1. Featured Article: Peacekeepers of the
IMMUNE SYSTEM, By Zoltan Fehervari and Shimon Sakaguchi, Scientific American
Regulatory
T cells, only recently proven to exist, keep the body's defenses from attacking
the body itself. Manipulations of these cells could offer new treatments for
conditions ranging from diabetes to organ rejection
"H o r r o r a u t o t o x i c u s."
A century ago the visionary bacteriologist Paul
Ehrlich aptly coined that term to describe an immune system attack against a
person's own tissues. Ehrlich thought such autoimmunity - another term he
coined - was biologically possible yet was somehow kept in check, but the
medical community misconstrued his two-sided idea, believing instead that
autoimmunity had to be inherently impossible. . .
Slowly, though, a number of mysterious ailments came
to be recognized as examples of horror autotoxicus - among them multiple
sclerosis, insulin-dependent diabetes (the form that commonly strikes in youth)
and rheumatoid arthritis. Investigators learned, too, that these diseases
usually stem from the renegade actions of white blood cells known as CD4+ T
lymphocytes (so named because they display a molecule called CD4 and mature in
the thymus). Normal versions of these cells serve as officers in the immune
system's armed forces, responsible for unleashing the system's combat troops
against disease-causing microorganisms. But sometimes the cells turn against
components of the body. Ehrlich was
correct in another way as well.
Recent work has identified cells that apparently exist
specifically to block aberrant immune behavior. Called regulatory T cells, they are a subpopulation of CD4+ T
cells, and they are vital for maintaining an immune system in harmony with its host. Increasingly, immunologists are also
realizing that these cells do much more than quash autoimmunity; they also
influence the immune system's responses to infectious agents, cancer, organ
transplants and pregnancy. We and others are working to understand exactly how
these remarkable cells carry out their responsibilities and why they sometimes
function imperfectly. The findings should reveal ways to regulate the
regulators and thus to depress or enhance immune activity as needed and, in so
doing, to better address some of today's foremost medical challenges. . .
Imperfect Defenses
Like the immunologists of Ehrlich's time, many people
today would be dismayed to know that no matter how healthy they may be, their
bodies harbor potentially destructive immune system cells quite capable of
triggering autoimmune disease. Yet this immunological sword of Damocles can be
easily demonstrated. If a mouse, for
example, is injected with proteins from its own central nervous system, along
with an adjuvant (a generalized immune system stimulus), a destructive immune
reaction ensues. Much as in multiple
sclerosis, T cells launch an attack on the animal's brain and spinal cord. By varying the source of the injected
selfprotein, researchers can provoke other autoimmune diseases in laboratory
animals - which indicates that potentially harmful immune system cells can
mount self-attacks on a wide variety of tissues. The risk appears to hold true in humans, too, because
autoreactive immune system cells can be captured readily from the blood of a
healthy person. In a test tube, they react strongly to samples of that person's
tissues. Given such demonstrations of
clear and imminent danger, investigators naturally wondered how it is that most
animals and humans are untroubled by autoimmune disease. Put another way, they
wanted to know how the immune system distinguishes threats such as microbes
from a person's own tissues. They found that to achieve self-tolerance - the
ability to refrain from attacking one's own organs - the immune system enlists
numerous safeguards. The first defense, at least where T cells are concerned,
occurs in the thymus, which lies inconspicuously in front of the heart. In the
thymus, immature T cells undergo a strict "education" in which they
are programmed to not react strongly (and therefore harmfully) to any bodily
tissues. Disobedient cells are destroyed. No system is perfect, though, and in
fact a small number of autoaggressive T cells slip through. Escaping into the
bloodstream and into lymph vessels, they create the immune system's potential
for unleashing autoimmune disease.
Blood and lymph vessels are where a second line of
defense comes into play. This layer of protection against autoimmunity has
several facets. Certain tissues, including those of the brain and spinal cord,
are concealed from immune cell patrols simply by having a paucity of blood and
lymph vessels that penetrate deep into the tissue. Their isolation, however, is
not absolute, and at times, such as when the tissues are injured, self-reactive
immune cells can find a way in. Additional modes of protection are more
proactive. Immune cells showing an inappropriate interest in the body's own tissues
can be targeted for destruction or rendered quiescent by other immune system
components.
Among the immune cells that carry out these proactive
roles, regulatory T cells may well be the most crucial. The majority, if not
all of them, learn their "adult" roles within the thymus, as other T
cells do, then go forth and persist throughout the body as a specialized T cell
subpopulation. . .
To read the entire article, please go to (Subscription
Required) www.sciam.com/print_version.cfm?articleID=0005AFFE-A2F0-150E-A26183414B7F0000.
ZOLTAN FEHERVARI and SHIMON SAKAGUCHI began
collaborating in 2002, when Fehervari took a postdoctoral position in
Sakaguchi's laboratory at the Institute for Frontier Medical Sciences of Kyoto
University in
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End of the week launch planned; new prescriptions
added, significant savings projected for
BENTONVILLE, Ark. - Oct. 5, 2006 - Responding to customer demand and
requests from Florida state officials, Wal-Mart Stores, Inc. (NYSE: WMT)
announced today that it is rolling out its $4 generic prescription program in
Florida beginning Friday, October 6, 2006 - nearly four months earlier than
expected. The program was originally planned to be rolled out statewide in
January 2007.
"This program makes everyone at Wal-Mart proud.
It enables us to respond to the needs of our customers who have struggled far
too long with the high cost of prescriptions," said Wal-Mart President and
CEO Lee Scott. "Part of this is about saving these customers money, but
even more importantly, it's about making sure they get the medicines they need
to live healthier lives."
The $4 generics program has been expanded to include
314 generic prescriptions available for up to a 30-day supply at commonly
prescribed dosages. The list of 314 generic prescriptions is made up of as many
as 143 compounds in 24 therapeutic categories. Since launching the program in
the
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3. International Medicine: German
HealthCare Reform, Collapsing Again? Can There Ever Be A Common Sense Approach
Once Government Takes Over?
Merkel forced to rethink healthcare reforms, By Bertrand
Benoit in Berlin , FT, Sept 22 2006
Angela Merkel, the German
chancellor, on Friday sought to reclaim control of her conflict-ridden grand coalition,
taking her ambitious and controversial healthcare reform plans back to the
drawing board.
In what appeared to be a
calculated concession to her Christian Democratic Union's unruly regional
grandees, she said the most contentious aspect of a reform blueprint agreed
between the two governing coalition parties in July would now be renegotiated.
"Thoroughness comes before
speed," she said after a hastily convened meeting with Kurt Beck, chairman
of the Social Democratic Party, the CDU's junior coalition partners, suggesting
the timetable for introducing the reform may not be met.
The overhaul of the 123-year old
health scheme is the coalition's most ambitious undertaking since Ms Merkel
took office 10 months ago. Its collapse would be a devastating blow and raise
doubts about her ability to head her national-unity government for its
four-year term.
* * * * *
Wal-Mart Discounts Politics,
Wall Street Journal,
. . . Chicago Mayor Richard Daley issued his first
veto ever, striking down a living-wage bill that would require "big
box" retailers like Wal-Mart and Office Depot to pay a super-minimum wage
of $10 an hour plus $3 in benefits to all employees by 2010. The national
minimum is $5.15, and in
In his veto message, Mayor Daley, a pro-union
Democrat, declared that the wage law would "drive jobs and businesses from
our city, penalizing neighborhoods that need additional economic activity the
most."
Wal-Mart and Target have announced plans to cease
expansions in the city if the law is enacted. The city already loses $300
million a year in sales tax revenues when
It turns out that the wage bill's chief sponsor,
Alderman Joe Moore, shops at suburban big-box retail stores, for the usual
reason. His campaign committee has purchased $30,589 worth of supplies at
big-box retailers outside the city, according to disclosure forms. Alderman
Moore isn't alone out there with a cart among the high stacks. A review of
Illinois State Board of Elections disclosure forms finds that the 35 aldermen
who voted to stick it to the "big box" retailers have spent $114,000
patronizing these non-Chicago stores.
And why not? The virtue of superstores isn't just that
they're prodigious creators of jobs -- Wal-Mart alone has hired 240,000 workers
since 2001 -- but that they hold down costs and pass on the savings to
consumers, even to
http://online.wsj.com/article/SB115802354054560149.html (Subscription
required)
Government is
not the solution to our problems, government is the problem.
- Ronald Reagan
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5.
Medical Gluttony:
Government Benefits Just Keep on Getting More Gluttonous.
Government became involved in health care for those
over age 65 in 1965. Since then, its involvement has mushroomed. Costs have
escalated, not by five or 10 percent over budget, but by hundreds of percent.
As if that isn't enough, new benefits are frequently added. The kidney lobby
was most successful in getting coverage for anyone, including those not yet 65.
The county hospital system for the poor was supplanted by a federal monstrosity
called Medicaid, which now covers more people than Medicare. Many are no longer
poor. I have Medicaid patients in my practice with household incomes approaching
$50,000 annually. The Medicare recipients have a vast network. Knowledge of
benefits received in one locality are quickly known in new locations and thus
new benefits grow at an unbelievable rate. Likewise, the Medicaid network. The
current status symbol is the electric wheelchair. Certainly this has improved
the lot of many disabled, but many are able to function rather well without
one.
Traditionally, pulmonary rehabilitation programs
advised against patients with pulmonary disabilities obtaining disabled parking
stickers or electronic wheelchairs, and instead advised them to park at the far
end of the parking lot and walk to the store or their church or their club.
These activities themselves would be "pulmonary rehabilitations."
Once the disabled placard and the electronic wheelchair became readily
available as coverage by Medicare and Medicaid mushroomed, doctors no longer
had the clout to prevent what they knew inherently was bad for their patient's
welfare. Medicare and Medicaid Services blamed the doctors for over utilization
despite the fact it was their programs that caused the stampede into the
doctors' offices.
Recently, I observed two electric wheelchairs collide
at a cross street. Both individuals simply got up and walked quite ably to
disentangle their motorized vehicles. Many are in fact using their electric
vehicles as their primary mode of transportation - going to the grocery store,
shopping centers, and to visit friends. This frees up their own cars to give to
their other relatives. Central planners can never foresee all the instances of
providing what can become an additional non-medical benefit - another mode of transportation.
Government programs were never designed to replace cars.
Similarly, I see many who reside in nursing facilities
at Medicaid (taxpayer's) expense who are quite mobile, ambulating to the day
rooms and to the dining rooms, which they could also do in the homes of their
families. But freeing up their home to sell at today's market prices does add
large sums to their children's wealth. Government programs were never designed
to replace homes.
Government, despite thousands of new laws each year,
is unable to control costs, over utilization, or inappropriate utilization.
Frequently the onus is put upon another scapegoat, such as the doctor, making
costs seem like an overcharge, an inappropriate charge, or some other
trumped-up fraud. All government programs create fraud by what seems initially
as a slight variation in utilization, which mushrooms out of control.
Government medicine will always spiral upward in cost
and downward in quality of care.
Only private competitive individualized health care
will decrease costs to the absolute minimum and increase quality of care
without any laws being invoked.
The healthcare professions, doctors and nurses, should
awaken to this deception before it's too late.
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6.
Medical Myths:
Doctors Can Do Several Things at Once?
Multitasking, by Jared Sandberg, Wall Street Journal,
"Yes, Sell All My Stocks. No, the
A few months ago, Victor Grillo, the chief executive
of a marketing company, was in his office doing two things at once -- neither
of them very well.
He was on the phone booking a vacation in
His "Sent" messages folder revealed he had
inadvertently sent the message to the person on the block. In a panic, Mr.
Grillo hastily told the travel agent to finish booking the trip. He then made a
mayday call to IT. Too late; an angry R-rated email soon arrived from the
canned employee. And when he got to
Multitasking, a term cribbed from computers, is an
information age creed that, while almost universally sworn by, is more rooted
in blind faith than fact. It's the wellspring of office gaffes, as well as the
stock answer to how we do more with less when in fact we're usually doing less
with more. What now passes for multitasking was once called not paying
attention.
Today's workers typically have to do three things
while arguing on the phone with a spouse. David Gardner, who writes
instructional material for trainers, now knows better than to try. He once
worked for a marketing company stretched so thin it sent 4,000 nuns direct mail
offers addressed "Dear Mr. Sister."
Employers continue to seek out jugglers despite
decades of research showing that humans aren't great multitaskers. (And in the
case of distracted driving, we're downright dangerous.)
"Multitasking doesn't look to be one of the great
strengths of human cognition," says James C. Johnston, a research
psychologist at NASA's
Researchers say analytical thinking can happen in
parallel, as long as the tasks have been practiced. But the amount of practice
is "too high for the practical world," says Dr. Johnston. And that
wouldn't include, say, responding to emails, which requires "fantastically
more cognition" than the much simpler tasks often included in multitasking
research. . .
Pamela Johnston, president of her own communications
company, often dials clients, then begins other work while waiting for them to
pick up. When they finally do, she sometimes forgets who she's called. So
she'll either come clean, or just hang up.
Something else left out of the multitasking
calculations -- beside the fact that we don't do it very well -- are
"resumption costs." These are the seconds it takes your brain to say
"Where was I?" when resuming an interrupted task. Depending on the
tasks, those resumption costs can be high enough to make it faster to unitask,
which researchers say produces better performance in the first place. . .
To read the entire article, go to http://online.wsj.com/article/SB115801096324259803.html (Subscription required).
Email Jared.Sandberg@wsj.com. To see past columns, go to CareerJournal.com.
[Doctors
are expected to multitask or sequential task at a rapid rate. They frequently
are involved in patient care and a well-meaning nurse will ask about another
patient, a social worker will come by to obtain permission to order an electric
wheelchair on a third patient, a physical therapist will come up to obtain an
order for treatment on a fourth patient, and another doctor will briefly
mention a follow-up evaluation on a fifth patient. It really is impossible for
even a physician to keep five different medical records revolving around in his
brain and not occasionally get an order on the wrong patient.
[Rapid
sequential tasking is not much different. HMOs expect a doctor to recall a
patient's entire medical history, obtain new medical information since his last
evaluation, examine the patient for any new findings, assess all the data, come
to a new updated diagnostic conclusion, write new lab or x-ray orders to
confirm the new diagnosis, record a complete record of the event, and be able
to greet the next patient with a great smile and a pleasant "I've been expecting you all afternoon"
greeting all within 12 minutes.
[Why
do doctors continue to allow these medical bureaucrats to jeopardize our
patient's health?]
* * * * *
7.
Overheard in the
Medical Staff Lounge: Only the Government Can Legally Do the Illegal.
Dr Sam: Did
you see that the Feds are instituting a sliding premium schedule for Medicare?
For a couple where each make $50 an hour, the premium will be $400 a month in
three years. That's $5,000 per year or about a 450 percent increase in just
three years.
Dr Rosen:
Speaking of sliding fees, as a medical student, I spent an afternoon in a
Dr Sam: The
Feds are unconscionable in their raping the public for their ineptitude. Why do
people put up with this?
Dr Michele:
Because only the government can regulate fees fairly.
Dr Sam:
That's a bunch of Bull.
Dr Rosen: In
1965, my father had Blue Cross-Blue Shield for our family which had a premium
of about $100 a month. If health care had remained on the open Medical
MarketPlace where providers bring their fees down to meet any competition, that
premium would probably have gone up to about $400, about fourfold or 400
percent in four decades, but it would have covered hospital, outpatient
laboratory, x-rays, physician fees just like it did in 1965. Now that $400 a
month that Medicare will charge for Part B only covers outpatient benefits and
doesn't even touch hospital care. And it covers outpatient medicine very
poorly.
Dr Michele: Come
on guys, you'll never get the government out of healthcare. Get real.
Dr Rosen: With
the doctors in
Dr Sam: I
think I'll get one of those cheap HSA plans, give up my Medicare, and have all my
big stuff done off shore. Not only will I save Big Bucks on health care, I'll
also save $5,000 in Medicare taxes.
Dr Rosen: If
all of those high premium Americans did that, Medicare would collapse, wouldn't
it Michele?
Dr Michele: I'm
beginning to dislike all of you anti-Americans. I think I'll cool off by seeing
some patients.
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8. Voices of Medicine:
1965 Intel cofounder Gordon Moore observed
that the number of transistors per square inch (data density in its current
iteration) on an integrated circuit had been doubling every 18 months. Known as
"
Since the first third of the twentieth
century, there has been a similar proliferation of medical technology, broader
in scope (and therefore less obviously definable) than the elegant simplicity
of data density on a chip. The total knowledge base of medically associated pursuits
is doubling at least every couple of years, but less visibly because the
advances, like single stalks of bamboo in a hedge, shoot up at different times
from different related disciplines. . .
In technical endeavors (surgery,
cardiology, radiology, gastroenterology), we have seen the endoscope and the
catheter revolutionize the traditional concept of surgery. All kinds of medical
devices (diagnostic and therapeutic, invasive and noninvasive) are more
specific and effective. Pharmacological interventions are exploding, perhaps
more in cost than effect, but significantly in both.
The difference between
New technology has the burden of
demonstrating the importance of its superiority over its predecessor. Of the
big four incentivesemotional, political, social, economicthe price of new
nonmedical technology is determined more by economics than anything else (with
a not insignificant, but really optional, advertising emotional/social boost),
and the cost of acquisition has regularly come down.
When applied to medicine and its seemingly
mandatory entitlements,
We who manage health services should have
a broader view of the effects of what we do and what we use to do it. It is not
sufficient just to control our own contribution to resource mismanagement. We
must seek to constrain political and business behaviors that wantonly succumb
to or exploit human narcissism in expensive Pyrrhic battles that ignore
reality. A good physician gives patients what they need rather than what they
want, and we owe the same tough love to the society that depends on us.
To read the entire article, please go to www.smcma.org/Bulletin/BulletinIssues/June06issue/Moore's%20Law.html.
Dr. Zacharia is an orthopaedic surgeon in
There's A New Doctor In The House, by Michael Wilkes, MD, Sacramento October
7, 2006
To the spectator, the practice of medicine is a bit
like visiting a foreign country. A trip to either is often magical, mysterious
and expensive.
In
both cases, the locals wear costumes (lab coats, etc.), speak an unusual
language (medicalese), and have their own rituals (autopsies) and ceremonies
(grand rounds).
Beginning this week, it is my distinct pleasure to be
your medical docent on a weekly adventure through clinics, hospital corridors, laboratories
and medical school classrooms. Each week, I have been asked to dispense with
jargon, cronyism and hype to give you a look from the inside at doctoring. I
will call it as I see it, and share real stories of health, disease, and
science.
The world of medicine is changing - rapidly. Sometimes
these changes are for the better. We have a new, powerful antibiotic they can
eradicate entire categories of bugs. We have vaccines that have wiped out
infectious diseases and new vaccines that may prevent certain types of cancer,
such as cervical cancer. We have probes and lasers and scanners and robotic
arms that can reach the inner premises of the human body. We can take whole
pieces of people and swap down for defective pieces in other people.
But these advances have brought with them ethical,
policy and financial controversies.
There are tough questions. What do we value more, the latest and greatest chemotherapy that
cost $45,000 and offers one person a five percent chance of surviving an
additional 12 months, or an immunization program that also cost, but has the
potential of providing 34 people -- most of them poor -- with an additional 10
years of life?
Sometimes, medical changes are for the worst. Today our doctor spend far less time with us
one-on-one. There are new deadly
viruses that did not exist before, and new diseases, some which are caused by
the medical profession itself. There are people on street corners pushing
illegal, dangerous and expensive drugs that come to us from distant lands, and
there are people on our TV screens and in our magazines pushing legal,
expensive and dangerous drugs that come to us from corporate boardrooms.
I will show you a side of medicine very similar to
what we teach our medical students. I worked as a dean at the UC Davis School
of Medicine, a professor of medicine, a clinic director, a volunteer physician
at free clinics, a researcher, a doctor in foreign countries and a ship's
doctor. But that's only half the story. I have also worked as a journalist
covering the health beat for newspapers, TV and public radio. I have seen
firsthand the various snafus in the system that result in you receiving
misinformation -sometimes from the news, your doctor, your health plan or the
Web. . .
To read the rest of the story, please go do www.sacbee.com/296/story/28096.html.
Michael Wilkes, M.D. is a professor of medicine at the
To read more Voices of Medicine, please go to www.healthcarecom.net/vom2003.htm.
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9.
Book Review: Lord of
the Flies by William Golding
At the dawn of the next world, a plane crashes on an
uncharted island, stranding a group of schoolboys. At first, with no adult
supervision, their freedom is something to Celebrate. This far from
Civilization they can do anything they want. Anything. But as order collapses,
as strange howls echo in the night, when terror begins its reign, the hope of
adventure seems as far removed from reality as the hope of being rescued
This brilliant work is a frightening parody on man's
return to that state of darkness from which it took him thousands of year to
emerge. (NYT)
Lord of the Flies was recently released in a new
edition with new notes from the author.
William Golding (born
The theme of Lord of the Flies is described by
Golding as an attempt to trace the defects of society back to the defects of
human nature. The moral is that the
shape of the Society must depend on the ethical nature of the individual and
not on any political system however apparently logical or respectable.
This is a book worth rereading as our political
system, thinking it is acting in a logical and respectable fashion, is
destroying the moral nature of individuals since all repercussions come from
the government and the individual is no longer sacrosanct, a constitutional
guarantee. Physicians can no longer act in the patient's best interest, but
must look first to government rules and regulations before ministering to the
patient's needs. We must daily make this point to our patients. They, not we,
have the power to change government to restore freedom.
A Perigee Book, published by the Penguin Group, May
2006. Copyright by William Golding, 1954
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10. Hippocrates & His Kin: Blenderized Feces
In a recent lecture on C. difficile diarrhea, which
occurs when patients are on prolonged antibiotics, it was pointed out that in
many instances it has been difficult to re-establish normal flora or bacterial
population in the human gut. In one instance, when nothing else worked, doctors
took the stool of a normal person with the appropriate bacteria in the bowel
and fed it to the sick patient through a naso-gastric tube. Apparently the
procedure worked.
But will they be able to keep nurses on the job who
will have to blendarize stool from one patient and feed it to another? How will
they camouflage the smell?
Speaking of smells, have you ever walked into a restroom
and been greeted with a floral odor? Ever wonder what inhalants or fumes were
being camouflaged?
To read more medical vignettes, please go to www.healthcarecom.net/hhk2000.htm.
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11.
Organizations
Restoring Accountability in HealthCare, Government and Society: