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.

Sherwin Nuland on ECT

Nuland is the author of my favorite medical history text and a bunch of other more famous books I haven't read, a former Yale surgeon, and just an all-around brilliant kinda guy.

I highly recommend

The Stool Pigeon Memoirs.

Gee, never saw THAT one coming...

Pfizer said yesterday that it would stop selling Exubera, its inhaled insulin, less than two years after introducing the drug. Despite Pfizer’s heavy promotion, Exubera’s sales were minuscule, with prescriptions amounting to less than 1 percent of the insulin market.

Pfizer will take a charge of $2.8 billion for costs associated with Exubera, making it one of the most expensive failures in the history of the pharmaceutical industry.

Rarely does a pharmaceutical company actually feel such nasty repercussions for producing a more expensive product with little value added to the prior product. Needles may hurt, but so does interstitial lung disease. And you just look silly taking a hit of insulin from a bong.

To offset the cute puppy

Lunetta P, Ohberg A, Sajantila A. Suicide by intracerebellar ballpoint pen. Am J Forensic Med Pathol. 2002 Dec;23(4):334-7.

Picture stolen from and explanation at Retrospectacle, one of the SEED Science Blogs written by UofM cochlear implant ninja Shelly Batts.

The War on VBACs

For those who haven't stayed up all night checking to see if mom's ready to push, a VBAC is a Vaginal Birth After a C-section. During a Caesarian, besides cutting through mommy's belly, mommy's uterus gets cut as well. When a woman has another child, the worry is that since the uterus has already been cut before, the spot of healing isn't as structurally sound as the original uterine wall, thus the pressure placed on the uterine wall during subsequent pregnancies would then result in uterine rupture, and the need for emergent surgery. Emergent surgeries carry a multitude of greater risks than elective procedures.

But then some studies cited in this NPR story mention that the actual rate of uterine rupture in VBACs isn't that large, but when a uterine rupture DOES occur during a VBAC, outcomes are comparably terrible. This lead ACOG to recommend that adequate surgical faculty be available when a woman was attempting a VBAC. The problem arises when smaller hospitals simply don't have the resources to ensure those adequate surgical backups are at hand, and hospitals then ban VBACs because they simply can't afford to keep a full back up team on call.

Which creates the interesting public health versus personal autonomy dilemma we've all come to know and love. Women absolutely have a right to attempt a VBAC (and yes, "attempt" is the correct terminology) with a fairly low threshold for proceeding to a repeat caesarian should complications arise. And hospitals have a right to not offer services they simply can't afford to offer when medically acceptable alternatives exist. "Medically acceptable" and "personally acceptable" are, of course, not always in agreement.

Where I've trained, the VBAC was always an option, mostly because the hospital is equipped with the staff to handle any complication that could arise because patient volume and the high-risk patient population justify their use. On a population level, the risk is astronomical. On a personal level, the risk is miniscule.

Of course, the naturalist spin is that obstetricians are evil bastards who want to cut so they can go home and get some sleep so they'll have time to wake up early enough to spend their hefty salaries. Actually, obstetricians, like other physicians, don't like the idea of folks dying during an emergency from a partially preventable incident.

The woman in the NPR story gives the most revealing quote, however. She is rightfully upset that she is being forced to have a VBAC. When presented with the rationale for why this is so, she replies:

"That's what they hospital is there for, to handle emergencies. And so, in that respect, the policy never made sense to me."

No, emergency rooms are there to handle emergencies, as long as by "handle," you mean do the best that anyone can to stabilize an unstable situation, recognizing that some unstable situations simply cannot be stabilized, and should be avoided if possible.

Hospitals exist to provide inpatient medical care following complicated medical algorithms in which physicians and patients take action to minimize the risks associated with illness and treatment. If a particular hospital can't handle a particular risk, it shouldn't try to do so. It should refer to a tertiary care center, and it should be blatantly honest with its patients about local limitations.

We don't send burn victims or trauma victims to any old hospital and expect that hospital to be staffed to handle those emergencies. We have regional burn centers and a tiered-trauma centers so that patients can receive quality care, and our society can afford to provide that quality care.

A woman has every right to demand an attempt at a vaginal delivery after a caesarian section for a prior pregnancy. Heck, I imagine if I were a woman on my second pregnancy after having a C-section the first time, I would almost certainly demand a VBAC. However, no hospital can be expected to offer a service it simply can't afford to offer. If I want the VBAC, I have to go find a facility that does offer that service, since I'm probably unwilling to spend the extra zillion dollars required to keep sufficient surgical staff available during my delivery. And my current providers have an obligation to help me find that facility.

For the most part, Starbucks has an obligation to give you precisely what you want, because coffee isn't dangerous, and they can charge you whatever that coffee is worth to them.

For the most part, your medical provider has an obligation to give you precisely what you want, as long as what you want is reasonably safe, economically viable, and consistent with what can comfortably be called standard of care. For example, elective abortions and emergency contraception meet each of those criteria, and thus each woman has a right to receive them. In some contexts, a VBAC doesn't meet those criteria (according to ACOG... that's certainly up for further debate). Thus, the provider's obligation is limited to directing the patient to a context in which the patient's preferences do meet those criteria.

Update: The Onion offers the proper supplement to this story:

Woman Overjoyed By Giant Uterine Parasite

NEW BRIGHTON, MN— "I'm so happy!" Crowley said of the golf ball–sized, nutrient-sapping organism that will eventually require hospitalization in order to be removed.

The More You Know, Nasonex Spanish Bee edition

So I tried to earn my "not worst husband ever" stripes by making Courtney breakfast this morning before she drudges off to work. While the Food network (since my cooking was obviously not enough to hold our attention), this uber-strange ad pops on the screen:

Courtney: Wtf? Why is the bee Hispanic? It sounded like Antonio Banderas or something.

Garrett: (grumpily) He's not Hispanic, I think the bee is Spanish.

Courtney: (knowingly) That's where you are wrong, pitiful derelict intellect!

And she's right, on so many accounts. First: (thank you, Dictionary.com)

Usage Note: Though often used interchangeably in American English, Hispanic and Latino are not identical terms, and in certain contexts the choice between them can be significant. Hispanic, from the Latin word for "Spain," has the broader reference, potentially encompassing all Spanish-speaking peoples in both hemispheres and emphasizing the common denominator of language among communities that sometimes have little else in common. Latino—which in Spanish means "Latin" but which as an English word is probably a shortening of the Spanish word latinoamericano—refers more exclusively to persons or communities of Latin American origin. Of the two, only Hispanic can be used in referring to Spain and its history and culture; a native of Spain residing in the United States is a Hispanic, not a Latino, and one cannot substitute Latino in the phrase the Hispanic influence on native Mexican cultures without garbling the meaning. In practice, however, this distinction is of little significance when referring to residents of the United States, most of whom are of Latin American origin and can theoretically be called by either word. · A more important distinction concerns the sociopolitical rift that has opened between Latino and Hispanic in American usage. For a certain segment of the Spanish-speaking population, Latino is a term of ethnic pride and Hispanic a label that borders on the offensive. According to this view, Hispanic lacks the authenticity and cultural resonance of Latino, with its Spanish sound and its ability to show the feminine form Latina when used of women. Furthermore, Hispanic—the term used by the U.S. Census Bureau and other government agencies—is said to bear the stamp of an Anglo establishment far removed from the concerns of the Spanish-speaking community. While these views are strongly held by some, they are by no means universal, and the division in usage seems as related to geography as it is to politics, with Latino widely preferred in California and Hispanic the more usual term in Florida and Texas. Even in these regions, however, usage is often mixed, and it is not uncommon to find both terms used by the same writer or speaker. See Usage Note at Chicano.

To add insult to injury, the bee really was Antonio Banderas!

So there you go. Don't a) question your wife, b) muddle the distinction between Hispanic and Latino, which the standard OMB demographic form seems to do, and c) mistake Antonio Banderas for a common Hispanic bee voice.

Which doesn't answer the greatest existential crisis evoked by the commercial. Why the hell is Antonio Banderas the voice of the Nasonex Bee? Only celebrity willing to humiliate himself as a bee besides Jerry Seinfeld? A well-meaning (but totally failing) attempt to be more inclusive, the way that every picture in every textbook or academic brochure that has three people must include two women and two African American, Hispanic, and/or Asian folk, despite the fact that the random probability of those three people actually hanging out is like 1 in 3 trillion? Or does Antonio Banderas only voice Puss-n-Boots after spiking some Nasonex?

Best Cross Promotion Ever?

The blood drive will coincide with the Halloween premiere of the latest title in Lionsgate and Twisted Pictures' "Saw" franchise, Saw IV, which opens nationwide on October 26, 2007.

The Saw "Give Til It Hurts" blood drive has become a key element of the "Saw" franchise, as much a part of the horror hit's annual rituals as its Halloween premiere date. Since the first SAW blood drive in 2004, "Saw" filmgoers have donated nearly 38,000 pints of blood to help save as many as 112,500 lives.

The Saw films are dropping off in quality exponentially, and I found Saw III mostly unwatchable. But this certainly demonstrates that marketing schemes can have a little social conscience.

Sounds evil, until you keep reading...

So there's this headline:

Johnson & Johnson Sues Red Cross Over Symbol

Sounds evil, right? I salivate at the opportunity to rip J&J for corporate greed and evil, picking on a little non-profit like that. But, then there's the rest of the article:

The two had shared the symbol amicably for more than 100 years — Johnson & Johnson on its commercial products and the American Red Cross as a symbol of its relief efforts on foreign battlefields and in disasters like floods and tornadoes.

From time to time, the American Red Cross sold products bearing the symbol as fund-raising efforts. Jeffrey J. Leebaw, a spokesman for Johnson & Johnson, said the company had no objection to that.

But in 2004, the American Red Cross began licensing the symbol to commercial partners selling products at retail establishments. According to the lawsuit, those products include humidifiers, medical examination gloves, nail clippers, combs and toothbrushes.

Sorry, J&J. And more:

Mr. Crisan said it was not clear how far the American Red Cross wanted to go in licensing the symbol for commercial purposes, noting that the red cross was a trademark of Johnson & Johnson before the American Red Cross was officially chartered. Mr. Crisan said that some of the items being sold under licensing agreements by the American Red Cross seemed to compete directly with products sold by J.& J.

What planet does the Red Cross live on that it thinks this is a legitimate practice? And Mark Emerson, president of the ARC says:

“The Red Cross products that J.& J. wants to take away from consumers and have destroyed are those that help Americans get prepared for life’s emergencies,” Mr. Everson said. “I hope that the courts and Congress will not allow Johnson & Johnson to bully the American Red Cross.”

Yes, Mr. Emerson. Nobody else makes disaster kits except for the companies to which you license J&J's commercial logo. Americans are gonna die because they can't buy products with your license. Right.

Religious doctors not more likely to care for poor

That's no surprise, and not even the reason why I would draw attention to it. Here's the real reason this study is significant:

He and colleagues at Yale New Haven Hospital in Connecticut mailed surveys to 1,820 practicing doctors. Of those, 63 percent responded.

What is it about a study on religiosity that would inspire a 63% response rate? Physician survey studies typically consider themselves sterling successes if they achieve anything above a 20% response rate.

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.

Doctor Terrorists

Howard Markel on NPR, exploring the Hippocratic Oath and the recent news of physician involvement with terrorism in Britain. Markel is one of a handful of history-of-medicine ninjas at the University of Michigan.

Would you like some loss of sensation with that lopping of your foreskin?

Male infant circumcision is the most common medical procedure performed in the US (although an article I ran across last week said rates were dropping, and most of that rate drop was due to the assimilation of folk from non-penis-disfiguring cultures). Matz and I spent way too many arguments (according to him, I always enjoyed them) in med school over whether circumcsion was Matz: a benign procedure, culturally significant, and good for hygiene, or Garrett: medical barbarism fueled by the inability of American parents to ask why they should be attacking their male children so they can "look like Dad."

So yeah, I don't like circumcision, and I want my foreskin back, despite the marginal improvements in hygiene suggested in a shoddy body of medical literature, although I'm intrigued by literature suggesting that circumcision may have some role in preventing HIV transmission in Africa.

One of the high points of our arguments was always whether circumcision created a differential in sexual pleasure between the lopped and the non-lopped. This study doesn't answer that question, but it's a great demonstration from which we can extrapolate future work:

Adult male volunteers were evaluated with a 19 point Semmes-Weinstein monofilament touch-test to map fine-touch pressure thresholds of the penis. Circumcised and uncircumcised men were compared using mixed models for repeated data, controlling for age, type of underwear worn, time since test ejaculation, ethnicity, country of birth, and level of education.

Analysis of results showed the glans of the uncircumcised men had significantly lower thresholds than that of circumcised men (P = 0.040). There were also significant differences in pressure thresholds by location on the penis

This study suggests that the transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. It appears that circumcision ablates the most sensitive parts of the penis.

I repeat, this study does not adequately address the magnitude of sexual pleasure experienced either way. Circumcision occurs when the brain is still markedly plastic, and it's certainly reasonable to think that some rewiring could compensate for the loss of sensation caused by circumcision. But, the results do suggest that the anti-circumcision crowd may be correct: a foreskin is a terrible thing to waste.

During my third year pediatrics rotation, our attending (Matz and I were actually on the same service that month) brought us to the procedure room to assist in a circumcision. Matz was kind enough to speak up for me, that I had some moral cat in the fight, so as to save some face for me and make me not look like a disinterested medical student who didn't want to learn how to do "procedures." The attending asked me about my objection, and I remember replying earnestly that I didn't see any evidence for a benefit to performing the procedure, and I did see evidence for harm. Her reaction was markedly benevolent (she could have destroyed me for daring to openly question an attending's judgment), and assigned me to my greatest role as a medical student: she handed me a pacifier and a packet of sugar, and suggested I keep the little guy as happy as possible while she and the resident elegantly lopped off the poor little guy's foreskin.

Hopefully our lives never depend on our performance on a penile sensation microfilament test.

Ritalin use doubles after divorce

Which of course means that divorce is a disaster for kids and parents and doctors just want to shove pills down their throats to shut them up. Or, at least that's about what the headline and the article want you to believe.

Children from broken marriages are twice as likely to be attention-deficit drugs as children whose parents stay together, a Canadian researcher said on Monday, and she said the reasons should be investigated...

"So the question was, 'is it possible that divorce acts a stressful life event that creates adjustment problems for children, which might increase acting out behavior, leading to a prescription for Ritalin?'" Strohschein said in a statement.

"On the other hand, there is also the very public perception that divorce is always bad for kids and so when children of divorce come to the attention of the health-care system -- possibly because parents anticipate their child must be going through adjustment problems -- doctors may be more likely to diagnose a problem and prescribe Ritalin."...

Her study was not designed to find out why the children were prescribed the drug.

I try to be slightly cautious of criticizing research on days when I'm far too lazy to go read the original study, but it's always easy to criticize how studies are presented to the people who are paying for them through tax dollars (yeah, it's a Canadian study, but still).

I won't entirely dismiss the mechanisms of increased stimulant prescription proposed by the study, as they're narratively compelling and probably are true on at least a limited scale. But why do children become children in a divorced household? Probably because mom and dad can't make things work. What's one reason that's often true? Mental illness, and given the prevalence of adult ADHD (that thing that was childhood ADHD before the child became an adult), we could imagine that folks who get divorced have a much higher prevalence of ADHD. What has a heritable component? ADHD.

So, I'd be shocked if diagnoses of ADHD, and psychostimulant prescriptions, didn't go up after divorce. Not because parents or doctors are seeing children any differently (although they probably are), and not even necessarily because divorce, even one that's best for all parties involved, is a stressful event for a child, which it most certainly is. As a cohort, children from divorced households would be expected to have much higher rates of ADHD from a purely genetic standpoint.

The fact that the risk of receiving a stimulant prescription only increases by a factor of two may be the most surprising result of the study, and might even suggest the opposite of what the article suggests: that doctors and parents view attention-deficit and impulsivity symptoms in a child in such a stressful situation as a transient phenomenon, and thus fail to prescribe in some instances.

Maybe, and maybe not. But the last thing we need is more articles in the media that suggest that a neurological condition is nothing but a result of an unfortunate but statistically normal childhood experience for many children, and the impatient parents (probably mothers) and physicians who want to chemically lobotomize children who display problem behaviors.

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.

Link Roundup, listening to Nirvana edition

I fail miserably every time I try to expand my listening tastes into Nirvana's whole catalog. Back in my Baptist brainwashing days, I wasn't allowed to listen to the band with the baby dick on the cover, so I missed the boat the first time around, and in 8th grade when Kurt did his thing, I was largely confused. God, those t-shirts everybody wore were just ugly as hell, and the people that wore them, on average, wore nothing else and stunk of patchouli oil, like about 40% of my high school did anyway.

The only band I'd really effectively sneaked through the decency barrier was R.E.M., just because my parents couldn't understand most of the curse words on Automatic for the People, and if you didn't listen to Nirvana or Pearl Jam in middle school, you just weren't cool (and thus, I wasn't). I only ever bought "Ten" because the girl I wanted in middle school couldn't stop talking about it.

For some reason, R.E.M, Weezer, and Radiohead, the bands I preferred instead, just weren't cool. A friend of mine who went to a local county school was called 'gay' every time he wore an R.E.M. shirt, as we'd largely found the band together (in that, ya know, heterosexual sorta way). So it goes.

So Nirvana is just weird for me. I could probably mention about 15 songs that I thought were all genius, and then anything else I ever hear by them sounds like cats scratching a chalk board. Usually there's some middle ground, but Nirvana for me is either rock-out or suck-out.

1. If benzylpiperazine is going to be the next ecstasy, its really going to have to work on some new nicknames. 'The piper' seems cute. Has anybody heard what this stuff is called on the street? The wiki articles says it's called "The Lovely" or something stupid like that in Canada. They would.
2. Stuff Medicare won't cover: carotid artery stents and vagus nerve stimulators for chronic depression. The article for the latter mentions quite a few reasons why vagus nerve stimulators aren't trusted by the psychiatry community, although its hard to think that the "implantable psychiatrist" approach might not be a valid approach someday.
3. This article suggests that girls abuse prescription drugs more than boys, and then mentions tranquilizers and antidepressants. How the hell do you abuse an antidepressant? It's like trying to abuse bread. Sure, you can make yourself sick by taking a bunch of them, and in the case of TCAs, which are rarely prescribed for adolescents, you could really hurt yourself. But chewing a pencil would be more exhilarating than dropping Prozac on the weekend. Note: I only post this article because it's a great example of the way the media can write something without actually conveying any actual information.
   
4. Penn folk say that psychotherapy can't extend the life of cancer patients. If I track down the pdf, I might plunge into this in a post on its own, since the review flies in the face of about 15 years of assumed truth.
5. Gulf War Syndrome patients have some pretty weird findings on neuroimaging compared to other Gulf War vets without symptoms. Corpus Callosum posts a quote from one of the authors being a good neurologist by frankly criticizing psychiatric illness in general:

   Study coauthor Dr. Ronald Killiany, PhD, from Boston University School of Medicine, told Medscape that these data are an "important first step for Gulf War veterans as well as the scientific community in validating the fact that so-called 'soft' neurological conditions can have a pathological basis."

   Can have a pathologic basis? Those are fighting words.
6. Oxytocin for autism? Stranger things have happened. Here's one of the best quotes I've seen in a long time from a medical journalism article:

   While it is hardly implausible that a hormone involved in orgasm would have positive effects on anyone, these findings of improvement in adults with autism given oxytocin are based on measurable changes in behavior as well as visible changes in their brains as seen through functional magnetic resonance imaging.

   Can't argue with that logic. At least, not without giggling.
   
7. Just a brief overview of bipolar disorder in kids, which may be much more common that thought, especially in those mistakenly diagnosed as ADHD.
   

How could you write any less intelligently about menstruation?

I know nothing about Stephanie Saul, and I don't know anything about having a period. I know a lot about living with someone who has them and constantly complains about them, and yet doesn't really have any interest in not having them. I can accept that sort of doublethink just fine. God knows I probably exhibit behavior and attitudes at least that discordant.

Let me be absolutely clear: If a woman has a complicated relationship with her menstrual cycle that relates to her identity and personal relationship with her body, that's great. Seriously. I don't bleed. I don't know what it's like. If there's something symbolic about it for you, that's cool. If it helps you understand your relationship to your body, awesome. I can at least imagine it on a literary level. I can't think of any exact analog for a guy's relationship with his sexual anatomy, but if there was one, I bet I'd have a complicated relationship with it too.

But if a woman doesn't have a complicated relationship with her menstrual cycle, then my God, why does she have to bleed if she doesn't want to? Since when has feminism become about limiting a woman's choice?

So here's a brutal jump-around fisking of Ms. Saul's pseudofeminist drollery.

For many women, a birth control pill that eliminates monthly menstruation might seem a welcome milestone. But others view their periods as fundamental symbols of fertility and health, researchers have found. Rather than loathing their periods, women evidently carry on complex love-hate relationships with them.

Oh my God! Women don't agree on everything! Holy shit, there's more than one valid opinion on a matter in this world! How will we ever survive until next week without our unity?

This ambivalence is one reason that a decision expected next month by the Food and Drug Administration has engendered controversy. The agency is expected to approve the first contraceptive pill that is designed to eliminate periods as long as a woman takes it.

Alberto Gonzales: controversy. Gun control on college campuses: controversy. Approving a new birth control pill that ruins the old misogynistic proverb "never trust something that bleeds for a week and doesn't die?": Yawn.

“My concern is that the menstrual cycle is an outward sign of something that’s going on hormonally in the body,” said Christine L. Hitchcock, a researcher at the University of British Columbia. Ms. Hitchcock said she worries about “the idea that you can turn your body on and off like a tap.”

Two points here. The first one, valid. Amenorrhea is an outward sign that something isn't working quite right, and this pill would mask that. Valid point. The second one, the "turning your body on and off like a tap" thing, is this woman for real? Who cares? If people want to contemplate the symbolic nature of their own menstrual cycle (which I certainly do not oppose), that's cool. But to unilaterally say that every woman out there, whether she finds her cycle to be something personally important to her or not, should necessarily have to have the thing, with only poetry to back you up, is pretty dumb.

That viewpoint is apparently one reason some already available birth control pills that can enable women to have only four periods a year have not captured a larger share of the oral contraceptive market.

Oh my God! The market can handle a diversity of goods!

“It’s not an easy decision for a woman to give up her monthly menses,” said Ronny Gal, an analyst at Sanford C. Bernstein & Company.

Or its just not a necessary decision. If a woman is on a birth control regimen that works for her, and the benefit of not having a period isn't worth having to fiddle with that regimen, that seems pretty reasonable to me.

Doctors say they know of no medical reason women taking birth control pills need to have a period. The monthly bleeding that women on pills experience is not a real period, in fact.

Okay, this is when Ms. Saul really loses my vote. "Hey birth control pill users, you phonies, you don't even have real periods!!! That's not blood dripping from you for five days every month, that's really just cherry slurpee the drug company implanted in you while you were asleep! Fooled you!"

What the hell? No, you don't have an egg to shed when you're on the pill, because you don't ovulate. But you still shed some endometrial tissue, and unless I just totally failed my GYN rotation, I'm pretty sure that constitutes a "real" period. Labeling an on-the-pill period as "fake" seems a little, well, nutty? To make such a claim, you either a) have a really bad understanding of science, b) believe everything you're told, or c) have a very specific agenda.

And studies have found no extra health risks associated with pills that stop menstruation, although some doctors caution that little research has been conducted on long-term effects.

Welcome to drug research. How do you conduct research on long-term effects if people don't take the medication for long periods of time? It's not like we have a colony of research-people on the moon we can feed Seasonale for the next fifty years to see if they grow an extra arm on their head or something, and then get back in our space ship-time machine to come back to 2007 to tell everybody that it's totally safe, except for that arm-growing-out-of-your-head thing. We don't have long-term research on most of the birth control regimens in existence now, as most research I've seen just lumps OCPs into one big catch-all category. That might be totally appropriate, but maybe this progestin analog causes arms to grow out your head, and another one doesn't. We won't know for fifty years.

The topic has, however, inspired an hourlong documentary by Giovanna Chesler, “Period: The End of Menstruation?,” currently screening on college campuses and among feminist groups.

Ms. Chesler, who teaches documentary making at the University of California, San Diego, said she became concerned about efforts to eliminate menstruation when she first heard about the idea several years ago.

“Women are not sick,” she said. “They don’t need to control their periods for 30 or 40 years.”

Geez, and I thought the "Left Behind" people needed to get a life. No, women are not sick, but they take birth control pills because they'd like to actually be able to enjoy sex without having seventeen children. If stopping ovulation with pills is okay, why is stopping menstruation with pills somehow worse? At least, medically.

There has also been a backlash among groups that celebrate the period as a spiritual or natural process, like the California-based Red Web Foundation. “The focus of our group is to create positive attitudes toward the menstrual cycle; suppressing it wouldn’t be positive,” said Anna C. Yang, a holistic nurse and executive director of the organization.

What a bunch of hippies. Nobody's FORCING this stuff down your throat. If you love your menstrual cycle, knock yourself out. If you want to celebrate your menstrual cycle as a central theme of womanhood, have fun. But leave women alone who don't think it's fun to bleed 20% of the time for thirty years.

Eliminating menstruation is not a completely new concept. Women who take any kind of oral contraceptive do not have real periods.

Because the hormones in pills stop the monthly release of an egg and the buildup of the uterine lining, there is no need for the lining to shed — as occurs during true menstruation.

Not again. Space cadet.

At the alternative Bluestockings Bookstore on the Lower East Side of Manhattan early this month, several dozen women gathered for the New York premiere of “Period: The End of Menstruation?,” Ms. Chesler’s hourlong documentary. It explores the idea of suppressing the menstrual period but leaves the viewer to make up her own mind.

One who attended the screening, Aviva Bergman, a 22-year-old student at Goucher College in Maryland, said she would not use products that suppressed her period because it seemed unnatural.

You know what else is unnatural? Being able to have sex without worrying about getting pregnant. Injecting yourself with insulin because your pancreas doesn't work. Getting a heart transplant. Nuclear bombs. Soy milk.

You know what's perfectly natural? Earthquakes. Floods. Hurricanes. Puppies. Rainbows.

Natural doesn't seem like the best proxy of goodness. Seems like most of us evolved with intellects that can stomach a bit of nuance and context here and there.

“I just feel that there’s a reason you’re getting it every month,” she said.

Feel away! It's your menstrual cycle. Do what you want with it. But it's your menstrual cycle, and not that of the woman sitting next to you. Make your own decisions, and leave other people alone.

Yeah, there's a reason "you're getting it" every month. It's because (oh hell, you can look it up on wikipedia, if you're that interested in reproductive endocrinology). I'm pretty sure there's nothing magical about pulses of GnRH, although I'm not a medical student at Hogwarts, and may be out of my league on this one.

I don't anticipate that anyone is actually going to read down this far. If you did, please keep all these comments in focus with the overriding thesis.

1. Women should get to decide what they do with their own bodies.
2. There's nothing feminist about trying to limit the choice of other women for poetic reasons.
   
3. We don't know much about the long term effects of suppressing periods indefinitely. but we also don't have much medical reason to think that regimens that suppress periods indefinitely will really be much of a problem in comparison to contraceptive regimens already available.
   
4. There's nothing magic about things that are natural. Cancer is natural. Air conditioning is unnatural.
   
5. I've never had a period. I'm only qualified to speak about the medical and political implications of this stuff. I do not question anyone's personal experience with menstruation.
   

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.

Sorry Zombie lovers, the McCoys were not infected with rage

Despite the fact that I'm currently reading Max Brook's oral history of the coming Zombie war, I was a bit put off by the misleading headlines last week. Imagine that, misleading headlines about medical research. The media went haywire about a report that a genetic disorder in the McCoy side of the Hatfield-McCoy might have caused all that hillbilly rage. You know, like in 28 Days Later.

Mostly for the non-medical folk who read this blog:

McCoy descendants have been found to have a high number of cases of Von Hippel-Lindau Syndrome (VHL). On my week of neurosurgery last year, I met a patient with VHL, and believe me, they weren't chasing me around the table, infected with rage. VHL doesn't cause rage. It causes tumors in lots of places, usually around rich vascular supplies, because of an autosomal dominant lack of a certain binding protein. One of the tumors that are common in certain subtypes of VHL are pheochromocytomas, adrenal gland tumors. Pheos present clinically with sudden episodes of sweating, crazy high blood pressure, etc., from basically a big dumping of catecholamines (like adrenaline) into the blood stream. Anyone who's watching 24 this season knows what happens when you inject people, like presidents, with shots of adrenaline. They start pretending to drop nuclear bombs on unnamed Arabic nations.

Pheochromocytomas are rare, but for some reason are classically represented on boards exams, so every medical student on earth can pick out a pheo on a standardized test from 20 miles away. But because they're so rare, and typically not as interesting as in the above test, non-medical folk just don't know anything about them.

Pheochromocytomas are also most commonly not related to VHL, although they are a hallmark of several of the multiple endocrine neoplasia syndromes. Again, boards questions for medical students, rarely obscure for non-medical folks.

Of course, my question immediately becomes, has there been an episode of CSI about a pheochromocytoma? Has there been an episode of House? If not, I bet you won't have to wait much longer.

Lithium cuts suicide risk in recurrent depression

The overall rate of suicidal acts was 1.48 percent annually among those not given lithium compared with 0.17 percent per year among those treated with lithium -- an 88.5 percent reduction in risk.

For better or worse, current thought among the medical community is that SSRIs are so safe, a monkey could prescribe them. Just above monkeys, of course, are psychiatrists, family docs, and nurse practitioners. Psychologists typically gain the most support for their petitions for prescribing rights on the safety of SSRIs.

But lithium is something altogether scarier, again, for better or worse. Psychiatrists prescribe lithium. Nobody else does. And now there's evidence that, at least in the population defined in this study, the attributable benefit of lithium could be about 8/9 for suicide prevention. So some questions immediately arise (some maybe because I just haven't got around to looking at the original article yet):

1) What patients with depression (since most depression is undoubtedly recurrent depression) would benefit from lithium? I don't know what it feels like to be on lithium, but from Kay Redfield Jamison's An Unquiet Mind, it doesn't sound like the most benign drug. Thus, balancing the way lithium makes patients feel, in addition to all the long term nephrotoxicity and such, with the benefit of less death by suicide will be quite an important endeavor. Will that be an endeavor for psychiatrists, or for the larger mental health practitioner community?

2) Do all of these patients suddenly need psychiatrists to prescribe their lithium, or would non-psychiatrists become more comfortable prescribing lithium, at least as a depression adjuvant, which would likely be a far less complex endeavor than managing bipolar disorder?

3) Does this strengthen or weaken the case for prescribing rights for psychologists? After all, this paper is proposing a change to our current care model that could cause a dramatic increase in the need for more specialized mental health services. Of course, this assumes that the answer to question 2) is that non-psychiatrists would not become more comfortable prescribing lithium adjuvant therapy for depression.

4) And of course, if one mood stabilizer decreases the risk of death by suicide for folks with recurrent depression, what would the others do? Now that some atypical antipsychotics have been approved as mood stabilizers, where do they fit into this picture?

5) Do SSRIs remain relevant to the treatment of recurrent depression? Not to be too cynical, but all but Lexapro are off patent.

On a parallel note, check out The Last Psychiatrist's take on new evidence that adjuvant SSRI therapy adds nothing to patients with bipolar disorder already on a mood stabilizer. Especially relevant to question 5).