Sunday, 29 March 2015

Patient Privacy - my eye!

                The Electronic Medical Record, of which I was an unequivocal supporter for many years is causing me increasing concern.  The very concept of patient privacy, regarding which we pretend to be fervently committed, is now not much more than pretense.   I would go so far as to say there is no longer any.    When the innermost secrets of the Department of Defense, the Government and Target can be easily hacked into, getting into medical records is child's play.  Every physician knows that and so does every administridiot in the Department of Health.   Although the rationale behind EMR was improvement of health care, there seems to be little evidence to support that thesis, in fact suggestions have been made that the doctor - patient relationship has deteriorated  as a result of the effort and concentration to  input and  retrieve data to and from the machine.  Much of that data is not directly related to the health care of the patient.   All of that data will be available forever and because of the omnipresent data-gathering applications it will be linked to applications such as facebook, linked in, inquiries that you make to medical and other health  related sites on the internet, as well as sites not directly related to health, such as the increasingly ubiquitous observation cameras.
                 Data Brokers have a goldmine in the sale of sensitive material, regardless of the use to which it may be put.   Experian is a global information services group with operations in 40 countries.  Initially a credit rating company, it has now morphed into something quite different.  The company collects information on people, businesses, motor vehicles and insurance. It also collects 'lifestyle' data from on and off line surveys.  The company sells personal information and it is very likely that it sometimes includes medical data too.
                The Government also likes to have as much information available on its citizens as possible, partly so that it can be aware of individuals or groups likely to cause it problems.   As George Orwell said in '1984', "We know that no one ever seizes power with the idea of relinquishing it."    Government will use whatever means it can to remain in  power.  The greatest source of power is information. Organizations like Experian are likely to proliferate greatly.   Your health care history will be one of the more easily accessed sources of information.
               So don't be surprised when people keep their health issues secret when they perceive that revealing them may have a deleterious effect on their job, or life in general.  That reluctance to seek treatment because of fear of failure of medical  confidentiality may be one of the main reasons deterring some patients from seeking  help.

Tuesday, 24 March 2015

Testosterone- again!


         Manufacturers of prescription testosterone products must change their drug labels to include a warning about increased risk of heart attacks and strokes.

         The change, announced today by the US Food and Drug Administration (FDA) addresses the use of testosterone by men whose decreased level of the hormone is due to aging. The warning requirement could erode a multi-billion-dollar market for testosterone replacement products for men whose main concerns are more lifestyle than medical.

          “Based on the available evidence from studies and expert input from an FDA advisory committee meeting [on Dec. 18, 2014 ] the FDA has concluded that there is a possible increased cardiovascular risk associated with testosterone use,” the FDA announcement said.

          “These studies included aging men treated with testosterone” and some reports in those studied that found an increased risk of such events, including death.

            Like estrogen replacement for menopausal women, testosterone therapy does reverse some effects of hormone loss due to aging, but carries health risks.
The FDA announcement noted that testosterone is being widely prescribed as an anti-aging remedy for men.

           Testosterone is FDA-approved only when low levels are due to “disorders of the testicles, pituitary gland, or brain that cause hypogonadism” and not “for no apparent reason other than aging.”
           There is much hyperbole in  the advertizing that needs to be curtailed and that probably will be in due course when a negative outcomes lead to litigation.   In the meantime the billions will continue to roll in!
           According to Medical Marketing & Media, among the more successful marketing campaigns is AbbVie’s “Low-T” campaign for AndroGel. The product had $1.37 billion in sales in the 12 months ending Oct. 31, 2013, making it the market leader.

          Manufacturers offer testosterone replacement in gels, injections, implants and transdermal patches.


- See more at: http://www.hcplive.com/product-news/FDA-Warning-Testosterone-Can-Kill#sthash.00I7ZqHU.dpuf


Manufacturers of prescription testosterone products must change their drug labels to include a warning about increased risk of heart attacks and strokes.

The change, announced today by the US Food and Drug Administration (FDA) addresses the use of testosterone by men whose decreased level of the hormone is due to aging. The warning requirement could erode a multi-billion-dollar market for testosterone replacement products for men whose main concerns are more lifestyle than medical.

“Based on the available evidence from studies and expert input from an FDA advisory committee meeting [on Dec. 18, 2014 ] the FDA has concluded that there is a possible increased cardiovascular risk associated with testosterone use,” the FDA announcement said.

“These studies included aging men treated with testosterone” and some reports in those studied that found an increased risk of such events, including death.

Like estrogen replacement for menopausal women, testosterone therapy does reverse some effects of hormone loss due to aging, but carries health risks.
The FDA announcement noted that testosterone is being widely prescribed as an anti-aging remedy for men.

Testosterone is FDA-approved only when low levels are due to “disorders of the testicles, pituitary gland, or brain that cause hypogonadism” and not “for no apparent reason other than aging.”

According to Medical Marketing & Media, among the more successful marketing campaigns is AbbVie’s “Low-T” campaign for AndroGel. The product had $1.37 billion in sales in the 12 months ending Oct. 31, 2013, making it the market leader.

Manufacturers offer testosterone replacement in gels, injections, implants and transdermal patches.


- See more at: http://www.hcplive.com/product-news/FDA-Warning-Testosterone-Can-Kill#sthash.00I7ZqHU.dpuf
Manufacturers of prescription testosterone products must change their drug labels to include a warning about increased risk of heart attacks and strokes.

The change, announced today by the US Food and Drug Administration (FDA) addresses the use of testosterone by men whose decreased level of the hormone is due to aging. The warning requirement could erode a multi-billion-dollar market for testosterone replacement products for men whose main concerns are more lifestyle than medical.

“Based on the available evidence from studies and expert input from an FDA advisory committee meeting [on Dec. 18, 2014 ] the FDA has concluded that there is a possible increased cardiovascular risk associated with testosterone use,” the FDA announcement said.

“These studies included aging men treated with testosterone” and some reports in those studied that found an increased risk of such events, including death.

Like estrogen replacement for menopausal women, testosterone therapy does reverse some effects of hormone loss due to aging, but carries health risks.
The FDA announcement noted that testosterone is being widely prescribed as an anti-aging remedy for men.

Testosterone is FDA-approved only when low levels are due to “disorders of the testicles, pituitary gland, or brain that cause hypogonadism” and not “for no apparent reason other than aging.”

According to Medical Marketing & Media, among the more successful marketing campaigns is AbbVie’s “Low-T” campaign for AndroGel. The product had $1.37 billion in sales in the 12 months ending Oct. 31, 2013, making it the market leader.

Manufacturers offer testosterone replacement in gels, injections, implants and transdermal patches.


- See more at: http://www.hcplive.com/product-news/FDA-Warning-Testosterone-Can-Kill#sthash.00I7ZqHU.dpuf

Wednesday, 18 March 2015

Vaping versus Varenicline!


                 The U.S. Food and Drug Administration (FDA) is warning that the prescription smoking cessation medicine Chantix (varenicline) / Champix in Canada can change the way people react to alcohol. In addition, rare accounts of seizures in patients treated with Chantix have been reported.  Various psychiatric symptoms have also been reported. They have approved changes to the Chantix label to warn about these risks. Until patients know how Chantix affects their ability to tolerate alcohol, they should decrease the amount of alcohol they drink. Patients who have a seizure while taking Chantix should stop the medicine and seek medical attention immediately.
              Millions of Americans have serious health problems caused by smoking, which can be reduced by quitting.  Chantix is a prescription medicine that is FDA-approved to help adults quit smoking. In clinical trials, Chantix increased the likelihood of quitting smoking and “staying quit” for as long as 1 year compared to treatment with a placebo, an inactive treatment.
                 It is  somewhat ironic that Chantix/ Champix  is widely accepted despite its recognized dangers, while vaping, which seems to be relatively innocuous so far, is looked upon disapprovingly by many.
                Could it be that the witch hunt is so much fun that anything that even looks like a cigarette should be hunted down even if it helps people to quit smoking?
                    
                       Tell me what you think!

Saturday, 14 March 2015

3D Printing and Health.

         3D printing is a process to make a three dimensional object by printing it.  The process consists of laying down successive layers until the complete object is created - or printed.  Particles of plastic, metal, ceramic or glass powders are fused by laser into the desired shape.   Fascinating as 3D printing is for a huge variety of engineering and artistic endeavors, none in my opinion matches its potential for use in medicine and healthcare.
       Tissue printing is likely to be the most exciting use of  3D printing in the foreseeable future.

           In 2012  a baby was born with a rare condition called tracheobronchomalacia: the tissue of one portion of his airway was so weak that it persistently collapsed. This made breathing very difficult, and it regularly blocked vital blood vessels nearby, including the aorta, triggering cardiac and pulmonary arrest. The infant was placed on a ventilator, while the medical team set about figuring out what to do. The area of weak tissue would somehow need to be repaired or replaced—a major and dangerous operation in so small a patient.  The medical team constructed a replacement splint that would eventually dissolve using 3D printing. In May of 2013, in The New England Journal of Medicine, the researchers reported that the boy was thriving and that “no unforeseen problems related to the splint have arisen.       
             '
         Surgeons in Wales used a 3-D printer to reconstruct the facial bones of a twenty-nine-year-old man named Stephen Power, who fractured his left cheekbone, eye sockets, upper jaw, and skull in a motorcycle accident. The medical team scanned Power’s skull and, based on the unbroken bones, determined what his full facial structure should be. They then printed a replica in titanium and successfully implanted it.
        
        3D printing has been aiding doctors prepare for numerous surgeries by providing highly-detailed, patient specific models to better inform surgeons and practice before entering the operating room.
Artificial tissue has always lacked a key ingredient: blood vessels. A new 3-D printing technique seems poised to change that.
           
The range of uses for three-dimensional printers is increasing all the time, but now scientists are developing 3D "bioprinters" that will be able to print out skin, cartilage, bone, and other body parts.

Read more at: http://phys.org/news/2011-02-3d-bio-printers-skin-body.html#jCp
         The exVive3D Liver Model is not big enough to be considered an organ, but works in the same way that a real liver might and lives for up to 40 days or longer, making it ideal for testing the toxicity of new medications on human liver tissue.  Organovo points out that “Since 2007, 16 drugs have been withdrawn from the market due to safety issues. It costs more than $1 billion and takes more than 12 years to bring a drug to market.” Current 2D liver assays can’t provide a realistic environment for testing purposes and die in only a few days.  In their retrospective study, however, Roche and Organovo found that only the exVive was able to identify a formerly FDA-approved drug, later removed from the market, as toxic.
        Organovo CEO, Keith Murphy, said of the new product, “Pharma companies can use our bioprinted liver tissue to weed out toxic drugs early in drug development rather than after they have failed expensive clinical trials.”  One day, such products could, in addition to improving drug safety, bypass the need for animal testing in medicine research as well.
         
          Prosthetics. Many prosthetics have been modeled using 3D printing to custom make parts that are extremely difficult to fit and manufacture by less precise methods.   

           Many of these processes  are well demonstrated in youtube video clips.  Well worth viewing to see what is going on in this cutting edge area of medicine.




Wednesday, 11 March 2015

The Pathologist. Pt 3.

 

            By the time we had done a half dozen autopsies or so we had a pretty smooth working relationship.        I now understood what Jim was talking about when he mentioned the 'fast way'.  While both methods achieved the same results, the 'fast way' was a good deal less delicate than the careful dissection carried out by Dr. McMurray.  In fact it relied more on brute strength than skill.  After Jim used the electric saw to remove the sternum and the anterior part of the ribs, the technique consisted of tying off all the structures at the highest possible level before cutting them. They were also cut just above the diaphragm after being tied off there.  No fine dissection here. I just grasped all the structures in both hands and then with all my strength gave a mighty tug, removing all of the structures out of the chest cavity simultaneously.  Not very elegant, but effective.  We then went on to examine and section the individual  organs looking for pathology.

              The extra stipend made a big difference.  Even after I gave Jim his twenty - five shillings, if we did a couple of autopsies each week, it still added up to more than my regular paltry pay and I certainly needed anything extra I could earn.  All the money that Irene and I had saved from playing at Dublin's Paradiso nightclub, and from selling all our possessions, including her beloved piano was almost gone.  

            My old friend, from my undergraduate days,  Arthur, kept in touch and we went out for coffee once in a while to compare personal as well as professional notes.

          "Thank god I have that extra few pounds a month coming in from the autopsies.  At least that keeps us eating and pays the rent."I  said.

             "Sounds like a good deal,"  responded Arthur,  "I know we are having a really tough time at my hospital as well, because of the current pathologist shortage. I've heard some of residents complaining that they're expected to do autopsies and that they haven't faintest idea about how to go about it.  Maybe you  could come over and do them and I'd assist you and we could split the fee."

               "I could sure use the extra dough," I said, "The extra I'm  earning doing these autopsies just about make it possible for us to survive."

                "yes, you had some pretty bad luck.  But don't worry, things will  get better."

                 Over the next few months, Art called me several times to come over and do an autopsy.  By  this time, I was starting to consider myself a bit of an expert at the autopsy game.   As so often  happens when one arrives at that conclusion, events prove otherwise.

            The midnight DOA had been scheduled for postmortem at eight the following morning.  A forty-five year old man who had collapsed at home, just before midnight, as he was getting into bed.  Attempts to resuscitate him in the emergency department failed.   Jim and I went through the usual routine without finding any cause of death.

            "There has to be a cause of death, Doc, you've got to find something.  This is a coroner's case and there's got to be a cause of death  on the birth certificate, otherwise the fella can't be buried."

            "You're right, Jim, but you saw how carefully I've looked.  This type of death from heart attack is almost always due to coronary thrombosis.  I've sectioned the arteries really carefully and can't find anything that remotely resembles a clot."

            "Then we'll just have to have the coroner come over and see what he has to suggest." Jim said.

            "Yes, I suppose so," said I.   

             I phoned the coroner's office, and spoke to Dr.Murphy, the city coroner, both a physician and a lawyer.

            "Did you section those coronaries carefully?" he asked me. "Sounds like a classical coronary thrombosis."

            "Yes, I did," said I, "and found nothing."

             "Ah, it must be there," said the coroner.  I'll be right over."

             Jim and I set out all the specimens for Dr. Murphy's inspection.

            About a half hour later, Dr.Murphy arrived.  A distinguished, gray-haired man in his middle fifties, he lit a cigarette, pulled on a pair of rubber gloves started examining the specimens.

            "Make sure to send away the gastric contents to be analyzed and make sure he wasn't poisoned deliberately or accidentally.  I don't see anything much here,"  he remarked as he examined the liver, kidney and spleen. 

            Let's take a careful look at those coronary arteries."

             He flicked the long ash off his cigarette and lit a new one from it's stub.  He held out his hand for the heart.

            I handed him the heart with its neatly sectioned coronary arteries.

            "I've looked really carefully, sir, and can't see any abnormality."

            Dr. Murphy took the heart in  his hand  looked at it for a while, and said,

"let me have that scalpel for a minute.  I don't think you've sectioned the coronary arteries quite closely enough."

            He took the scalpel and started to section the arteries with closer cuts.

            "Ah, here it is, see it?" he exclaimed, pointing with the bayonet tip of the scalpel, at the lumen of the anterior descending branch of the left coronary artery.

            "No sir," I said, "I don't see anything."

            "Look man, right there," he said, somewhat irritably, jabbing the scalpel at an area in the artery.  "I'll section another area there.  Now you can see it?" he demanded.

            I  nodded miserably, not sure that I could see anything out of the ordinary and feeling quite inadequate on  that account.

            "Now you can put on the death certificate acute coronary thrombosis."

            He peeled off his gloves and groped anxiously through his pockets until he found his cigarettes.  He stuck one in his mouth, lit up and took a deep drag.  He smiled benevolently, as the tobacco alkaloids crossed the blood-brain barrier and produced the desired effects.

            "Good lad, Smith," he said kindly, "I hope that this has provided a valuable learning experience for you.  You'll know what to do the next time, eh?"

            "Yes sir," I said, and never called the chief coroner again.

Saturday, 7 March 2015

Death by Prescription. Pt 5.

Death by prescription.

          Finally and long overdue the Canadian Medical Association has spoken.  I suspect it was urged to do so by a significant portion of its membership.  This is what it said: MDs can't be forced to assist deaths.  They went on to say that no physician in the country should be forced to play a role in any aspect of assisted dying against their moral or religious beliefs, including referring patients to another doctor willing to help them die.  Perhaps they realize that what has kept medicine an honorable profession has mainly been the ethics, morals and philosophical principles, religious or otherwise of most physicians.  The dictates of the administridiots played no role in the crafting of the Hippocratic oath.
          The Ontario College of Physicians and Surgeons (the licensing and disciplinary body) seem to be taking a different position.  It would appear that they intend to make it mandatory to participate or at least refer to someone who does.  The College, unfortunately regards itself  as the ultimate arbiter of all ethical issues and indeed is in  that they can withdraw the  license to practice medicine.   However, it has a responsibility to physicians as well as patients and sometimes exceeds reasonable boundaries.  Physicians are wary to protest for fear of some sort of future consequences.  The College rulings on this current issue requires careful scrutiny, evaluation and discussion before implementation.  They also need to be reviewed in the light of the decisions of licensing bodies in the other Canadian Provinces.

Tuesday, 3 March 2015

The Pathologist. Pt 2.

Autopsy Time.
          I showed up in the hospital morgue bright and early, for an eight am autopsy.  I made sure to be there a few minutes early, so that Jim and I  could make sure that everything would be laid out just the way Dr. McMurray liked it.  Eight o'clock came and went, without sign or sight of Dr. McMurray.  I was getting a little nervous. 
            "She's late," I said, "I just hope everything is okay."
            "Ah, don't be worrying," Jim said optimistically, "everything will be just fine."
            "I hope so, I'd hate to be left to do this on my own."
            Jim grinned that leprachaun smile that the Irish sometimes have.
   "Ah sure if the worst came to the worst, you and I could do it ourselves.  I've been hanging around these post-mortems and helping out long enough to be able to do them myself."
            There was a knock at the door, immediately a the secretary poked her head around it.
            "I'm afraid you fellows are going to have to do the post-mortems on your own.  Dr. McMurray was admitted to the hospital in the small hours of the morning in labor, so I don't think she's going to be in to help you out today."
            With that the door slammed closed and she was gone. I almost panicked, then I re-called Churchill's war time credo. 'keep calm and carry on!' and  I determined to try to do just that.  And, after all, the patient was dead before I got to him.
            "We'll have to find another pathologist right away, Jim."
            "There's no other pathologist available.  There's a critical shortage of pathologists in Dublin right now." Jim laughed.  "How do you think you, a first year intern, got the job in the first place.  That job usually goes to a senior house officer, who's specializing in pathology.  They knew Dr.McMurray was going to be having a baby soon and I suppose they thought that having you was better than nothing." Jim answered unceremoniously.
            That certainly sounded more realistic than my previously held belief that they had just conjured up a position to slot me into, to help me out. What a fool I was, they were helping themselves out, albeit with a grossly under-qualified candidate.
            "Anyway Doc, don't worry, I'll show you how to do a post-mortem.   Sure, who do you think taught Dr. McMurray to do them?" he asked modestly.  "She was just at your stage when she first came down here to learn how to do autopsies.  And there's one piece of good news, the house officer who does or helps with an autopsy gets a fee of five pounds and five shillings.  Not many junior interns get a deal like that.  They usually give me a pound for my help," he added, meaningfully. 
            "Don't worry about that, Jim.  If you can get me through that, I'll give you twenty-five shillings.  Do you really think we could do the complete job ourselves?"
            "Sure I'd teach you to do an autopsy on my old Granny for twenty - five bob!" he laughed.
            "So, if we're going to get out of here tonight we'd better get started," I said.
            "Yep, Doc, now you've got to decide if you want to do it Dr. McMurray's way or the quick way!" Jim said.
            "Well, what's the difference?" I asked..
            "It's like this Doc, in the long run it doesn't make any difference.  In either case, the stiff, er, I mean the corpse, ends up nicely put together and is sewn up neatly, all ready for the undertaker. But one method takes two hours and Dr. McMurray's method takes four or more hours.  It's up to you."
            "Now wait a minute, what's the point of taking four hours when you can do the procedure in two hours?  Dr. McMurray is a very practical doctor, why would she opt to spend four hours doing a procedure that could be done in two hours?" I asked.
            Jim shrugged his shoulders.
           "I asked her the very same thing myself.  What's the difference, Doc, I asked her.  'Ah Jim,' she answered, 'the difference is the human dignity and respect that every human being is entitled to.'   That's where we differed and I told her so.  You got it wrong, Doc,  Jesus Christ himself is looking after the immortal soul and its dignity, all you're looking after is an auld corpse!"
          So we agreed to disagree, and she was the doctor and all I was, was a morgue porter, so of course, we did it her way.  But we had some grand discussions.  Which way do you want to do it, Doc?"
            I knew that everything took at least twice as long as anticipated and sometimes three times, so I had no difficulty in making the decision.
            "I want to do it the fast way."
            He answered without hesitation.
            "I can see we're going to work just fine together. Now Doc, you just pick up this scalpel and make a long incision, starting right up here at the sternal notch and extending down to the xiphi-sternal joint."
            I picked up the scalpel.