Monday, June 17, 2013

Neurologic Damage in Gulf War Syndrome

Finally. Now there is clear evidence that the symptoms associated with Gulf War Syndrome (sometimes called CMI or chronic multisystem illness) have a biological basis. Recent studies have revealed that veterans of the Persian Gulf War who have been complaining of chronic fatigue, muscle and joint pain, gastrointestinal symptoms, problems of cognition and depression) have areas of their brains that have atrophied (become smaller) and that their physical response to pain and exercise is different from that of control patients. The cause of this condition is not known, but it is strongly suspected that exposure to nerve gas that was released when we destroyed Saddam Hussein's chemical weapon stockpile is the culprit. Other suspected causes include infectious agents, vaccines, and exposure to other toxins - especially when waste is burned to dispose of it. That is why CMI is sometimes called "burn pit" disease.
     Many CMI symptoms are similar to other medical conditions that do not have an obvious cause; these include fibromyalgia and chronic fatigue syndrome. It is interesting that when physicians are faced with treating debilitating symptoms that have no obvious cause, there is a tendency to blame the patient's psyche. The medical euphemism used by doctors is to describe the patient as suffering from a "functional disorder." Without saying so, the doctor is suggesting that the illness is a "function" of the patient's inability to deal with his or her symptoms. It would be more accurate to say the patient has a condition of "undetermined etiology or cause" because the lack of clear diagnosis is often a consequence of the physician's inability to figure out what is causing the symptoms.
     Another commonly used term is "idiopathic" which literally means that the illness is caused by itself. Calling a condition idiopathic sounds more academic than admitting that we are clueless about what causes it. The difference between idiopathic and functional is that idiopathic illnesses are accepted as having a real or organic basis. Not so with functional illnesses where the physician believes it is more likely than not that the cause resides somewhere "in the patient's head." There can be a real dilemma sorting out which symptoms are psychological and which are organic because patients who have chronic symptoms - especially pain -  tend to become anxious or depressed because of the illness.  This is called somatopsychic illness; when anxiety and depression cause physical symptoms or make them worse, the condition is referred to as psychosomatic.
     Even though many physicians still believe that Gulf War Syndrome is a functional illness brought on by exposure to the stress of combat, to its credit, the Veterans Administration has granted benefits to most Gulf War veterans who have filed for disability because of these symptoms.  The military has been tracking patients with MSI using a voluntary registry, but it is probable that many veterans who would be eligible for benefits are not receiving them.
     As discussed in a previous post, 80 percent of veterans receive their healthcare from sources outside of the VHA, but most civilian physicians do not routinely take a Military Health History to determine whether their patients ever served in the military. Similarly, without a prompt, most veterans do not tell their doctors if they served, when and where they were stationed, and if they were exposed to known toxic substances. Without this information, a civilian physician would be unlikely to make the correct diagnosis of Gulf War Syndrome in a symptomatic patient. It is imperative that all patients be asked these questions and that their responses be entered into their electronic medical records. Veterans also need to be proactive and tell their physicians where and when they served  even when physicians did not ask for this information.

Thursday, June 13, 2013

Covert Marketing to Physicians Using Direct to Consumer Pharmaceutical Advertising

UK consumers recently rejected the type of direct-to-consumer-pharmaceutical-advertising (DTCPA) that we see in the United States.  BMJ 2002;324:1416.4   Advocates who support a pharmaceutical company's right to advertise prescription drugs directly to patients correctly argue that some patients (and even some physicians) may become aware of treatments they were not previously knowledgeable about. And because the FDA requires these advertisements to carry the same kinds of warnings that a drug's package insert might contain, they believe that these ads are balanced. The presumption is that when a consumer-patient sees the ad, he or she will ask the doctor to prescribe it, and published research seems to support this presumption.
     But the negatives associated with this kind of advertising may not be as apparent. The content of the ad may seem balanced, but the drug's long list of side effects often contains medical jargon that a consumer will not understand, and while the 50 word a minute voice-over cheerfully warns that this medicine may cause heart attacks, stroke, dementia, or psychosis, the visual picture shows a happy patient playing with her grandchildren. I doubt we will ever see the picture of the stroke patient being carted off to the hospital in an ambulance. These ads also don't tell either the doctor or the consumer when a less expensive medicine with a better track record might be a better choice - and because this medicine is "newer" and "Seen on TV" many assume this newer medicine is somehow "better."
     Like any consumer, a physician is susceptible to name recognition, so if she sees this medicine advertised the night before a patient's visit, she might be more likely to prescribe it the following day. More worrisome is that physicians frequently watch these advertisements with the mindset of a consumer rather than a professional. When I read an advertisement for a pharmaceutical in a medical publication, I am much more likely to pay attention to the negatives than I am when I watch the same content during my favorite TV show. Even though I am aware of this problem, it takes great effort for me to maintain focus because I am watching this show as an escape from my work mentality.
     The most covert and dangerous effect of patient advertising on physician behavior is that doctors may be more likely to prescribe medicines for conditions they would not have treated previously. The prototypic example is prescribing Viagra for "Erectile Dysfunction". Before a massive advertising effort, if a patient approached his physician with a complaint of sexual dysfunction, the doctor would have checked the patient for depression, anxiety, cardiovascular disease, diabetes, and other potentially serious conditions. After ruling these out, the patient would usually have been referred to a urologist to rule out anatomic problems and to discuss a variety of treatments. But, because the advertisements for "ED" appeared with the same frequency as those for laundry detergents, it created the impression that this is an everyday non-medical problem that can be adequately treated by any doctor willing to phone in a prescription for blue pills. No examination or history-taking is necessary. Luckily, most patients with ED do not have serious underlying illness, but physicians should remember the Viagra story as a cautionary tale. Advertising to patients may have more impact on physician behavior than has been previously recognized.

Sunday, June 9, 2013

Unintended Consequences of Zero Tolerance for Guns in the Home

The recent tragic story of a 4 year old boy who accidentally shot and killed his father with a gun "found in the living room" teaches many valuable lessons. As a pediatrician, I am willing to support responsible gun ownership if it includes legislative proposals that require background checks for all gun-buyers, safety and proficiency testing for gun owners, safety devices on weapons kept at home, a ban on the sale of assault weapons to the public, and an increase in penalties for carrying or selling illegal guns. Many pediatricians endorse policies that would help to keep children out of harm's way, but our zero-tolerance for accidental and purposeful behaviors that might harm children can sometimes make us less critical of pertinent data. Emotional responses to stories like this one are understandable but they also make it harder to set priorities when deciding where we should direct  limited time and money in order to accomplish our goal.
Our most common error is not matching numerators with denominators. If one-third of households with young children have guns in the home and a tragic story like this one is reported in the national rather than the local news, a thoughtful reader should wonder whether the incidence of serious accidental gun-related home injuries by young children or to them might actually be VERY low. We are quick to criticize pro-gun enthusiasts when they publicize the rare case of a gun owner who successfully protects his family without also shooting himself or an innocent bystander. And we criticize the media when they ignore numerators and denominators as a way to sensationalize the evening news ("Health officials warn that during this past week there were 20 cases of disease X reported in the greater New York area" - without also mentioning that they occurred in a population of 22 million people.)
Zero tolerance for anything - but especially child injury - is a laudable but emotional goal that is not usually pragmatic and is rarely achievable. (Using the same resources, preventing 80 percent of serious injuries from three sources might save more lives than trying unsuccessfully to prevent 100 percent of the injuries from one high-profile cause.)  Personal and professional emotional responses should not be confused one with the other. We must take care to exercise the same numerator/denominator awareness that we accuse opposing special interest groups of ignoring if we are to maintain credibility and find practical solutions for these difficult problems.

Friday, June 7, 2013

Fallacy of Relying on Evidence Based Medicine

Contrary to common belief, medical treatments classified as "evidence based"  don't work for everyone and non-evidence based treatments frequently work for some patients. Recently, parents who believed that their children's autistic symptoms improved while taking an experimental medication were dismayed when the drug trial was discontinued because the medicine's efficacy was questioned. (A Drug's Bitter End, NY Times, June 7, 2013) 
     Pharmaceuticals designed to treat autism are especially difficult to evaluate because the condition is multifactorial and patients may have different conditions that cause similar symptoms. At the most simple level, lower abdominal pain caused by appendicitis and the pain caused by a ruptured ovarian cyst might feel the same to the patient and even have similar findings on examination, but the treatment for these conditions is different: If the two conditions were combined in the same study, appendectomy for appendicitis might not pass the test for statistical significance. 
     If we think of the unifying symptom of autism as a severe learning disability for socialization (especially an inability to interpret social cues), it is easy to understand that children who have this symptom as an isolated finding might require different treatment from those who have the same symptom as part of a global intellectual delay.
     As a general principle, it is good policy to prefer a treatment that is "evidence based" over one that is not because it is reassuring to know that scientific studies have confirmed efficacy for the majority of patients. In many cases, if a treatment does not meet this standard, insurance companies and government agencies will deny payment. Unfortunately, the term is frequently misinterpreted: When a treatment is classified as "evidence based" because it works 70 percent of the time, 30 percent of the treated patients will either receive no benefit or possible get worse - sometimes because of the treatment. Conversely, if a treatment only works 30 percent of the time, it will not be classified as evidence based, but the 30 percent of patients who might have been helped will simply be out of luck.
     No one wants to see useless therapies replace those with proven efficacy, but  patients and physicians should be aware of the limitations of relying solely on treatments that are described as evidence based. There are times when being "too scientific" will not be in a patient's best interest.

Wednesday, June 5, 2013

Vietnam Veterans, Agent Orange Exposure, and Diabetes; An Incomplete NY Times Article

An article in the June 5, 2013 NY Times ponders the reasons for the marked increased incidence of debilitating diabetes in Vietnam. The author fails to mention that in November 2000, using data analysis from the National Academy of Science, the Veterans Administration added Type II diabetes to the long list of probable illnesses caused by Agent Orange exposure in Vietnam. Virtually all Vietnam veterans were exposed to dioxin in Agent Orange, and almost all who develop Type II diabetes can claim VA benefits for this condition as a service-related condition. Toxicity of Agent Orange is measured in parts per billion, and this virtual epidemic of diabetes in Vietnamese civilians who have continued exposure, adds further evidence to the VA/NAS position.
     The problem for Vietnam veterans is that many who have and will develop Type II diabetes will never know that this and other Agent Orange conditions are service-related because most veterans (from all wars) receive their healthcare from non-VHA civilian physicians. Although 10 percent of adults in the US have served in the military, civilian doctors are not trained to routinely ask their patients if they are veterans, where and when they served, and if they may have been exposed to toxic substances known to cause illness. It is therefore prudent for veterans of all wars to give this information to their doctors - whether their doctors ask for it or not!
     The Association of American Medical Colleges is working with the White House initiative, Joining Forces, to encourage medical schools to add military health history and veterans' cultural awareness to medical school curriculum and to electronic health records. And the Veterans' Health Administration has been made aware that physicians who rotate through their facilities do not routinely receive this training as part of their orientation.
     Further information can be found at advocate.html

Monday, June 3, 2013

The Military Has Found the Enemy and It Is Them

A recent story in the Washington Post described an effort to identify high-cost military spending items that could be reasonably cut without having a significant impact on its members. Maintenance of commissaries (the equivalent of discount military supermarkets) seemed like a good target if the costs of providing this valued perk could be transferred to the private sector. By convincing major supermarket chains to provide military discounts that were roughly equal to the cost-savings achieved at commissaries, military members could shop closer to home, have as broad a selection of goods at similar discounted prices, and the billion dollars required for maintaining commissaries (personnel, rent, shipping, etc.) would be freed up to allow for military salary increases that had to be deferred this year because of limited funds.
     Nevertheless, special interest groups protested and military members were encouraged to cry foul to their congressmen - which resulted in this excellent plan being shelved. Once again, the "lemming factor" won out over common-sense reasoning.
     It is not always bad when caution slows down change to minimize harm from unintended consequences. It is bad when caution is incapacitating to the extent that reasonable changes are rejected because of narrow-mindedness and campaigns from fear mongers. The military isn't the only victim of the lemming factor. Unneeded medical tests will continue to drive up medical costs as long as the public (and many physicians) believe that having more test data is the equivalent of practicing better medicine even when that data is unreliable or not useful for saving lives or decreasing morbidity.

Saturday, June 1, 2013

Youth is not Wasted on the Young

Youth is not wasted on the young.

Age and wisdom are paradoxically symbiotic.
If we were wiser when younger,
We would not make mistakes
Required for learning wisdom.

And if we could regain youth
During our later years,
Exuberance would overwhelm common sense
And we could no longer see the world
Through Wise Eyes.  
-                   jlb 2012