Link Roundup, Drug-Withdrawal edition

Pergolide, dopamine agonist used as an adjunct to L-Dopa and Carbidopa, is withdrawn voluntarily when evidence showing that the drug increases the risk of damage to heart valves puts the drug on tremulous ground. *Rimshot*

In crappier news, IBS pro-motile drug Zelnorm apparently increases the risk of pretty much everything. FDA asks Novartis nicely to please quit selling people heart attacks and strokes.

Some NIH folks figured out that when monkeys concentrate voluntarily, their prefrontal cortex is in charge, while distractions activate the parietal cortex. ADHD neuroscientists start writing new grants furiously, buying extra bananas.

Nature addresses the growth of dichloroacetate sales (for veterinary uses *wink nudge*) on the internet for cancer patients, and how such activity, besides being illegal, throws a huge monkey wrench into the process of actually testing DCA in real clinical trials.

While the FDA hasn't found anything particularly wrong with Pfizer's inhaled insulin formulation Exubera, doctors and insurance companies just aren't impressed.

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.

And I thought my high school biology teacher was an idiot (not clairvoyant)

I REALLY wish I had made this story up, rather than being forced to document the sad truth about secondary science education in the Bluegrass State.

Imagine fifteen year old Garrett:

[Biology classroom, fifth period right after lunch. Garrett resumes his daily routine of walking into biology class and promptly falling asleep on his back pack. For some reason, Garrett can't sleep today, and feels a little guilty for being so flippant about a science class. He tries to feign some interest in Ms C's biology lecture]

Ms C: So, you get twins when two sperm fertilize the same egg...

Garrett: [mystified that the state of Kentucky would pay someone to say something like that in a biology class, sits up] Wait, did you just say that twins are caused by two sperm fertilizing the same egg?

Ms C: Yeah, that's how we get twins.

Garrett: [looks around room to other people he knows with IQs over 12, fails to find anyone else even remotely paying attention] But...

[Ms C continues with lecture on nothing, Garrett is able to return to his post-lunch nap with a clear conscience]

But now, Ms C's delusions are newly-minted medical science. Semi-identical twins, produced by the fertilization of one egg with two sperm, have now been documented.

[Cue Fade Music: "It's the End of the World as We Know It (And I Feel Fine)"]

Now if that whole Creationism thing would just pan out, Ms C might win the Nobel Prize.

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.

Sunday Link Roundup

1) Jay Farrar and Son Volt's new album The Search on All Things Considered.

2) Because of some loophole in a new Medicaid rebate law, pharm companies now have no incentive to offer OCPs cheap to universities. Because pregnant college girls are good health policy. Obviously.

3) But maybe that's okay in Texas. State Rep Dan Patrick (R-ealAsshole) wants to offer pregnant women considering abortion 500 bucks not to get abortions. Hey, Texas girls, have twins, and you might be able to pay for your books next semester!

4) Patients really don't give a flip if you wear scrubs, a white coat, or monkey boxer shorts. They do care if you are a douche nozzle. (For a history of the "douche nozzle," Ctl-F the term here.)

5) Docs around the world are calling for a boycott of Reed Elsevier (they publish the Lancet, among other obscure journals to which your EBM searches inevitably lead you), since apparently they have something to do with arms fairs to showcase cluster bombs, or something sketchy like that.

6) Disaster averted: Emma Watson will play Hermione through Film 7. Reports last week said she wanted to bail.

7) Creepy much?

In what is becoming a trend among conservative Christians in the United States, girls as young as nine are pledging to their fathers to remain virgins until they wed, in elaborate ceremonies dubbed "Purity Balls."

"Since I'm just the return on Daddy's investment into Mommy's sperm bank, he owns my hymen until he tells some boy its okay for him to have it." Eww.

Morris heading to the Knicks

I'm slow on the draw, and every Cat fan knows that RaMo had 1.6 million reasons to leave. Plenty of griping going on, but I just wanted to put my two cents in to the world: good for you, Randolph.

Thanks for all the fish.

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.

WTF???

Tubby Smith leaving Kentucky for Minnesota.

Didn't actually see that coming, because I didn't imagine Mitch Barnhardt was that inept as an AD. Does that leave us anywhere with Patterson or Lucas?

Gore's next greatest invention? Flame retardant babies!

“The planet has a fever. If your baby has a fever, you go to the doctor. If the doctor says you need to intervene here, you don’t say, well I read a science fiction novel that tells me it’s not a problem. If the crib’s on fire, you don’t speculate that the baby is flame-retardant. You take action. The planet has a fever.”

For some reason, I do expect that, in most pediatricians' careers, they'll have at least one parent argue with them over something they read in a science fiction novel. Maybe once every few months might be a better estimate, depending on the population.

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.

Boutique hospitals suck

A recent study published in JAMA indicates that specialty cardiac hospitals might be cathing everyone, whether they need it or not. They found that in areas where new hospitals opened, there were more revascularization procedures (CABG, PCI) than in areas where new cardiac programs opened at regular hospitals (thus it's not just the "if you build it, they will come" issue of adding resources to an area). Given the fact that these specialty hospitals are also exempt from the requirement that they provide emergency services (thus they don't have ER's and don't really benefit the community) and tend to skim well reimbursed patients from general hospitals (who are left with the expensive, uninsured, patients and less funding to provide care for them), this merely adds to my general hatred for these hospitals. That being said, my partial ownership of the local bariatric center has been very lucrative.

Deep Thoughts (with Derby Spotterparks)

"Hmm... who would have thought that those silly Wildcats could do no worse than Duke, Louisville, or Arizona by Saturday afternoon of the first weekend of the tourney..."

The best of times, the worst of times

According to Pat Forde (who is apparently the only guy at ESPN I find worth reading, or at least quoting:

KENTUCKY (8)

Best case: Randolph Morris and Joe Crawford reach previously untapped reservoirs of passion, Ramel Bradley quits throwing the ball away and the Wildcats surprisingly pull out of a two-year tailspin by upsetting Kansas and reaching the regional final. Fans at least halfheartedly chant "Tub-by! Tub-by! Tub-by!" after every victory. Back home in Rupp Arena, Louisville loses in the first round.

Worst case: Fans chant "Tubby Must Go!" after phlegmatic Cats bow out against Villanova, their seventh loss in the final 10 games. To their dismay, athletic director Mitch Barnhart stands by his man for another season. Morris and Crawford go pro, hotly pursued recruits Patrick Patterson and Jai Lucas go to Duke and Oklahoma State, respectively, and Rick Pitino takes Louisville to the Final Four again.

Word on the street is that Patrick Patterson reads a lot of message boards and the such (maybe that's just the anxiety of those of us who worry about what retards say on those things). So, Patrick, if you happen to run across Sparkgrass, know that the rational wing of the Kentucky Wildcat Nation will be throwing huge parties on the day you join us, and wearing blue and black instead of blue and white for weeks if you don't.

Same goes for you, Jai. But the rumors don't tell us that you read blogs and message boards quite as fervently.

Note: I claim exemption from delusions of grandeur when I think that there is an infinitesimally small chance one of these guys would run across this page. That infinitesimal chance is more than enough

Happy Match Day!!

For all your M4 med students out there - Happy Match Day! Best of luck, I hope you end up where you want to! :)

Who's the candidate for LGBT voters?

There has been a lot of talk in the past few days about what the candidates think about homosexuality and morality. Most disconcerting is the way Obama and Clinton sidestepped the question and waited for their campaigns to issue statements later clarifying their positions. Does this mean that the most LGBT-friendly candidate in the pack is a Republican (Guliani)? If so, what's happening to the Democratic party?

Sparky Update: ThinkProgress has statements from both Clinton and Obama retracting their non-answers. It's sorta sad that left-leaning candidates have to be so careful to not piss off the fundies that they can't even allow themselves to be on film saying that homosexuality might not be the greatest plague ever.

New risk factors for DVT?

Every good medical student can tell you the primary risk factors for Deep Vein Thrombosis (DVT, or blood clots in your legs): smoking while on birth control, cancer patients, hypercoaguable abnormalities, and long plane flights. Well, add a new one to the list - office workers!

This study from New Zealand demonstrates that office workers are at increased risk of DVT formation, even compared to "long plane flight" patients. Who knew? I guess people need to get off their asses more at work instead of sitting in front of a computer screen all day. Not only is it good for cardiovascular health, but it just may prevent DVTs too.

what the market wants to do

Very rarely do I read an article on health care reform and think that an author actually gets it. Not like I have any answers, but almost every solution I see thrown out, by left and right alike, just seem like disasters waiting to happen, ya know, sorta like the current health care system. So Kudos to Tim Noah, who ends his article on a brilliant note:

The overall trend—the gift of an increasingly market-driven health-care system—is to undermine the very idea that the cost of illness should be spread out among the general population, healthy and unhealthy alike. In this sense, the market is too efficient. Assigning health care costs to sick people is what the market wants to do.

Markets can do many wonderful things, which is why I'm glad to live in a capitalist country. But they've made a complete hash of the health-care system. Doesn't that reality deserve more than passing respect?

In the rest of the article, Noah reviews Jonathan Cohn's to-be-soon-published history of health care disasters, Sick: The Untold Story of America's Health Care Crisis—And the People Who Paid the Price. Going straight to the top of the Wishlist.

Salt, Meet Wound

I always appreciate Pat Forde's ability to make Kentucky fans want to slit their wrists:

Tubby Smith. NCAA winning percentage: .700. He's lost only one first-round game, and that was at Georgia back in 1997. Took Tulsa and the Bulldogs to the Sweet Sixteen, and has gotten Kentucky there six times. Caveat: Hasn't gotten Kentucky to the Final Four since 1998, and the Wildcats are looking at the longest Final Four-less streak in school history if they don't make it this year.

Forde was a sportswriter at the Courier-Journal before his time at ESPN, so at least he has witnessed the moral depravity of Kentucky fandom at its lowpoints.

Eating-disorder education shows unintended effects

I keep accumulating all of these eating disorder research blurbs I want to blog, so here goes this one:

Yale University researchers found that when they presented female high school students with videos on eating disorders, it met the intended goal of boosting their knowledge about anorexia and bulimia.

However, the team saw that the students didn't necessarily find the results of eating disorders unappealing. Teens who watched a video featuring a woman recovering from an eating disorder became more likely to view girls with eating disorders as "very pretty," and some thought it would be "nice to look like" the woman in the video.

Health educators are clearly losing the battle in the prevention of eating disorders when students don't find vomit and electrolyte abnormalities particularly unappealing.

[T]he girls were more likely to say after [watching the educational videos] that "it's not that hard" to recover from an eating disorder. They were also more likely to believe girls with eating disorders have "strong" personalities.

At some point we have to wonder if such a study isn't just a strong cautionary tale against not pilot testing your educational materials. Our understanding of the teenage psyche somehow immediately disappears around the time that we can legally drink alcohol. Adults can pretend to understand why teenagers would think girls with eating disorders have strong personalities. We could draw flow charts and propose mechanisms, but I'm betting we'd never "get" it. That of course doesn't mean we shouldn't try to advance our understanding of disease context in eating disorders to its fullest. But we better be pretty humble in our pursuits.

The strongest message we might draw from this study might be that assumptions are futile in child psychiatry. And as soon as we know something, its probably changing due to social dynamics that defy our best mathematical models.

Kumar comes home from White Castle

Dana Stevens seems convinced that the film adaptation of Jhumpa Lahiri's really shitty novel The Namesake won't suck nearly as bad as the book did. Is there nothing that a little bit of Kal Penn idiocy can't save?

To be clear, there are very few books that I love, and very few books that I loathe. Any book within two standard deviations of my personal mean, I generally like a lot, even if I don't love it. The Namesake, I loathed. Maybe it's just from hanging around with too many Indian kids in high school. Maybe it's how Lahiri managed to create a stock character from second generation Indian-Americans, when no stock character really existed to my knowledge. Besides an interesting name, Gogol (whom Kal Penn must desperately save from lameness) is completely uninteresting. If you've ever met a single person whose parents immigrated from India, no matter how boring a person that person might be, that person is more interesting than Gogol.

The Unknown is Unattainable

So Josh sent this to me, and I stared at it with the sound off. He finally IM'ed me to tell me that the sound sorta added something. Strangely hypnotic.

Don't do this at work or anywhere where other folks are going to wonder what the hell you're listening to.

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.

Ibuprofen best for treating kids' pain

The first head-to-head study of three common painkillers found that ibuprofen works best, at least for kids with broken bones, bruises and sprains.

Available generically and under the brand names Advil and Motrin, ibuprofen beat generic acetaminophen and codeine in an emergency room study of 300 children treated at a Canadian hospital.

Not that I don't have enough soapboxes, but one of them is certainly the incredible underuse of ibuprofen and other NSAIDS for acute pain. Granted, I haven't read the real paper, and there's certainly a chance that narcotics may have been underdosed (which resembles real world situations--docs aren't nearly as afraid to prescribe higher doses of NSAIDs compared to narcotics). But I think we at least see further evidence that, barring any reasonable contraindication, there's little reason not to include ibuprofen as either a primary or adjunct pain reliever in the setting of acute pain.

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.