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Monday, August 07, 2006




Saturday, August 05, 2006

Hit The Breaks, Online Poker

Wired discusses the legailty of online poker. This is my favorite opinion,
[M]any argue poker tournaments online technically are not gambling.

"You get a prize for a competition," said Howard Krent, dean of the Chicago-Kent College of Law at the Illinois Institute of Technology.

A Sign of the Times...

...more like of the mystery surrounding Castro and his health. Several gambling sites are taking bets on whether Castro is dead, will die, or in slightly more taste, whether he will make a public appearance before his 80th birthday.


I'm late to the ball here. Even so, as it was all over the news when I was in England in March, I thought I'd provide a summary post.

In case you don't know what I'm talking about, this is one of the worst modern Phase I trial disasters of all time. Six test subjects injected with an immunomodulatory drug called TGN1412, suffered severe excessive immune reactions reactions, swelled up like "elephant" men from inflammation associated with excessive cytokines, suffered gangrene, and possibly face severe long term consequences.
NRI student Nav Modi, one of the "Elephant Men" who nearly died in March during a botched drugs trial in a London hospital, fears he may have only two more years to live.

"It's a really bizarre feeling when you discover you might be dead in a couple of years or even in a couple of months," 24-year-old Modi who has just graduated from university and was looking forward to a career in his family's electrical business told The Sunday Times.

The botched drug test has been one of Health Care Renewal's category coverage issues. From their first post to the most recent, it's a good resource.

The broad idea was for the drug to work as an immunosupressant for B Cell leukemia patients by activating regulatory T Cells. An odd idea to say the least, seeing as the drug worked as a superantigen, activating T Cells independent of the T Cells specificity or of the antigen being presented by an antigen presenting cell. The Telegraph provides a description of what might have gone wrong.
The drug, called TGN1412, is an antibody treatment designed for some forms of leukemia and rheumatoid arthritis. It stimulates the production of T-cells with the aim of improving control of a malfunctioning immune system.

"This is a different sort of antibody and I don't know of another antibody that is on the market that works in the same way," Sir Gregory said. "It is a different and very potent process and very difficult to predict in advance how mild or severe the clinical response might be."

Not all explanations of what went wrong have been so kind as to claim that this effect was impossible to predict or judge. In New Scientist,
An immunologist contacted by New Scientist, but who asked not to be named, says: "You don'’t need to be a rocket scientist to work out what will happen if you non-specifically activate every T cell in the body."
Even so, the company that carried out the testing was found to have followed all procedures, and cleared of wrong doing in both an interim report and final report by the Medical and Helathcare products Regulatory Agency of the UK.

The manufacturer (not the same company as the one who carried out the test), TeGenero, filed for bankruptcy limiting the financial compensation available to the six victims. They did have these kind words.

Meanwhile, the future of drug testing and the future health of the TNG1412 victims remains in the air.

More on Doping

ESPN Cycling has an interview with a World Anti Doping Agency doctor who talks about testing and testosterone. It is about a week old but answers some questions.
[Testosterone is] certainly not one of the first-line drugs one thinks of for racing. Steroids can increase strength and improve recovery time and prevent the breakdown of muscle, maybe make him more assertive and aggressive. All of those could have some positive attribute. But most steroids are given in cycles [6-12 weeks] and in context of working out in a gym with weights. It makes no sense to me why an athlete would take testosterone the day of a race when it doesn't work that way. It doesn't make sense in terms of the pharmacology of the drug, and it really doesn't have the attributes that would be attractive to a cyclist -- particularly one running the risk of violating anti-doping regulations.

Still Here, But No One Is Talking

Remember when avian flu was rearing to be the next great pandemic? Well, it still may be, but as I contended, as it stands right now it has gone the way of the other public health media freakouts. At least as far as the media coverage is concerned.

B Sample Is Positive

Landis' B sample has completed the testing regimine and came back confirming the elevated levels of testosterone that Landis showed in the A sample.
The official decision to strip Landis of the victory rests with the International Cycling Union (UCI), but Tour de France director Christian Prudhomme said: "It goes without saying that for us Floyd Landis is no longer the winner of the 2006 Tour de France."

Friday, August 04, 2006

Attempts At Photography In Europe 2

Responsibility In HIV

A man loses an appeal against Iowa's HIV spreading law.
Court documents indicate Musser, 25, of Iowa City, learned in July 2000 that he carried HIV after being tested at a free health clinic. Although he knew he carried the virus and was taking medication for it, he had unprotected sex on several occasions with different partners.

The high court rejected several constitutional arguments in Musser's appeal, including that the state law requiring a carrier of HIV to notify a partner violates the First Amendment protection against forcing speech against one's will. The court ruled that the state law promotes a compelling state interest and is narrow enough in scope to be constitutional.
What are the arguments for and against such laws? What are the rights at stake here? What about he stigmatization of HIV+ individuals? UCSF has a nice article on the criminalization subject.

Attempts At Photography In Europe

We're Listening

The EFF's suit against AT & T is taking a brief hiatus. Still better than the ACLU's attempt. Thank God for civil liberty friendly judges,
The ACLU argued that the practice was no longer secret, because numerous news reports had made it clear that phone records had been given to the agency.

But the judge said the news reports amounted to speculation and in no way constituted official confirmation that phone records had been turned over.

Yeah, those newspaper reports were just speculation but if it came out during a court case then I'd believe it. Without the AT&T documents the plantiffs couldn't prove they had personally been spied on, and without that proof they had no standing.

Just How Sick Is Castro?

With no sign of him or his brother for days, it is making everyone wonder. If you don't know, Castro turned over power to his brother for a brief period in order to go under the knife for an intestinal bleeding condition. Speculation on his health is nothing new.

Talk of Castro‘s mortality was taboo until June 23, 2001, when he fainted during a speech in the sun. Although Castro quickly recovered, many Cubans understood for the first time that their leader would eventually die.

Castro shattered a kneecap and broke an arm when he fell after a speech on Oct. 20, 2004, but laughed off rumors about his health, most recently a 2005 report he had Parkinson‘s disease.

You have to suspect that they wouldn't be leading their populace to dissappointment, by claiming he's recovering nicely, if he was already dead or on his way too it. Still, not everyone is convinced that he's okay.
Anne Louise Bardach, author of the best-selling book Cuba Confidential, is one who believes Castro's condition is more serious than the official line indicates. She says the timing of the announcement - how it was handled in Havana post-surgery as opposed to pre-surgery - says a lot. She also believes that when Castro dies, the world won't know about it until days later, when the succession has been put in place.
Other theories arise in the same article.

But Maria Werlau, executive director of the Cuba Archive project that documents human rights abuses in Cuba, is convinced the exercise is an elaborate ruse.

"Castro has a long record of turning weakness into strength and I think he's doing it again," says Werlau, the daughter of a Cuban exile killed in the Bay of Pigs fiasco. "Castro knew his 80th birthday was going to attract a lot of negative publicity, but in handing over to Raul and ordering his birthday celebrations delayed to December, he's diverted all the negative attention. It's very clever: he's managed to use his mortality as a weapon." Werlau also believes it's a strategy that will allow Castro to determine who in Cuba remains loyal to him, a way "to gauge his control internally and then come back stronger than ever".

Ah, Good To Be Back...

...okay, it isn't at all. I finished my first Pharm exam today.

I'm one of those jerks who listens to the same song over and over and over for days straight and then gets bored with it and doesn't listen to it for months or years. In that spirit, I found at the end of last year (and apparently it has carried over into this year) that I pick a theme song or two during chrunch time, right before exams.

I'm not sure Dexy's Midnight Runners and Pharmacology are the best mix.

Can Democrats Fix Healthcare?

Over at the Decision '08, they're preparing for the worst. Republicans should be, well the one's who haven't jumped ship.

I've more than alluded to my personal political views and I, like many physicians (medical students other than myself tend to be a little more liberal. But that is before they have to start paying back their student loans) am a little conservative when it comes to medical matters. Organized medicine has found allies on the state level in Republicans when it comes to medical liability reform, residency training funding, battling expanded procedures for non-physician practitioners, and a host of other issues.

However, is a Democratic controlled House really such a blow to the political goals of the nation's physicians? Well, maybe; a split Congress, with an unpopular President isn't exactly going to put out groundbreaking reforms. And we remember this debacle.

Its interesting that the flop of the last major Democratic health initiative was instrumental in bringing in a Republican majority in 1994. Of course, more substantial matters are likely to fell the ruling party this time around.

But, back to my point, what have Republicans really accomplished on health care in Washington? Frist can't even appropriately schedule a vote or throw his support behind national tort reform. We can't get substantial reform on the SGR, and so battle year to year on Medicare cuts. We've seen the implosion of the extreme disappointment that is Part D.

Some of the most discouraging signs have been the lack of substantiated effort by the Republican majority.

In anycase, I'm sure we can't expect more from a split government, but we probably can't expect less either. I find myself not particularly mourning a Republican absolute shelacking in November, and that is exactly what it is shaping up to be.

More Steroid Use

A backup USC safety (and his identical twin) quit the USC football team after testing positive for steroids.
Just last week, Brandon and his identical twin, Ryan, also a defensive back, announced they were quitting football to concentrate on preparing for medical school. Neither could be reached Wednesday for comment.


USC Athletic Director Mike Garrett said the drug test that Brandon Ting failed was administered by the NCAA. If still on the team, he would have faced a one-year suspension.

It remained unclear how this situation might affect his stated ambition to study medicine, preferably at USC. In a prepared statement, the university's Keck School of Medicine declined to "engage in a discussion of hypothetical situations concerning applicant qualifications."

An NCAA official said that if USC provides drug education - and school officials say they have -— teams are not held accountable for use of banned substances by players.
"A positive drug test is basically an individual sanction," said Mary Wilfert, an NCAA associate director of health and safety.
Here's an interview with the twins, after they had announced they were leaving the team, but before it came out one of them had tested positive for steroids.

This of course is just another dent in USC's very recent horrific set of off field problems. USC has turned into the new Miami.
In the final week of April, Bush and All-American receiver Dwayne Jarrett came under scrutiny for potential violation of NCAA rules. News cameras showed quarterback Mark Sanchez arrested - he was not subsequently charged - on suspicion of sexual assault.

In June, the Los Angeles City Attorney's office charged former defensive lineman Frostee Rucker with two misdemeanor counts of spousal battery and two counts of vandalism in connection with an alleged August 2005 altercation.
Pete Carrol keeps insisting our All-American reciever, in Dwayne Jarrett, will not face any suspension for his faults of NCAA rules. As for the very serious matter of Bush's family's housing arrangement, that could take some more time, but the longer it drags on, the less likely I think it is that USC will face major future penalties (losses in scholarships, etc.) It would be scary though if USC had to forfeit games Bush played while his parents were living in the house.

At least we're not the only team facing these problems.

College Football Is Back

USC, despite losing two Heisman Trophy winners, has come out ranked #3 in the preseason Coaches' poll.

1. Ohio St.
2. Texas
T-3. USC
T-3. Notre Dame
5. Oklahoma
(Missing Starting QB)
6. Auburn
7. West Virginia
8. Florida
9. LSU
10. Florida St.

It's a shame USC only got one first place vote (I wonder who that was?) It is also a crime that Texas is ranked so high and W. Virginia and LSU ranked so low.

Grossberg v. Merck

Merck won its second Vioxx case in a month. This is Forbes with prelim reporting, as well as more extensive quotes from Merck counsel in another piece, and here is Point of Law's archive on its coverage of the ongoing situation.

Here's some history on the Grossberg case at Drug Injury Watch (nice name for a blog). Unlike some other cases I can't find mention of any of the extreme MI risk factors in Mr. Grossberg that have appeared in other plaintiffs (both victors and losers) - extremely high cholesterol, disjointed lipid profiles, hypertension, diabetes.

Monday, July 31, 2006

Home Based Surgery

A couple are charged after a woman they were doing liposuction on, in their basement, died. Neither of them are physicians.

"Honey! Turn down the washing machine, I can't concentrate!"

The district attorney's office said authorities believe that Ribeiro and his wife administered illegally obtained drugs and performed the surgical procedure on the woman. Neither Ribeiro nor his wife are licensed to practice medicine in Massachusetts.

Police charged Ribeiro with unauthorized practice of medicine, drug possession and distribution, and illegal possession of a hypodermic needle. His wife was charged with unauthorized practice of medicine and drug distribution.

Synthetic Testosterone

A French newspaper is reporting that some of the testosterone in Landis' sample could not be simply of his incredible masculinity, as it is a synthetic variety.

A New Symptom

I no longer simply go blank and quite when I walk into a standardized patient's room. No, I've gotten passed my nervousness and I'm actually fairly competent with the physical exam. However, I have developedaprettysloppyhabitwhere

AIDS Caused By HIV?

I suppose for anyone who keeps up with conspiracy theories this is nothing new. Indeed, the documentary is kind've old. It argues that HIV is not the causes of AIDS. I guess this fact sheet didn't exist when this video was published.

Here's another documentary which looks at the theory that HIV was first introduced through contaminated Polio Vaccines in Africa, which is advocated by Edward Hooper.

Thursday, July 27, 2006

I Love Local News

At least they don't show a picture of a bad staph infection. I'll spare you as well.
It looks like a spider bite, but doctors say it's really much worse than that.

It could be MRSA, a type of staph infection that looks much like a spider bite or a boil. Right now, doctors all over the city are seeing cases of MRSA.

Home Use

I Always Thought This Was Wierd

Why did earlier med mal studies (including at least one in which Studdert was involved) find such higher rates of frivolous lawsuits than the recent Harvard School of Public Health study? Well, we don't actually get an answer to that question (I'm sure an excuse is around somewhere) but Specialty Insurance Blog discusses how the study was spinned to look like a victory for the current method of reimbursing people. I always thought the title of that HSPH press release was a little more than just announcing the findings.

What Does It All Mean?!

Doping in professional cycling. Everyone let out a *gasp*.

Okay, so we don't know anything officially yet. It could all be a big mistake. But, how exactly does testosterone help professional athletes? And just how plausible are Landis' potential excuses?
Landis told that elevated levels of testosterone are a common problem among cyclists and that he is retaining the services of Spanish doctor Luis Hernandez to help prove his innocence. "In hundreds of cases, no one's ever lost one," Landis told the Web site.

Landis also told that he has been taking an oral dose of thyroid hormone to help a thyroid condition he's been treating. He also suggested cortisone shots he's been given for his hip might have contributed to the test result.

Testosterone and other androgens promote muscle growth and hematopoietic stem cell maturation (we all remember when Lance was accused of giving himself EPO, a drug specifically used to raise one's red blood cell count and thus increase your oxygen delivering capacity).

As for Landis' claims, they sound semi-plausible. I have no idea how one identifies testosterone in the lab, but increased levels of thyroid hormone could raise one's testosterone levels. From what I understand increased levels of thyroid hormone increase the overall level of testosterone in your body, but also increases the levels of SHBG. Since most of your testosterone is bound to that, the level of free testosterone isn't greatly affected by increases in thyroid hormone. If they're measuring levels of free testosterone, I'm not sure how strong Landis' argument is, but if the lab is deducing the levels from SHBG, then Landis might have somewhat of an argument.

Wednesday, July 26, 2006

Something to Look Forward To...

Why 3rd year is so much better than the 1st two over at MedRants.

I was stressed first year, I'm getting stressed second year, but I will say I'm a lot less of a nervous wreck than some of my classmates. I mean, I think I'm pretty friendly, even in the midst of exam weeks. To be honest with you I don't know if that's a good thing or a bad thing.

All of that might change the closer I get to Step 1, I will say...

Tuesday, July 25, 2006

Quackery As A Substitute

A Virginia judge has lifted the order for a 16 year old boy to restart chemotherapy until his appeals have been exhausted.
A lawyer for Abraham and his parents argued that if the lower court order was allowed to stand, any further legal appeals would be moot.

"Once those doctors take control of Abraham, then the game is over in terms of their appeal that they're entitled to by statute," said John Stepanovich, lawyer for Jay and Rose Cherrix.

Of course, the evidence for this homeopathic treatment isn't looking good,

The type of cancer Abraham has is highly treatable in early stages. Abraham had court-ordered X-rays at CHKD in June. He also had a follow-up exam with his doctors at the Biomedical Center in Mexico, where he'’s receiving the Hoxsey treatment. Both exams showed that his tumors - one in his neck and one near his windpipe - had grown since February [when he started the herb treatment].

At least the center in Mexico admits his tumors have grown. I'm not really sure what that says though.