One that won't make me nervous

I'd been meaning to get rid of some comment-spam on this blog, from dubious web hucksters selling percocet and vicodin... but an FDA advisory panel may have solved my problem in a different way, today recommending to ban painkillers that contain acetaminophen (this was part of a series of decisions to limit overdoses of tylenol, in the hopes of preventing what is now the #1 cause of liver failure in the US).

The panel's decision let to my first front page post on Metafilter which recapped some of tylenol's history and its popularity (because of their rigid self-link rules, I couldn't highlight my Medgadget post on Tylenol at 50).

The Metafilter discussion was intelligent as usual, though unfortunately I couldn't stick around to address some misconceptions that arose. Some highlights for those who don't want to sift through 100+ comments:

Meehawl wrote:

you could just mandate that all paracetemol be combined with a sufficient dose of methionine to replenish the liver's glutathione levels and so lower the probability of a runaway toxic fulmination. This would of course make the pills more expensive to manufacture so that's not really going to happen. The argument against it, using the high NNT of 999 people who would be pre-treated with methionine so that the 1 overdoser can benefit seems lacking given the severity of the outcome, the cost of the post-exposure treatment, and the lack of side effects of the pre-treatment.

homonculus wrote:

Also, it is important for pain patients to be heard by the FDA about this: if they are thinking of pulling something like getting rid of Vicodin and Percoset *without* offering replacements without the acetaminophen that are the same level controlled substances, it would be very bad for pain patients.

There does appear to be a hydrocodone (Vicodin) which is schedule III and an oxycodone (percocet) with ibruprofen instead, which is schedule II, which would be existing options but schedule II's are more of a pain in the butt.

I just read a bit about that. From MedPageToday:

In a far less decisive vote, the committee voted 20 to 17 in favor of a more extreme recommendation to pull all prescription products containing acetaminophen from the market.

Because the split was so close, it is unclear whether the FDA will adopt the recommendation, but if it did, some options would be eliminated for pain patients. For instance, patients taking Vicodin would not have an acetaminophen-free option because there is no hydrocodone-only formula.

In addition, removing the acetaminophen from the Vicodin would move the drug into the more-strictly regulated "class II" schedule of narcotics from its current classification as a class III drug, creating additional barriers for physicians prescribing the drug to patients.

That makes me think it's unlikely the FDA will ban them. The outcry would be too great.

stopgap looked up the other drug use mortality data and compared it to tylenol's 56,000 OD presentations and 1000-1600 liver failures:

For the others, the following stats are from 2005. I saw some reports that suggest MDMA might be around 50, and I also saw marijuana as 0.

Heroin: 2,011
Cocaine: 6,228
Ecstasy/MDMA: no data
Marijuana (Cannabis poisoning): 112
Cars: 45,343

Clearly, we need to reduce the standard dosage of motor vehicle use.

But the most spot-on comment may have been the first one, by inigo2:

Sweeeet - my medicine cabinet's gonna be worth a ton in a few months.

Thanks to our collective number crunching, we now have a handle on the problem -- 56,000 acetaminophen overdoses, with 1600 progressing to liver failure. It sounds unacceptable until you realize there were 124 million prescriptions of tylenol combined with opiates, and untold numbers of OTC Tylenols taken as well. Suddenly the number of complications looks manageable, compared to the amount of patients that rely on these drugs. That, plus the UK's mixed results in managing this problem, suggests to me that banning percocet and vicodin is not the solution.

I'm looking forward to reading more from medical bloggers in the days to come about this practice-changing recommendation. But for now I just want to reflect on a rite of passage: tomorrow, graduated medical students become interns and start ordering and prescribing their first drugs. I remember receiving advice about this transition, hearing that 'in July, when you're first adapting to responsibility for patients, you'll think twice before even ordering Tylenol for a fever.' Well, with a likely black box warning to come and increased scrutiny on dosing, tomorrow's interns will be anxious about ordering Tylenol long past July.

Get back to the basics for you

Folks with writer's block have no end of excuses-- I'll just offer up as a defense that even as output on blogborygmi trickled to nothing, I was blogging a lot on my residency's website. And, honestly, I didn't want anything I wrote to be misinterpreted during interview season, which has a stifling effect on creativity.

But there's another possibility that's been rattling around my brain, more since Farhad Manjoo phrased it so succinctly a few weeks ago in Slate. What if I stopped contributing to the medblog community because I had changed the way I accessed it, in moving from bookmarked websites to RSS? Quoth Manjoo:

RSS started to bring me down. You know that sinking feeling you get when you open your e-mail and discover hundreds of messages you need to respond to—that realization that e-mail has become another merciless chore in your day? That's how I began to feel about my reader. RSS readers encourage you to oversubscribe to news. Every time you encounter an interesting new blog post, you've got an incentive to sign up to all the posts from that blog—after all, you don't want to miss anything. Eventually you find yourself subscribed to hundreds of blogs, many of which, you later notice, are completely useless. It's like having an inbox stuffed with e-mail from overactive listservs you no longer care to read.

It's true that many RSS readers have great tools by which to organize your feeds, and folks more capable than I am have probably hit on ways to categorize their blogs in a way that makes it easy to get through them. But that was just my problem—I began to resent that I had to think about organizing my reader. Moreover, I hated the software's bland interface; when you read blogs through RSS, you're only getting text, not design, so every blog looks like every other blog. But I didn't want Gawker to look like the New Republic; I needed a visual difference, in the same way that I want the National Enquirer to look distinct from the New York Times

He goes on to describe his new system for perusing websites, which sounded a lot like my old bookmark hierarchy. Since reading his article, I've started trying to recreate that old system, but now using Speed Dial groups for firefox. With any luck, I'll soon feel that vibrant sense of community that I enjoyed so much, years ago...

Social coteries, that's me

I'm helping my hospital draft a policy on The New Media. Is there anyone out there who's worked on something similar, or can point me to another institution's document?

If so, please leave a comment below, or email me, or give me a tweet, or contact me via LinkedIn or Facebook...

He's just resting

The report of my [blog's] death is... an exaggeration.

Which is to say: some responsibilities have come to an end, others have yet to begin, things have come into focus, and now's a good time to return to blogborygmi.

Thoughts arrive like butterflies

There's an irony here, because I found the following critique of Twitter while searching for a blogger-to-twitter solution. But I think the author is essentially right, based on his (and my) understanding of Flow. Excerpt below:

Worst of all, this onslaught is keeping us from doing the one thing that makes most of us the happiest... being in flow. Flow requires a depth of thinking and a focus of attention that all that context-switching prevents. Flow requires a challenging use of our knowledge and skills, and that's quite different from mindless tasks we can multitask (eating and watching tv, etc.) Flow means we need a certain amount of time to load our knowledge and skills into our brain RAM. And the more big or small interruptions we have, the less likely we are to ever get there.

And not only are we stopping ourselves from ever getting in flow, we're stopping ourselves from ever getting really good at something. From becoming experts. The brain scientists now tell us that becoming an expert is not a matter of being a prodigy, it's a matter of being able to focus.

This nearly two-year old critique hasn't really put a damper on Twitter's increasing popularity. Maybe there's some new data I'm not aware of, to show Twitter makes people more productive or creative.

I check Twitter updates almost exclusively via Twinkle, an iPhone Twitter client that's got a neat 'nearby tweet' feature. I really only am moved to use it when I'm in line for something, or stuck on a train. For all the talk of twitter in academia and medicine, I don't think the advantages would outweigh the frequent disruptions if I checked Twitter from my desktop.

Half a page of scribbled lines

Two full calendar months without a blog post? Yikes!

I don't want to end up on GruntDoc's Dead Blog list (even though it is Halloween) so let me just quickly link to my recent activity on Twitter.

While I'm not sure how often I'll use Twitter, it seemed helpful in communicating some of my impressions of this week's ACEP conference in Chicago.

And look! My twits will now appear on blogborygmi's sidebar, somewhere between RSS highlight and photo highlights.

Little souvenirs

One of the nicest perks of being an established-and-at-one-point-somewhat-prolific medical blogger is that really talented people send me really good books.

Two I'd like to highlight for you now are below.

Dr. Jay Baruch's Fourteen Stories: Doctors, Patients and Other Strangers. This award-winning collection of short stories from an ED physician had me pretty engrossed. Dr. Baruch does a good job of motivating his characters, and often the motivation is fear -- not just the sick patient but the student with an HIV needlestick, the doctor walking home late at night who encounters a dissatisfied patient. The dialogue is minimal, and often at odds with the situation -- but he's written these characters in such a way that it's easy to crawl into their thoughts and insecurities.

In his afterward, Dr. Baruch gives his take on the difference between getting to the truth of a medical presentation, and the truth of a short story. It's an informed and insightful essay -- required reading for aspiring physician-writers.

The other book I received recently is Laurie Edwards' Life Disrupted. I first read this author in the pages of the Boston Globe Magazine, then learned of her blog and finally, got to interview her for Medscape's Pre-Rounds.

Unlike Dr. Baruch's book above, Life Disrupted is decidedly nonfiction -- the subtitle is "Getting Real about Chronic Illness in your Twenties and Thirties." Medical blog readers will recognize many of the book's subjects, like Jenny Prokopy (chronicbabe.com) and Kerri Morrone (sixuntilme.com). Even some of the insleeve reviewers are longtime bloggers (Amy Tenderich, Paul Levy).

I'll confess, these familiar names actually helped me approach this book, which is an expert guide on empowering patients to get more out of life, and more out of the medical world. Why should I even be reluctant to read it? Because (though this has never been true of Edwards' earlier works) I've seen too many patient-empowerment books that read like self-help bromides or screeds against modern healthcare.

Not surprisingly, my reluctance was completely unfounded. Edwards is too smart, and has been through too much, to simply encourage her readers to distrust all medical professionals (although some of her readers and subjects have earned the right). Instead, she treats the physicians and nurses much like she considers her fellow patients: motivated, knowledgeable, but sometimes inflexible and afraid to adapt.

Her candid and conciliatory writing style quickly won me over. Her book is full of specific advice regarding relationships, socializing, career, and yes, navigating hospital stays and the healthcare system. I found it extremely practical and accessible, and learned a lot more than I had expected to. So, I heartily recommend it.

From the threshhold, what's to see

I love playing with Microsoft's new Photosynth but I'm still curious if it can handle this. Or this.

Grand Rounds: Change of the Guard

This week, GruntDoc hosted the 200th edition of Grand Rounds.

When this series started, the word "blogger" was just entering the public consciousness. The value of healthcare blogs -- to entertain, inform, and improve understanding -- this was clear to us, but we weren't really sure if anyone outside our group would ever notice.

Two hundred weeks later, every major media site has a blog on medicine and health, the industry is paying to access what physicians write online, and the transparency of blogging is transforming healthcare from the ground up (or, in some cases, from the top down).

Healthcare bloggers now have access to figures like the Surgeon General or AMA president. Healthcare bloggers write op-eds for major papers, appear on TV, and publish books.

Grand Rounds, I think, has had a role in this. This carnival has served as a weekly focal point, highlighting the most compelling voices and insightful ideas in this vibrant community. Grand Rounds made the world of healthcare blogging accessible and appealing to outsiders, and offered veteran bloggers and newbies a chance to touch base and rub elbows.

As the healthcare blogging landscape has changed, though, new challenges and opportunities have presented themselves. I've been unable to properly address these issues, however, since being named a chief resident at my program a few months ago. While the experience has been exhilarating so far, the task of organizing my department's Grand Rounds has left little time for planning Grand Rounds online.

But we're fortunate that our weekly roundup of medical blogging has attracted a number of dedicated benefactors. Beyond the hosts whose creativity and effort make each week so memorable and enjoyable, a few people have distinguished themselves with their belief in the concept and potential of Grand Rounds.

One such person is Colin Son, a medical student, longtime blogger, and previous host of Grand Rounds. He'll be taking over the Pre-Rounds series for Medscape and scheduling new Grand Rounds hosts. Working with him will be none other than Dr. Val Jones, the extraordinary blogger behind The Voice of Reason at Revolution Health.

They have the energy and enthusiasm to not only maintain this series but take Grand Rounds to new heights -- opening up the medical blogging world to new readers and venues. Please join me in welcoming them, and wishing them well. With your support and Colin and Val's stewardship, the quality and success of Grand Rounds will be insured -- for the next two hundred editions, and beyond.

Playin' with your food like it's some kind of game

Longtime readers (and really, that's the only audience, at this point) are well aware of my fascination with competitive eating. Beyond the awful, mesmerizing spectacle, there's the physiological aspect -- how can some people shovel so much into their gut, so fast?

At one point, I was actually thinking of making this into a research project. I spoke with a few contestants, and like to think my frequent phone calls to IFOCE chair George Shea in 2006 led to him bill that year's Nathan's Hot Dog Contest as, "The Mount Sinai of Mastication" -- but then again, he also dubbed it the Madison Square Garden of Gorging, and finally, the battleground where God and Lucifer fight for men's souls (such gifted hyperbole cannot be ascribed to any single influence).

But I digress. Since first blogging about the topic in 2004, offering some speculation on how elite eaters succeed in 2005, and calling for more research two years ago, well, I neglected to keep up with this topic. Even as a new champion was crowned, I overlooked this important addition to the body of evidence:

Competitive Speed Eating: Truth and Consequences
Marc S. Levine, Geoffrey Spencer, Abass Alavi and David C. Metz

OBJECTIVE. The purpose of our investigation was to assess the stomachs of a world-class speed-eating champion and of a control subject during a speed-eating test in our gastrointestinal fluoroscopy suite to determine how competitive speed eaters are able to eat so much so fast.

CONCLUSION. Our observations suggest that successful speed eaters expand the stomach to form an enormous flaccid sac capable of accommodating huge amounts of food. We speculate that professional speed eaters eventually may develop morbid obesity, profound gastroparesis, intractable nausea and vomiting, and even the need for a gastrectomy. Despite its growing popularity, competitive speed eating is a potentially self-destructive form of behavior.

Not Totally Rad's got a nice discussion of the paper, as well as some personal perspective:

After a few preliminary tests, these two subjects were asked to eat as many hot dogs as they could. The big burly dude ate 7 before feeling uncomfortably full. The champion eater then proceeded to down 2 dogs at a time for the next 10 minutes. After he ate 36 hotdogs, the investigators terminated the experiment.

Despite the speed eater’s insistence that he felt no sensation of satiety, fullness, bloating, or abdominal discomfort, we became concerned that further dilation of his already enormous stomach could be associated with a small theoretic risk of gastric perforation. Therefore, a decision was made to terminate the speed-eating test over the objections of our participant.

While all of this was going on, the radiologists asked the eaters to also ingest a barium sulfate solution so they could watch the stomach under fluoroscopy. The control dude's stomach showed a large mass of partially chewed hotdog bits, but only minimal gastric dilatation. The eating champion looked a bit different:

His stomach now appeared as a massively distended, food-filled sac occupying most of the upper abdomen, with little or no gastric peristalsis and emptying of a small amount of barium into the duodenum.

It's hard to generalize these findings to all eaters everywhere when one only has 2 subjects in one's experiment. However, the investigators concluded:

Our observations suggest that successful speed eaters expand the stomach to form an enormous flaccid sac capable of accommodating huge amounts of food.

Having seen the competitors up close, I still think there's something more at work, at least when you compare Takeru Kobayashi and Joey Chestnut to second-tier hot dog eaters like Tim Janus and Cookie Jarvis. Everyone seems to eat 3-5 or so hot dogs per minute in the first minute or two, but while the others visibly slow down, Chestnut and Kobayashi can keep up the pace throughout the 12-minute race. I think this happens too soon to be mediated by gastric dilatation. Rather, what separates the new champs from lesser eaters is an ability to relax and really open the gullet. I found an old WaPo article that discusses this:

Stanford's Triadafilopoulos has another theory. When the muscles that line the esophagus initiate swallowing, they alternately relax and contract in a rippling pattern that pushes food downward. It typically takes 9 to 15 seconds for a swallow to convey food to the stomach, he said. This makes the esophagus the real bottleneck in competitive speed eating, with a mouth full of food waiting for traffic to clear in the tunnel.

Some people can relax all those muscles at once, momentarily turning the esophagus into a hollow pipe. "That's how people in circuses can swallow swords," Triadafilopoulos said. Some eaters may do the same thing, and literally pour food down the hatch.

"These people have somehow developed the ability, probably through some kind of training, to relax everything at the same time," he conjectured.

Metz doesn't buy that idea...

Metz, it should be noted, is one of the study authors cited above. I'd like his next fluoroscopy study to include a look at swallowing, and compare hot dog champions who can eat 50+ dogs in 12 minutes to those that top off around 30.

And my original questions to George Shea remain unanswered: What is the IFOCE's stand on performance enhancing substances (like glucagon, or even just topical anesthetics). What if a gastric bypass patient wanted to compete -- would that be fair? If Shea is looking to legitimize and mainstream this activity, he may have to answer these questions. But my hunch, as years go by and disturbing evidence begins to accumulate, is that IFOCE will remain the stuff of traveling sideshows.

So that's today's memory lane

The Scene: An ICU, on an early July morning. A well-dressed man is standing at the nurses' station, scribbling notes. Our main character walks in.

Me: Hey, where's the post-call intern?
Intern: That would be me. Would you like me to tell you about the overnight admissions?
Me: Sure, sure... Say, if you're post-call, why are you wearing a shirt and tie?
Intern (defensive): I... I wore scrubs overnight. I just changed back.
Me (with genuine admiration): Wow. Good luck with that.

The scene: A Welcome Fete. The new interns are meeting the residents.

The mature, confident resident (to a group): Hi, I'm Nick.
Intern A: Hey! I read about you. You're that blog guy.
Me: Oh, ha. Um, yes. But, you know, that's just kind of a computer thing I do... on the side.
Intern B: Hey, I remember you from interview season. But the website you were talking about, it had something to do with free drinks.
Me: Hmmm... Myopenbar.com?
Interns A, to Intern B: I love this town.

Cover me

After more than a few years of schooling and training, the day is approaching when my erudition and skills may be of some value. So, I recently applied for a disability insurance policy.

These insurers, they ask a lot of questions. When they got to the part about traffic citations over the past five years, I had to stop and think. It's been three years since I've even owned a car (but what a car it was). And I know I had a speeding ticket at some point in the early part of this decade. But was it 2002 or 2003?

I was reminded of Michael Moore's documentary, SiCKO, where a health insurance company denied coverage to a young cancer patient because she had forgotten to disclose an old, easily treated yeast infection. They called it a pre-existing condition.

And suddenly, it's became very important that I dig up old car documents from another state, even though I don't drive. God forbid I'm denied coverage at some point because of a misrepresentation in my original application (after talking to enough insurance agents, "God forbid" is a phrase that has worked its way into heavy rotation).

Does anyone know if I'm being paranoid about pinning down the date of an old speeding ticket?

Another question: I've often wondered why health insurance companies don't push harder for DNR status on elderly, moribund patients with dense dementia. Find and talk to the next of kin, work with the guardian, adjust expectations and prepare everyone for the inevitable.

Yeah, it's unseemly, but so much of what they do is already unseemly. And having seen too many of these unfortunate resuscitations, it seems that getting more aggressive about DNR status is more humane than trying to cheat otherwise healthy, active people out of coverage for out-of-the-blue health problems.

One that won't make me nervous

I used to read Andrew Sullivan's blog a lot in grad school. He's bounced around several times over the years -- both on the web and on major issues -- but I rediscovered him this primary season. I was drawn to his optimism and enthusiasm, even as some of his opinions are difficult to defend.

Anyway, he was recently musing about the latest ketamine-for-depression research, and wondering if this notorious drug could someday have a clinical use.

I wrote in to tell him I use it (clinically) quite often -- not for depression but for procedural sedation.

To my surprise, he printed the letter. And now I wish I had included more from my informed consent spiel, mentioned the sialorrhea, and maybe talked about that one time I pushed it too fast...

Far-Flung Correspondence

As I was always fond of his writing in high school English class, I was happy to see H. L. Mencken's name come up in this NYTimes piece on handling a large volume of correspondence:

We all can learn from H. L. Mencken (1880-1956), the journalist and essayist, who was another member of the Hundred Thousand Letters Club, yet unlike Edison, corresponded without an amanuensis. His letters were exceptional not only in quantity, but in quality: witty gems that the recipients treasured.

Marion Elizabeth Rodgers, the author of "Mencken: The American Iconoclast” (Oxford, 2005), shared with me (via e-mail) details of her subject’s letter-writing habits. In his correspondence, Mencken adhered to the most basic of social principles: reciprocity. If someone wrote to him, he believed writing back was, in his words, "only decent politeness." He reasoned that if it were he who had initiated correspondence, he would expect the same courtesy. "If I write to a man on any proper business and he fails to answer me at once, I set him down as a boor and an ass."

Whether the post brought 10 or 80 letters, Mencken read and answered them all the same day. He said, "My mail is so large that if I let it accumulate for even a few days, it would swamp me."

Yet at the same time that Mencken teaches us the importance of avoiding overnight e-mail indebtedness, he also reminds us of the need to shield ourselves from incessant distractions during the day when individual messages arrive. The postal service used to pick up and deliver mail twice a day, which was frequent enough to permit Mencken to arrange to meet a friend on the same day that he extended the invitation. Yet it was not so frequent as to interrupt his work.

Today’s advice from time-management specialists, to keep our e-mail software off, except for twice-a-day checks, replicates the cadence of twice-a-day postal deliveries in Mencken's time.

Ms. Rodgers said that Mencken was acutely disturbed by interruptions that broke his concentration. The sound of a ringing telephone was associated in his mind, he once wrote, with "wishing heartily that Alexander Graham Bell had been run over by an ice wagon at the age of 4."

Mencken’s 100,000 letters serve as inspiration: we can handle more e-mail than we think we can, but should do so by attending to it only infrequently, at times of our own choosing.

Sage advice. And -- you know you're in trouble when Mencken thinks you're an ass. But, truthfully, the Times writer is focused on the volume of correspondence -- 100,000 letters -- but I don't think Mencken's or Edison's volume of correspondence is what's truly noteworthy.

Even if you only count emails of more than two sentences, you only need five or six emails a day, every day, to hit 2000 a year. I think I'm at about that level, and I don't even work in an office (though the vast majority of these emails, I'm sorry to say, are not as timely or well-written as a Mencken letter, but they seem to be about as long). Still, if I live another fifty years (and if we're still corresponding with written words in the 2050's) I should make it to the hundred-thousand club -- and I think many of my peers will, too.

But correspondence today is undeniably more result-driven ('how is this project coming along?' -- 'are you free this weekend?' -- 'will you host Grand Rounds?') and virtually necessitates a reply (I hope). I can't imagine carving out the time to reply to five or six unsolicited emails a day. And that's what makes Mencken's achievement all the more remarkable.

Host Defense Activation

Ok, so, remember when those outrageous subway ads asking passengers to "demand a CAT scan" appeared, and prompted me to suspect, offhandedly, that the group behind the ads was receiving funding from GE or another CT-scanner manufacturer?

And when the awful truth came out, that the Lung Cancer Foundation was actually funded by a tobacco company -- a firm likely invested in the notion that smoking-related cancer is preventable and thus limits their liability -- well, I fretted that I wasn't cynical enough -- that it would be a far more straightforward and relatively benign conflict of interest if the funding just came from GE.

Well, here's some comforting news -- members of the Lung Cancer Foundation was also receiving money from GE! From WSJ comes news that the lead authors of a controversial 2006 NEJM report on CT-detection of lung CA were getting royalties from a major CT scanner manufacturer (these same authors are prominent members of the Lung Cancer Foundation, the group behind the dangerous advertisements):

In today's correction, the New England Journal acknowledges that the study's lead authors, Claudia Henschke and David Yankelevitz of Cornell University's Weill Medical College in New York City, received royalties from GE, a big maker of CT scanners, for pending patents on ways to manipulate and interpret CT scans and other medical images. The Wall Street Journal's Health Blog reported the royalty payments last October. Dr. Henschke said then that the royalties were small and declining.

A spokesman for both doctors said they had told the New England Journal that Cornell had licensed the pending patents to GE before the study was printed in 2006, but not that they were personally receiving a share of the royalties. Jeffrey Drazen, the New England Journal's chief editor, said the publication had learned of the royalties only recently.

I call this news 'comforting' because it suggests people behave predictably, that a truly disturbing action can be thwarted by the by lesser, more mundane transgressions. Al Capone getting busted for tax evasion is the first example that comes to mind, but there are probably more fitting precedents.

The NEJM article now carries a "correction" up front that addresses the GE conflict.

Cornell issued a press release clarifying the conflicts of interest:

The original $2.4 million pledge to the Foundation -- and the work funded by the Foundation at Weill Cornell -- was publicly disclosed at the time through a press release, and was covered in the lay media, including USA Today...

The gift was unrestricted, which means that, unlike industry-funded research agreements, it allowed for research to be conducted independently and without restriction in areas of significant but uncertain promise, without the gift-recipient being held accountable in any way to the gift-giver. Significantly, there were no restrictions on publication of results or data; WCMC was not required to keep the donor informed of how the funds were used; and the donor was not entitled to have access to any of the research results.

It is very important to note that the I-ELCAP project -- which comprises more than 50 institutions in nine countries and in 26 states -- has been funded only, in part, by this Vector/Liggett unrestricted gift. The basic research concepts behind the screening project have been developed by Dr. Henschke and Dr. Yankelevitz since the early 1990's, long before the Vector/Liggett gift. I-ELCAP has obtained considerable funding from other sources, and has been able to recruit additional screening centers which, in turn, have developed their own funding resources.

The gift was originally made as part of a grand plan and vision on the part of public health and lung cancer advocacy groups and Vector/Liggett to provide screening research centers throughout the country. The Foundation was organized by Dr. Claudia Henschke and Dr. David Yankelevitz and other advocacy-individuals associated with the I-ELCAP program, with the expectation that other major tobacco companies, in addition to Vector/Liggett, would contribute to this national effort. The initial decision to establish a foundation was thought by them to be the most appropriate and effective fundraising vehicle to achieve such a national research plan...

It is noteworthy that, like Weill Cornell, many of our peer institutions and medical schools do accept funding from tobacco companies and from institutions that manage funds from tobacco settlements for responsible research, and do establish legitimate foundations to manage the administrative and financial aspects of grants and gifts. We recognize, due to the extreme concern about tobacco companies' attempts to misuse research to the detriment of public health, that broader and continuing disclosures could and should have been made. But Weill Cornell strongly rejects the thesis of The New York Times article that any omission was deliberate.

Regarding the matter of allegedly undisclosed patents and patent applications by Dr. Henschke and Dr. Yankelevitz, Cornell Research Foundation, Inc., a subsidiary of Cornell University, licensed technology to General Electric (some of which is now patented) related to detection and measurement of nodules developed by Henschke, Yankelevitz and others. As is generally required at academic medical centers, the royalties were distributed to Cornell, which, in turn, provided a share to the inventors under Cornell's intellectual property policy, which is based on the Bayh-Dole Act. NIH Conflict of Interest regulations currently do not require individual disclosure of royalties paid to them by the employer institutions. Nonetheless, the royalties from the GE licensing agreement, the issued patent, and the patent applications were typically disclosed to journals and at CME meetings, when such disclosures were deemed relevant by Dr. Henschke and Dr. Yankelevitz.

Some of those publications have disagreed with Dr. Henschke and Dr. Yankelevitz's judgment on these, and corrections and apologies have been published in those journals...

NIH disclosure rules are surprising. Someone could patent a device or technique, and a university tech transfer office could license the idea to a big firm, which finds the idea so valuable they pay the university royalties for it. That money finds its way back to the original scientist, who can conduct research showing how great his idea is... and yet never be forced to disclose that he's making money off it, and could make a lot more if everyone believes his research.

It's got to be better to just fully disclose the potential conflict from the outset. That is, I think, what many successful scientists do, and it doesn't stop their research from being accepted.

I don't know why this process wasn't followed with the lung cancer research, and I don't know why the foundation instead chose a dangerous and misleading advertising campaign to advance their cause. These actions make the protestations about their level of disclosure being mischaracterized that much tougher to stomach.

The Lung Cancer Foundation has been mum on the entire debacle, save for two brief blog entries that, curiously, makes no mention of the fact that the 'tainted' researcher is the founding board member of the organization that produces the blog.

On the plus side, I don't recall seeing any new subway ads urging me to "demand a CAT scan," and I believe a few older ones have disappeared.

Metastasis

Last month, when I (and others) noted the ominous ads appearing in NYC subways, urging riders to "demand a CAT scan" -- I looked into the foundation that supported the ads. While the mass-market message was completely irresponsible (the use of CT scans for lung cancer screening has only been tested in smokers over 40, so there's no apparent reason for most riders to 'demand a CAT scan' from their doctors) I was nonetheless impressed by the credentials of their medical advisory board:

I see a medical advisory board full of oncologists, thoracic surgeons, and indeed, the author of the aforementioned 2006 NEJM study touting early detection via CT. Several board members are themselves lung cancer survivors.

I can't doubt this group's dedication or integrity (I originally expected "demandaCATscan.org" would be backed by GE Lightspeed scanners or something similar).

But I must ask, were these board members behind the subway ad campaign? Do they really want the general public demanding a CT scan? Because it's hard to believe such an informed and experienced group could endorse this approach.

Well, it turns out I wasn't cynical enough. The Lung Cancer Foundation is not backed by CT scanner manufacturers -- it's backed by cigarette companies.

Today's NYTimes drops the bomb:

In October 2006, Dr. Claudia Henschke of Weill Cornell Medical College jolted the cancer world with a study saying that 80 percent of lung cancer deaths could be prevented through widespread use of CT scans.

Small print at the end of the study, published in The New England Journal of Medicine, noted that it had been financed in part by a little-known charity called the Foundation for Lung Cancer: Early Detection, Prevention & Treatment. A review of tax records by The New York Times shows that the foundation was underwritten almost entirely by $3.6 million in grants from the parent company of the Liggett Group, maker of Liggett Select, Eve, Grand Prix, Quest and Pyramid cigarette brands.

The foundation got four grants from the Vector Group, Liggett’s parent, from 2000 to 2003.

Dr. Jeffrey M. Drazen, editor in chief of the medical journal, said he was surprised. "In the seven years that I’ve been here, we have never knowingly published anything supported by" a cigarette maker, Dr. Drazen said.

An increasing number of universities do not accept grants from cigarette makers, and a growing awareness of the influence that companies can have over research outcomes, even when donations are at arm’s length, has led nearly all medical journals and associations to demand that researchers accurately disclose financing sources.

Dr. Henschke was the foundation president, and her longtime collaborator, Dr. David Yankelevitz, was its secretary-treasurer. Dr. Antonio Gotto, dean of Weill Cornell, and Arthur J. Mahon, vice chairman of the college board of overseers, were directors.

So, after decades of denying the link between smoking and lung cancer, now a cigarette company has chosen to fund research in cancer detection. That's a good thing, right? It's even charitable, isn't it? Again it's necessary to ratchet up the cynicism:

Dr. Jerome Kassirer, a former editor of The New England Journal of Medicine and the author of a book about conflicts of interest, said he believed that Weill Cornell had created the foundation to hide its receipt of money from a cigarette company. "You have to ask yourself the question, 'Why did the tobacco company want to support her research?' " Dr. Kassirer said. "They want to show that lung cancer is not so bad as everybody thinks because screening can save people; and that’s outrageous."

Dr. Henschke’s work, while controversial among cancer researchers, has been embraced by many lung-cancer advocacy organizations, which have pushed for legislation in California, New York and Massachusetts to create trust funds to pay for lung cancer screening — often with language tailored to benefit Dr. Henschke’s group.

From this perspective, a mass-market campaign for lung cancer screening, instead ads targetted to smokers over 40, makes much more sense. What better way to build the association, in the public mind, that lung cancer is detectable and treatable if caught early? You could even imagine tobacco companies trying to limit future medical liability by pointing to the research they funded. "Everybody knows smoking causes cancer," they'd say -- "but everybody also knows a screening CT would have caught this early, while it was treatable."

So, the millions Liggett gave to Dr. Henschke wasn't motivated by charity or guilt, but rather, looks like a wise investment. Similarly, the misleading subway ads were never designed to protect the public -- the exist to protect cigarette company interests.

Blood Makes Noise

I recently heard US Army Major (and emergency medicine physician) report on his research, conducted in a major trauma center in Iraq. To give some context to his investigations on Factor VII and clotting, he mentioned a number of incredible statistics about the volume his hospital sees, the throughput his ER achieves, and even the turnaround time for lab results.

But one thing he said really stayed with me: all the hospital personnel have their blood typed and crossmatched. When a wounded soldier or Iraqi civilian requires a massive transfusion in the OR, they'll summon someone with the right blood and just hook them up to the patient, in the OR. He said, "There's nothing like transfusing warm, fresh whole blood to a patient -- it's like a magic bullet. Too bad we could never do that in the States."

(Another Iraqi hospital, one not run by the US Army, has apparently adopted different techniques).

But more data is accumulating on the inadequacy of current blood products practices. We already knew banked blood has poorer oxygen carrying capacity and is immunosuppressive (at best). Now, the NEJM just published a paper from Koch et al that demonstrated more post-operative complications from older blood transfusions. Cardiac surgery patients were significantly more likely to stay intubated, to have their kidneys fail, to develop sepsis, and to die -- when they were transfused packed red cells that had been stored more than two weeks.

Blood transfusion has come a long way and the practice of whole-blood transfusion has fallen out of favor, at least among US civilian institutions. But military studies have shown, at least, non-inferiority of the practice fresh whole blood transfusions, compared to frozen blood products (and patients requiring FWB required more blood, which is typically associated with worse outcomes). And others are looking at ways to mitigate the risk of infection.

It will be interesting to see this military practice finds some applicability in stateside trauma centers, and if the pendulum swings back towards whole blood transfusion in certain cases. If reviews bear out the benefit of fresh whole blood, hospitals should set up some kind of system where volunteer employees can be summoned to the OR to donate. It somehow seems more immediate and personal than current blood donation and banking. And when you consider all the expensive, marginal interventions we use in emergency medicine, it's nice to think we're sitting on something that could make a dramatic difference for a critically ill patient.