Look, whether you like it or not, you can’t live forever. I bring this up because there is always a new book or new add purporting to have “the answer” to long life and good health, which never includes modern, evidence-based medicine. Still, perhaps some of these books contains good advice. Or not. Let me explain.
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Category: Medicine
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Live forever!
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DrPal, tell us more about HPV and cancer
OK, if you insist. This comes with the usual caveat directed at scientists that I know this is oversimplified, but I wish to reach the largest audience possible. Feel free to correct my mistakes, but please don’t bother me about oversimplification.
So here’s the deal. Several decades ago, it became scientifically fashionable to believe that most cancer had a viral cause. This belief coincided with the discovery that some viruses do cause cancer. And while it turns out that most cancers are not caused by viruses (probably), many of them are. Viruses can cause cancers in a number of ways, but since you said you were interested in HPV (human papilloma virus) we can use this as an example.
First, there is no scientific question about the causal relationship between HPV and cervical cancer (and certain oral cancers, anal cancers, and penile cancers, but we’ll use cervical cancer as shorthand for all of them). There is excellent epidemiologic evidence to support this, and virologic evidence that proves it.
Now that we’ve got that out of the way, how does this cancer virus thing work?
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Galileo, Semmelweis, and YOU!
To wear the mantle of Galileo, it is not enough to be persecuted: you must also be right.
–Robert ParkI used to spend a lot of time on the websites of Joe Mercola and Gary Null, the most influential medical cranks of the internets (to call them “quacks” would imply that they are real doctors, but bad ones—I will no longer dignify them with the title of “quack”). I’ve kept away from them for a while in the interest of preserving my sanity. Unfortunately, Orac reminded me this week of the level searingly stupid and dangerous idiocy presented by these woo-meisters.
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Privacy Cagematch—DHS vs. HHS
OK, this post gets a big IANAL stamped across it. I don’t know the legal ins and outs here (and I’m not sure if anyone does), but the new announcement by the Department of Homeland Security (DHS) regarding laptop computers puts physicians and other health care providers in a bit of a spot.
HIPAA (the Health Insurance Portability and Accountability Act) is the law that governs the privacy of your medical information. It is very, very detailed, and requires quite a bit from your doctor. You’ve signed a form at the office of every provider you’ve visited that notifies you of your privacy rights. I cannot discuss your care in a hospital elevator. I can’t send you an email regarding your health without making it very clear that any information in the email cannot be considered secure. I cannot disclose your health information to anyone else except under very specific and limited circumstances. HIPAA has radically changed the way we do things with health information (sometimes for the better, sometimes not).
Moving on to Homeland Security—DHS agents may, for any reason or none at all, seize my laptop and demand any security or encryption codes. My laptop not infrequently contains information covered by HIPAA (known as PHI, or Protected Health Information). Because of that, my laptop is secured via HIPAA-compliant security measures. Under the new DHS guidelines, I can be required to hand over my laptop and help officers access the information without any suspicion of wrong-doing. We have a little problem here…
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Diagnosis–what is the value?
In an earlier post, I wrote about the epistemology (or perhaps ontology—we never really did settle it) of disease. Defining what is disease is sometimes obvious, sometimes not. If you have HIV, you have HIV—a test is positive or negative, treatments are known. If you have high blood pressure, it’s a little trickier. How do we know that 140 mmHg is “hypertension” and that 139 is not? Does it even matter? An essay in this week’s Annals of Internal Medicine says “yes”.
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Conscientious objector or deserter?
The discussion we’ve had since Friday regarding the Bush administration’s latest foray into theocracy brought up some interesting points. We discussed implications of the draft regulations including likely limitations on access to safe and effective birth control. But there is another issue here that disturbs me greatly.
Last week we talked a little bit about medical ethics. I’m not an Ethicist (Mike! Are you reading?), but I am a “practical ethicist”, as are all health care providers. How do ethics inform the discussion of what care we can or cannot provide?
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Theocracy in action—HHS proposes to limit birth control
I’m so angry I can barely type coherently. I have very strong feelings about abortion, but I believe it is possible to respectfully disagree about the ethical issues involved. I have an obstetrics colleague who does not perform abortions, but refers patients needing this service to others. That’s the ethical way for a doctor to oppose abortion—don’t do it, don’t prosteletize, refer out. My personal feeling is a woman has the right to control her body and all that dwells within, but I can see why others would disagree.
All that being said, if you chose a profession that will, by its very nature create an insoluble ethical conundrum, you need to get a new job. Pharmacists who refuse to dispense birth control when given a lawfully written prescription should be fired immediately and consider a change in careers.
The Religious Right is trying to protect these types of “acts of conscience.” Traditional passive resistance in the model of Thoreau and King emphasized the breaking of unjust laws and the acceptance of any punishment that goes with it. The religious right in this country is not content with this model—they would prefer to allow for acts of conscience without consequences. In this vein, the Church Amendment was passed. This amendment protects professionals who are trying to impose their values on others by mandating that health care providers who receive federal funds not require providers to provide services that to which they morally object. This has not been widely enforced apparently, because a draft is circulating at the Department of Health and Human Services that would step up enforcement, and broaden the services to which people could object, even protecting them if they refuse to refer to an alternate provider. This document terribly flawed for a number of reasons.
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More on the effects of tobacco poisoning
My recent post on tobacco poisoning focused on chronic obstructive pulmonary disease, the cause of about one-third of smoking related deaths. Let’s move on to cardiovascular disease (CVD), which accounts for another third.
When we talk about CVD, what are we taking about? The pathophysiology is very interesting…go and read.
Heart disease, which includes heart attacks and heart failure, kills about 100K smokers yearly. This includes people who have a heart attack and die suddenly, but also people who develop heart failure and linger on swollen and breathless.
Strokes kill about 16.5K smokers yearly, which doesn’t include smokers who are only disabled by strokes.
Aortic aneurysms kill about 8.5K yearly. That’s a fun one. An aortic aneurysm is a dilation of the main blood vessel that leaves the heart. When this tears or bursts it causes horrific pain in the chest or abdomen that radiates to the back. Thankfully the pain often doesn’t last long, because if the aorta actually bursts, you bleed out into your chest or abdomen very quickly.
Oh! Wait! I forgot peripheral vascular disease! Who doesn’t like gangrene? (Don’t click unless you’re ready for the gangrene picture.)
Peripheral vascular disease often starts as pain in the calves when walking, but can rapidly progress to loss of a limb. Eww.
I always tell my residents that helping a patient to quit smoking is usually the best thing you can ever do for their health. Smoking is the cause of most preventable deaths in the U.S. and causes about 20% of all deaths. It is impossible to overstate the public health menace that smoking presents. Cessation programs have become more sophisticated, as have the drugs that are available. Patients often ask me if nicotine patches are safe. My usual response is, “Well, are cigarettes safe?” There are very few bad ways to quit smoking. The first step is deciding you’re ready. Then, get educated. Resources abound.
Ach! I forgot to tell you….
Average monthly cost of cigarettes: 350 USD. That’s a whole lot of money.
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Another reader question, and open thread
This is one of those topics I’ve always sort of avoided, and I’m still avoiding it for now. But that doesn’t mean you have to remain silent. Here’s the reader comment/question:
This is off-topic, but I wanted some doctorly input to a discussion that I am having over at another blog.
This lady is hyperventillating about the “sinister” (her word) policy of the Oregon Public Health Plan.
They won’t cover curative treatment for people who have a “less than 5% chance of surviving five or more years”
Instead, they cover palliative treatment, hospice, and Doctor-Assisted suicide.
This lady is setting it up as a moral judgement that the government is making a value judgement on 1,2,3, or 4 years of life.
To me “less than 5% chance of surviving five or more years” doesnt sound like curative treatment doesn’t have a very good chance of buying you even one year of additional life. I think that she has an unrealistic view of what it means to have a less than 5% chance of surviving five or more years” means.
Heres the story:
http://conservablogs.com/haemet/2008/07/28/the-real-face-of-choice/
It’s all yours, folks.
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How real science works
Every once in a while I like to do a piece on how real science works. The New England Journal of Medicine was kind enough to serve up a nice example for us this week.
Real science is hard. It’s time-consuming, expensive, and leads down many blind alleys. That’s one of the reasons pseudoscience is so alluring—anyone can do it. It doesn’t require an education, an R01 grant, or really even a grasp of reality.
So on to the current article. Heart disease is a big killer. Over half-a-million people yearly have the worst type of heart attack, called an ST-segment elevation myocardial infarction (STEMI). Coronary heart disease kills almost a half-a-million Americans yearly and around 300,000 people die of heart attacks in American ER’s every year.
So this is a pretty important disease. Here’s how it works…
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