healthcare (13) Long live Jane Brody and the NYT

Apart from the several physicians I have seen in recent years, most of my health related info comes from Sanjay Gupta's program on CNN, the New York Times reporting on medical malfeasance and especially from Jane E. Brody's Tuesday columns in the Science Section of the NYT. Hers is great public service as she presents her research without hype (the sober evidence is often bad enough). They are examples of "you can trust what you read" in this newspaper at least. It seems to me that much of  the recent "medical reporting" results from the passage of the Affordable Care Act (Obama Care) that continues to fuel the political debates; a good deal of it, incl. in NYT Editorials, aims at reducing the coasts of healthcare, e.g. her column of May 28, 2012 on trimming the "Bloated Health Care System."

In April 2012 I began to collect NYT articles and pretty soon I got the impression that for the health profession April was "the cruelest of months." But I was wrong, once my curiosity was awakened I ended up with frontpage items as well as pages from the Business Section. I started this blogpost in September, but as becomes clear, the bad news endures.

Then there is also the scarifying arrogance of the drug industry's warning pages that accompany their advertising, some of which I already dealt with in earlier posts. (An interesting change in vocabulary, no doubt reflecting the difficulty of getting in touch with one's physician, is the recurrent advice to "consult" or "notify your HEALTH CARE PROVIDER" or "PROFESSIONAL" i.p.o. "your doctor." Apparently they now assume practical nurses and qualified pharmacists are safe enough.) I call their warnings, meant more to forestall legal action than to inform (their nomenclature being generally too confusing for the lay person) "arrogant," for under the guise of advising the patient, drug companies reveal that their medicines often do not work and are frequently harmful, yet still ask your doctor prescribe them. One may be amused by the advise to Viagra victims to call their doctor who can't be reached because he's enjoying the sunset with his partner in separate bath tubs after having taken Cialis. But there is nothing humorous about an ad that recommends ABILIFY, an anti-depressant prescribed as an add-on treatment when a weaker antidepressant alone is not enough; the first warning is that "elderly patients with dementia-related psychosis (eg. an inability to perform daily tasks due to increased memory loss) cannot take it because of an increased risk of "death or stroke," Is this because of the ingredients or because the elderly may take more than the prescribed dose by mistake? One may develop "neuroleptic malignant syndrome" (NMS) as well as tardive dyskinesia (TD) - which may happen also AFTER you consulted your doctor and were advised to "stop taking Abilify." In sounds like Abilify may be incapacitating.

It turns out that Abilify, described as a "powerful  anti- psychotic" is the 5th best selling drug in the US (NYT, p.D6). The prescriptions for such drugs have risen though the rate of serious psychiatric disorders remained the same. These drugs were developed for use in cases of schizophrenia and bipolar disorders but drug companies tested them for use against depression and anxiety disorders, thus increasing their sales but means of t.v. and magazine ads that cause the (self-diagnosed) Patient to pressure the doctor to prescribe the medicine even in case of insomnia or every day, situational anxiety. But, as the article also points out, these stronger drugs are not more effective than the first generation of anti-psychotics.

[Febr. 3 2013 addendum: In a frontpage and front section article of nearly 3 full pages, the NYT chronicles the medical history of a young man who became addicted to Adderal, an attention deficit/ hyper activity drug, who resorted to faking the sumptons to get more prescriptions. In one of his actual psychotic conditions he was also prescibed Abilify. While this patient abused the system, experts feel that alarm bells should have been ringing, espec. when the parents began to demand that his Adderall treatment be stopped as they feared "it would kill him." It's a truly sad story.]

Abilify is a drug to be used as an ad-on, perhaps for all those anti-depressants currently listed in tv ads by a law firm organizing a class-action suit. Those drugs were once recommended "at the drop of a hat," almost like "take some liquid and 2 aspirins and call me in the morning." But then aspirins, as well as other pain remedies turned out to have bad side-effects and Tylenol became the safer remedy. Until this year and another law firm is advertising for victims of Tylenol and a set of other drugs in which the Tylenol ingredient is used.

Replacing drugs with safer ones sounds like a good thing. But it begins to sound like trading in one side effect for another. Thus fluoriquinolones, the chemical in the strong antibiotics Cipro and Levaquin,  replaced aminoglycosides and chloramphenicol that had potentially life threatening complications. Wow, one says, the pharmaceutical industry really looks out for our health. But then there is Jane Brody (9-11-12) who headlines her column "A Cure That Can Be Worse Than the Illness." She points out that these drugs are often wrongly prescribed for minor infections rather than only in such serious life-threatening cases as life "hospital-acquired pneumonia." Among possible side effects are blinding retinal detachment and acute kidney failure. The culprits here appear to be physicians who do not inform the patients of the FDA warnings carried by these drugs and i wonder whether they actually read them carefully; after all didn't they take the oath: First do not do harm!"? Meanwhile several of these drugs have been removed from the market. There are also some 2,000 lawsuits.

That physicians often fail to exercise the proper caution when prescribing medicines is a constant refrain in the medical pages of the NYT Sciences sections. On 2-28-12 I found the headline "A Cocktail of Drugs May Cloud the Brain," which addresses that cumulative effect of anticholinergetics found in pain killers like prednisone, Tylenol, Advil PM, antihistamines like Benadryl, etc. These anticholinergetics can block the action of a neurotransmitter that is needed in various functions including the cognitive one and memory production. Elderly patients, like me, are more at risk and that brings me to Jane Brody's column of 4-17-2012 entitled "Too Much Medicine, and Too Few Checks," which opens with a reference to her 92-year old aunt as "a walking pharmacy."   She was taking 6 prescription medicines and several over the counter ones as well as a multivitamin, vitamin C and vitamin D. In the hospital a neurologist prescribed one medicine and a cardiologist another. As she was being discharged she collapsed. After that, still in the hospital she developed double pneumonia. Fortunately she responded to antibiotics and began to recover. Brody then goes on to describe the knowledge available to prevent similar crises including that of a team of experts that listed 53 potentially inappropriate medications or classes of medication. About one third of the column deals with "The Patient's Responsibility" including downloading a Drug Diary from the Foundation for Health in Aging, which should be shown to one's physician.

Unfortunately the problem may originate before a physician administers a medicine. Not only have pharmaceutical companies skipped tests or not revealed "negative results" but researchers may have published fraudulent papers that even if retracted may already have found their way into the literature, the retractions coming much later and/or having escaped the relevant database. A very recent and truly abysmal case concerns Yoshitaka Fujii who falsified data in no less than 172 papers (NYT 10-2-12, p. D3). And then there's the revelation of the existence of pharmacies that have in fact become drug companies but which as pharmacies escape to the FDA's scrutiny. One of these, New England Compounding (what's in a name!) Center, sold the drug methylprednisolone that was used in spinal injections and which was contaminated with a fungus that caused the death of 11 patients (by 10-10-12) and hospitalized others. A NYT front page article (10-7-12) documents the widespread use of medicines produced by numerous compounding "pharmacies" either because there is a shortage, they are less costly or because the salesperson has been seductive. This particular scandal remains in the news as more patients are coming forward and dying. Several Representatives have started an official inquiry and meanwhile it became known that medicine from that Compounding Center have also been used in open heart and other surgery. The NYT on 10-16-12 had a front page follow up and its Science Section 2 more articles, and on 12/24 it detailed some longstanding problems, incl. lax inspections and poor sterilization practices at NECC, whose family ownership also is involved in two more compounding firms, one of which had very dismal hygienic conditions according to a NYT article of 11-13-12, p. A13). In view of all the problems plaguing the health services, I find it incomprehensible that compounding pharmacies have escaped close supervision and that their use has become widespread. The NYT reports (11-14-12, p. A16) that "friends in Congress" thought it ok for the Compounders to be regulated by the individual states. But it's also one more "serious lapse of judgment" on the part of physicians.

Sales practices "may be colored by the financial interests of the producers" suspects a letter from the Senate Finance Committee to various pharmaceutical companies. The senators focused on the overuse of narcotic painkillers (NYT. 5-9-12, p.B7). Lo and behold, the NYT Business Section of July 3, 2012, continues a frontpage article about GlaxoSmithKline admitting, after years of being sued, criminal fraud in its sales practices and settled for 3 BILLION dollars. These practices included not only trips to the Caribbean but also helping to publish a medical journal article that misreported data from a clinical trial. Three billion sounds like a lot, but several of the drugs in question brought about 28 billion in sales for the years covered by the settlement. In this case whistleblowers provided important information.

Such fines occasion a bit of wistful thinking: Can they help reduce the national deficit? On 4-11-12 Johnson and Johnson and a subsidiary were fined $ 1.2 billion for its marketing practices of Risperdal; and the NYT article summarizes some more penalties:in January a Texas judged levies a fine of $158 million, in 2011 a Sth Carolina judge levied $327,000,000 and in 2010 a Louisiana jury settled on $258,000,000 (it's fun to type all those zeros!), and an Arkansas judge issued a penalty of $1.19 billion for nearly 240.000 violations of the state's Medicaid law. The article recalls other cases, eg. Pfizer's $2.3 billion in 2009, Eli Lily's $1.4 billion. There's more: The NYT reported on 5-8-2012 that Abbot agreed to pay $1.6 billion in connection with its anti-seizure drug Depakote. Some of these marketing practices involve selling the drugs for conditions not approved by the FDA. It must be that the pharmaceutical industry has decided that fines are part of the cost of doing business and calculated them into the price of the medicine so that the patient is actually paying them.

Among all the newspaper clippings I found a scribbled note on Pradaxa, an anti-bloodclotting drug that had been haled in 2009 as a wonder drug that would replace Warfarin, the rat poison.  That's what I had to take when I had my knee operation. At the time I was amused for I had used the poison, successfully, against rats and mice. It turned out that the FDA was too quick in its approval of Pradaxa, and when I googled Pradaxa I was suprised to find so many websites, several of which by law firms (the Internet has replaced "ambulance chasing"). Pradaxa is made by Boehringer Ingelheim, a family owned company in Germany. My undated note quotes Boehringer saying in Nov. 2011 that 50 deaths were within a "reasonable order of magnitude," but later admitted of knowing 260 deaths. This was when lawsuits had begun. The company's total sales amounted to 12.7 billion in 2009 and more than 1 billion in Pradaxa sales in 2011. The problem with the drug is that it can cause severe bleeding and even when you could get to a health professional it would be in vain for there is NO REVERSAL AGENT. Interestingly enough the official company's website provides a link "Talking to Your Doctor" that allows you to "create a personalized doctor discussion guide." Even more interesting was the fact that when I printed the entire website I got the good news and the coda, but the intervening material with all the possible side effects came out blank.

Whistleblowers are important but rarely welcome. This was made clear once again by the reports in July 2012 of the FDA spying on and monitoring the e-mails of its own experts and their contacts with members of Congress and the media, even though the Insp. Genl. had refused to give permission. The issue here was the FDA's alleged failure to adequately review medical devices, especially those used in breast cancer screenings.

The next month Jane E. Brody produced a column, NYT 8-21-12  "Medical radiation Soars, With Risks Often Neglected." She reproduced a table showing the amount of background and direct radiation of various procedures. Medical radiation "can be used to treat and sometimes cause certain cancers." But doses are high and have downsides, eg. they can damage DNA and cause cancers later. She quotes one expert's warning that there is  "widespread overuse". Then there are untested procedure of ct-scans for detecting calcium in coronary arteries as well as the great variation  in amounts of radiation from the same procedure even at the same institution at different times.Reasons for the increased use include paying for the equipment of doctors in private practice or in hospitals that duplicate nearby hospital equipment.

It's abundantly clear that there's something rotten in state of medicine. And now we have first hand testimony by Sanjay Gupta, himself a brain surgeon. The NYT on 8-1-12 carried his Op-ed with the title "More Treatment, More Mistakes." But, while telling the reader about some abhorrent errors he also reports on the lessons learned and subsequent preventive protocols that were put in place (some of which seem to me so common sensible that I wonder why it took serious errors for them to be decreed. On 9-25-12, the Times enumerated a number of mistakes under the headline "No Sponge Left Behind" that illustrates my point).  The cases Gupta described were necessary interventions, but in line with the "widespread overuse" of  medical radiation reported by Brody, there is also an apparently widespread overuse of unneeded cardiac treatment.

The NYT of Aug. 7, 2012 published a long investigative report on the HCA chain of for profit hospitals, after a nurse alerted the chief ethics officer, engaged an outside reviewer who found  "excessive and risky cardiac work . . ." This drove up costs (mostly reimbursed by Medicare) but also increased profits. Some doctors made misleading statements to show treatments were needed. Photos of doctors involved show them all to be of S.E.Asian origin and one wonders whether their status as foreigners allowed them to be more easily influenced to produce more profits from unneeded procedures. One of them was named "most profitable" and in spite of the review he's still on the staff of his hospital.  Moreover, unnecessary treatments had already been investigated by HCA in 2003. It's a sordid story of a company unable (Unwilling?) to clean house. To make matters still more horrendous, the Times published another investigative report of two full pages concerning the financial shenanigans at HCA over the last decade that makes on think consolidation of hospitals into a giant network and leveraged buyouts to increase the bottomline of  equity firms  forces people, including doctors who are supposed to "do not harm," to tolerate and probably promote the mistreatment of defenseless human beings.

Any more of this and I'd be ready to ask: Anyone ready to call the PROFESSIONAL CAREGIVER? At least my own, as well as those of Colette, my long time partner, is among the reliable ones.