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

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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.

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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.

Organic?

As we enjoyed the RHS show at Tatton Park, little did we realise how the average gardener and allotment enthusiast has suffered recently in switching from chemical fertilisers to “organic” regimes.

These escaped!

Tatton Park Royal Horticultural Show 2008

It would appear now that staying with simple chemical fertilisers may indeed have been better off for some.
The problem is with “organic” manure.

The Observer broke with the news a few weeks ago after gardeners approached the RHS and the government Pesticides Safety Directorate (PSD) with problems regarding distorted crops, particularly potatoes, tomatoes, peas, beans, carrots and lettuce.

Is any produce not affected?

“The Royal Horticultural Society (RHS) has been inundated with calls from concerned gardeners who have seen potatoes, beans, peas, carrots and salad vegetables wither or become grossly deformed. The society admitted that it had no idea of the extent of the problem, but said it appeared 'significant'. The affected gardens and allotments have been contaminated by manure originating from farms where the hormone-based herbicide aminopyralid has been sprayed on fields.”

I am not sure which is more palatable: deformed or withered. I doubt if I would eat either.

So the herbicide gets into hay, which is fed to farm animals, and the manure is now contaminated.

Dow AgroSciences, which manufactures aminopyralid, has posted on its website advice to allotment holders and gardeners. Dow was one of the companies that manufactured Agent Orange, the herbicide used in Vietnam.

“Aminopyralid is popular with farmers, who spray it on grassland because it controls weeds such as docks, thistles and nettles without affecting the grass around them. It binds itself to the woody tissue in the grass and only breaks down when exposed to bacteria in the soil.”

“Guy Barter, the RHS head of horticultural advisory services, said they were receiving more than 20 calls a week. He said, 'It is happening all over the country. A lot of cases we are seeing is where people have got manure from stables and the stables have bought their hay from a merchant, and the merchant might have bought hay from many farmers, possibly from different parts of the country. So they have no idea where the hay came from. So finding someone to blame is quite difficult.' Weedkiller in the soil should dissipate by next year, but in stacks of contaminated manure it might take two or more years to decay, he added.”

As the phenomenon is not localised I suspect we could be heading for another major food disaster.

First we had faked organic dishes, then 500 million faked organic eggs. Now manure.

Is anything safe anymore?

ADHD: Why?

I have in my travels met other psychiatrists who often ask why there is such a discrepancy in the diagnosis of ADHD in the US and the rest of the world.

WHY! 

Perhaps it is something they have in the diet.

Dietary causes have been popular for a while and we all know the kind of food American kids have.

 

Perhaps it is the television programmes they watch.            Scenes now change every few seconds – used to be every three minutes or so.

Perhaps it is something in their genetic make-up. But the US takes the gene pool from literally every country in the world.

Perhaps they have too many cars. But they took lead out before anybody even consider the harm lead can do.

What about vaccines? Please, we are not going there.

Up until recently American kids consume 90% of the world’s consumption of stimulants although Canada is now taking a bigger share.

The answer may not lie with environmental or genetic factors.

"Psychiatrists Top List in Drug Maker Gifts", reported the New York Times last year, citing disclosures by an unlikely state: Vermont.

I have been to Vermont and in the winter it is as beautiful as the photo shows.

“Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005.”

The Vermont Attorney General’s office’s report: Pharmaceutical Marketing Disclosures was issued recently (8^th of July).

Here is their top 10 drugs list:

Two ADHD drugs top the list.

Now we know.

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Bottled Water for Dogs and Birds

All is not well with the nuclear industry.

This time the mishap was not in Russia, but in France. During a draining operation at the nuclear treatment centre, about 75kg of uranium seeped into the ground and into the Gaffiere and Lauzon rivers which flow into the Rhône, according to the Guardian.

A field of sunflowers in front of the Areva Tricastin nuclear plant in in Bollene, in the south of France. Photograph: Fred Dufour/AFP/Getty images

After the incident there was a ban on drinking the groundwater, using it to water fields (as all local farmers do) or swimming or fishing in local lakes and streams. Men in green overalls from the nuclear site appear at local residents’ doors to collect the daily sample of water from their taps to analyse it for uranium. Levels have fluctuated daily.

A few days after the major incident, a tiny amount of lightly enriched uranium leaked but not beyond the plant. This week, about 100 staff at Tricastin's nuclear reactor number four were contaminated by radioactive particles that escaped from a pipe. EDF described the contamination as "slight".

The French government has now ordered tests on the groundwater around all nuclear sites in France. The environment minister, Jean-Louis Borloo, said there were 86 level-one nuclear incidents in France last year and 114 in 2006.

According to the Guardian, President Sarkozy recently announced that France will build a second new-generation nuclear reactor, a European pressurised water reactor or EPR. He said nuclear power was France's best answer to soaring energy prices and global warming. France is of course wanting to be a major player in the building of UK’s new generation of Nuclear Reactors.

For now the Rhone wine industry is under the shadow of the Tricastin leak. Coteaux du Tricastin wanted to change their name.

The locals continue to be cautious. To wash up, locals go out to the yard and fill a bowl from a specially delivered plastic tank of purified water on a fork-lift tractor. They carry the water up to the bathroom to wash.

Even the dog drinks bottled water, and the same is left out for the birds.

The File Snatching Sign

Not much in medicine is 100% and certainly not in Child Psychiatry.

The most recent addition to important medical signs is The Sleeping Husband Sign, which, according to the Happy Hospitalist, can predict the lack of acute major illness in the spouse 100% of the time. While this is obviously useful in Emergency Rooms, perhaps it is not so in the practice of Child Psychiatry.

However, I do have a similarly ideal tool to detect malingerers in our practice.

Child Psychiatry is one rotation in Psychiatry that often reduces grown men to jelly. All that you have learnt at medical school and afterwards is suddenly of no use at all. Many juniors do not have problems dealing with adult patients. When faced with a child, some feels like being thrown a scalpel and told to get on with an operation that he or she has never performed.

Where do I even begin this story?

We have juniors from all parts of the world. I being Chinese, ethnic doctors find it easy to bond with me. The truth is that we often still share the same family values.

Now this new doctor comes from a culture where you can only address your parents as father or mother, in your language of course. I point out to him that children in England seem to be on Christian name terms even with their parents. Five years after his consultant appointment, he finally starts calling me by my given name.

He agreed though that he would just have to accept little kids calling their parents Sharon or Kevin.

So Sharon brought this boy to see him. It happened to be his first ADHD assessment. He came out to see me after an hour. He did not think the boy suffered from ADHD but every answer Sharon gave on Conners would point to that diagnosis.

Just spend some time with the boy, I told him.

He did, but the outcome was not what I expected.

In conversation with him, the boy suddenly said, “Sharon is not my mum, my mum is Sheila.”

He went to the waiting area to challenge Sharon.

Sharon tried to snatch his file from him. Luckily he has good reflexes but before he knew both Sharon and the boy disappeared.

So there you have it: The File Snatching Sign – 100% accurate too.

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