Tuesday, January 25, 2011

T-cell Small Bowel Lymphoma

Interesting case of a small bowel obstruction due to a T-cell lymphoma. T-cell lymphomas arise in the setting of underlying celiac sprue. The prognosis is generally poor, even after definitive surgical resection and adjuvant chemotherapy. One and five year survival rates are 38% and 19%, respectively, according to this paper.

Sunday, January 23, 2011

American Exceptionalism Needs a New Heart

Former Vice President (and still war criminal) Dick Cheney may soon place himself on the list for a heart transplant, according to this WSJ article. Usually heart transplants are restricted to those patients younger than 70 (Cheney turns 70 next week). I say, let the old bastard get on the list, on the condition that he submits to being waterboarded as a live, pay per view event on HBO. He doesn't have to get the full KSM treatment (i.e. 187 waterboardings). Just once is good enough for me.

Saturday, January 22, 2011

Lethal Shortages

It seems there is a critical shortage of sodium thiopental in this country. Sodium thiopental, you may be curious to learn, is one of the main drugs used in lethal injection cocktails administered by state governments to condemned convicts. So unfortunate. Now we won't be able to continue with the barbaric task of state-sponsored executions in this country. Well, at least in some states. I'm sure Texas and Nevada are dusting off their hangman's scaffolds and electric chairs as we speak.

And why is there such a shortage of sodium thiopental, you ask? Because the American company that produces it actually makes it at a plant in Italy and the Italian government prohibits export of the drug if its intended purpose is for capital punishment. What, are you surprised by this? You thought the rest of the world also strapped their murder convicts to gurneys and pumped life sucking chemicals into their systems? Actually, no; most of western civilization has banned it. It's just the United States and other paragons of liberal democracy such as China, Cuba, Egypt, Iran, Iraq, Jordan, North Korea, Libya, Malaysia, Pakistan, Rwanda, Saudi Arabia, Singapore, Sudan, Syria, Thailand, and Uganda.

Besides, trial by jury is a 100% infallible method of determining guilt, right?

Gawande and O-Mama-Care

Atul Gawande's latest piece in the New Yorker is out this week and I suspect the raves will be soon to follow. President Obama is assuredly frantically scrambling to slide a reference to it in his upcoming State of the Union Address.

The article deals with a possible solution to the conundrum of "high utilizers" in the health care system. By "high utilizers" (HU's) we mean those 1% of patients who, due to a combination of generalized sickness/ non-compliance/poor physician management, account for gargantuan shares of systemic health care costs (sometimes up to a third of all hospital expenses). Gawande investigates why this is the case and hangs out with a couple of idealistic physicians who may have stumbled upon a potential fix.

Unsurprisingly, HU's tend to come from lower socioeconomic classes. The diabetic who doesn't have health insurance and only rarely seeks medical attention for severe complications of his diabetes in an ER is obviously going to accumulate more societal costs for his disease over the course of a lifetime compared with the compliant diabetic with decent health coverage who sees a doctor every six months for preventative therapy. So Gawande discovered a couple of altruistic visionaries who decided to create entire medical practices devoted to the care and management of these HU's. Sounds pretty cool so far, right? Focus on the non-compliant patients without insurance who plow through health resources like my buddy Starhay does sliced cheddar at a fantasy football draft and you may be able to lower overall expenditures.

But here's where Gawande's paragons of medical philanthropy start to lose me. The practices he follows around (one in Camden, NJ and the other in Atlantic City) aren't just garden variety charity clinics for unhealthy, uninsured patients. These practices are High-Intensity, Life-Management Centers for the downtrodden and woebegone. Multidisciplinarian teams of doctors, nurses and social workers attack these HU's like it's the first day of July two a days for a team coming off an 0-10 football season. Patients are assigned "health coaches" who schedule appointments, make sure patient X has a ride to office, double check that patient X has filled prescriptions, double checks that pills are actually being taken on a daily basis, arrange exercise time, suggest dietary changes, encourage religious worship (?!?!), make follow up house calls, fill out paperwork for disability/public aid, provide psychologists for mental health issues, enroll in Yoga classes, improve housing conditions, and provide hour long full body massages once a week. (OK, I made the last one up). There's even a passage detailing how one health coach was able to reduce 911 calls and ER visits. Initially, the patients were told to simply program the clinic number into their cell phone speed dials. But too many didn't know how to do this. So the coaches did it for them. Voila. Reduced 911 calls.

I mean seriously? Aren't we talking about grown adults here? Apparently there are professionals who think that taking someone's cell phone and programming a number into his speed dial because he can't figure out how to do it himself, or even just write the damn clinic number down on a piece of paper taped to his refrigerator is some sort of triumph in social re-engineering? This isn't a solution to the health care crisis. It a thinly veiled play for bureaucratized, state-sponsored citizen dependency.

I mean, I'm all for social safety nets and making sure a bare minimum of health care is universally available to all. But this is crazy. Whatever happened to personal responsibility? Why is it "inhumane" to expect an adult human being to take care of himself? People talk about the encroachment of the "nanny state" with health care reform--- but this is a Mommy State plan. Besides, how many people are going to want government-subsidized social workers and psychologists crawling up their ass every minute of every day, asking if they ate their vegetables for dinner.

To be clear, I am impressed by the results achieved by the doctors cited in the article. Their selfless toil and humanistic approach to health care is admirable. But we have to expect a little more from our citizenry. There are many ways we can be better. Foremost involves acting like a freaking responsible adult.

Wednesday, January 19, 2011


Before a Dept of Surgery meeting the other day, a rep from some company called Proxy Biomedical gave a presentation on a newer anti-adhesion barrier called Human Peritoneal Membrane (HPM). HPM is similar to the more well known Seprafilm--- marketed as a product that can theoretically reduce adhesions that form between the bowel and mesh/abdominal wall after open surgery. Fewer adhesions can potentially mean fewer subsequent bowel obstructions and certainly will make any re-operative surgery much less difficult.

The rep was very smooth and tall and quite possibly has a minor recurring role in Mad Men. The crux of his argument rested on an article that had been published in some on-line outfit called the Journal of Surgical Research last year. The "study" had been entirely funded and conducted by researchers affiliated with Proxy Medical---i.e. propaganda under the guise of scientific inquiry. Usually I just use these faux-science articles as a placemat for my morning bagel. But I read this particular one because one of the "authors" was Michael Rosen MD, an eminent local surgeon here in Cleveland, well known for his work on abdominal wall hernias. Plus, the rep's gleaming white cinder block teeth were too much for me to look at any longer.

The study was conducted as follows. Nine pigs were anesthetized and then had an anti-adhesion barrier sewn into its abdominal wall after laparotomy. Laparoscopies were then conducted at day 30 and day 90, noting the degree of relative tenacity of visceral adhesions. Then the pigs were killed and the extent of tissue inflammatory response was determined microscopically.

Now I'm certainly no fan of PETA. I actually have a pronounced distaste for most animals. Cats suck. I don't believe dogs should live under the same roof as a human. I hate movies where the animals talk and perform human-esque feats. I'm especially averse toward the porcine species. If I had to choose a favorite Winnie the Pooh character, it's certainly not the lugubrious, wimpy Piglet (Tigger is the pick here). No moral compunction prevents me from enjoying one or three hot dogs layered in brown mustard at the ballpark. Every time I read The Three Little Pigs to my little girl I make sure to change the plot such that the wolf actually gets to eat the cheap assed pigs who built their houses out of sticks and straw. I don't allow any books about Porky the Pig in my house.

So I'm not some bleeding heart porkophile. Nevertheless I found myself feeling strangely disturbed by the article. Nine pigs were basically sliced and diced and then euthanized in order to determine that.... some new-fangled anti-adhesion barrier (which costs 800 bucks per 10 cm square, incidentally) may lead to a decrease in intra-abdominal adhesion formation? Really? That's it? What's next on Proxy Medical's to-do list of Mengelian science experiments? Chop off 58 monkey hands in order to determine which brand of gauze is more highly absorbent of blood (squaring off against competitors from Johnson & Johnson and Brawny)? Forcibly break the front legs of 17 cougars to assess the relative comfort of their new knee immobilizer (based on decibel levels of cougar screams)?

I dunno. It all seems like a hell of a macabre business to me.