Stay Free! Daily

Ritalin Side Effects: Honey, I Shrunk the Kids!

Is your child acting up? Would it be easier for you if that child were, say, smaller? Then we have the drug for you: Ritalin!

After three years on the ADHD drug Ritalin, kids are about an inch shorter and 4.4 pounds lighter than their peers, a major U.S. study shows.... children who had been taking ADHD drugs before the study began were smaller than kids who had not yet started treatment. Those who first began treatment at the start of the study were normal in size, but grew more slowly than normal kids as the study went on.

In addition to being smaller, kids on Ritalin are less creative, less interesting and less trouble.

Ritalin, for the reduction of everything.

Via American Iatrogenic Association

The libertarian response to Sicko

I'm on an email list devoted on iatrogensis—medical problems created by medical treatments—that has a strong libertarian contingent, so I've had a chance to read several right-wing critiques of Michael Moore's new movie, Sicko.

I agree with one popular criticism: Moore should have acknowledged that Cuba is a hell hole. But I've yet to find any serious argument debunking the main point: that American health care is seriously screwed. In fact, the critiques all follow pretty much the same formula. Most cite inconsequential anecdotes of bad health care experiences in Canada, England, and the other countries Moore visited. The more substantial criticisms point out that people in, say, Canada and England may face long waits for medical care, that hospital infection rates are high, and that some people may be denied care if that care is deemed "experimental."

...and so?  I'm still waiting for a problem that's not also common in America. Canada has long waits in emergency rooms? Been to an American E.R. lately? England has high rates of hospital-induced infections? America's private market hasn't solved that problem yet either. (The iatrogensis email list was created to respond to the problem of hospital-borne disease in the US!) Experimental treatments are explicitly excluded from all American health care plans—and the insurers get to decide what counts as "experimental," even if a treatment plan has evidence of past success.

The one thing Canada, England, and the other countries don't have in common with the US is 47 million people who are uninsured. That feat is America's alone. For many of those people, that means no medical care at all. Somehow America has managed to have the worst of both worlds—we have all of the disadvantages of the other healthcare systems without the advantages: 47 million uninsured, relatively low life expectancy, high infant mortality, and low overall health compared to other industrialized nations. (See This New Yorker story.)

The only complaint that makes sense applies only to those Canadians, Europeans, and Cubans who have so much money that they can afford whatever health care they want, when they want it. Okay, you win: if you're super rich, America is the place to be. But Sicko wasn't created for the super rich; it was created for the rest of us.

Take A Look at the Smartest Breasts in Town

This image came from the website for Allergan Silicone Breast Implants.

I have nothing to add.

(Via Heaneyland!)

The Curious Tale of the Advertising Illness

In response to my post about autism and TV, reader Bernardo tipped me off to this story from China Daily about autistic kids' penchant for reciting advertising:

"Liang Liang, come here to use the washroom," asked the teacher, but the five-year-old boy astonished his teacher with an advertisement punch line "frequent urination, urgent urination, and delayed urination."

Liang Liang, who keeps himself in fashion of the latest advertisements by frequently speaking them out, is a kid suffering autism in Qiseguang Children Potentiality Exploration Center in Northeast China's Jilin Province. A lot of other kids in the center suffering from the same disease do not like to talk much, but once they open their mouths, it's usually an advertisement line.

I guess this shouldn't be all that surprising. Advertising is designed to stick in your brain... and if you don't have a firm grasp on social parameters, whatever sticks in your brain is likely what you'll repeat.

Panexa Commercial

I've been doing marketing for an amazing drug, Panexa, for quite some time now. Now that marketing has been taken to the next level, thanks to the excellent efforts of Kirby Furgason and associates, who have produced Panexa's first commercial!

Can good design save lives?

Yes, in fact. Yes it can. But it's only thanks to skyrocketing malpractice costs that hospitals are bothering to notice. The Wall Street Journal reports on several health-care facilities pioneering architectural and other design changes: nonslip flooring, bathrooms located near beds to prevent falls, enclosed window blinds to reduce germs, improved air-conditioning.

I'm not sure anyone deserves any awards here, though - that'd be like thanking the pilot for not crashing the plane. Most of the new initiatives sound like nobrainers but one manages to sum up everything wrong with health care in America:

At SSM Health Care's new hospital in St Louis, Mo.... nurses will pass medicines to patients via a small sliding drawer from an adjoining alcove. This limits the number of times a nurse enters the room, thus lowering the infection risk for a patient.

In other words, nurses (and doctors, for that matter) are more inclined to make you sick than well. I guess it's easier to remove them from the picture than to get them to wash their hands. But if this solution is taken to its natural end, the only humans patients will ever see are the ones who come to collect the check. Haven't administrators heard about the healing power of human touch?

Full article below the fold

Ounce of Prevention To Reduce Errors, Hospitals Prescribe Innovative Designs Newest Layouts Stress Safety

Wall Street Journal
By GAUTAM NAIK
May 8, 2006; Page A1

WEST BEND, Wis. -- In May 2003, St. Joseph's Hospital hired a local accounting firm to install a hotline for staff to anonymously report medical errors and near-misses, either their own or those of colleagues. Before the system was set up, the hospital collected 250 reports per month. Afterward, the number shot up to 3,000 per month.

The cases confirmed what administrators at St. Joseph's had suspected: The hospital wasn't adequately addressing safety issues. At the same time, the cost of the preventable errors was escalating. St. Joseph's paid more than $70,000 in malpractice insurance premiums in 2000. In 2004, the figure exceeded $440,000.
[John Reiling]

Rather than merely overhaul medical procedures, the hospital decided to try a different approach. St. Joseph's then-chief, John Reiling, was already leading a $55 million effort to build a new facility. His idea: cram the new building with innovative design to help staffers do their jobs more precisely, more carefully -- and, he hoped, prevent errors in the process. "We decided to use patient safety as the guiding principle," he says.

Many hospitals aim to improve safety by focusing on ways to reduce human error. They encourage nurses to wash their hands more often to prevent the spread of infections and push doctors to write prescriptions more legibly in order to avoid mix-ups. A growing number of administrators are now factoring hospital layout and design into the patient-safety equation.

Traditionally, architects designed hospitals much like any other building -- making adjustments along the way for things like toilet location, medical equipment and ventilation. Mr. Reiling persuaded the facility's architects to draw up blueprints with specific medical benefits -- such as slip-proof floors and soundproof walls -- already built in.

The old St. Joseph's suffered from all the faults of a typical U.S. hospital. Lighting varied from one area to the next, making visual diagnoses inconsistent. Noise levels were higher than those recommended by health experts, making it harder for patients to rest.

At the new 80-bed facility, which opened its doors in August, the size and set-up of every room is identical. That means doctors and nurses quickly can find everything from syringes to emergency oxygen lines. Nurse stations are placed so that all patients are visible -- without pillars to block the view. Filters and ultraviolet devices trap and kill germs and other particles, making for healthier airflow throughout the hospital.

Though the changes are relatively new, the hospital says it is reaping benefits on both safety and financial fronts. Anecdotal evidence suggests that infection rates, injuries from falls and medication errors are lower than at the old facility. The hospital expects that over the next year, the average length of stay could decline by as much as half a day -- freeing up beds more quickly and allowing St. Joseph's to serve more patients.

"Many people are now aware of the impact that environment has on patient safety," says Craig Zimring, an environmental psychologist and a professor of architecture at the Georgia Institute of Technology in Atlanta. He is also a member of the board of the Center for Health Design, an advocacy group whose main goal is to provide "researched and documented examples of healthcare facilities whose design has made a difference in the quality of care." The group has identified at least 35 health organizations that are building such new facilities.

Concerns about hospital safety intensified in 1999, when the Institute of Medicine reported that between 44,000 and 98,000 patients die each year because of medical mistakes, making them a bigger killer than breast cancer or car accidents. The institute, part of the National Academy of Sciences, estimated the annual cost of those preventable errors -- including corrective treatments and disability expenses -- at between $17 billion and $29 billion.

Federal and state regulators are pressuring hospitals to reduce medical errors, too. A recent impetus is the Patient Safety and Quality Improvement Act, which President Bush signed into law in July. Borrowing an idea from the aviation industry, the new law allows doctors and nurses to report medical errors voluntarily and confidentially.

Insurers are also taking a tougher safety stance. Many health-maintenance organizations, as well as Medicare, now refuse to reimburse doctors for certain procedures that merely rectify a physician's mistake. Some insurers, such as Blue Cross and Blue Shield of Minnesota, are granting easier patient access to hospitals' records of medical mishaps.

The emphasis on safety helps explain why design has been enlisted in the battle to reduce hospital errors and insurance rates.

The University of Michigan Health System has made patient safety its main priority at its new $523 million children and women's hospital in Ann Arbor, Mich. Virtually all corners in the hospital interior are being built with round edges. And while most hospitals recycle their air up to eight times -- thus increasing the risk of spreading infectious germs -- the new building won't recycle air at all.

A big benefit of the system: "Our terrorism expert advised us that if a biological or chemical outbreak or attack occurred, the agent would be confined to one room," says Robert Merwin, CEO of the hospital's owner, Mills-Peninsula Health Services in Burlingame, Calif.

HCA Inc. of Nashville, which runs more than 180 hospitals, says it will no longer use vinyl coverings on exterior walls because the material attracts infection-causing mold. At SSM Health Care's new hospital in St. Louis, Mo., set to open in 2008, nurses will pass medicines to patients via a small sliding drawer from an adjoining alcove. This limits the number of times a nurse enters the room, thus lowering the infection risk for a patient.

Few efforts are as ambitious as those at St. Joseph's. Mr. Reiling, who until recently served as CEO, says that personal experiences with medical errors "sparked" him to push for a much safer facility. In the early 1990s, the young daughter of a friend had a curable form of cancer but died from an overdose of chemotherapy at another hospital. Soon afterward, the father of the girl, who was chairman of a Minnesota hospital, was shaken by the death of another child who died in his hospital due to a surgical error.

In February 2003, Mr. Reiling approached architects Gresham Smith and Partners of Nashville, Tenn., and asked them how they might design a safer hospital. "I admitted I didn't know how," recalls Tom Wallen, a veteran health-care architect at the firm. "But we knew that the automotive and aerospace industry had improved safety for its customers, so we tapped into those resources."

One key idea was standardization. Airplane pilots and car drivers know precisely where to find emergency controls; the designers aimed to create a similarly familiar hospital set-up.

Mr. Reiling had to rally his board. He brought in patient safety experts for talks. At the board's annual strategy meetings, he screened patient-safety films, such as one that recreated a malpractice case. He persuaded the chairman and other board members to attend a big brainstorming meeting in April 2003 that included safety-minded representatives from the American Medical Association, Johns Hopkins Hospital in Baltimore, and the Mayo Clinic in Rochester, Minn. Their goal was to answer a single question: How could a hospital be designed from the ground up to maximize patient safety?

Not everyone embraced the concept. Dan Johnson, vice chairman of St. Joseph's board, expressed doubt to other members that Mr. Reiling could pull off his bold idea in tiny West Bend, Wis. "I thought that there was no way we could do this," says Mr. Johnson. "We'd be engineering huge expenses into the project."

Many ideas came from doctors, nurses and patients. At the old facility, architects built life-size mock-ups of what the new rooms would look like, and invited the medical staff to stick notes or scribble suggestions on the walls. One such test room went through more than 30 revisions before the final design was pinned down.

Mr. Reiling did considerable legwork on his own. He visited General Electric Corp.'s Lighting Institute in Cleveland, and ordered lighting that best simulated natural light. Today, doctors no longer have to wheel newborns to a window to check for jaundice.

Since window blinds are a known breeding ground for germs, the hospital installed windows that enclose the blinds within the glass. Heating vents above the windows reduce the condensation that usually lets germs thrive.

Mr. Reiling pushed to make every patient room look the same, so that in an emergency doctors and nurses would know exactly where to find things. The standardized, pre-fabrication approach enabled the hospital to get discounts from vendors, and whittled down the budget.

The savings allowed the hospital to build other facilities it hadn't previously planned: a postpartum recovery room for new mothers, a new diagnostic area and an education center. Even with the additions, the hospital came in $500,000 under budget.

For the labor delivery room, the architects wanted to stick with the standard of placing the patient toilet along the headwall of the bed, so patients could get there easily and would be less likely to take a tumble. But nurses and doctors argued that they and family members are often milling around the patient's head, so it was safer to place the toilet door away from the traffic, on the opposite wall. Their approach prevailed.

Next to each room is a glass-fronted alcove with a computer, allowing nurses to order drugs or enter medical data while the patient is constantly in view. Based on an idea known as "continuous flow" that's popular in manufacturing, the approach lets a nurse complete all tasks related to one patient before moving on to the next.

Not everything has gone smoothly. Because the new rooms are larger, some of the corridors in the new facility are long, so it can take a while to reach a patient. And since every floor looks alike, some disoriented patients can get lost.

Much of the artwork is bland, and few walls are cheerily painted. "They put most of their budget into safety and had little left over for aesthetics," says Sara Marberry, spokeswoman for the Center for Health Design, who has visited the new facility. Serene designs can be less stressful for patients, she says.

Nonetheless, St. Joseph's is attracting plenty of attention. Mr. Reiling has been invited to describe the design at conferences, while several health administrators from the U.S. and overseas have visited to take a firsthand look. Denver Health, a big public hospital, has hired architects Gresham Smith to apply St. Joseph-style concepts at a new pediatric and maternity wing in Denver. Pembury Hospital in Tumbridge Wells, England, plans to incorporate many of the St. Joseph's ideas into a new 512-bed facility.

Mr. Reiling is determined to help keep up the momentum. Earlier this year, he left St. Joseph's to become project manager of another safety-driven project, the design of a $700-million facility for Boca Raton Community Hospital in Boca Raton, Fla.

Woman Becomes Quadruple Amputee After Giving Birth

Here's a good story to remember the next time you hear about hospitals and doctor groups complaining about the high costs of malpractice insurance:

ORLANDO, Fla. — A Sanford mother says she will never be able to hold her newborn because an Orlando hospital performed a life-altering surgery and, she claims, the hospital refuses to explain why they left her as a multiple amputee.

The woman filed a complaint against Orlando Regional Healthcare Systems, she said, because they won't tell her exactly what happened. The hospital maintains the woman wants to know information that would violate other patients' rights.

Claudia Mejia gave birth eight and a half months ago at Orlando Regional South Seminole. She was transported to Orlando Regional Medical Center in Orlando where her arms and legs were amputated. She was told she had streptococcus, a flesh eating bacteria, and toxic shock syndrome, but no further explanation was given.

The hospital, in a letter, wrote that if she wanted to find out exactly what happened, she would have to sue them. [emphasis added]

This would be unbelievable, except that medical professionals respond this way all too often. The Orlando hospital may cite Florida's "Patients Right To Know" statute as its rationale, but the code of silence is common throughout U.S. health care. The reasons are varied and complicated, but for a quickie intro to the topic, check out some of the sources mentioned here.

How Hip Health Plan helps breed superbugs

I realize that tales of HMO ripoffs are a dime a dozen but I have to vent:

After two weeks of suffering through my annual bout of sinusitis/tonsilitis, I recently buckled and talked to my doctor about getting some antibiotics. I asked for Augmentin - it's worked well for me in the past... and that's what he prescribed: a 14-day supply of Augmentin XR 1000 MG.

When I go to pick up my meds, the pharmacist informs me that my insurer - HIP - will only authorize a 10-day supply at one time. In order to get the remaining pills, I'll have to wait until I finish the first batch and come back again. Why on earth does HIP have such a policy? Is the drug not approved for the formulary? Nope, it's there. Is 10 days the standard dosage? No, the standard dosage is either 14 or 28 days.

No, the reason HIP covers less than a full supply is Because it wants two co-payments out of me. At $30 each, that makes the drug $60. This not only makes the drug unduly expensive, but  it encourages patients not to take their full course of antibiotics.... which, if you know anything about antibiotics, is dangerous from a public health perspective, because it can lead to drug-resistant bacteria.

Anyway, I plan on calling HIP to complain - as soon as its member phone line is up and working.

CORRECTION 12/26/05: It turns out that the pharmacist was wrong and that Augmentin is typically prescribed for 10 days. Still annoying, but not nearly as unreasonable. Thanks to commenter Michael.

Alternative medicine on PBS's Frontline - Tues. 9 pm

With all the stuff we've been posting about medicine lately I figure it'd be worth plugging this showing on PBS's Frontline tomorrow night (9 pm):

The Alternative Fix:  Americans are spending billions on alternative medicine treatments. And major hospitals and medical schools are embracing them. But do they work?

And if you miss it, fear not: the entire show is viewable online, along with additional interviews and analysis.

The human lab rat racket

If you don't know much about the drug testing industry, well, you're not alone. Until coming across this Bloomberg News story, I didn't realize that pharmaceutical companies outsource most of their clinical trials to third parties - private companies that are scarcely regulated, practice under dangerous working conditions, and often lack licensed medical doctors. Drug companies love 'em, though, because the outfits turn trials around quickly and, should something go afoul, the drug companies can maintain plausible deniability.

Of course, if there is one job title that makes working at Wal-Mart sound good, it is "human lab rat." But the illegal immigrants and other poor who participate don't have much choice, and the companies take full advantage.

[A drug trial for Purdue Pharma] paid volunteers $2.78 an hour, or $66.72 per 24-hour day, for the first nine days of confinement. For those who remained, payment jumped to $333.33 a day for the final three days, with a bonus of $800 paid following a single follow-up visit.

Such payment backloading is coercive and thus unethical, says Peter Lurie, a physician who is deputy medical director of Public Citizen, a Washington-based group that monitors patient safety issues. "It provides a very powerful incentive for somebody to continue in a study even if they're being made uncomfortable by it,'' he says.

What's more, like good marketers, the clinical farms describe tests to subjects in a misleading way. For instance, one company lists the goal of one of its study as determining "the highest daily dose of TD-6301 that will not cause an undesired increase in heart rate." But as a University of Miami biologist points out, what they should really be saying is: the purpose of this study is to make you sick in order to find out how much of this drug people can handle.

Anyway, those curious to learn more about clinical testing should check out Guinea Pig Zero. Formerly a print zine, GPZ is now defunct but an anthology is available and selected archives are  online.