road to extinction, we may be in for a treat as far as wine is concerned.

This time back to France.

As we all know, many other countries produce good wine and France has suffered in recent years from the weather, high labour cost and reluctance to move with the times. They can do with some help as far as weather is concerned. I am all for it, as their good wines can still be very good in the good years. The microclimate and the soil (terroir in wine terminology) can work magically to give us the complexity that many new world wines never come close.

There is little doubt that the hot years give Bordeaux their best vintages. What ultimately determines yield and quality is of course not just high summer temperature, but a combination of factors such as late spring frost and how dry it is in the days leading up to vintage time. Burgundy is a different story as Pinot Noir needs to struggle with the weather to develop that beautiful bouquet.

Sheer sunshine is simply not enough.

As for Alsace and Rhone, we really do not want the alcohol content to go any higher, 15% or above is just too much alcohol for one to savour the subtlety of the marvelous grape varieties of those regions. Some wines are reaching 16% now!

So global warming will at least give us some good wines although there are some who is predicting that temperature is going to be lower in 2008 thus signally the start of our planet’s cooling cycle.

The great find in recent times is from the eastern edge of Bordeaux: Château d'Aiguilhe.

Ch. d'Aiguilhe Web Photo

Their main wine will require at least an hour of breathing and is at its peak after three hours. This is probably due to the tannin's properties.

"It exhibits a dense purple color as well as a big, sweet nose of scorched earth, blackberries, underbrush, cherries, and smoke. Layered, opulent, powerful, and rich, with its tannin character well-hidden by abundant fruit, it should drink well for 10-12 years. It is another example of this backwater appellation producing a wine that transcends its pedigree."                                                      Robert Parker

"This powerful wine reflects its terroir with intensity and panache. Vigorous and fruity, it is a favourite of people who love wines of character."

                                                                                                           Stephan von Neipperg

The great value is their second wine: Seigneurs d'Aiguilhe 2005.

It is so full of character that you will need to forget the price you are being charged. It has a fine nose, very soft but assertive tannin and has the lingering finish of a more expensive wine without the need to wait for years for it to open up: just the right thing to do with second wines. You simply can taste the care that is put into the wine making process and a reminder of what the First Wine is about. The clay-limestone soil, 30 year old vines and the weather of 2005 all helped.
It has a nicer price tag too! Check it out.

Alaska Zyprexa: Follow Up

My guru warned me years ago that anyone who wrote a long psychiatric report must be trying to hide something. I have in my time seen reports over 70 pages or more, often from psychiatrists acting in a private capacity. Independent expert opinion is indeed subjective, and none more so than arguments in the courts of law on psychiatric matters.

This is a follow up to my earlier post on Alaska, Good Friday Earthquake and Zyprexa.

In March Eli Lilly settled the Zyprexa case for $15 million, according to the New York Times. (Alaska v. Eli Lilly and Co., 3AN-06-05630 CI, Alaska Superior Court, Anchorage District)

Bloomberg News filed a motion to unseal all the documents related to the case and was granted the motion in July. They reported:

Lilly Trained Sales Force to Ignore Drug's Risks (Update2)

“Eli Lilly & Co. trained its sales force to downplay risks for Zyprexa and encourage doctors to prescribe the drug beyond approved uses for schizophrenia and bipolar disorder, according to court documents.

“Lilly's research showed some patients on Zyprexa gained as much as 80 pounds and that the incidence of high blood sugar at diabetes levels was 3.5 times higher than for placebos, according to documents filed in a lawsuit brought by the state of Alaska.”

“We believe it is essential to weaken this link to neutralize the diabetes/hyperglycemia issue,'' the company said in the sales document, which was provided for the Alaska case. “Neutralizing any concern from our customers will be essential to the future growth of Zyprexa in the marketplace.''

Strong words indeed, sounds more like a task for Bond. Psychiatrists better watch out.

But this is not just about psychiatrists.

“Zyprexa became the company's top-selling drug, with $4.76 billion in sales last year -- about a quarter of Lilly's revenue. Company sales representatives disputed or ignored the risks and pursued primary-care and nursing-home doctors as well as psychiatrists.”

There were more than 20 million pages of submission. 20 million pages!!!

How did Bloomberg sieve through 20 million pages? Good job, Bloomberg.

Lilly faces suits by nine other states alleging failure to warn and improper marketing, separate consumer-protection investigations in about 30 other states and an investigation of off-label marketing by the U.S. Attorney in Philadelphia.

“Lilly pushed Zyprexa sales to primary care physicians and doctors in nursing homes for patients who weren't diagnosed with schizophrenia or bipolar disorder, according to complaints filed by Montana and Mississippi.”

Those interested may like to read the full Bloomberg account.

There are some gems in the quotes:

“Zyprexa's attributes line up so beautifully in the elderly,'' Alan Breier, then-team manager for the drug, told the group. “The need for better treatment in Alzheimer's and other elderly conditions is so paramount and so key.''

But Zyprexa wasn't approved for use with Alzheimer's or for elderly conditions.

“He's talking about the characteristics of the molecule which might make it a good agent for Alzheimer's,'' Sidney Taurel, current Chairman testified. "He was not giving them instructions as to what to do the next day in the field.''

Very smart answer indeed. But that is not the end of it.

“The doctor's thinking that he does not see a schizophrenic or bipolar patient,'' Bandick said in a December 2000 internal e- mail to the marketing department. “But he probably does see patients with symptoms of behavior, mood and thought disturbances,'' he wrote. "Even if the doctor does not have diagnosis, he should treat anyway.''

It was not until October 2007 when Lilly finally added to its packaging a warning about weight gain.

Documents show that in 2002, the Zyprexa sales force was advised:

“We will NOT proactively address the diabetes concern.”

An in true Olympian spirit, they proclaimed:

“The competition wins if we are distracted into talking about diabetes.”

Let us wait and see what the judges in other States think. The earthquake in Alaska happened a while ago but this one may rumble on a bit longer.

We doctors must continue to resist being badgered, coerced and manipulated by pharmaceutical sales reps.

☺☻☺☻This Week in Mentalists (41)

◄◄◄Similar Posts OTHERS►►►

Popular Posts:
Picasso and Tradition?
Teratoma: One Patient One Disease?
Teratoma: An Extract,
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
House M.D.: Modern Tyranny
House M.D. : 95% vs 5%

Evidence Based Medicine: Whose Evidence?

The Story Behind Senator Kennedy’s Surgery

A recent article in The New York Times analysed the medical world with reference to the case of one of the most famous patients, Senator Kennedy’s brain tumour.

Evidence based medicine is now the cornerstone of medical practice but unfortunately it has been hijacked by politicians in their attempt to control cost and to control doctors.

I have always maintained that we need to strike a balance between sound evidence and the need to make progress. Progress in medicine cannot be achieved if we are ideologically stuck with outdated evidence and worse, evidence that suited politicians. In recent times this has led to gross discrepancies across countries in the treatment of Alzheimer, lung and breast cancer, where some treatments have been accepted by other developed countries including USA and France, but not in U.K.

Sometimes acceptance seems to depend on where the evidence originates from. For some time when Europe was merrily using Clozapine for schizophrenia, the US was still humm’ing and hah’ing to the point that there were grey imports of the said drug.

Those entering the medical profession must realize sooner or later that we can only make progress if we keep an open mind and refrain from being dogmatically stuck with old ways.

Now it is interesting when a politician falls ill with something serious. It is unclear what exactly Senator Kennedy’s brain tumour was but from all the information in the public domain it is safe to say it was a glioma and most likely glioblastoma.

As the third longest serving Senator in America’s history and chairman of the Senate’s health committee, he can certainly pull strings. He was not going to listen to just one doctor from Massachusetts General Hospital and accept that operation was out of the question. That conclusion was based on their interpretation of the evidence. He was able to get a number of eminent doctors across the whole country, some flying into Boston and others on the phone, for what amounted to a top level medical conference.

The result? The New York Times reported,

“Two weeks later, Mr. Kennedy, 76, flew to Durham, N.C. There, at Duke University on June 2, neurosurgeons operated for three and a half hours and declared the procedure ‘successful,’ though they did not specify their criteria.

“Whether the surgery was justified or not, that Mr. Kennedy had it at Duke embarrassed the Massachusetts General Hospital, a Harvard teaching institution. The change in venue strongly suggests that the meeting somehow led to the more aggressive surgical approach.

“Senator Kennedy has had a track record of being thorough and diligent in researching medical options when relatives or friends have fallen ill.” These included two of his own children and for both he helped them choose a more aggressive route. Both seemed to have done well, according to the New York Times.

Is this new approach going to be an adopted practice, I have my doubts. For the influential, EBM has a different slant and perhaps a different meaning: evidence from a number of top doctors and the patient gets to pick what he sees as the best treatment option.

It pays to be a Senator, I suppose.

Edwin Leap: Grand Rounds

MedBlogs Grand Rounds 4(45). ‘Why do we do it?’
29 July, 2008
My post was picked and it also impressed someone in Colorado

“For more on how listening - even when what is being said sounds improbable - is an important skill, check out the Cockroach Catcher’s post about a talking yucca and a stowaway family of tarantulas.”

Monash Medical Student continued with House revisions. This time ECHO. Not everything is MRSA or C. diff.

Dr Bongi of South Africa will probably be living in the hospital from now on.

I do not have shares in Wii, but having tried it recently it was interesting to read the blog. I was hoping my golf game will improve.

Don’t miss Rural Doctoring, have some Kleenex ready.

It took me a while to read through the whole thing and realised it is Friday.