Posts Tagged ‘health care’

Does Hillary Clinton have Parkinson’s Disease?

Sunday, September 18th, 2016

The Hillary collpase last Sunday has prompted a lot of speculation on her condition. Early on I was inclined to blame her neurological condition on her history of concussion and cerebral vein thrombosis.

That seemed logical, given her history. However, it does not explain her quick recovery. It also has nothing to do with pneumonia.

This video has now convinced me that she has Parkinson’s Disease, and it is fairly advanced. In the video, the physician mentions Apomorphine, which is not morphine but an alpha adrenergic drug used in Parkinson’s Disease.

Currently, apomorphine is used in the treatment of Parkinson’s disease.

What use does it have in Parkinson’s? It is used for “Non-motor symptoms.”

What does that mean ? Parkinson’s Disease is characterized by a serious of motor disabilities.

The cardinal symptoms of Parkinson’s disease are resting tremor, slowness of movement (bradykinesia) and rigidity. Many people also experience balance problems (postural instability). These symptoms, which often appear gradually and with increasing severity over time, are usually what first bring patients to a neurologist for help. Typically, symptoms begin on one side of the body and migrate over time to the other side.

These symptoms are typically controlled with Dopamine like drugs, such as L-Dopa. There are other symptoms less easily controlled.

For example, in advanced cases, difficulty swallowing can cause Parkinson’s patients to aspirate food into the lungs, leading to pneumonia or other pulmonary conditions. Loss of balance can cause falls that result in serious injuries or death. The seriousness of these incidents depends greatly on the patient’s age, overall health and disease stage.

Hmmmm.

There are also side effects of L Dopa.

L-DOPA therapy is further complicated by the development of movement disorders called dyskinesias after 5 – 10 years of use in most cases.

Dyskinesias are movement disorders in which neurological discoordination results in uncontrollable, involuntary movements. This discoordination can also affect the autonomic nervous system, resulting in, for example, respiratory irregularities (Rice 2002). Dyskinesia is the result of L-DOPA-induced synaptic dysfunction and inappropriate signaling between areas of the brain that normally coordinate movement, namely the motor cortex and the striatum (Jenner 2008).

(more…)

Interesting comment on Hillary’s career.

Friday, July 29th, 2016

This was posted on facebook as a comment to a WSJ piece on her campaign strategy.

Dick Morris, former political adviser to President Bill Clinton: If you happen to see the Bill Clinton five-minute TV ad for Hillary in which he introduces the commercial by saying he wants to share some things we may not know about Hillary’s background, beware as I was there for most of their presidency and know them better than just about anyone. I offer a few corrections:
Bill says: “In law school Hillary worked on legal services for the poor.”
Facts are: Hillary’s main extra-curricular activity in ‘Law School’ was helping the Black Panthers, on trial in Connecticut for torturing and killing a ‘Federal Agent.’ She went to Court every day as part of a Law student monitoring committee trying to spot civil rights violations and develop grounds for appeal.

Was this true ? Snopes has a sort of rebuttal.

Hillary Rodham (as she was known then) wasn’t a lawyer then, either: She was a Yale law student, and like many of her politically-minded fellow law students who saw the latest “trial of the century” taking place just outside the main gate of their school, she took advantage of an opportunity to be involved in the case in a minor, peripheral way by organizing other students to help the American Civil Liberties Union monitor the trials for civil rights violations. Her tangential participation in the trial in no way helped “free” Black Panthers tried for the murder of Alex Rackley

So the description credited to Morris is correct.

(more…)

Another update on the NHS, Bernie’s favorite health plan.

Friday, February 12th, 2016

NHS

I have mentioned problems with the NHS here before.

That was about emergency care.

Last fall there was a concern about junior doctors emigrating to other countries.

Britain is already suffering from a serious, and unprecedented, shortage of GPs, on a scale that doctors’ leaders say is fast becoming a crisis.

According to figures released last week, a staggering 10.2 per cent of full-time GP positions across the UK are currently vacant, a figure that has quadrupled in the past three years.

Two-thirds of practices are now finding it ‘difficult’ or ‘very difficult’ to find locums — freelance medics — to cover the shortfall.
As our population gets steadily older, and sicker, frontline surgeries are becoming increasingly swamped.
‘We are in dire straits if we do not act to address the GP recruitment crisis immediately,’ the Royal College of GPs warned last week.

In standard government medicine fashion, the British Health Minister imposed a new employment contract that ignored doctors complaints.

The result ?

Junior doctors are threatening a mass exodus to Australia after Jeremy Hunt forced through his controversial new contract yesterday.
There has been a huge surge in the numbers seeking certificates to practise abroad and some have already lined up jobs.
Almost 760 doctors were issued with documents by the General Medical Council in the first four weeks of this year – nearly 200 a week and almost double the usual number. Although they include some older GPs and consultants, the vast majority were disillusioned younger doctors.

Becoming a doctor is a classic middle class occupational choice. Few doctors become rich and almost none do so from actual practice. There was a phase in the 1960s when doctors suddenly became much more prosperous as Medicare was introduced, providing payment for care that had been done for no charge mostly. With time, the US government has reduced compensation and imposed rules designed to reduce costs. With the imposition of Obamacare, many older doctors who do not have heavy student loan balances and whose own children are educated, are choosing to drop all insurance, including Medicare, and practice for cash.

Obamacare has resulted in many hospitals consolidating and buying up medical practices to develop a vertically integrated system of health care delivery that resembles old industrial models. The result for physicians is a trend to salary jobs and dissatisfaction with their careers.

I met a woman geriatrician, the only fellowship trained geriatric specialist in central Iowa. She had quit Medicare. That sounds a bit suicidal if all your patients are Medicare age. What had happened was she was being harassed by Medicare because she was seeing patients too often. Many of them were frail elderly living at home. She dropped out and began charging her patients cash for services. She was making a decent living after a year and was happy with her decision. I don’t know how many realize that geriatrics, as a specialty, is a university subsidized field. There is no private geriatric practice because the doctor can’t survive on what Medicare pays. She tried and had to quit. She is doing it on her own now.

That was about Medicare. The same is happening with Obamacare and the medical conglomerates that have been assembled in anticipation of the “Industrial Model” of medical care. How is that working out in Britain ?

(more…)

The Muslim war on immunization.

Saturday, January 16th, 2016

If anyone wonders about the level of civilization in Muslim countries and especially those in “radical” or “takfiri” subsets, the war on polio immunization should be a clue.

Recently, a suicide bomber attacked a polio immunization center in Pakistan.

The World Health Organization’s anti-polio vaccination program inside Pakistan has been a prime target of the Taliban. Mullah Fazlullah, the emir of the Movement of the Taliban in Pakistan, was one of the first leaders to have opposed polio vaccinations. On his radio program, Falzullah, who is also known as Mullah Radio, denounced polio vaccinations as Western attempts to sterilize Muslim boys.

Other Taliban commanders, including Mullah Bahadar and Mullah Nazir, who was killed in a US drone strike, as well as Pakistani clerics and leaders in the tribal areas, suspended polio vaccinations in areas under their control until the US ceased drone strikes against Taliban, al Qaeda, and other jihadist commanders.

Taliban commanders have also accused vaccination programs as serving as cover for CIA and western operations to target jihadist leaders inside Pakistan.

The largely Muslim state of Uttar Pradesh in India has been the last outpost of remaining polio cases in the world.

India was declared free of the wild polio virus in January 2011 however cases of flaccid paralysis continue to be reported in thousands from across the country. “In spite of the WHO declaring India polio-free, there has been an increase in the cases of non-polio paralysis. It is a huge cause of concern,” said Dr SD Gupta, president, IIHMR University.
In 2004, 12,000 cases of non-polio paralysis were reported which increased to 53,563 cases by 2012. According to the data published by the union health ministry in July, 2015, the total number of non-polio acute flaccid paralysis (NPAFP) cases across the country were 18,141, of which 5918 were reported from UP, 668 from Rajasthan, 102 from Telangana, 385 from Karnataka and 865 from Maharashtra, among others.

What is going on ? It seems that new enteroviruses may be involved. India has been largely successful in eliminating wild Polio virus.

India’s success in eliminating wild polioviruses (WPVs) has been acclaimed globally. Since the last case on January 13, 2011 success has been sustained for two years. By early 2014 India could be certified free of WPV transmission, if no indigenous transmission occurs, the chances of which is considered zero.

Great efforts were made.

The VE against types 1 and 3 was the lowest in Uttar Pradesh and Bihar, where the force of transmission of WPVs was maximum on account of the highest infant-population density. Transmission was finally interrupted with sustained and extraordinary efforts. During the years since 2004 annual pulse polio vaccination campaigns were conducted 10 times each year,

Muslims are determined to stop this effort. More evidence that they are not ready for civilization.

2015 is gone, thank God.

Friday, January 1st, 2016

2015-a-maes-Marty_thumb

I am content to see the year 2015 gone. I can remember as a college student thinking that 1960 would never come. That was a good year. I didn’t graduate from USC as planned but I did get married and I did get accepted to medical school.

Some of the story is here in my short biography. More of it is here in my “stream of consciousness.” The next installment is here as I describe Basic Training.

When I got back from Basic Training in December 1959, I had my first date with Irene Lynch. A year later to the day, we were married and a week later, I got a letter from SC Medical School telling I had been accepted to the class beginning in September 1961. So, 1960 was a pretty good year.

In 2015 I spent what I think will be my last year teaching medical students at what is now named “Keck School of Medicine of USC” and is where I attended from 1962 to 1966. I went back to teaching there in 1998 in a program called Introduction to Clinical Medicine, which seems to be disappearing into the “Family Medicine” Department which is a shame.

I now have a book of memoirs called “War Stories: 50 years in Medicine” and which is a Kindle book only so far. Much of my medical school experience is included along with stories from my years as a surgeon. It started to be “40 years a surgeon” but I decided to include the rest and changed to 50. In June 2016, it will 50 years since I graduated from Medical School and that seemed a appropriate.

I enjoyed my time with students and I am quitting only because of frustrations with the Electronic Medical Record, about which I used to be enthusiastic, and with changes in the County Hospital which used to be a wonderful teaching institution. The Electronic Medical Record, now more often called The Electronic Health Record, probably because much of it is not about medicine, is a big problem.

The EHR, as it is called, has acquired a bad reputation.

(more…)

An update for fans of the NHS

Friday, November 27th, 2015

NHS

I have posted a number of essays on what I think health reform should look like. None of it looks like the NHS. Now, we have new information about how the NHS is functioning.

Figures collected by the Royal College of Emergency Medicine (RCEM) over the last seven weeks showed 88 per cent of A&E patients were treated or admitted within four hours – seven per cent below the 95 per cent target.
The report said that hospitals are also experiencing major problems discharging patients who are medically fit to go home.
Hospitals in England are failing to meet the 95 per cent target of seeing patients within four hours

The problem is being exacerbated by ‘bed blocking’ – where a patients cannot leave because there is not the right support in place in the community – with about a fifth of hospital beds being occupied in some parts of the UK.
Experts say the increasing problems in social care are having a major impact on the NHS.

This is an old problem with free care. We used to have patients in County hospital who would heat thermometers with hot coffee to avoid being sent home. Some of them were mentally disturbed and I have one such story in my book, “War Stories; 50 years in Medicine.

The NHS is having troubles all over.

The data shows performance getting worse since hospitals began submitting the data at the start of October.
Then, just over 92 per cent of patients were seen in four hours, falling to 88 per cent in the middle of November.
More than 6,300 planned operations have been cancelled over the seven-week period.
As an overall average, each site cancelled 21 operations per week, ranging from no cancellations to 137 in a single week.
The Department of Health and NHS England used to publish weekly data for England on how A&E departments were performing but have now stopped doing so.
Instead, data is published monthly but only covers figures from more than a month ago.

Hiding bad news is an old tactic of bureaucracies.

The Medical History of the American Civil War IV

Friday, September 4th, 2015

More of the series on my lecture on the Civil War.

Slide30

The Ambulance Corps were organized and the photo shows one group during the war.

Slide31

The next Army Surgeon General was Letterman who changed Tripler’s organization and built larger hospitals and worked on sanitation projects that had been ignored by the early medical services. Disease was a greater risk to soldiers than wounds and had been since Classical Greece. When large numbers often were accumulated without proper sanitation, disease was rampant. Florence Nightingale was one of the first to realize the importance of cleanliness.

Slide32

One of the greatest medical pioneers of the Civil War was John Shaw Billings who designed hospitals, including The Johns Hopkins Medical Center. He was never Surgeon General but he did organize what became the Public Health Service.

Slide33

One of Letterman’s new hospitals was this one which was constructed in time for the battle of Gettysburg.

Slide34

One of the brilliant surgeons who joined up and contributed was this man, John H. Brinton. Typically, he was dismissed by the politicians around Lincoln because McClellan had appointed him.

Slide35

The most common medical problem was chronic diarrhea.

27,558 Union soldiers died of chronic diarrhea. Without bacteriology, still unknown in 1865, it is impossible to trace the causes.

Typhoid fever killed another 27,056 soldiers.

In the Boer War, in 1899 to 1902, typhoid fever killed thousands of British troops.

of the British Force of 556 653 men who served in the Anglo-Boer War, 57 684 contracted typhoid, 8 225 of whom died, while 7 582 were killed in action.(11) As had been the experience in America, the disease was found to be one which occurred in static camps.

This occurred years after infectious diseases had been identified and the cause of illnesses had been described.

The First Word War was the first war in which more men died of wounds than of disease.

Slide36

This slide, from the “Medical and Surgical History of the War of the Rebellion, shows the seasonal nature of the disease. The nutritional aspects are seen in the incidence during the siege of Atlanta.

Slide37

One example of another page of the History. There were over a million cases of acute diarrhea during the war. “Colored Troops” only appeared after 1863.

Slide38

Diseases were classified according to the medical knowledge of the time. “Miasma” were those which we now know to be infectious. Malaria, for example, mean “Bad Air” in Latin.

Slide39

Tuberculosis was a severe chronic disease which would not be curable until Streptomycin came along in 1946. There were two forms, “consumption” which was the pulmonary form, was not known to be contagious. “Scrofula” is the cervical lymph node form and is associated with milk from infected cows. This was the form studied by Louis Pasteur who recognized that it was transmissible and that heating milk prevented it.

Slide40

Treatment of disease was as primitive as one might expect although quinine was known and used by the Union Army. The blockade of the South prevented its use there. Vaccination was widely practiced and opium was used for pain. There was anesthesia since 1846 and chloroform was more common than ether.

Slide41

Malaria was widespread in the US at the time. Mosquitoes were vaguely known to be associated. Mosquito nets were used although the mechanism was not well understood.

The Medical History of the American Civil War III

Friday, September 4th, 2015

This continues the series from a lecture I have given a few times.

Slide23

William W Keen was a student when he first served as an Army surgeon at Bull Run. That experience changed the Army medical services and gave a great deal of power to the volunteer organizations.

Slide24

William Hammond quickly replaced the incompetent surgeons who had been in place when the war began. He was competent but argumentative and clashed with Stanton who became Secretary of War.

Hammond met Jonathan Letterman. Hammond worked with Letterman and Rosecrans on the design of a new ambulance wagon.

The atmosphere in the upper levels of medical services was then one of internal strife and personal conflicts. Hammond—a tall and imposing young man[12]—was no man of intrigue, nor even, according to all accounts, a very flexible person. However, the situation offered him the possibility for advancement. When Finley, the 10th Surgeon General, was fired after an argument with Secretary of War Edwin M. Stanton, Abraham Lincoln, against Stanton’s advice and the normal rules of promotion, named the 34-year-old Hammond to succeed him with the rank of brigadier general. Hammond became Surgeon General of the Army on 25 April 1862, less than a year after rejoining the army.

Lincoln liked “Men who fight” and defended his choices but Hammond was just too hard headed.

On his initiative, Letterman’s ambulance system was thoroughly tested before being extended to the whole Union. Mortality decreased significantly. Efficiency increased, as Hammond promoted people on the basis of competence, not rank or connections, and his initiatives were positive and timely.

On 4 May 1863 Hammond banned the mercury compound calomel from army supplies, as he believed it to be neither safe nor effective (he was later proved correct). He thought it dangerous to make an already debilitated patient vomit. A “Calomel Rebellion” ensued, as many of his colleagues had no alternative treatments and resented the move as an infringement on their liberty of practice. Hammond’s arrogant nature did not help him solve the problem, and his relations with Secretary of War Stanton became strained. On 3 September 1863 he was sent on a protracted “inspection tour” to the South, which effectively removed him from office. Joseph Barnes, a friend of Stanton’s and his personal physician, became acting Surgeon General

Stanton later died of an asthma attack so his “personal physician” was important to him. Calomel was “The Blue Pill” that had been advocated by Benjamin Rush. It was an ancient remedy based on the success of mercury in the treatment of syphilis dating back to Paracelsus in the 14th century. Medicine until the 20th century was quite primitive and many remedies were tried for wildly inappropriate indications.

van gogh

For example, a Van Gogh painting of his doctor shows evidence of digitalis intoxication which might have caused his death. Yellow vision is one indication of overdose of digitalis (sudden death is another) and a Van Gogh painting, Portrait of Dr. Gachet shows the characteristic yellow tint plus an example of the plant held by the doctor.

Anyway, Hammond was replaced after some of his innovations including evacuating the wounded from the Peninsula Campaign of McClellan. They were taken by ship back to large hospitals near DC.

Slide25

Slide26

Treatment of the wounded early in the war was primitive and would soon improve under Hammond’s reforms.

Slide27

The volunteer organizations began to make their influence felt and the Army was unable to resist the reforms.

Slide28

Tripler, for whom the great Army hospital in Hawaii is named, was chosen by McClellan to be the chief surgeon for the Army of the Potomac. His great innovation was the “Ambulance Corps.”

Slide29

The “Ambulance Corps” restored the invention of Baron Larrey and began the reforms of the Union

To be continued

The Medical History of the American Civil War II

Friday, September 4th, 2015

This continues the story of medicine in the Civil War. Samuel Gross, a Professor of Surgery at Pennsylvania Hospital in 1860, realized that no textbook of military medicine and surgery existed so he wrote his own in 60 days. It is shown in this exhibit at the Warren Collection at Harvard’s medical library.

manaual of mil surg

The Confederate Army also had no manual so the Gross manual was used by both sides in the war. It was quickly copied for Confederate Military surgeons. A copy of the manual, which was identical to the Union Army manual is preserved at Jefferson Medical College in digital form.

Slide16

The first battle, famously, was at Fort Sumpter where the commanding office during the battle was actually the medical officer, Samuel Crawford.

Slide17

The woeful state of the army medical department was recognized immediately and a volunteer organization quickly organized. The first was the US Sanitary Commission. It was rebuffed by the Army but quickly became very powerful. This was a people’s war and the Army was incompetent, as everyone knew.

Slide18

Here is the cover of Gross’s book. It was used throughout the war, which had enormous influence on American and world Medicine. The book from which this lecture is taken was used by Theodore von Billroth to design the Prussian Army medical corps for the Franco-Prussian War in 1870. The French had forgotten Baron Larrey’s lessons and suffered terribly.

Slide19

The cover of the Confederate version of Gross’s textbook.

Slide20

Joseph Woodward was an academic surgeon, such as it was known at the time.

“Woodward was the first scientist to establish photomicrography as a tool for both scientific and medical investigations.” According to an article in the Archives of Pathology and Laboratory Medicine:[2] “In addition to collecting specimens for the museum’s archive, he co-authored the definitive medical history of the Civil War in the 6-volume 1870 publication of the MSHWR.4 Woodward’s technique using aniline dyes for staining thin sections of tissue, along with his pioneering work in photomicroscopy, helped prepare the groundwork for modern surgical pathology.”

The “History” is “The Medical and Surgery History of the War of the Rebellion” of which there are six existing full copies. I found one copy in the USC Medical Library and asked the library staff, who had no idea of its value, to place it in a locked collection room. It would be like finding a copy of “De Revolutionibus” on the shelves of an open university library.

Slide21

The design of Union Army Hospitals was entrusted to Frederick Olmsted, who had designed New York City’s Central Park. He was, after the war, very involved in establishing The National Park Service.

Slide22

The first battle of the war illustrated the appalling condition of the medical services of both sides. There were no ambulances and the wounded and to walk back to Washington City, as DC was known then.

A famous American surgeon, who would write one of the world’s great medical textbooks, William W Keen acted as a young army surgeon at the battle.

He studied at Brown University, where he graduated in 1859. He graduated in medicine from Jefferson Medical College in 1862. During the American Civil War, he worked for the U.S. Army as a surgeon. After the war, he spent two years studying in Paris and Berlin.

His “An American Textbook of Surgery” was a hugely influential text and the 1905 edition had a chapter on brain surgery by Harvey Cushing and a chapter on “Appendicitis,” the first use of the term in medical literature, written by John B Murphy, who was the first advocate of early appendectomy for appendicitis.

To be continued.

The Medical History of the American Civil War.

Wednesday, September 2nd, 2015

Slide01

This is a lecture I have given a few times and am converting to a long blog post. The American Civil War was the first major war since a number of major advances of medicine had occurred. Sanitation had been studied by John Snow and Florence Nightingale. Anesthesia had been discovered by two Americans, Morton and

Unfortunately, antisepsis would not be described until, 1867, after the war. Infection than was the great scourge of the wounded.

Slide02

The state of medical art before the war was limited.

Slide03

Baron Larrey was the greatest army surgeon of the Napoleonic Wars. He invented the ambulance and pioneered some sanitary advances but the cause of infection was still obscure.

Slide04

Benjamin Rush was a famous American physician but little of what he knew or advocated was of use.

Slide05

The discovery of Ether anesthesia was momentous but it did add the factor that more operations would be attempted before infection was understood.

Slide06

Semmelweiss was tragic figure who realized that infection was transmissible from physicians’ hands to patients but he was unable to convince his colleagues. His discovery of the uses of hand washing were ignored.

Slide07

Florence Nightingale discovered the use of hand washing in caring for the wounded but she did not know why it worked. She is a great hero of the British Army and her apartment in Scutari Barracks in Istanbul is preserved in a shrine.

Slide08

The Scutari Barracks from across the Bosphorus.

Slide09

I visited the museum about ten years ago and visited her quarters which the Turkish Army preserves.

Slide13

The history of Military Medicine really begins with Ambrose Pare’ who served several French Kings and who invented the hemostat.

200px-Ambroise_Paré

His methods were a huge improvement on the Greeks but not much else can be said for their efficacy.

Slide14

The American Army in 1860 was tiny and the medical establishment was a joke.

Slide15

The war resulted in many of the army surgeons resigning to join the Confederacy. The lack of military medical texts resulted in Samuel D Gross, professor of surgery at Jefferson Medical College, writing his own textbook.

To be continued.