Vaccine Smack

Mostly because I'm sick of seeing that scary Huckabee-Squirrel picture every time I pull up my site for link shortcuts, here's another Slate video, this time with some good old-fashion take-your-autonomy-and-shove-it vaccine cautionary tales.

To be clear, I think people who don't vaccinate their children are about as smart as people who eat their own poop. But I wouldn't kick someone out of my practice for any reason save concerns of personal harm, and I don't think it's particularly responsible for pediatricians to threaten parents that they will no longer be their child's pediatrician just because the parent smokes mercury-laced crack.

Don't punish a child just because the child's parents are idiots. The kid is going to have enough problems surviving 18 years with their anti-vaccine asshat mom and dad without getting fired by their pediatrician.

My Quality Adjusted Life Year may be different than your Quality Adjustment Life Year

Slate's Darshak Sanghavi discusses some of the problems with the way health care economists judge the cost-effectiveness of various health treatments, within our culture and across cultures. Paul Farmer's Partners-in-Health group is used as anecdotal evidence (as Sanghavi's critique is almost verbatim the one that Paul Farmer gives in his lectures), and Farmer's infamous "before-HAART" picture is included in the article. Farmer hates the QALY (quality adjusted life year) metric, mainly because the QALY assumptions break down the more unlike the treatments are in their target population, and easily damns treating anyone in an impoverished nation with anything more expensive than penicillin and a mosquito net. Despite being an excellent primer in global cost-effectiveness, the article does a great job exploring the extent to which the assumptions of economics, like any statistical science, greatly limit our ability to generalize the results it produces to real policy decisions.

James Holsinger, a simple prop to occupy our time

The American Public Health Association, founded in 1872 and made up of 50,000 U.S. public health professionals, said it is "very concerned with Dr. Holsinger's past writings regarding his views of homosexuality, which put his political and religious ideology before established medical science."

It was the second time ever, and the first in 26 years, that the group has opposed a U.S. surgeon general nominee.

Funny, the headline reads "Health group opposes Bush surgeon general pick." As if the APHA is just a 'health group.' That's like saying "Book opposes money lending," when said book is the Bible.

Corpus Callosum et al. document well the recent controversy stirred by Richard Carmona's obvious-but-gutsy admission that the Bush administration places politics above science, as well as Holsinger's own personal failings, i.e., being willing to write an article named "Pathophysiology of Male Homosexuality." I initially gave the guy a bit of slack, partially out of pure Kentucky hopeful nostalgia, and because I do earnestly believe that evangelicals could have particular insane political beliefs, and yet place them in proper context when formulating opinions about policy. Alas, James Holsinger will never be my insane-but-straight-shooting evangelical.

I'd be thrilled for this guy to prove us all wrong. But, if confirmed, Carmona's testimony suggests that Holsinger wouldn't have a shot at making any real decisions anyway.

I believe this post completes the R.E.M. trifecta, for those following along at home.

NPR on James Holsinger

James Holsinger, University of Kentucky cardiologist and public health professor recently nominated for the Surgeon General position, gets some positive treatment from NPR. He has his conservative credentials: a theology degree from the conservative (but not really in that nasty Falwell/Dobson sort of way) Asbury Theological Seminary, and a history of serving on the judicial council of the United Methodist Church which supported a ban on homosexual clergy (at least according to a questionable reference on his Wikipedia site).

Buzzflash, which I'm not familiar with, but looks like a potentially very fringy far-left sort of source, has an article expressing its mass unhappiness with Holsinger's nomination. I don't necessarily trust the claims of malfeasance and malpractice, but it's always interesting to see what sort of dirt is being thrown at someone from either side of the wingnutsphere.

For example, while I find it personally unacceptable that homosexuals be excluded from clergy positions, I also don't think that someone who disagrees with that position would necessarily discriminate against homosexual persons in health policy. The latter is the question to be asked, not the former. He's being nominated for Surgeon General, not National Chaplain. If that's the most damning criticism a far-left source can expose towards a public health official's treatment towards the LGBT community, then concern over his policy positions towards the LGBT community may be a general non-starter.

Here's hoping that Holsinger at least represents the best of what we could expect from the Bush administration. I wouldn't anticipate a nominee wholesale interested in the best available evidence outside the realm of a conservative, fundamentalist world-view. So if Holsinger is a nominee who stands on the side of medical evidence, we may have a much better nominee than we ever would have anticipated.

The Farm Bill as Government Subsidized Obesity

Michael Pollan, author of The Omnivore's Dilemma, writes in the New York Times Magazine:

A public-health researcher from Mars might legitimately wonder why a nation faced with what its surgeon general has called “an epidemic” of obesity would at the same time be in the business of subsidizing the production of high-fructose corn syrup. But such is the perversity of the farm bill: the nation’s agricultural policies operate at cross-purposes with its public-health objectives.

Read the rest: "You Are What You Grow" (h/t: Will Samson)

What do 5 members of the SCOTUS and near-sighted gynecologists have in common?

They all have wet noses! (Apologies to the 98% of you that don't get the reference)*

I held off posting on the Supreme Court's decision to be supremely retarded, figuring someone else would write something more measured and that would hit all the points I wanted to hit. Lynn Harris at Salon did a pretty good job.

In general, critics of "partial-birth abortion" bans -- which are also on the books in 26 states (though enjoined in 18) -- have long argued that not only is there no such medical term as "partial-birth abortion," but that such laws define it so as to appear to also include a variation of dilation and evacuation (D&E), by far the most common -- and safest -- method of second-trimester abortion (which is relatively rare itself; at least 85 percent of abortions take place in the first trimester). In other words, the ban could be interpreted to outlaw abortion procedures used very early in the second trimester (not to mention those used for women who have learned via amniocentesis, as late as 20 weeks or more, that they're carrying a fatally abnormal fetus).

And even better:

Make no mistake: "This ban is not just about later-term abortion," says Janet Crepps of the Center for Reproductive Rights, who argued Gonzales v. Carhart. "The options for all women -- particularly women facing serious medical conditions -- have been dramatically reduced. No longer can women and their physicians decide what's in their best interest. Now there's the added concern about whether what's in their best interest will be in violation of federal criminal statutes." Among opponents of the ban, gallows humor was the order of the day. As in: "I'd like to give you the best possible care," your doctor might say, "but first let me check with my lawyer."

*The UMMS 2007 Smoker included the joke "What does my dog Winston have in common with a near-sighted gynecologist? They both have wet noses!"

NB: My dog is not named Winston.

Link Roundup, random med news buffet edition

1. Do fictional diseases increase the risk of cardiovascular disease. Probably not. So Restless Leg Syndrome probably isn't a fictional disease. I get so tired of the "nobody'd ever heard of RLS until just a few years ago, but now because some drug company can make money, everybody has it!" argument. That's not to say that I don't think problems like this get over diagnosed after physicians and patients are suddenly inundated with a new possible answer to old problems, but that doesn't mean RLS isn't a real entity.
2. The NHS has just NOW apparently figured out that it's not a good idea for patients and doctors to be inserting probes into one another for procedures that they can't bill for.
   
3. Alpha-blockers for nightmares in PTSD? Will urological psychiatry become a new fellowship?
4. Glucosamine/Chondroitin Sulfate still doesn't do shit except take your money.
5. Jonathan Cohn Jonathan Cohn Jonathan Cohn. I'm going to have to read his stupid book before I go nuts hearing something new about it three times a day. He sounds sensible enough on NPR.

Kids with ADHD more likely to abuse alcohol

Strangely enough, from the same research group at WPIC that produced a big chunk of the research I used for term projects in Adolescent Health and Mental Health Policy classes last semester:

The 15- to 17-year-old children in the study with childhood ADHD reported being drunk 14 times, on average, in the previous year, versus only 1.8 times for age-matched teens who did not have childhood ADHD.

Fourteen percent of 15- to 17-year-olds with ADHD were diagnosed with alcohol abuse or dependence compared with none of the similarly aged subjects without ADHD.

My question would then be, how does effective ADHD treatment relate to allaying, if at all, the risk for substance abuse in ADHD teens? I might mail email the study author to see if her group has addressed/wondered about that as well.

Drugs Equal Benefits of Artery Stents

Was it for this my life I sought?
Maybe so and maybe not
-Phish, Stash

I don't really have anything to add to the New York Times article, which explores the study in remarkable detail impressive even for the NYT. Except that this, like any study, isn't the final say in the debate. It's just a really loud and integral portion of the debate.

But this has to be required reading for anyone in medicine or health policy and economics. Or anyone screwed with a load of Boston Scientific stock.

Abolishing the Middlemen Won’t Make Health Care a Free Lunch

Tyler Cowen takes a pot shot at the argument that Medicare's low overhead would still be a good thing in a Medicare-for-all scheme.

Not saying I buy it, or that I've had time to think about it, but Cowen's always at least smart and avoids partisan hackery.

Step 2 awaits Saturday, and I can't really think until after that. Not between Step 2, and Tubby going to Minnesota.

Kennedy vs Kennedy in pursuit of the ghost of Paul Wellstone

The NYT describes the competing versions of a mental health parity bill, the Paul Wellstone-inspired House bill sponsored by Kennedy Jr., and the surprisingly pro-business bill sponsored by Papa Kennedy in the Senate.

The American Psychiatric Association supports both bills, describing them as different approaches to the same goal. Mental Health America, an advocacy group for patients, also supports both bills. But Ralph J. Ibson, the chief lobbyist for Mental Health America, said, “The House bill has greater protections and is therefore a stronger bill.”

The House bill is named for Paul Wellstone, the senator from Minnesota who championed similar legislation before he died in a plane crash in 2002. Jeff Blodgett, executive director of Wellstone Action, a nonprofit group that is continuing the Democratic senator’s work, said, “The Senate bill is a step forward, but the House version is true to Paul Wellstone’s vision.”

On behalf of the senator’s sons, David and Mark Wellstone, Mr. Blodgett said, he asked the Senate sponsors not to put the Wellstone name on the Senate bill at this time.

One of the biggest differences between the House and Senate bills is that the House version defines the “minimum scope of coverage.” Under the House bill, if a group health plan provides any mental health benefits, then it must cover the same wide range of mental illnesses and addiction disorders covered by the health plan with the largest enrollment of federal employees.

By contrast, the Senate bill does not specify what mental conditions or diagnoses must be covered.

Given that even Bush has endorsed the notion of mental health parity, at least in principle, I don't quite understand the necessity of the watered-down Senate Bill. Of course, industry doesn't like things that could possibly cost them money. Several policy memos I've read suggest that mental health parity probably wouldn't cost all that much anyway, and that concerns that the worried well (a term I despise, but will use in the context of this debate, in which it is so often cited) will flock to therapists for self-actualization probably don't make much sense.

Having seen at least one case in which a severely depressed patient ran out of psychiatry visits for the year during March, I'll be the first to admit that I'm going to be biased towards mental health parity. Since my salary will most likely depend on NIH instead of insurance companies, I can't say I have too much personal financial incentive in the matter.

But at some point, it seems like a lack of mental health parity comes down to simple discrimination against those with mental illness. We'll pay for your sprained ankle treatment, but not for your bipolar disorder. I'm pretty sure the situation isn't much more complicated than that, though I've seen plenty of people try to make it more complicated by distorting the realities of mental illness.

I Don't Want Health Care If Just Anyone Can Have It

How do you seek such truth, Onion?

Health care is all about exclusivity, pure and simple. It's for a group of like-minded people bonded by the dream of only having to contribute a portion of their weekly wages to ensure unfettered access to a number of licensed health care professionals. If we change all that, health care will be about as elite as a public restroom, open to any yokel who waltzes into an emergency room and can legally establish California residency.

Iowa relaxing blood donation ban?

The largest blood donor service in Iowa is recommending that a ban on gay-men donating blood be re-examined. As we all know, the ban on men who have sex with men from donating blood dates back to the 1970's when the height of the HIV scare was just beginning. However, since that time our ability to test for the HIV virus has improved dramatically.

Each year during this week, the fraternities and sororities of Iowa State University hold a contest to see who can collect the most blood donations. However, one fraternity (Delta Lambda Phi - an LGBT fraternity) complained that they would be unable to participate as a result of the ban. So the entire greek community has decided to not hold the competition. They estimate this will amount to a loss of 500 units of blood.

While as a physician-to-be I cannot support boycotting blood donation, I do applaud the campus community for supporting their LGBT brothers and sisters who are being unfairly discriminated against. Maybe someone with authority will finally listen and re-think this unnecessary and discriminatory policy.

God save the Veterans

Anyone who hasn't had their head in the sand over the last week has heard about how veterans discharged from a major VA hospital have been forced to live in substandard housing, fill out mountains of paperwork to get follow up medical care that may never arrive. The situation is so bad that politicians and military officials are tripping over themselves to apologize to everyone and fire anyone involved. And while I have a great deal of respect for our veterans, I'm getting pretty annoyed with the implicit implication. Much of the US lives in substandard housing and many more individuals with mental and other health issues are forced to wade through a public health nightmare of limited resources, bureaucratic hoops, and substandard care. But we don't seem to care about these people, because they're NOT veterans (nor children, nor pregnant mothers). It would seem that this country values health care as a basic right (why else would ED's be required to evaluate and stabilize EVERYONE who walks in the door), but when it comes down to the details (those details numbering in the millions of uninsured) we just don't seem to give a damn. Gee, if only all the uninsured were veterans, then we would actually care about their health care.

Moving up in the world

It's nice reaching a point in your career when you can say something on a website that gets you a personal email reply from Steven D. Levitt, author of Freakonomics.

Steve has a controversial post at the Freakonomics blog: The editor of the Journal of Clinical Psychiatry needs to have his head examined. The post references a recent research report that suggests that smokers may have worse outcomes after traumatic events than non-smokers. Levitt appears to go after some low-hanging fruit in his criticism of the press release, and a portion of his criticism only holds given the information in the press release, but not in the actual article. Citing the original article, the research design appears fairly sound, although not perfect, just as no epidemiologic study is craziness-free.

A part of freakonomics is taking causal pathways assumed true based on correlational evidence and examining the plausibility of the opposite direction. Levitt and Dubner are making quite a popular career (in addition to an impressive academic career, in Levitt's case) of questioning assumptions that certainly deserve questioning. In this case, Levitt suggests that the folks who smoke are probably the ones that are helped the most by smoking in coping. He therefore finds no evidence to suggest that smoking cessation might be beneficial, and reasons that it might even be harmful.

Levitt's points make sense, but they assume that there's no significant difference in the biology of stress regulation between folks with psychiatric trauma symptoms and those who don't have them. Smoking may be a coping mechanism with calming properties in the short run, a potential effect in the long run of further dysregulating the HPA axis could plausibly account for the smoking causing worse symptoms in the smoking group.

Levitt's argument, in whole, seems to be one of biologic plausibility. It is more plausible, given the knowledge of psychology of the average well-educated person, that people who were worse off (or in this case, going to be worse off, as I would argue that effective controls are in place at the first assessment of smoking) were more likely to smoke.

But the biology of trauma, stress, and anxiety, a field outside the knowledge pool of even the average medical student, suggests that PTSD-like symptoms could certainly be modulated by smoking if smoking, a biologically stressful event in itself, modulates the HPA axis in an unhealthy way.

So in summary,
A) Press releases of medical research, in a paraphrase of one commenter, do little more than let you know which author you should be looking for on PubMed.
B) Freakonomics methodology is valuable, but it may be limited when examining fields for which specialist knowledge may be necessary. Biologic plausibility is an important aspect of epidemiologic research.
C) Steven Levitt is gracious in his emails.
D) I'm a total nerd, because I get all excited about getting an email from a University of Chicago economics professor.

SSRIs and suicide

Mankiw links a paper from the National Bureau of Economic Research on the cost effectiveness of SSRIs in decreasing mortality from suicidal behavior.

We find that an increase in SSRI sales of 1 pill per capita (about a 12 percent increase over 2000 sales levels) is associated with a decline in suicide mortality of around 5 percent. These estimates imply a cost per statistical life far below most other government interventions to improve health outcomes.

The paper doesn't do anything to distinguish who might be at risk for a personally increased risk of suicide, but it does help us keep SSRIs in perspective: they do a lot more good than they do harm. The question remains, of course, how to reduce that harm.

Counting the homeless

For those of you interested in the homeless or in the difficulty of epidemiology field studies, this NPR report on a bunch of NYU students bouncing around New York until 5 AM every night yields the appropriate amount of non-insight. Winter or summer? Sidewalks, restaurants, and private property?

Youth suicides rise as antidepressant use diminishes

A disturbing, new study... shows a sharp jump in the number of young Americans committing suicide. Almost 2,000 young people age 19 and under killed themselves in 2004. That's an increase of more than 18 percent in the rate of teen suicide from the year before. . . The alarming, new suicide figures have some child psychiatrists worried that these black box warning labels on antidepressants may be keeping them from getting to the children that need them the most. After a decade of steady decline, teen suicides spiked sharply in 2004 -- the very same year that the FDA man mandated that the antidepressants come with warning labels, about a possible link to suicidal thoughts in adolescents and children. The warnings led to a 20-percent drop in antidepressant prescriptions for those under 18.

It's only one point of data with circumstantial association but it does seem to make sense and a lot of psychiatrists have been worried about this exact scenario. The question now becomes, will wacky parents swing the other way and demand antidepressants for their slightly mopey kids? If only the public could understand a message slightly more complicated than "pill = bad" or "pill = good".

HPV vaccine for gay men?

Merck, the makers of Gardasil (the HPV vaccine now being given to women) is conducting a trial of 4000 men, including 500 self-identified gay men, to test the effectiveness of HPV vaccination in men to prevent anal cancer. Although I think this vaccine should be given to all gay men, especially "bottoms," I'm glad to see the company pursuing this study. Obviously there are far more women who are eligible for the vaccine than gay men, but that they're still going after this market is a good sign, in my opinion.

Finally, a real reason to move to Europe

Europe-wide smoking ban proposed!

Places usually only ban smoking in public places AFTER I live there. My podunk, asscrack-of-earth hometown has banned smoking at bars and restaurants, and people are ready to throw a fit because of a new proposal to ban smoking at the park (which is where people go to smoke because they can't smoke at the private hospital across the street). And Lexington, the cultural capital of the #2 tobacco state in the union, banned smoking in bars and restaurants right after I left my undergraduate career there.

I move to the most left-leaning, health conscious, crazy-ass hippy white-bred hybrid-SUV driving college town in the entire Midwest (sorry, Madison), and people can still smoke at restaurants and bars? Who did I piss off to deserve this crap? They can ban smoking smack dab in the middle of a zillion acres of tobacco fields, but folks haven't even put it on the ballot in Ann Arbor?

They're probably more likely to legalize smoking pot in bars than they are to get rid of smoking tobacco in bars. Damn hippies!