The Austringer

I ran across this in the Autobiography of Benjamin Franklin:

In 1736 I lost one of my sons, a fine boy of four years old, by the small-pox, taken in the common way. I long regretted bitterly, and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.

The anti-vaccination impulse seems to be ancient, and anciently rebutted.

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An op-ed column by Nicholas Kristof in the New York Times referenced Panda’s Thumb blogger Tara Smith. The op-ed is about the incidental evolution of a superbug in hogs given antibiotics and the health risks that now entails.

Since then, that strain of MRSA has spread rapidly through the Netherlands — especially in swine-producing areas. A small Dutch study found pig farmers there were 760 times more likely than the general population to carry MRSA (without necessarily showing symptoms), and Scientific American reports that this strain of MRSA has turned up in 12 percent of Dutch retail pork samples.

Now this same strain of MRSA has also been found in the United States. A new study by Tara Smith, a University of Iowa epidemiologist, found that 45 percent of pig farmers she sampled carried MRSA, as did 49 percent of the hogs tested.

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Marcia Angell has an article in the New York Review of Books that considers three books touching upon modern medicine and unseemly links to corporate pharmaceutical companies.

Angell takes up various problems, but I was intrigued when she got around to how companies now control research, sometimes shading a negative experimental result in a way that is perceived as a positive outcome for their product. See if the following paragaph from Angell strikes you in the same way it did me:

The suppression of unfavorable research is the subject of Alison Bass’s engrossing book, Side Effects: A Prosecutor, a Whistleblower, and a Bestselling Antidepressant on Trial. This is the story of how the British drug giant GlaxoSmithKline buried evidence that its top-selling antidepressant, Paxil, was ineffective and possibly harmful to children and adolescents. Bass, formerly a reporter for the Boston Globe, describes the involvement of three people—a skeptical academic psychiatrist, a morally outraged assistant administrator in Brown University’s department of psychiatry (whose chairman received in 1998 over $500,000 in consulting fees from drug companies, including GlaxoSmithKline), and an indefatigable New York assistant attorney general. They took on GlaxoSmithKline and part of the psychiatry establishment and eventually prevailed against the odds.

I wonder whether the fact that the last person referred to in the next to last sentence was Eliot Spitzer, subject of a sex scandal, led to the elliptical references all around. It stands out in the article as one place where Angell eschews naming names. Would the fact that someone with an all-too-human failing was involved in standing up to corporate misdeeds really detract that much from the force of the article? [Comments point out that Bass's focus was not on NY AG Spitzer, but to NY AAG Rose Firestein, and thus there is not a specific reason to avoid naming the cited person. My apologies to Marcia Angell.]

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A press release points out a review of the likely effects of the plan proposed by John McCain to change health coverage. The results? They don’t look so good.

“Moving toward a relatively unregulated non-group market will tend to raise costs, reduce benefits, and leave people with less consumer protection,” says Sherry Glied, PhD, professor and chair of the Department of Health Policy and Management at Columbia University Mailman School of Public Health and one of the paper’s authors. “The system Senator McCain envisions is one in which many more — perhaps most — insured Americans would buy health insurance and health services in a national, relatively unregulated, competitive market. Because this is a radical departure from the current system, its likely effects deserve close attention.”

Well, I guess we weren’t expecting McCain to propose something that would be socially progressive on the healthcare front, and he apparently does not disappoint on the “let them eat cake” factor.

As someone who has benefited greatly from having health care group plans available through my employers (or Diane’s employers), I can be pretty confident in saying that if I had significantly less coverage, I wouldn’t be writing this, I’d have kicked it about the time my colon perforated in 2004. That was caught quickly because I was already hospitalized and had attending physicians who were paying attention to symptoms that were not at all obvious to me.

According to Dr. Glied, the elimination of the income tax preference for employer-sponsored insurance would cause 20 million Americans to lose coverage, but the effect could be much larger especially if employers are quick to drop health benefits in response to the McCain plan, or if employers drop coverage for low wage workers. She suggests that “while initially there will be no real change in the number of people covered as a result of the McCain plan, people are likely to have far less generous policies than those they have today.”

It seems to me that it is silly to spend billions per year for critical care treatment for the un- or under-insured and act like spending any part of that for preventive medicine for the same groups would be somehow un-American. Saving lives is un-American? Saving money is un-American? It sounds to me like the McCain plan simply shifts more people to having astronomical medical costs assessed against them personally, rather than having effective health insurance, or to being indigent non-paying patients crowded into hospital emergency rooms, our health poor-houses.

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Michelle Mayer had to become a difficult patient to secure adequate health care for a misdiagnosed illness that actually turned out to be scleroderma. She has a blog, Diary of a Dying Mom, where she discusses her own case and the larger policy issues of how health care is managed — or mismanaged — in this country.

I’ve seen the necessity for being alert and my own advocate while hospitalized for the last part of my ulcerative colitis. There was the critical information that, at the time, seemed trifling: the acquisition of a sharp pain in my shoulder during a shower. What it suggested to my internist was something I had not considered for a moment, that my inflamed and weakened colon had perforated. Follow-up X-rays and a CT scan confirmed that, and set me up for an emergency complete colectomy. At another point, I requested the re-insertion of a naso-gastric tube to reduce the chance of vomiting during my recovery. At another, I refused to take a provided medication that didn’t match up physically to the shape and color of the pill I was expecting.

Mayer’s sojourn covers far more ground, though, as her case pitted her against the policies that make doctor-patient interactions fleeting and cursory. My own case had something of the inverse problem Mayer had. For Mayer, an early diagnosis of a more minor malady prevented the attention needed to make the real diagnosis of a major illness. For a couple of years, I had an internist who refused to believe that I actually had an ulcerative bowel disease, until I presented at a colonoscopy with a full-blown flare-up plus a Clostridium difficile infection on top of that. (”You’re sick,” was his simple admission that the previous five doctors had not gotten it wrong.)

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A friend of mine emailed me one of those humorous things, this time it was Dave Barry’s article on the experience of having a colonoscopy. Apparently, everybody posts these all over the place; go have a read at the link if not a few hundred other webpages with the essay.

I tried to read it aloud to Diane and was reduced to incoherent bouts of laughing several times. The primary experience Dave relates is the day-before cleanout and its inherent horrors, which Dave turns into light humor. Here’s where Dave talks about the colonoscopy itself:

If you are squeamish, prepare yourself, because I am going to tell you, in explicit detail, exactly what it was like.

I have no idea. Really. I slept through it. One moment, ABBA was yelling ‘Dancing Queen, Feel the beat of the tambourine,’ and the next moment, I was back in the other room, waking up in a very mellow mood.

I think that holds for most people, especially when slightly out of shape people prone to a bit of hypertension go get a coloconoscopy. OK, so I’m slightly out of shape myself, but my blood pressure is a bit on the low end of normal, so the last couple of times I had a colonoscopy, you can erase the bits about the anesthesiologist obligingly making the world go away during the main event. That’s right, I could fill you in on the part Dave could not, but a mere five years remove is not yet enough to turn the recollection humorous. So the one positive benefit one can get from high blood pressure is assurance that they would have little reservation at knocking you out for a colonoscopy, and a positive benefit of total colectomy, like I had, is that I never need another colonoscopy, especially one without anesthesia.

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World first: researchers develop completely automated anesthesia system

My first science-related full-time job was in the Anesthesiology Department of the College of Medicine at the University of Florida. My job required me to be at the continuing education lecture series the department held, those starting promptly at 7 AM each weekday. While I didn’t have the benefit of medical school and residency in anesthesiology, there was quite a bit of information appreciable to the lay audience as well. For one thing, anesthesiology is a very demanding specialization in medicine. As various lecturers made clear, a person under anesthesia is about as close to death as medical practice allows, notwithstanding whatever surgical procedure might be going on. Another thing oft repeated was to choose your anesthesiologist with care, but surgeons… hah, they’re a dime a dozen.

One of the large projects going on in the lab toward the end of the time I was there was a study on vigilance. Residents participating in the study were given several hours of a video to watch, after they had completed one of their usual mind-numbing marathon shifts on duty. The video was of monitoring equipment used for anesthesiology, and at points within it would be fluctuations that could indicate a problem. The residents were supposed to note these. Of course, their performance was neither perfect nor was it close to what they could do if well-rested before starting to watch.

The result of the linked article is a computer-automated anesthesia system. It sounds like they have incorporated something very much like an expert system in software, as well as sensors and actuators such that precise dispensing of anesthetic agents can be delivered and results monitored. This is something that may be the harbinger of a means to help reduce the vigilance problem that I got acquainted with back in the early 1980s. It sounds like a good step forward, in any case, though it seems that the initial notion of the market for this system is to fill in for an absent anesthesiologist. I’m thinking that it is more likely to help reduce the strain on anesthesiologists on the spot.

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