Wednesday, October 8, 2008
In the August 21, 2008 issue of the New England Journal of Medicine they published a special article by Kim and Goldie titled Health and Economic Implications of HPV vaccinations in the United States that concluded that such a vaccination program may be cost effective. In the same issue there was a dire warning framed as an editorial by Haug that warned of the unknown adverse side effects of such a vaccination program. Unfortunately, I think the pundits from New England missed the boat. What we may unknowingly do by instituting such a vaccination program is that we may inadvertently prevent a whole bunch of cancers in other areas. The discussions that were presented limited themselves to discussing the value of vaccination against human papillomavirus (HPV) for the currently approved indication, the prevention of cervical cancer. This indication alone is a certainly sufficient to merit serious consideration of the benefits of such a program, cost effectiveness be damned, but when the discussion is expanded to include other malignancies associated with HPV the potential benefits are of a significantly larger magnitude.
An association of HPV and oral squamous cell carcinogenesis has been discussed since 1983 . Early studies which included all cases, and included leukoplakia, estimated that between 11 and 15% of these lesions had evidence of HPV DNA . In later studies looking at oral cancers in non-smoking individuals the percentage of those cases associated with HPV jumped to 60-78% . The increase that was seen was largely due to improved methods of detection of HPV DNA. When sub-type analysis was performed, it was shown that 70 % of oral carcinomas contained HPV 16 or 18 . Which are the same strains currently protected against by the commercially available vaccinations for cervical cancer.
In the United States in 2007 there were 11,150 new cases of carcinoma of the uterine cervix diagnosed, while there were 34,360 new cases of carcinoma of the oral cavity and pharynx. Carcinomas of the vagina, vulva, and anus have also been linked to HPV exposure, and when added together would account for another 15,000 cases of cancer that be impacted by a vaccination program. In my mind, the question we should be asking is not should adolescent females be vaccinated against HPV, but shouldn’t all adolescents be so vaccinated. Isn’t it worth considering the 14,507 cases of carcinoma that could be prevented in men by such a vaccination program?
Kim JJ, Goldie SJ. Health and Economic Implications of HPV Vaccination in the United States. N. Engl. J. Med. 359:821 Aug. 21,2008
2 Haug CJ. Human Papilloma Vaccination – Reasons for Caution. N. Engl. J. Med. 359:861 Aug. 21, 2008
3 Syrjanen, et al. Morphologic and Immunohistochemical Evidence Suggesting Human Papillomavirus (HPV) in Oral Squamous Cell Carcinogenesis. Int. J. Oral Surg. (6) 418-24 Dec. 12, 1983
4Gassenmaier A., Hornstein O. Human Papillomavirus DNA in Benign and Precancerous Leukoplakias and Squamous Cell Carcinomas. Dermatologica 176(5) 224-233.1988
5 Syrjanen, et al. Human Papillomavirus (HPV) DNA Sequences in Oral Precancerous Lesions and Squamous Cell Carcinoma Demonstrated by In Situ Hybridization. J. Oral Pathol. 17(6) 273-278 July 1988
6 Honig. Non-Radioactive In Situ Hybridization for Detecting Human Papillomavirus DNA in Squamous Cell Carcimona of the Tongue. Bull. Group Int. Rech. Sci. Stonatol. Odontol. 3-4(35) 107-115 Sept-Dec 1992
7 Woods, et al. Analysis of Human Papillomavirus DNA in Oral Squamous Cell Carcinoma. J. Oral Pathol. 22 (3) 101-108 Mar 1993
8 Barten, et al. [p53 alterations and HPV Status in Oral Squamous Cell Carcinoma]. Verh. Dtsch. Ges. Pathol. 78: 255-259 1994
9 Jemal, et al. Cancer Stastics 2007 . Ca Cancer J. Clin. 2007: (57) 43-66
Wednesday, September 24, 2008
Homophobic, Surrealistic, Racist, Fascist, Soporific
You can hand me the phone, you can text me the truth.
Call me your names, but then cut me loose.
You can be sure I won't be taking your cure,
And I'll be drinking the poison I choose.
Cannibalized, Eroticized, Smoking, Joking, Super-sized
So hide all your flaws, push your secrets down deep.
Conceal all your scars with the clothes that you keep.
Keep a hat on your head and tin foil on your bed,
So they can't read all your dreams while you sleep.
Here’s your little valentine, cut out and stitched upon my sleeve.
It’s a small world after all, but it offers no reprieve.
Every cow is sacred, and every word a blade,
Careful as you tiptoe through the minefields that I’ve laid.
Murderer, Voyeur, Stupid, Vapid, Soul Destroyer
I have to be who I am, though I might look just like you.
A little less tan, different laces in my shoe.
Non-conformity, it’s said, the different thoughts in my head,
Make it me who is me and not you.
Thursday, September 11, 2008
It reminded me of a story I read by Ray Bradbury in high school about a family that knew that the world was going to end that night, and they did all of the things that they did every other night, ate dinner, read, put the kids to bed kissed them goodnight, and went to sleep. Probably they were a little nicer than usual. No one screaming, "Get to bed!" or "Don't you know tomorrow's a school day?" It was all sweet and nice. The mom probably made a nice dinner, one everybody liked. I don't think it would be like that at my house, but maybe it would, we didn't lie awake waiting for them to light off the LHC, we just went to bed and went to sleep, just like the people in the story. I think it would be this way no matter what.
We can't conceive of a world without us, and we sure can't conceive of a universe without our world in it. Besides, what are you going to do? Drive all over the place trying to get off. Order a bunch of things on the internet on your charge card? Why? You're never going to have to pay for them, but you're never going to get them either. For me at least, just ordering stuff isn't good enough. I have to drive myself crazy trying to get whatever it is, out of the packaging. Then I look at it for a few minutes, savoring its specialness. Then I put it someplace safe, and promptly forget about it, until I trip over it three months later and wonder what I was thinking when I ordered this piece of junk.
Maybe you could get on e-bay and buy five Ferraris just for the joy of winning the auction.
"See, I got every one of them." You could say to yourself.
But, if everyone knows the world is going to end everybody's going to bid like there's no tomorrow. Because, there isn't. But what if you’re wrong?
You wake up late for work the next morning. You didn't set the alarm clock. Why? It wasn't supposed to be there. You're running around like a chicken with its head cut off trying to get the kids ready for school and you ready for work. The kids are wondering what in the heck is going on. "Boy, they were so nice last night. Now they're hollering like crazy. Dad cussed a blue streak because he forgot to put the garbage out last night (remember, it wasn't supposed to be there in the morning)."
Then you remember the five Ferraris, the ones you were bidding against all the other poor saps that didn't think the world was going to be here this morning. What was the final bid? Thirty-four trillion apiece? "Oh crap," you exclaim, watching the neighbor shoving his three kids still in their pajamas into his Suburban. “I put that on the American Express, the one with no limit."
Now that's the end of the world.
Thursday, July 3, 2008
Sunday, June 29, 2008
We live in a whole big world of scary stuff; floods, wars, nuclear bombs, and reality TV just to name a few. In a solar system full of scary stuff, like asteroids, comets, and other stuff that might fly out of the sky and squish us. In a universe full of scary stuff, I don't even want to think of what a supernova or black hole would do. We've done a lot of injury and damage in the name of science in the past. Can the world really be any more over than it is for the amazing number of native populations decimated by smallpox, syphilis, and TB, all in the name of expanding our universe.
I can hear you saying, "We're not like that anymore." Heck boys and girls, we weren't completely sure when we set off the first fusion based "H-bomb" that it couldn't set off a chain reaction that would light up all of the hydrogen floating around our little planetary home. We didn't think it would and it didn't but, "Who knew?"
The chances of the accelerated protons or lead ions we send racing around the new thirteen-mile nuclear racetrack they've built three-hundred feet below the ground over on the Franco-Swiss border, forming a black-hole that doesn't dissipate, or an uncontrolled annihilation reaction due to anti-matter generation is less than one in fifty-million.
The good news, if you believe in string theory, is that even if it happens, we may end up in one of the other ten, twenty, or hundred other dimensions we aren't able to see, but that have to be there for the universe to work right.
How will it turn out? Only God knows, and he isn't telling, but he does give us a few hints, while the LHC may be the most powerful collider on earth it doesn't come close to reaching the energies that particles accelerated through the universe possess when they slam into our atmosphere. If they haven't blown us up yet, why should we be afraid of man's puny attempt to mimic nature's great collider?
Thursday, June 26, 2008
What you don't do is ask someone else to write your story, or screenplay, or poem for you. I've had several people ask me to write their stories for them. Unless its one of my partners and they're ready to start a new project, I never have. That doesn't count kids. My kids and I paint, write, or make-up and sing songs all of the time. Sometimes the kids will put on whole stage shows complete with choreographed dance numbers for a paying audience of six or seven (that depends on if we let them bring the goldfish.) Anything that allows them uninhibited creativity is a plus and should be encouraged, so that when they're adults, they aren't sitting around wondering if they need to take a course or read a book to create something worthwhile.
So what do you do? You write. You write all kinds of stuff. You write as if someone is out there to read what you're creating, whether there is or not. That's where blogs come in. Offer an opinion, create a story, do anything; to quote Nike, "Just do it." When you're done writing, read it, then tear it to pieces, and rewrite it. Whoever said writing is rewriting was only ninety-five percent correct. When you feel like it is the best you can write, post it and get some friends to read it and offer criticism, and if a stranger slams it, save the righteous indignation and try to see if what they are saying has any validity. I'm lucky enough to have a lot of what I write reviewed by professional editors, and I still have a little difficulty keeping that righteous indignation at bay.
Will this really work? Can writing regularly in a blog that no one reads improve your writing skills? Who knows? I'll get back to you in a few years, but in the meantime, I'll keep blogging, just for practice.
Wednesday, June 25, 2008
Because our economy is, to say the least, less robust than it was a few years ago, coupled with, the increasing number of folks entering the "Medicare years" due to baby-boomers pouring in like a damn busted, the formula stopped working several years ago. Everybody knows it doesn't work; the lawmakers, the doctors, the hospitals, even the HHS folks who administer Medicare know. Guess who doesn't know? For the most part patients have no idea about the costly, intricate dance that goes on every year, with doctors and hospitals spending millions of dollars to convince the lawmakers to do what they know they are going to have to do anyway. And each time they patch it the formula gets farther and farther away from anything approaching reality. We are now so far behind that a 20-22% cut in current reimbursement rates would be needed to set things straight. That, or the jobs we've allowed to be outsourced overseas will have to start spilling back into the US, the dollar will have to drop so low that its cheaper to make things here than it is in China. Think that's gonna happen soon?
The closest thing I can think of as an example, is that if you needed a new car, and you set the amount of money you could spend on that car a year as a set portion of your income. Now, some hard times come. You make less money. Gas goes up to four dollars a gallon. Could you go to the bank and say, “I’m going to have to cut what I’m paying you on this loan.” Or go in to the gas station owner and tell him, “Sorry buddy, but all I can give you is two dollars a gallon.” You’d be a no car, no gas, walking the road son-of-a-gun. And, if you don’t believe me, just try it.
So what do we Americans do if we want the system to function and doctors to treat us when we become geezers, ( I stand on the very verge of geezerhood myself). The answer is simple we need to SCRAP the CRAP. The SGR can't be fixed so start over. The House has just passed another bill to put another bandage on it for 2008-2009, the Senate has yet to act, but if it doesn't the first 10.8% cut is already programmed into the HHS computers for July 1, with another catch up cut of 10.2% set for January 1st. We have to have the bandage, but before this issue becomes a crisis again we need a serious discussion about a meaningful and realistic fix. We have two new contenders for that big white house on Pennsylvania Avenue, and we need to ask them what they think about it, and what they plan to do to fix it. If we don't, its like the old gospel song says, "Ain't nobody's fault but mine..."
Monday, June 23, 2008
“There’s a threat on the horizon. In terms of lives lost this threat will dwarf 9/11 and the war in
Let me let you in on one of the basic facts of life, and no, you don’t have to be a doctor to know this one, everybody wants more- more money, more fulfillment from their lives, more love. If you need proof, look in the self-improvement section of any bookstore, or just turn on your television during the day and flip through the channels.
Why do we need more? Well, we need more money so we can get more stuff. Our society and our economy are based on a simple principle…consume, consume, consume. I hate to admit it, but I’m no different from anybody else, I need the newest two terabyte MP3 player, my crummy eighty gig is way too small, it only holds a thousand or so CDs. Who can put up with that? Unfortunately, as much as I delude myself to believe it is, my need isn’t a real need, I don’t have time to download a hundred CDs, much less a thousand. I have about thirty-seven CDs on my player, and yet I believe I need a newer, more technically sophisticated model. With the rapidity of technological evolution in the modern world, this cycle of need and fulfillment is never ending, as soon as I buy the new “two-T”, within weeks of the purchase of this technical marvel, they’ll begin to advertise a newer model, one that comes with a cell phone in it, and as soon as I get that, there’ll be an even newer model with both a cell phone and a miniature computer in it, and so it goes ad infinitum.
In a lot of ways medicine is the same way, but instead of ego and vanity being the only driving forces, it may truly be that our lives are at stake. We want more and we want better, the heck with better, we want the best. Who doesn’t feel that they deserve the best health care?
This isn’t a medical decision, medically, the answer is obvious. From a risk-benefit standpoint the drug is amazingly effective, so it’s all benefit with no risk. The only risk is to the solvency of the largest health care provider in the
Do you know which segment of the population is the fastest growing pool of the uninsured? Poor people, right? Perhaps, the unemployed? Nope, on either count. That distinction goes to working males over fifty, that make over seventy-five thousand dollars a year. That can’t be right. That’s what I thought, until it happened to me. When a misrouted bill went unpaid, my insurance was cancelled without notification until sixty days after the action. And once you find out your policy has been cancelled, if you’ve gone more than thirty days without a bridge policy, you have to jump through hoops and throw around a good deal of loot to get any type of coverage. After several rounds of denials, and a total inability to get a private policy to cover either myself or my wife (every company was happy to cover our perfectly healthy children, for the same price we had been paying as a family). Thankfully, I have a good income and the cost of establishing a group policy and hiring my wife wasn’t an undue hardship, but it cost twice what I had been paying. Most families can’t absorb this.
In my opinion, any, health care reform has to deal with both of the issues we’ve dealt with. Until there’s some type of controls on drug pricing and insurance reform that actually reforms the practices of private insurers, any health-care policy we undertake is a mere band-aid.