Canadian Medicine

Pesticide punch

noreply@blogger.com (David Elkins and others) — Wed, 15 Jun 2011 21:56:00 +0000

Wading through the produce aisles

If you think apples don’t taste like they used to, you’re probably right. The Environmental Working Group (http://www.ewg.org/foodnews/) has just updated its list showing pesticide levels in 53 types of produce, and apples – formally No. 4 of their “Dirty Dozen” – now weigh in at No. 1!

Researchers at Purdue University in Lafayette, IN, analyzed 51,000 pesticide residue tests done over 10 years (2000-2009) by the U.S. Department of Agriculture and the Federal Food and Drug Administration. 98% of the apples tested contained pesticides out of over 700 samples. And most of the fruit and veggies under scrutiny had been washed and peeled, in order to represent more realistic eating conditions.

Others that made the Dirty Dozen were celery, strawberries and peaches – which contained 57 different chemicals – along with greens such as kale, lettuce and hot peppers – treated with as many as 97 pesticides.

If we stick to Canada’s Food Guide we’d consume a minimum of five servings of Mother Nature’s bounty every day. By choosing these from the least contaminated foods we’d ingest less than 2 pesticides. However, picking them from the Dirty Dozen would up our daily pesticide intake to 14 different chemicals – some of which are associated with nervous system disorders, chronic problems including cancer, endocrine system dysfunction, and lower intelligence levels in kids – who may (along with those in the fetal stage) be the most vulnerable to the synthetic residues.

There’s also evidence that the phosphorus-rich fertilizers used in fields have contributed to the toxic blue-green algae blooms in our freshwater lakes, reported to cause vision loss and difficulty walking in some people who’ve been in contact with it, but that’s another story.

When organic produce isn’t readily available -- at the market, or due to budgetary constraints – these lists could be your best shopping companions.
Milena Katz

UBC hospice gets rubber stamp

noreply@blogger.com (David Elkins and others) — Tue, 14 Jun 2011 17:15:00 +0000

Hospice residents are the winners

It’s been five months since the UBC put their plan to build a hospice on the Point Grey Campus on hold. After checking out 15 locations, the Board of Governors agreed yesterday to stick with the plan, despite objections raised by the mostly new-immigrant Asian community living in the high-rise condo facing the sight. They say their opposition to the 15-bed facility has nothing to do with fears that property values might decrease or the "idea" of a hospice but rather deeply held cultural convictions based on their conceptions around death.

According to Professor of Chinese Religions Paul Crowe, Chinese believe “on the assumption the world as we understand it is a unified, single place that’s inhabited by both the living and the spirits of the deceased; and there’s this deeply held concern that we need to keep the spirits of the deceased separate from the living.”

Residents of the luxury tower say the prospect of having the hospice as neighbour has already triggered sickness and stress for them and their families.

UBC delved deeper into possible concerns and did further study on the potential impact on traffic and property values. They concluded that the hospice development be ratified with additional conditions. They recommended that UBC plant trees between the two facilities, maintain outreach programs for new immigrants, and “identify other housing opportunities on campus for residents of the adjacent building who wish to move.” Also, UBC’s VP Stephen Owen stated, “An open-air courtyard in the hospice will be open-air but screened so that it is not visible to the outside.”

The $15 million hospice would be used as a place for research and education, along with providing hospice care, a sorely lacking service for dying Canadians.
Milena Katz

End of the line for the gravy train?

noreply@blogger.com (David Elkins and others) — Fri, 03 Jun 2011 21:43:00 +0000

Pharma giant AstraZeneca will no longer fund doctors' travel to medical congresses, becoming the first leading drugmaker to renounce this common perk.

Announcing the step at an industry conference in Istanbul, CEO David Brennan said that pharma "is a force for good. But if we're honest with ourselves ... we’re often seen as the bad guys."

He cited a recent Harris poll in the U.S., which found that only 11% of Americans rated big pharma as trustworthy, when even banks had scored 20%. The same poll also found, though he didn't mention it, that pharma, along with oil, was the industry Americans most wanted to regulate more strictly.

His company had resolved to address the problem by "never doing anything that could be misinterpreted," said Mr Brennan. "We have decided that we will no longer pay for doctors to attend international scientific and medical congresses but will instead focus our educational efforts on local educational opportunities for healthcare professionals."

He added an interesting take on the doctor/pharm rep relationship from the other side of the fence: "I know from my own experience as a sales representative, you will encounter people who will ask for gifts, or other inducements. And they will threaten to take their business elsewhere, if you don’t acquiesce ... we have made it clear that our sales force have to say no."

It's likely that other pharma companies will follow AstraZeneca's lead. The industry acted in a fairly coordinated manner in abandoning free gits like mugs and mousepads in recent years. And the announcement carries extra significance because Brennan, the only leading pharm CEO to come from a background in sales rather than medicine or chemistry, is also president of the the International Federation of Pharmaceutical Manufacturers and Associations.

The drug industry has come under pressure recently over dealings abroad, particularly with employees of foreign public health services, including doctors. AstraZeneca and other British companies have had to contend with a new bribery act in the UK, while in the United States has been investigating big pharma under the Foreign Corrupt Practices Act (FCPA). Johnson & Johnson paid $78 million last month to settle British and American charges that it paid kickbacks to win business overseas. AstraZeneca itself is being investigated under FCPA for its dealings in China.

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Army of psychopaths to spring up in 2013

noreply@blogger.com (David Elkins and others) — Fri, 03 Jun 2011 20:19:00 +0000

If you thought grim things were forecast for 2012, just wait till 2013. An army of psychopaths will spring up overnight. Many of our friends and neighbours will suddenly develop alcohol problems. In fact, eminent psychiatrists fear that millions of us will slip over that ephemeral frontier that separates the normal from (to use the proper medical term) the Crazy.

That's because 2013 will see the fifth coming of the brain-doctor's bible, the Book that tells us who is normal and who has a "disorder" - the Diagnostic and Statistical Manual of Mental Disorders. Is that weird neighbour just a jerk or does he have a syndrome? DSM-5 will decide.

Maybe he's a psychopath. Because, after 33 years' absence, the honest psychopath makes his comeback in DSM-5. In DSMs III and IV, psychopaths were hidden under the euphemistic category of Antisocial Personality Disorder. But the latest draft of DSM-5 will brand these undesirables as Antisocial/Psychopathic Type, which has a fine condemnatory ring. In fact it sounds more like a judgement than a diagnosis. You can presumably cure a disorder, but can you cure a "type"?

If anyone thinks this is all just semantics, consider the impact in recent years of three disorders that were redefined by DSM-IV in 1994: attention deficit disorder, autism, and child bipolar disorder. The Chairman of the DSM-IV task force, psychiatrist Allen Frances, now says his panel "inadvertently contributed to three false 'epidemics'."

"I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences," wrote Dr Frances. "Clearly, our net was cast too wide and captured many 'patients' who might have been far better off never entering the mental health system."

DSM-5 offers the opportunity to undo some mistakes in DSM-IV. The autistic spectrum was a bit of a dog's breakfast, and the next iteration will try to bring it some order, doing away in the process with Asperger's Syndrome and the unpopular diagnosis Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). It seems a little harsh on Dr Asperger, whose name is being de-immortalized, but fair enough.

But many more new diagnoses are trying to creep in, some pushed by eager researchers, others befriended by lawyers, all surely welcomed by big pharma. Each seeks to push the boundary between Normal and Crazy so that more people will fall into the second category. The draft includes a Hoarding Disorder. The proposed Mixed Anxiety Depression will capture millions who don't qualify for Major Depression but who constitute what we call 'the worrying type'. Irritable people who throw tantrums will have Disruptive Mood Dysregulation Disorder. There's Minor Neurocognitive Disorder for those with expected cognitive decline of ageing that's too mild to justify a diagnosis of Mild Neurocognitive Disorder .

There's also constant pressure to ease the criteria for existing conditions. A study in Australia finds that the prevalence of alcohol use disorders is 62% higher under DSM-5 criteria than under DSM-IV. Adult ADD is also getting more broadly defined. It's the medicalization of normal, if bad, behaviour that scares Dr Frances and many other critics.

Book needs appendectomy
To be fair, most of the worst ideas come from outside the American Psychiatric Association committees responsible for the drafts. Some of the silliest have already been rejected. Divorce lawyers will not get their "parental alienation syndrome", which would have allowed them to counter child abuse allegations by alleging that Mommy had turned Johnny against Daddy.

Disorders that have made it this far in the process, however, are so far advanced that to ignore them would apparently be rude, so those that don't get a disease code are likely to end up in the Appendix on Axes for Further Study, which is beginning to sound like a smorgasbord of half-baked ideas, about as useful as a human appendix. One pseudo-condition that's already definitely heading there is Hypersexual Disorder, which has been derided as a philanderer's charter.

The behavioural "addictions" - shopping addiction, computer game addiction, internet addiction, will also be relegated to the appendix, except for compulsive gambling, which became officially crazy in 1994 with DSM-IV. It makes the leap from humble Impulse Disorder to become the first recognized Behavioural Addiction. Can the others be far behind?

One new condition that teeters between recognition and the obscurity of the appendix is Attenuated Psychosis Syndrome, a diagnosis intended to catch mostly young people who might be at risk of developing a real psychotic episode later in life, but who have never met any criteria for one. Those diagnosed, including the many false positives, would be treated with atypical antipsychotics, costly drugs with a heavy burden of side effects. The creators of DSM-5 declare themselves torn on this one, and welcome outside comment. In fact the whole process is in an open comment period until June 15. You can have your say here.
OD

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Not out of the woods yet

noreply@blogger.com (David Elkins and others) — Fri, 03 Dec 2010 17:24:00 +0000

Last year, Canada saw the biggest increase in new physicians in 20 years. About 2,700 extra practitioners brought the national total to around 68,000, according to figures released by CIHI, the Canadian Institute for Health Information.

Most of the new physicians, about 2,300, were graduates of Canadian medical schools. A few more doctors returned to Canada than went abroad in 2009, perhaps partly due to the weakening of the US dollar. And about 300 new doctors were international medical graduates.

Until about 2004, the number of physicians was barely keeping pace with the rising population. From 2004 to 2008, the rate of increase in physicians was double that of the general population. The 2009 increase was three times faster than the rate of increase of the population.

Clearly, steps are being taken to address Canada’s chronic physician shortage. But a crunch is still coming, and this may not be enough to divert it.

For the first time in decades, the average age of physicians didn’t increase in 2009. But it didn’t decrease either, hovering at 49.7 years. Is there any other job on earth where the average age is 50? Maybe being a nun. Meanwhile, the population ages apace. Older patients mean greater need, older doctors mean less provision.

This is not to suggest that older doctors work less. On the contrary, many do longer hours than their younger colleagues. And many are delaying retirement. Quite a few may have been burned in the stock market collapse, and the 2009 figures may partly reflect their decision to work a few more years to replenish the retirement fund. Others aren’t retiring simply because they can’t find a replacement to take on their patients. Of physicians aged 70-79 in 2004, most were still working in 2008, a feat of endurance surely unmatched in any other profession.

But retirement must come eventually. And with an average professional age of 50, the numbers leaving are going to be significant.

At the same time, their young replacements appear to be working shorter hours. Doctors today want a life as well as a career. And the dramatic increase in female doctors means more family responsibilities – women doctors average about 8 hours less work per week. They have also proved more likely, in the past, to drop the profession altogether. Of the new class of 2009, 52% of general practitioners and 45% of specialists were women.

(Ratios of women to men, strangely, vary quite sharply from one province to another. In Quebec, for example, the numbers are almost even, while in Manitoba male doctors outnumber female by 2-to-1.)

Family practice continues to get short-changed, though the picture is improving. In 2004, just 23% of medical students said they wanted to go into family practice. In 2009, that had jumped to 33%. But it needs to be 40% to meet the actual need.

And why is the need growing faster than the population? Because, of course, of the ageing of Canada. In 1921, one Canadian in 20 was aged over 65. Today, it’s one in eight. In 2026, it will hit one in five. And the “oldest old”, the 85-plus, is the fastest-growing group of all. Consumption of healthcare is astronomically higher in these age brackets. We’re not out of the woods yet.
Owen Dyer

Avandia gets its death certificate

noreply@blogger.com (David Elkins and others) — Tue, 23 Nov 2010 19:29:00 +0000

For three years now, the once-promising diabetes medication rosiglitazone (Avandia) has been waiting for the axe to fall. Sales plummeted after a 2007 meta-analysis in the New England Journal of Medicine linked the drug to a sharply increased risk of heart attack.

Since then, further studies and observational data from Medicare have only confirmed that rosiglitazone increases heart attack risk in diabetic patients by 30 to 80%. Equally damning was data showing that this is not a class effect common to the thiazolidinediones – in fact rosiglitazone’s direct competitor pioglitazone has a fairly good cardiovascular risk profile.

Many diabetologists have suggested that rosiglitazone remains a useful option in reducing glycemia, so long as it’s used with care, and only in patients without heart problems. But pioglitazone’s better showing really kicks the last leg out from under this argument. Rosiglitazone delivers nothing that pioglitazone doesn’t, except for extra cardiovascular risk.

Rosiglitazone has had a Health Canada warning in its monongraph since 2007, issued a few weeks after the FDA gave it one of their notorious “black box” warnings. Its indications for use were also tightened considerably. Since then, sales have fallen by about two-thirds. The end has been drawing near, and this time, Health Canada beat the FDA to the punch.

From now on, the drug will only be prescribed in Canada if patients sign a consent form acknowledging that they’re aware of added dangers of heart attack, angina and heart failure, plus unspecified “other risks”. The patient must also certify their awareness that “there are other options to treat my diabetes.”

The physician, meanwhile, is enjoined not to use rosiglitazone-containing products except in cases when “all other oral antidiabetic agents, in monotherapy or in combination, do not result in adequate glycemic control or are inappropriate due to contraindications or intolerance.”

So farewell, then, Avandia. Neither patient nor physician is likely to go along with that, especially when there’s a boatload of promising new diabetes drugs hitting the market. Drugs whose hidden pitfalls, if any, have yet to be revealed.

What lesson may be gleaned from all of this? One reason rosiglitazone’s dangers went unnoticed for so long is that, while the drug brought much more cardiovascular risk than placebo, the effect was less noticeable when compared to other antihyperglycemic drugs like sulfonylureas and even the reliable standby metformin – because all of these drugs also increase the risk of lethal heart problems.

It may seem odd that, when cardiovascular disease is the thing most likely to kill diabetic patients, we routinely treat diabetes with drugs that increase the risk of cardiovascular disease. It seems even odder when we consider that there’s a safe, cost-free way to reduce blood sugar that actually improves cardiovascular health … that is, exercising and eating a healthy diet of low glycemic index foods.

Oddest of all, surely, is the fact that so many patients are apparently more comfortable with the idea of popping multiple pills with potentially grim side effects than they are with the idea of eating a few more vegetables and a bit less ice cream.
Owen Dyer

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A little bit of poison?

noreply@blogger.com (David Elkins and others) — Tue, 23 Nov 2010 17:06:00 +0000

Expert witnesses fail to acquit BPA in the court of public opinion

Last month, Canada became the first – and still the only – country to formally declare bisphenol A (BPA) a toxin, listing the organic compound as hazardous both to human health and to the environment.

BPA is an endocrine disruptor that can mimic the effects of estrogen. In vivo studies have linked even very low concentrations with permanent changes to the brains and reproductive systems of laboratory animals.

Two years ago, Canada announced its intention to ban BPA from baby bottles, as did several US states. In the event, they were largely pre-empted by the industry, as the shower of negative publicity surrounding BPA made it commercially nonviable.

But BPA hardly went away. In fact, it’s ubiquitous. It may be found in cellphone casings, cash register receipts, and all sorts of packaging, including and especially canned food. It’s an extremely common ingredient in the epoxy linings that cover the metal on the can’s inside.

This, most experts agree, is the number one source of human exposure. In Canada, the age group with the highest detected levels of BPA is teenagers, followed by younger kids. These are also the age groups most likely to eat canned foods.

This month, a panel of international experts sat down in Ottawa to get to the bottom of the issue of BPA in food. The meeting was sponsored by the World Health Organization, with support from the FDA, Health Canada and the European Food Safety Authority.

Their conclusion? That canned food is indeed the main avenue by which we absorb BPA … and it’s not a problem. Their modeling shows that BPA coming in through food consumption matches the quantity going out through urine. BPA does not significantly accumulate in the body, says WHO, and therefore action to remove it from food packaging would be “premature”.

Why premature? Because, as WHO acknowledges, there are still several studies suggesting adverse health effects even at very low levels, and finding worse overall health in people who work around BPA, for instance in canneries. Some of the best quality studies have still to report their findings, so the WHO wants to keep its options open.

But WHO also didn’t want to hurt industry by causing a public health scare before it knew the facts, so it held the meeting behind closed doors and made participants sign confidentiality agreements.

This approach may have backfired. Several manufacturers, apparently unable to stand the strain of not knowing, pre-empted the conference’s findings by announcing plans to remove BPA from their products while the experts were still deliberating. Among these was the world’s largest, Nestlé.

But Nestlé only said it would remove BPA from its US products – though many such products will undoubtedly find their way onto Canadian shelves. Different solutions might apply in different parts of the world, said the company, depending partly on local “cultural sensitivities” and consumer preferences. In other words, where the public shows no sign of caring about potential toxicity, manufacturers are unlikely to worry about it either.

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Kryptonite to the rescue?

noreply@blogger.com (David Elkins and others) — Thu, 28 Oct 2010 23:03:00 +0000

A superglue that can slash heart surgery recovery time shows super promise

We’ve all been warned of dire consequences if we accidentally get Krazy Glue on our fingers when we’re fixing the lamp the dog knocked over. Many glues are so strong savvy people use them to help close wounds. In fact, they are used in medicine during hip replacements and other procedures.

Dr. Paul Fedak, at Calgary’s Foothills Hospital Medical Centre has recently shown that a new superglue can be applied to the sternum after open-heart surgery, with superior results compared to conventional treatment.

Last Sunday, over 3,000 health professionals were treated to information on this super adhesive, called Kryptonite, at the Canadian Cardiovascular Conference in Montreal. The results from a trial on 55 patients who had undergone open-chest surgery – during which the breastbone must be cut open – received either standard treatment with steel wire closures (25 patients), or wires along with the superglue (30 patients).

The glue, made by Doctors Research Group in the U.S., bonded the bones together within 24 hours, without sticking to any other tissue, while the wires alone took up to eight weeks.

Because Kryptonite’s ingredients are derived from components in castor bean oil – fatty acids and calcium carbonate – Dr. Fedak says the stuff is “bio-compatible,” i.e. the polymer forms a porous, very strong bonelike substance, and it doesn’t contain the toxins found in most other bone cements.

Recovery time was cut in half and the pain encountered during healing was greatly diminished. Normally, just the thought of coughing, sneezing or even breathing deeply brings on dread to recuperating chest surgery patients. Those treated with the superglue needed far less medication for their pain.

Of course, the innovation comes with a price – in the arena of $700. Dr. Fedak, however, believes that the shortened hospital stays and reduced medication needed after operations using Kryptonite would help compensate for this cost.

Of the approximate 29,000 chest surgeries performed in Canada annually, it’s highly possible that if the next trial – of 2,000 people – on Kryptonite confirms this study’s results, only high-risk patients (those with internal bleeding or other complications) will not receive this breakthrough treatment in the future. I can’t wait for the results!
Milena Katz

Getting drug addiction treatment on track

noreply@blogger.com (David Elkins and others) — Thu, 14 Oct 2010 23:05:00 +0000

Implants may trump liquid and pills

Methadone has helped countless people hooked on heroin and prescription pain relievers wean themselves off for over 40 years. A methadone alternative may soon outshine the well-known withdrawal aid in some important ways.

Buprenorphine hydrochloride, a semi-synthetic opioid compound used for pain control and detoxification, has been available in pill form for two years. But its downside includes diverting the tablets for sale on the streets and crushing and liquefying them into an injectable – and therefore more potent -- form.

A recent study published in the Journal of the American Medical Association (http://jama.ama-assn.org/cgi/content/short/304/14/1576) shows promise for a buprenorphine implant, called Probuphine by its California makers, Titan Pharmaceuticals.

One hundred and sixty-three opioid-dependent adults (18-65 years of age) received either four 3-cm long (a centimeter shy of the width of a ping-pong ball), ethylene vinyl acetate and buprenorphine implants, or 4 dummy rods for 6 months. The 108 participants with the real deal received 80 mg per implant. All the subjects were given drug counselling, and urine samples were taken to detect illicit drug use.

If anyone felt the slow-release dose from the implants did not combat their cravings sufficiently, they could request sublingual tablets. Over the first 16 weeks, about 60% of the buprenorphine group requested extra doses, while over 90% of the placebo-implanted group did. Urine samples tested negative for illicit opioids more often in the buprenorphine implant group than the placebo group (approximately 40% vs 28%) over the same timeframe. And more of the buprenorphine group opted to stay in the study for the full 24 weeks (66% vs 31%).

Cravings and other withdrawal symptoms were generally reduced in the treatment group, although there were minor adverse reactions reported, i.e. discomfort at the implant site, in both groups.

Considering that Canada ranks almost as high as Germany and the U.S. for prescription opioid use, a six-month implant may be well worth the trouble – as long as it doesn’t dissuade regular visits to the clinic for counselling.
Milena Katz

Doctor, heal thyself

noreply@blogger.com (David Elkins and others) — Fri, 17 Sep 2010 22:15:00 +0000

Post-grads ignore their own signs and symptoms of sickness

We all know the definition of absenteeism: you fall ill, you call in sick, you stay home and nurse your cold. If you think you know the meaning of presenteeism, then, you’d be right: you feel ill, you go to work anyway. Presenteeism has remained a going concern for many medical residents, despite reforms made over the last decade, according to a recent study conducted by the Accreditation Council for Graduate Medical Education.

It seems junior docs in specialties as diverse as internal medicine, pediatrics, general surgery and obstetrics/gynecology will risk infecting their patients and co-workers, and risk affecting the quality of their performance more often than what might be prudent, because of the extreme dedication to their jobs. Or, might it as likely be a protection of their image? Often, they don’t want to appear to be shirking their responsibilities in the competitive hospital environments in which they must practice. Some don’t relish finding a replacement, when he or she may also be doing a gruelling 80-hour sleep-deprived week. Plus, add to the mix sincere devotion and empathy for the patients, who would not be familiar or comfortable with the substitute doc.

Study co-author Dr. Anupam Jena, a Massachusetts General Hospital medical resident who did not take part in the JAMA-published study (http://jama.ama-assn.org/cgi/content/short/304/11/1166-a?rss=1), admitted to once working overnight, despite developing food-poisoning symptoms. He has company. Of the 537 medical residents anonymously surveyed, almost 58% said they’d worked at least once while sick the previous year, 31% said they’d done so more than once, and at one hospital, a full 100% reported working when sick. Many said they also could not find time to visit a doctor for their symptoms.

Despite the unique pressures on these groups of young physicians, isn’t it time that program directors heighten the emphasis on the benefits of being a healthy hospital practitioner – especially during flu season?
Milena Katz

Better pink than dead

noreply@blogger.com (David Elkins and others) — Fri, 10 Sep 2010 20:43:00 +0000

Canada goes too far in excluding gay men from blood donation

It was fairly predictable that Canadian Blood Services would win their negligence suit against Kyle Freeman, the gay Ontario man who introduced syphilis into the blood supply after lying about his sexual history in a donor screening interview.

Mr Freeman lied, he gambled on the safety of his blood, and he lost. He must now repay the $10,000 that CBS spent tracking down and destroying his blood. Public sympathy is most unlikely to be on his side.

But things might have been very different if a more honest gay man had forthrightly challenged, in the courts, a policy that many consider discriminatory. Several such cases are now in the works, and here, the CBS is on much shakier ground.

The current policy demands that would-be male donors reveal, in a private interview, whether they have had sex with another man at any time since 1977. If the answer is yes, they can’t donate.

Obviously, Canada’s strict donor regulations – which prohibit plenty of other groups from donating – were born of the ghastly tainted blood scandal. Overreaction is natural after such an event. Few doubt that there was heavy pressure from Ottawa to err on the side of caution. That has certainly been the case in organ donation, where many specialists say retrictions imposed by Ottawa are far too tight.

In fact, Canadian Blood Services was set up with a mandate not just to be safe, but to be seen to be safe, to “(re)gain the trust, commitment and confidence of Canadians, particularly patients”. That may necessitate going beyond what the evidence justifies.

But with changing technology, the gap between the current policy and what the evidence justifies is growing every year. Until quite recently, there was a longish latent period during which HIV infection in blood could not be detected prior to seroconversion. But with nucleic acid testing, that window of danger has been reduced to about 12 days.

So why does CBS have a deferral period after sex between men of 33 years (and getting longer all the time)? One year would surely be enough, and indeed, that’s the period in numerous countries, including Japan, Australia, and Sweden. Already Héma-Québec, responsible for collection in that province, has said it wants to move to a 5-year deferral.

Nowadays, every single bag of blood is being rigorously tested before it reaches the patient. Mr Freeman’s syphilis infected no-one; the system worked.

The job of Canadian Blood Services is to keep the blood supply safe and visibly so. It has no mandate to make gay people happy. It isn’t required to treat everyone equally, but is free to differentiate between groups based on legitimate safety concerns. I myself am disqualified from giving blood, because I’ve spent too much time in Britain and am judged at risk of variant Creutzfeldt-Jacob disease.

That said, CBS does clearly want to accommodate the concerns of gay people. In fact, it’s had grant money on offer for years to study whether the rules can be safely relaxed. No qualified researchers have taken up the offer. That puts CBS in a weak position in any dispute with Health Canada, who will always be driven by the overriding political need to avoid new tainted blood scandals.

But, as a CMAJ article pointed out earlier this year, the policy may be costing Canada needed blood. Not only are we losing donations from gay men, there are also numerous blood drive boycotts by organizations who once helped, but who now opt out because they find this rule discriminatory. University blood drives have particularly suffered.

So much has changed since this rule was laid down. It’s time to change the rule. It would be nice if any new dispensation could be based on solid research. Because if scientists don’t step up and address this issue, lawyers may do it for them.
Owen Dyer

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How to deal with broken wrists

noreply@blogger.com (David Elkins and others) — Thu, 09 Sep 2010 20:28:00 +0000

A shift to splints?

September is here – a month when kids tend to break their wrists more than most others. A trip to the ER usually ends up with the unfortunate child garnering a heavy, new accoutrement – a cast. After 6 weeks of itchy discomfort and the sight of a scary saw used to take off the cast, said child’s almost good as new.

A new study done at the Hospital for Sick Children in Toronto has shown there may be a better way ( http://www.cmaj.ca/cgi/content/abstract/cmaj.100119v1 ). For kids with minimally angulated fractures of the distal radius, using a splint instead of a short arm cast was equally effective. The 96 5- to 12-year olds had similar range of motion, grip strength, degree of improvement, and complications at the end of therapy. However, the splint group could also remove the pre-fab splints to take a bath.

A previous study on 113 6- to 15-year olds with uncomplicated ulna buckle and/or distal radius fractures also concluded that splints were preferable for these types of fractures in children ( http://pediatrics.aappublications.org/cgi/content/full/117/3/691 ).

Right now, the Ontario healthcare system doesn’t cover the cost of prefabricated splints, but they’re cheaper than fiberglass casts and can be made out of plaster of Paris. “You can make them any size you want,” says Dr. Joe Hyndman of Halifax’s IWK Health Centre, a long-time veteran of treating kids’ fractures.

And, Dr. Kathy Boutis, an ER doc at SickKids and the study’s co-author, is confident that staff members will adopt this treatment quickly, considering her study’s results.

Most of the injured kids -- and their parents -- preferred the ease and versatility of the splints. Considering the comparable physical function the children enjoyed, which was measured by the Activities Scale for Kids (ASK) ( http://www.activitiesscaleforkids.com/ ) after their splints were removed, this shift in treatment seems like a no-brainer.
Milena Katz

A stethoscope app

noreply@blogger.com (David Elkins and others) — Thu, 02 Sep 2010 20:35:00 +0000

And now it’s free

The stethoscope is coming of age – that is, making a giant leap into the present. Like hundreds of other tasks, iPhones now have an app for listening to the heartbeat with iStethoscope.

It’s been around for a while and has, in fact, been downloaded well over 3 million times, by healthcare professionals and the lay population alike. But now, it’s free. Or, for 99¢ you could procure the “pro” variety. The latter allows you to email the heart wave and 8 seconds of the audio, on top of being able to listen to the beat.

As long as the user (of whom there are 500 new ones daily) knows where to place the iPhone’s microphone – any of those 6 vital locations between the ribs -- not press too hard, and make sure to press the device against skin – not clothing – the heartbeat will be heard -- strong and true.

It’s predicted that 80% of physicians will be whipping out their iPhones to gauge patients’ heartbeats by 2012. In fact, at least three American universities already require undergraduates to use one – Georgetown U., the University of Louisville, and Ohio State. These students have the luxury of seeing a phonocardiograph and spectrograph in seconds, as they learn to decipher the beats.

Apple’s iStethoscope app’s creator Peter Bentley, a researcher from Britain’s University College London, is a happy man and has many other applications he’s anxious to have approved (such as one to measure oxygen in the blood) – no easy feat for novel technologies in healthcare, due to the grey area of new medical device regulations.

Among the many others that do exist, however, there’s an app for instant ECGs, and one for fetal heart tracings used during labour, called AirStrip OB. But I don’t think stethoscope makers need to worry just yet.
Milena Katz

Obama crashes CMA annual meeting

noreply@blogger.com (David Elkins and others) — Fri, 20 Aug 2010 19:31:00 +0000

Well, not really. But with the CMA’s annual meeting set to begin this weekend, the long shadow of the US president is definitely looming over the coming debate on the future of Canada’s healthcare system.

It’s become a tradition in recent years for the CMA to release a discussion document prior to their annual shindig, laying out the leadership’s thoughts on weighty matters of health policy. And it’s also become traditional that this document should be a thinly-veiled call for more privatization, hidden under a few unconvincing nostrums about patient welfare.

But not this year. This year’s document actually calls for the principles of the Canada Health Act to be extended to prescription drugs and long-term care. Nor is there any of the nagging for private insurance and for-profit delivery that we’ve come to associate with these releases.

Is it coincidence that the CMA is changing its tune right after the US acted to curb the worst excesses of private healthcare? Unlikely. Obama’s reforms have changed the landscape.

In recent years, while Canadian patients looked at the US system and wanted to run away from it as fast as possible, CMA leaders looked at America and saw something quite different. They saw the doctors’ fat incomes, and they made it their task to keep up with the Joneses.

But now, we’re treated to the spectacle of the Americans themselves running away from their private system, albeit not very far away. No-one, least of all reform’s opponents, believes that the US will go back on these reforms, even if Republicans gain power. A slew of polls have just shown Obama’s health reforms steadily gaining in popularity south of the border. You can’t stop history. Privatization is in retreat.

The advocates of privatization within the CMA are also on the back foot. The CMA can’t credibly bemoan the “unsustainability” of Canadian healthcare expenditure– a theme they repeat this year – when their proposed role model is a system that was threatening to consume the world’s largest economy. They can’t credibly claim to be speaking for patients when they are the main source of schemes to squeeze more dollars out of the patient’s pocket.

Previous CMA leaders have nevertheless sought, like Obama’s health reform opponents, to portray themselves as the patient’s defenders against a heartless government. But the shoe fit poorly – poll after poll has shown that Canadians overwhelmingly favour government-run, publicly financed healthcare. It’s the CMA leadership that has been the odd man out, and its motives have been all too transparent.

The organization has done itself considerable harm with self-serving and intellectually dishonest arguments unworthy of a scientific body. For example, CMA leaders have argued that Canada needs reform because international monitors rank it poorly in quality of health delivery among developed nations. They make the same point this year, in fact. But they’ve routinely failed to mention that the same rankings score the US – towards which they’ve advocated moving – far below all publicly-funded systems including Canada.

The apparent shift in CMA policy is a step in the right direction. Canada's health system has many problems, but underpaid doctors really isn't one of them. One of the leadership’s new recommendations is a Charter for Patient-centred Care. Because, the CMA now says, the discussion in recent years has drifted too far from what should be the central issue: the needs of the patient. That is certainly true. Physician, heal thyself.
Owen Dyer

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Ask pregnant women if they’d like a drink

noreply@blogger.com (David Elkins and others) — Fri, 13 Aug 2010 20:26:00 +0000

But be sure to ask nicely

Canada may be a little short of babies, but it’s got plenty of alcohol. Keeping the two separate has mostly been the task of GPs. But the Society of Obstetricians and Gynecologists of Canada says they’re falling short. Many pregnant women who drink are missed, says the SOGC, often because physicians are unwilling to ask questions about alcohol.

Doctors who don’t make alcohol use a routine question on all visits may be particularly unwilling to suddenly raise the issue during pregnancy, given the stigma associated with mothers who drink. And even those who do raise it may not be getting honest answers.

“Many physicians don’t even ask the question,” says Gideon Koren, director of the Motherisk Program at Toronto's Hospital for Sick Children. “It’s not an easy thing to ask. We have a sad reality that physicians and other health professionals are not doing their job on that — namely that a lot of women are not asked and we do not identify the cases. At the end are kids who are very heavily affected.”

Dr Koren sat on an SOGC panel that has just issued new guidelines on alcohol screening in pregnancy. The guidelines offer an interesting snapshot of female drinking in Canada. Did you know that richer, more educated women, while less prone to binge drinking, are more likely to consume alcohol on a daily basis? Or that Quebec has the highest number of frequent women drinkers, by a wide margin? And where can you find the highest proportion of female teetotalers? You’d never guess – it’s Nunavut.

The SOGC takes a nuanced position on abstinence, recognizing that there’s just not enough evidence on the effects of low-level consumption. Essentially, the guidelines suggest you recommend abstinence in cases where you think you can make it stick, but avoid an all-or-nothing approach if you think it will scare the patient away.

Not scaring the patient away is the key thing in alcohol screening. While a record of maternal alcohol use has proven health benefits for the infant with a fetal alcohol spectrum disorder, its benefit to the mother is far less clear – it can lead to them losing custody of their kids and they know it.

A reliable lab test for long-term alcohol use is on the way, but it requires a six-inch lock of hair, and the SOGC acknowledges – perhaps a little wistfully – that it can’t really be applied to most patients. So we have to make do with self-reporting, and in that game, you catch more flies with honey.

Don’t ask patients how often they “use alcohol”, but instead enquire how frequently they “enjoy a drink”. Don’t tell them that by drinking they may have harmed their baby, but instead emphasize how cutting alcohol could help the baby’s health.

Don’t lowball. When prompting the patient on how many drinks she consumes a week, suggest a high number, because if you suggest a low one, the patient will be reluctant to incur your disapproval by admitting she drinks more than that.

While a warm, informal approach is generally best, validated alcohol dependence questionnaires like CRAFFT and TWEAK are useful. They avoid stigma because the patient tends to assume they’re routinely given in all pregnancies. (Or you could try our non-validated WYLAB questionnaire, which identifies at-risk patients with just one question: “Would you like a beer?”)

However you screen, the effort will pay dividends, says Dr Koren, who notes that 40% of pregnancies with high alcohol consumption result in a fetal alcohol spectrum disorder. About 3% of Canadian children are born with such a condition, with effects ranging from reduced IQ to violent aggression. In fact, says Koren, about half the inmates of Canada’s prisons are the offspring of hard-drinking mothers.
Owen Dyer

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Listening in to brain chatter

noreply@blogger.com (David Elkins and others) — Thu, 12 Aug 2010 19:55:00 +0000

A microchip will soon be wedded to human neurons

It looks like Canadian researchers are at the threshold of a scientific breakthrough that may pave the way to better meds and superior control of artificial limbs.

Dr. Naweed Syed, a neurobiologist at the University of Calgary, was part of the team that wowed the international scientific world six years ago by successfully fusing mollusc brain cells (in this case pond snails) with a one-millimeter square silicon chip. Now he’s at it again. Dr. Syed, who heads cell biology and anatomy at the U of C, intends to marry human neurons this time around – taken from the brain tissue of a patient undergoing surgery for epilepsy – with the silicon-polymer chip (Biomedical Microdevices).

This will be another step towards being able to not only “listen in on conversations” between synaptic connections as well as ion channels but may lead to more accurate use of drugs. “It means we can track subtle changes in brain activity at the level of ion channels and synaptic potentials, which are also the most suitable target sites for drug development in neurodegenerative diseases and neuropsychological disorders,” says Dr. Syed, who works out of a lab at the U of C's Hotchkiss Brain Institute. The research is also being supported by the National Research Council.

The prototype biochip in its new, more refined state will record messages of excitation and inhibition between neurons. It will also allow for communication between computers and itself. This could mean that future hybrid chips might operate protheses, help improve sight or language after a stroke, and repair malfunctioning neurons for those with Parkinson’s and Alzheimer’s disease.

The current chip is automated, making its use quick and easy, unlike the previous version, but 750 reuseable chips currently cost $300,000 – a definite deterrent for anyone planning to use them to build an Bionic Man.

Milena Katz

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Relistor may weaken the GI wall

noreply@blogger.com (David Elkins and others) — Wed, 04 Aug 2010 22:08:00 +0000

When to beware

As all meds do, mythylnaltrexone bromide (Relistor) has its share of possible side effects, the most common being dizziness, flatulence, mild diarrhea, nausea, stomach pain, vomiting, and hyperhidrosis. Severe reactions include a serious case of any already mentioned, or allergic reactions.

Today, Health Canada and Wyeth Canada added a new possible adverse reaction to the list: a heightened risk of gastrointestinal perforation, especially in those with GI cancers and other conditions that could weaken the gastrointestinal wall.

When Relistor came onto the scene – it was approved by Health Canada on March 28, 2008 – it relieved opioid-induced constipation in palliative-care patients with incurable cancers, end-stage COPD from emphysema, heart failure, Alzheimer’s disease, and so on, when other laxative therapies could not – in under 30 minutes. Administered by subcutaneous injection, it blocks opioids from entering cells, allowing bowels to revert to normal function, while not interfering with the opioid’s ability to relieve pain.

The current warning advises discontinuing Relistor and seeking professional help if severe, persistent symptoms like abdominal pain intensified by movement, nausea and vomiting -- possibly accompanied by fever and chills – worsen, as these can be signs of GI perforation.

It makes one wonder, though, if the original studies on this drug should have lasted a wee bit longer than four months.
Milena Katz

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MS and the powers that be

noreply@blogger.com (David Elkins and others) — Fri, 30 Jul 2010 16:39:00 +0000

At least 55,000 Canadians have multiple sclerosis, 3,500 of whom live in Saskatchewan. No one’s sure why our country is home to so many MS sufferers. Brad Wall, Premier of Saskatchewan, has taken a bold move in promising to help finance clinical trials on an unproven but promising new treatment – the “liberation procedure.” He’d like other premiers to follow suit. However, Ontario Premier Dalton McGuinty isn’t convinced the controversial treatment is ready for testing. So, afflicted Canadians are traveling to Bulgaria, Poland, Costa Rica, Italy and India, where the procedure is available, to benefit -- even if only minimally – from any relief it may offer, at an average of $30,000 a pop.

MS patients may have a range of symptoms that include balance problems, vision impairment, muscle spasms and weakness, diplopia, dysphagia, extreme fatigue, chronic or acute pain, and bladder and bowel difficulties, including incontinence. And the majority tends to live about as long as the healthy population.

It seems only natural that a minimally invasive procedure would be worth the risk to such individuals.

Dr. Paolo Zamboni, an Italian neurologist and director of vascular diseases, came up with the liberation therapy theory at the University of Ferrara, while trying to help his wife, who has the disease http://jnnp.bmj.com/content/early/2008/12/05/jnnp.2008.157164.full.pdf). Examination of the venous system of MS patients showed that 90% had stenosis or restricted valves in the jugular and azygos veins, interfering with blood draining. He also found high levels of iron deposits in their brains, which he surmised might be the cause of the abnormal MS immune response, where the immune system attacks the myelin sheath of brain and spinal cord nerves, causing scarring and plaques.

Dr. Zamboni dubbed the phenomenon “chronic cerebrospinal venous insufficiency” and used a type of angioplasty to relieve the blockage in these veins. He found 73% of his patients improved. But after about nine months, “re-stenosis” made it necessary to repeat the procedure.

Despite this drawback, it seems clear, with so many positive anecdotal reports on the Internet, that Canadian governments should consider giving more attention to this possible break-through therapy. Either that, or launching a thorough investigation of Canadian Hutterites, a group known to have a much lower than average risk of contracting MS.

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Between a rock and a hard place?

noreply@blogger.com (David Elkins and others) — Fri, 23 Jul 2010 20:33:00 +0000

Commission a report, then ignore it

With only 94 general practice posts, Prince Edward Island is small, but it's a microcosm of the health budget squeezes being felt around the world. Something needs to be done to arrest the spiralling expenditure ... but what? Time to call in global management consulting firm Hay Group to produce a $200,000 report.

Hay Group, not surprisingly, focussed their attention on one of the province's biggest expenses: doctors. How could the government reduce the amount it spends on doctors? To an accountant, the answer is simple and obvious - have fewer doctors.

That's precisely what the Hay Group is recommending as its report nears completion, and the area in which it finds the most room for cuts is family practice. In fact, Hay suggests cutting the number of GPs on P.E.I. from 94 to as few as 65.

Doing this would naturally require somebody else to shoulder the GPs' burden, and that's what the report recommends, suggesting new roles for nurses, nurse practitioners, and so on.

The province's College of Family Physicians argues it's already adopting these new models. But, says president Dr. Andrew Wohlgemut: "We're not for substituting or getting rid of family physicians and replacing them with other people."

On that issue, it seems, he has friends in high places. On the day the report's recommendations were made public, P.E.I.'s Health Ministry issued a press release trumpeting the hiring of seven new physicians, three of them GPs.

Provincial Health Minister Carolyn Bertram said she won't comment fully on the report until the final draft is submitted to the cabinet in about six weeks, but it seems she's already decided how to address its main recommendation: "We are not cutting doctors' positions," she told the CBC.

Some political realities can still trump even the budget squeeze.

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Future looks bleak for Avandia as safety trial put on hold

noreply@blogger.com (David Elkins and others) — Fri, 23 Jul 2010 20:30:00 +0000

Last week saw an FDA panel rule that there is reason to believe the troubled diabetes drug Avandia (rosiglitazone) does indeed increase cardiovascular risks compared to its direct competitor Actos (pioglitazone).

Now, the FDA appears to be moving to shut down the Canadian-led trial that represented the last chance for maker GlaxoSmithKline to prove its drug is safe. The agency put a "partial clinical hold" on new recruitment for the TIDE trial while it updates the lead investigators - Drs Salim Yusef and Hertzel Gerstein of McMaster University - on the results of last week's panel meeting.

While the FDA safety panel stopped short of voting to remove Avandia from the market, the agency can still take action without a vote, and most observers suspect the end is near for Avandia, which has already seen sales collapse in the wake of data suggesting it increases cardiovascular events.

In fact, the same safety concerns were inhibiting recruitment to the TIDE trial. GSK, which agreed in 2007 to fund a head-to-head comparison with pioglitazone, said last week that only 1,100 of an intended 16,000 study participants have volunteered to date.

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Little sympathy for lung cancer patients

noreply@blogger.com (David Elkins and others) — Fri, 23 Jul 2010 20:04:00 +0000

A critical perspective

Canadians tend to judge people stricken by lung cancer to a greater extent than do people of many other countries, according to a recent study conducted by Ipsos MORI for the Global Lung Coalition. Although this form of cancer is as painful and frightening as any other, consisting of symptoms that can include coughing (with and without blood), shortness of breath, chest and/or abdominal pain, weight loss, dysphagia, etc., because lung cancer is commonly believed to be brought on by the patients themselves, there tends to be less sympathy towards sufferers.

Survey results found 1 in 5 of us admit to this attitude – generally 22% of our population – with men making up 27% and women 19%. Though the Canadian view has much company among the other 15 countries surveyed, we’re far more critical than those with greater empathy such as Argentina – the most caring country, coming in at only 10%. Countries shown to have the lowest rates of smoking tended to be the least sympathetic to lung cancer patients, despite the fact that 15% of these individuals never smoked and acquired the disease through exposure to radon, asbestos, air pollution or second-hand smoke – often from co-workers or people with whom they live. Regardless of the cause, lung cancer currently kills four times as many people as does breast cancer – roughly 20,000.

Heather McQuaid, an oncology social worker maintains that lung cancer patients feel stigmatized. The superficial attitude that gives way to this stigma may very well be the reason why $25 million was invested in breast cancer research in 2007, compared with a paltry $8 million towards lung cancer, directly “impacting on the support these cancer victims receive, particularly from the healthcare system,” according to CEO and President of the Canadian Lung Association, Heather Borquez. Can’t we do better?

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5 risks to a woman's health

noreply@blogger.com (David Elkins and others) — Mon, 19 Jul 2010 17:18:00 +0000

Most physicians believe that too many Canadians eat too much and exercise too little. There are other health risks faced by women in particular. US gynecologist Jennifer Young put together a list of five female risks that can be avoided . It's been one of the most popular items on the Ivanhoe News Wire for the last couple of weeks.

Dr Young's Top Five

1) 50% of women with abnormal pap smears don't follow up.

2) Many avoid birth control pills believing they increase the risk of cancer. Dr Young suggests they actually reduce the risk of ovarian cancer by half. She asserts that studies done in the 1980s that linked breast cancer with the pills turned out to be wrong.

3) Quitting antidepressants cold turkey. Young advises lowering the dosage by ¼ a week for four weeks to mitigate the effects of sudden withdrawal.

4) Drinking too much. Women are smaller, have less body water and lower amounts of an enzyme that breaks down alcohol. She asserts that women who get drunk just once a month increase their risk of heart attack by one third.

5) Not taking folic acid regularly until they become pregnant. She recommends taking the vitamin for six months before pregnancy begins.

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Mother of all studies claims half a million Britons

noreply@blogger.com (David Elkins and others) — Fri, 09 Jul 2010 19:54:00 +0000

The world's biggest health study will shortly wind up recruiting, having today passed the 500,000 subject mark – persuading one in fifty Britons aged 40-69 to let researchers follow their health for the next 30 years.

The £66 million UK Biobank, backed by all the major institutions of British medical research, will "generate new knowledge about relationships between health, disease, genes and environment for many years to come", according to Sir Mark Walport, Director of the Wellcome Trust.

The study aims to be as deep as it is wide, with patients followed in considerable detail. Each has provided samples of blood, urine and saliva, and answered questionnaires on diet, exercise, family and personal history. Each has undergone a battery of tests including lung function, arterial stiffness, bone mineral density, grip strength, brain function, intraocular pressure, sight and hearing.

Much of the analysis won't be happening for at least a decade. But after that, organizers expect a steady stream of revelations in everything from cancer to heart disease to diabetes and arthritis. Needless to say, with their similar genetic heritage, many Canadians can expect Biobank will generate findings relevant to their lives. The study's ethical code dictates sharing anonymized data with all credible foreign researchers.

A key function of Biobank is to act as a gene database. As the NHS's reporting system picks up subjects' health woes, their samples will be analyzed to look for genetic correlations. But participants have been told they won't be getting any genetic analysis back. In fact, they don't stand to gain personally in any way. One striking feature of the study is that even if it detects evidence of illness in participants, whether through blood or urine samples, or because they have genes that turn out to be high-risk, Biobank won't inform the affected patients or their physicians.

One reason for this, the organizers say, is to stop insurance companies from penalising study volunteers. Insurance contracts often legally require purchasers to disclose test results they know, but not those they don't.

But a major ultimate goal of the Biobank is to find the links between DNA and diseases, and disseminate that knowledge as widely as possible. One suspects that at some point, the insurance companies are going to get involved in that process.

This morning, as they celebrated the recruiting of the half-millionth Biobank recruit, the great and the good of British medical research were effusive in their praise of these “local heroes” who will give so much of their time over the next 30 years for no obvious personal benefit. But hang on a minute – if they're all altruistic heroes, then how can they be a representative sample of the British population?

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Canada -- we're number six!

noreply@blogger.com (David Elkins and others) — Fri, 09 Jul 2010 19:06:00 +0000

Canada's health system was ranked last out of six public systems in an international survey that found only the United States delivering worse care to its patients. The private Commonwealth Fund, a group which advocates broader access to healthcare in the U.S., surveyed both patients and physicians on their experiences in seven countries.

The results are compiled in the 2010 edition of their ongoing report Mirror, mirror on the wall: How the performance of the US health care system compares internationally. The highly-regarded Dutch system came in first place, closely followed by Britain and Australia. Germany and New Zealand lagged behind, with Canada bringing up the rearguard of public health systems. The US, predictably, limped in a distant last.

The US scored badly not just on access, efficiency and equity, but even on quality of care, a category in which it came sixth, with only Canada doing worse.

Canada's great weaknesses will come as no surprise to anyone who lives here: primary care, primary care and primary care. The report reflects the growing belief among Canadians that if you haven't got a GP now, you may never get one.

A corollary of this is overreliance on emergency services and lack of adequate preventive care. Wait times are an issue for patients, who also complain of lack of out-of-hours care. And Canada gets very poor marks for our patchwork adoption of electronic medical records.

Canada was actually the biggest per capita spender of the "socialised medicine" countries, at US$3,895 a head. New Zealand occupied the bargain basement at a paltry $2,454. Needless to say, the USA truly was Number One on this metric, blowing away all opposition with its awesome $7,290 per capita health spending.

The Canadian Medical Association's president, Dr Anne Doig, told CanWest News that she accepted the findings, which matched those of other organisations. “These [Commonwealth Fund] reports are held to be reasonably accurate and methodologically sound,” she said.

Dr Doig agreed that primary care needs work and that electronic records should be adopted faster, but contended the problems go deeper than that. Canada needs a patient-centred system of care, she said. “One could argue the system serves itself rather than the patient.”

Canadians did well on the metric of "Long, Healthy, Productive Lives", coming second behind Australia. But Dr Doig said: “Arguably, that is deteriorating. And if things don’t change, we might find we don’t do as well in another 20 years. We are essentially enjoying the benefits of reforms that happened in the ‘60s and ‘70s.” Transforming the health system is the CMA's biggest single project these days, she noted.

Of course, the countries that get the most bang for their patient-centred buck, like Holland and France, also spend less on doctors' salaries than Canada does. We'll let you know when the CMA starts pushing for that reform.

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End in sight for Avandia?

noreply@blogger.com (David Elkins and others) — Fri, 09 Jul 2010 19:02:00 +0000

Health Canada waits to see which way FDA will jump

The diabetes drug rosiglitazone (Avandia) may shortly become the latest high-profile pill to meet an early demise after serious side effects emerged in real-world use.

The U.S. Food and Drug Administration will be meeting next week to consider the fate of the insulin sensitizer, whose cardiac safety has been called into question. Elevated risk of heart attack and other cardiac events has been documented by several studies.

An FDA advisory committee has already reviewed the evidence once in 2007. They concluded that rosiglitazone caused more ischemic events than placebo, but not more than metformin or a sulfonylurea.

The latest research, however, seems likely to drive a stake into rosiglitazone's heart [JAMA, June 2010;304(4)]. For one thing, this retrospective review of 227,000 elderly American patients compared rosiglitazone directly against the other drug in the thiazolidinedione class, pioglitazone (Actos), and found increased risk of stroke, heart failure, and all-cause mortality.

Worse for maker GlaxoSmithKline, the study was led by David Graham, the FDA's associate director of drug safety. Reporting a "number needed to harm" of 60 patients, Dr Graham recommends that rosiglitazone be taken off the market.

Dr David Juurlink of Toronto's Sunnybrook Health Sciences Centre, lead author of the largest Canadian study on the drug's safety (BMJ 2009;339:b2942), echoes Dr Graham's call in a letter in the same issue of JAMA.

In the past, beleaguered drugs have sometimes survived these FDA reviews after panel members with extensive ties to manufacturers voted to keep them on the market. But today's FDA is a chastened agency, stung by conflict of interest scandals. They need to show their regulatory teeth, especially in the current U.S. political environment where lax regulators are the villain of the moment.

Nobody at the FDA will feel like going to bat for rosiglitazone anyway, since the agency was criticized earlier this year in a report by the Senate Finance Committee for letting trials continue even as the extra heart attacks piled up among rosiglitazone patients – the FDA itself has estimated that the drug played a role in 83,000 heart attacks from 1999 to 2007. The Senate also accused the drug's maker of knowing the dangers early but sitting on the information, an accusation that GlaxoSmithKline vehemently denies.

Canadian regulators, meanwhile, say "the benefits are still considered to outweigh the risks" when the drug is used according to Canadian monographs, and within additional limits set by warnings issued in 2007. They will “monitor” the FDA meeting and will continue to review evidence submitted to them by the manufacturer.

Dr Juurlink argues that Canada should remove rosiglitazone from the market now, since doing it right after the FDA would be bad “optics”. Health Canada issued a statement on rosiglitazone today, proudly pointing out that their post-market recommendations on the drug's use are actually somewhat tighter than those of the American agency.

But Health Canada's warnings about rosiglitazone were issued in November 2007, right after the FDA reviewed the issue and decided to give it their notorious “black box”.

It's inevitable that, being a government ministry and therefore insufferably pompous, Health Canada will deny to their last breath that they follow the FDA. But if the FDA pulls rosiglitazone, can anyone envisage Health Canada keeping the drug on the market? Now that would be bad optics.

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