The Best Doctors

1.Drs Beutler, Hoffman and Steinman

These three were the winners of the 2011 Nobel Prize in Medicine and the impact of their research will be felt for many years to come.

In essence, they discovered receptor proteins in the body that can spot bacteria and other microorganisms and then activate the body’s innate immunity to defend itself. These dendritic cells activate the T cells which then produce antibodies which attack the invading germs.

Their studies determine  how clinicians prevent and treat infection, inflammatory diseases, and cancer in the future. Strangely enough, one of them, Dr Steinman (right,above pic) himself died of cancer of the pancreas before he won the award. This disease was one of the potential beneficiaries of his research.

2. Dr Valentin Fuster

This Spanish cardiologist, who is the Head of Mount Sinai Heart Centre in New York, is the only person to be awarded the top research awards from all the four main cardiovascular organisations.

He is best known for his profound contribution towards the understanding and prevention of atherothrombosis and was the first to have highlighted the role of platelets in acute coronary syndromes. In other words, how heart attacks happen-see below.

Dr Mark Kris

Lung cancer specialist at one of the top cancer centres in the world, Memorial Sloan-Kettering in Houston,Texas, he was recognised for his  dedication and compassion in his professional work and volunteer efforts by being awarded the inaugural ASCO Humanitarian Award .

He has built homes for families in Hyde Park, New York,  gone to Costa Rica to build a basketball court and a church and made several trips to assist with earthquake relief in Haiti; and helped with relief efforts in Biloxi, Mississippi  after it was hit byHurricane Katrina.

Of course, to the unsung heroes out there,those who have toiled without bells and whistles, well done for being a credit to your profession!

Related articles

• Remembering Ralph Steinman (06880danwoog.com)

The Worst Doctors

1. Conrad Murray,MD

Physician to the King of Pop.. in November he was sentenced to 4 years in jail for his conviction on a charge of involuntary manslaughter in the pop star’s death. There wasn’t much substance in his defence once he admitted to using propafol injected intravenously into Michael Jackson’s veins so as to enable him to sleep at home. What was worse was that this drug is normally used in a hospital setting with the patient hooked on close monitors; using it otherwise (at home) constitutes negligence and inappropriate use.

2. Gerald J Klein, MD

Gerald who? Well, he was one of 14 Florida doctors indicted in August 2011 for illegally distributing opioid analgesics such as oxycodone and sedatives like Xanax. Drug addicts and dealers would queue in their clinics to sell or receive drugs illegally under the pretext of valid medical reasons. Opioid analgesics were dispensed and prescribed on an assembly line basis,  paid for with cash and credit cards. Clinic employees hauled their money to the bank in large garbage bags. This way, each doctor netted USD 1 million yearly. “Drug dealers in white coats”, said the FBI.Read more here.

Dr Gerald Klein..described as a drug dealer in a white coat

3. John R McLean,MD and others

The Maryland cardiologist was convicted on 6 charges of healthcare fraud relating to insurance claims that he had filed for doing unnecessary coronary angiograms and angioplasties (invasive test and treatment of blocked heart arteries), as well as for ordering unnecessary tests and making false entries in patient medical records. In November, Dr. McLean was sentenced to 8 years in jail.

The buck does not stop here in Maryland – already two other cases are being heard (see here and here) of similar cases where cardiologists have done unnecessary procedures on otherwise well patients, in return for unethical financial rewards.

In the next blog entry, I will name the best doctors of 2011.

Related articles

• U.S. Drug overdose deaths are increasing (psychologytoday.com)

..and just in case, you’re thinking about giving up alcohol in January after the recent excesses, don’t bother say several researchers.

Promises to give up alcohol for a week or two, or even a month, are common in the New Year but are being described as medically futile.

As drinkers begin their DIY “detox” programmes by giving up alcohol, the British Liver Trust is preparing to launch a series of roadshows designed to focus public attention on the growing problem of liver damage.

A consultant hepatologist (liver specialist) in UK has the last word: “Detoxing for just a month in January is medically futile. It can lead to a false sense of security and feeds the idea that you can abuse your liver as much as you like and then sort everything else with a quick fix.“

This is not the same of course as saying that one should continue drinking!

Related articles

• Detox is ‘futile’, says charity (bbc.co.uk)
• New year liver detox ‘is futile’ (mirror.co.uk)

Former PM Badawi - a victim of OSA

In an interview in the latest issue of Health Today, a bimonthly publication for medical professionals, he discloses his initial state of denial for many years that he had obstructive sleep apnoea (OSA), a condition usually caused by blockage of the breathing passages in the mouth or throat causing the sufferer to snore, stop breathing while asleep and consequently feel drowsy during the day. Other symptoms include:

• snoring
• choking while sleeping
• daytime sleepiness (at meetings and at the wheel)
• morning headaches
• poor memory, depression, irritability,sexual impotence.

There is an increasing awareness towards this treatable condition because doctors have discovered a link between OSA and high blood pressure, heart attacks, stroke and death. A personal anecdote…I recall a few years ago,  a middle eastern gentleman who had scoured the globe in search of a treatment to lower his blood pressure. Despite being tried on a host of  medications, his blood pressure remained notoriously high. By the time he saw us professionally, he was about to give up in despair until we noted that he would doze off easily while talking to us. A visit to the ENT specialist resulted in some minor surgery to widen his breathing passage in the throat. and needless to say, his blood pressure dropped to normal within a few days without a single pill!

To better visualise what happens during OSA, watch this interesting video:

I had also written several times before on this fascinating but potentially lethal condition. You can access them here:

• Why People Doze Off During the Day.. Daytime Drowsiness Dissected

• “This is Your Captain Sleeping” – OSA affects Pilots,too!

• Pardon the Sleep…its OSA!

Back to Abdullah Badawi – in 2007 he underwent a successful nasal operation in Australia and can now claim that he has been cured of OSA and does not fall asleep unknowingly anymore..

Grapefruit,  a member of the Citrus family, has been shown to carry many health benefits: it is a rich source of Vitamin C and also contains bioflavonoids which have anti-cancer properties. However, when consumed with  a large variety of medications, it has the ability to make the dosages taken, albeit correct, multiply to several times the usual amount in the bloodstream. Cases have been reported of a person on Lipitor or Cordarone dying due to an accumulation of this drug in the bloodstream.

The reason for this is that grapefruit gets metabolised in the liver by  cytochrome P-450 3A4 enzyme , the same enzyme which also metabolises about half of the drugs consumed today. So when grapefruit keeps this enzyme busy, it is unable to metabolise drugs, causing its accumulation in the bloodstream. Depending on the drug, the person will experience a variety of side-effects due to the “overdose”.

The list of drugs which can be affected is numerous and includes anti-cholesterol medications as well as Viagra. See the list here.

 

Don’t take medications with orange juice, if you can help it

Recently, it has also been discovered that consuming grape juice or even orange juice can affect the absorption of some drugs when taken by mouth, which is why I have always maintained that medications should be taken with just plain water. These drugs include popular ones like beta-blockers (like atenolol), antibiotics( like ciprofloxacin) and anti-cancer drugs (like etoposide). Read mo

This Samsung Galaxy Netbook, retailing at GBP229, was offered at GBP22.

The retailer said that it was unable to sell the laptop for the amount shown online and has emailed or telephoned all the customers who tried to buy it to explain and apologise. At this point, many customers felt that they were within consumers’ rights to insist that the retailer honour its promise and deliver nonetheless.

But they did not reckon with the fine print in its terms and conditions on its website which made clear that if an item was priced due to human error, then the price does not hold.

And what was the human error? Currys blamed it on fat finger syndrome.

This condition has made headlines several times recently. Of note was the tokyo trader who, in 2006, mistakenly keyed in a transaction order which inadvertently cost him USD 18 million.(see here). In essence, this syndrome refers to the invocation of a unwanted secondary action due to (a) one’s finger being bigger than the envisioned touch zone, or (b) accidental inaccuracy in the fine motor movements of one’s extremities. In simple terms, accidentally pressing an unwanted key on a keyboard. Quite common nowadays with mobile phones being as small as it is!

The Original Fat Finger Syndrome case? A typographical omission of the word "not" in the sentence "Thou shalt not commit adultery." This printing of the Bible has become known as the Wicked Bible( from Wikipedia)

The anti-cholesterol pill Crestor..not better than the older ones

While drug pharmas may go to town extolling the virtues of their new drug releases (which they claim to have undergone extensive research and FDA-approved), it is easy for doctors and the public to be swayed by these promises and switch to the new. Some doctors know this can sometimes backfire. For instance, newer meds have a shorter track record of usage, sometimes not enough for side-effects to appear which  escaped scrutiny during the drug trial period. After prolonged use, previously-undetected side-effects can surface which may even lead to eventual withdrawal of the drug from the market.

The Orlando Convention Center- where the ongoing AHA Meeting is held,Orlando,Florida.

A case in point: at the ongoing American Heart Association (AHA) meeting in Orlando, Florida, November 2011, it was revealed that a popular anti-cholesterol medication Crestor  was not significantly better than the older more popular Lipitor that it intended to replace, in terms of reversing cholesterol blockages in arteries.

For the makers of Crestor, AstraZeneca, this is a double-blow: it had sponsored the clinical trial to demonstrate its superiority over its rival(the SATURN trial). Now that this failed to materialise, it is going to find it tougher to market its drug once its rival loses its patent rights this month.(This means bona fide pharmas can produce non-branded versions, aka generic types, which are considerably cheaper.)

This is of course good news to consumers who now can buy generic Lipitor, at a fraction of the price before, knowing full well that they will not lose benefits extolled by the newer ones. My take-home message though, is that none of the pills are going to work well if one does not incorporate it with change in life-style habits..

Related articles

• Astra’s Crestor Is Comparable to Lipitor in Study (online.wsj.com)

Efficient Justice - a police guard fastens the handcuffs soon after the verdict is read

The verdict’s in..and the stifled shriek heard in the courtroom when the jury foreman announced it appeared more of a confirmation of the expected, rather than a well-earned heavily-fought court battle.

Indeed, the alibis created by the Dr Conrad Murray‘s defence lawyers that MJ had drunk the propofol (which was eventually dropped) and  that he had self-administered the injection with the intention that the singer could be partially blamed for his death smacked very much of desperation than anything else.

It seemed clear to the jury that propofol, a drug that needs to be administered intravenously, was beyond MJ’s state of mind and ability, especially since  he had already popped in a myriad of sleeping pills earlier. Therefore, the drug had to be administered by the attending doctor. Therein lay the catch – propofol, as an anaesthetic, is only administered with continuous monitoring in a hospital setting, with emergency resuscitation equipment on standby and various devices monitoring the patient’s bodily functions.

The jury was sensationally shown this image of Jackson's dead body by the prosecution early on in Murray's trial (Reuters)

Under California’s tough involuntary manslaughter statute, it is not enough for the defence  to demonstrate that MJ had contributed to his death as a result of his drug addiction; Dr Murray should have forseen, as his attending doctor, that MJ was a drug addict, and hence should have forewarned the victim.

Given this tough standard, there was not much chance of Dr Murray escaping the inevitable conclusion..

Related articles

• Conrad Murray guilty (theage.com.au)

English soccer team Tottenham Hotspur’s manager, Harry Redknapp will undergo minor heart surgery on Wednesday, according to reports here. As always, the media tends to exaggerate, possibly to increase readership. As anyone knows, a medical procedure to relieve a blockage of one of the heart arteries is basically that – a procedure (called coronary angioplasty)  usually done under local anaesthetic with the patient able to go home the next day. Hardly what is implied when heart surgery is mentioned – an open-heart operation under general anaesthetic carrying far higher risks.

Anyway, the point here is that there seems an increasing number of soccer managers, especially in the English League that have succumbed to various heart ailments. The list includes:

• Gerard Houlier of Liverpool – in 2001, he  underwent an 11-hour operation for aortic dissection, only for it to recur last year while in charge of Aston Villa, forcing him to quit football altogether.
• Sir Alex Furguson of Manchester United – has had a permanent pacemaker fitted in 2004 for irregular heartbeats (supraventricular tachycardia).
• Sam Alladyce of West Ham United -  has had coronary angioplasty in 2009.
• Joe Kinnear of Newcastle FC -  has had bypass surgery in 2009.

Is there any connection between the rigors of running a Premier League soccer club with players valued at millions of pounds and shareholders baying for a healthy bottom-line with that of heart disease? Your guess is as good as mine. If one were to look at evidence-based clinical research, then there’s not going to be many that will link stress with heart disease. One report by the World Council for Cardiopulmonary Rehabilitation concluded that almost half of England’s football managers have “significant” heart problems and their life-consuming, high-pressure jobs are a “recipe for potential disaster” .However, there’s plenty of anecdotal evidence (see above!) that leads many to believe that a football manager’s life is full of stress, never mind the financial rewards.

The Stress of Managing A Football Club Can Make a Man Go On His Knees

Says Harry Redknapp : “I am absolutely fine and have no worries about my health but this game can make the most mild-mannered of people explode as when you are sitting on the bench you get eaten up inside from first to last whistle.”

 ”After a game I cannot sleep, there is too much going on in my head as I go over moves, think about game plans, think about which player has had a good or bad game – and it’s worse if you lose.”

Indeed, the beautiful game can kill you!

Related articles

• Spurs manager Redknapp to undergo minor heart surgery (guardian.co.uk)
• Heart Disease: When Surgery Is Required (everydayhealth.com)

In cosmetic surgery, pricing may not be as important as the reputation of the provider

If you’re a patient about to enter hospital for a procedure or treatment, one of the hardest things to obtain is an estimate of how much all of that is going to cost. Talk about healthcare being an industry, it is well within a consumer’s rights to know what he is paying for and how much it will set him back.

In today’s world of egalitarianism and transparency, one would expect that  hospitals would give a reasonable estimate of the expected expenditure, in much the same way that a consumer expects a price quote for services to be rendered in practically every other industry. But yet, as a government study in the US published last month confirmed, consumers are usually unable to get accurate information about how much medical treatment will cost them before they receive it.

There were several reasons disclosed for this: difficulty of itemizing health care services in advance, billing coming from multiple providers, and the variety of insurance benefit structures. Add to this legal and competitive concerns about sharing price information, causing price comparisons to be extremely difficult.

I have always maintained that unlike other industries and businesses, healthcare services do not provide any ‘money-back’ guarantees should good outcomes are not achieved. Even if the surgery was a failure and death results, the costs of services provided still have to be paid by the consumer. Worse, if the surgery undergoes complications despite competent surgeons and fail-proof equipment, the unexpected expenditure incurred will prove to be an extra burden for the consumer. Herein lies another problem – the nature of medical treatment and surgery is such that, despite the best of intentions, unexpected complications can occur and upset the most carefully-thought budgets.

In an emergency, pricing and choice goes out of the window

What do I recommend? Several hospitals now put up a price-list on their websites and it may be prudent to search around if you are price-conscious and paying out-of-pocket. But the final decision still depends on other factors like  the quality of healthcare delivery and the reputation of the attending doctor as these do determine a good outcome. Legislation is pending in many countries where it is mandatory to exhibit a price-list so that price variations are transparent.

Even then, these price-lists will come to naught in the case of a medical emergency, where its really a case of Hobson’s choice and the consumer is pressured to pay for the services, like it or not. Yet again another example of why healthcare is not like any other industry..

Related articles

• Want an Estimate of Medical Treatment Costs? Good Luck, GAO Says. (blogs.wsj.com)