I saw this when it first came out, but unfortunately I didn’t give it a second thought. Details, unfortunately are scarce, but it’s good news nonetheless. The NYT has more on the fun backstory of the plant-based remedy:

In some ways, it is a wonder that the work survived at all. In 1670, at the age of 42, Rumphius went blind. In 1687, his still unpublished manuscript and all of his illustrations were destroyed in a fire that swept through the European quarter of Ambon. Undaunted, he dictated a new version and commissioned artists to draw new illustrations.

Fortunately, the second time around he kept a copy of the manuscript. The original was lost when the ship carrying it back to the Netherlands was sunk by a French naval squadron. Still unfazed, Rumphius continued his work, finishing the last volume shortly before his death in 1702.

The extract shows some efficacy against E. coli and MRSA. It was used in ancient times as a remedy for dysentery.

The seeds of the tree, Rumphius wrote, “will halt all kinds of diarrhea, but very suddenly, forcefully and powerfully, so that one should use them with care in dysentery cases, because that illness or affliction should not be halted too quickly: and some considered this medicament a great secret, and relied on it completely.”

Very cool story. I just wish researchers knew more about the active compound itself, and whether it is related to any other antibiotics on the market. I could see it being entirely new or being related to a current antibiotic: it could be from the seeds themselves, which would indicate that it’s entirely new, or it could be from a fungus growing inside the seed (think a moldy peach pit), in which case it could be related to current antibiotics. I guess we’ll have to wait and see — I don’t have access to the BMJ, so any details about the extract itself are hidden from me, if they are even known. Alas.

Geographic isolation can make for some very interesting evolutionary developments. It would be really cool if this was completely new.

[tags]Medicine, MRSA, pharmacy, antibiotics, MDROs, drug discovery, botany[/tags]

There is a small body of research out there that indicates that thiazolidinediones (TZDs) — specifically rosiglitazone (Avandia) — may inhibit angiogenesis. Without new blood vessels to feed fuel tissue growth, there is no tumor growth. There aren’t many researchers out there experimenting with these drugs, unfortunately, but new findings published in the International Journal of Radiation Oncology – Biology –Physics indicate that pioglitazone (Actos) may prevent brain damage in mice undergoing radiation treatment for tumors, which could mean more studies looking at the effects of TZDs on cancer and its management.

The study involved young adult rats that received either radiation treatment equal to levels received by humans or a “sham” treatment involving no radiation. Animals in both groups received either a normal diet or a diet containing the diabetes drug.

Cognitive function was assessed a year after the completion of radiation therapy using an object recognition test. Rats receiving radiation exhibited a significant decrease in cognitive function, unless they received the diabetes drug for either four or 54 weeks after radiation.

The researchers are hopeful that the findings may allow clinicians to give higher doses of radiation. There is a strong correlation between higher doses of radiation and longer lifespans, but there has always been some reluctance to prescribe these higher doses for fear of damaging healthy, surrounding tissues.

[tags]Medicine, pharmacy, Actos, cancer, radiation, oncology, pioglitazone[/tags]

Kevin asks “How to get more medical students interested in geriatrics?” and suggests tuition loan forgiveness. Or rather, the article he links to, does.

My question is, do you *really* need more geriatric doctors?

I’ve opined extensively on pharmacists as prescribers, and I’ve basically concluded that it’s not a bad idea, so long as they’re not making the diagnosis. (Because that’s not part of one’s curriculum in pharmacy school.) With things like the CCGP certification, do you really need doctors who specialize in old people?

I’m inclined to think yes… and no. Surely you need some, but probably not the numbers that have traditionally done so. In fact, most of the CCGPs I know can, and do, run therapeutic circles around the doctors when it comes to managing drug regimens for the elderly. And that’s not meant as an insult to the MDs, it’s simply a fact.

Let the pharmacist deal with adjusting dosages and fixing interactions and managing polypharmacy; let the MD stick to making diagnoses. Clinical pharmacists are generally more interested in the management of drug regimens anyway.

I have a feeling this is the way geriatric medicine is going to mostly go in the near future. I wouldn’t be surprised to see other, select fields do the same thing. Pharmacists are, after all, cheaper than doctors. ;)

[tags]Geriatrics, medicine, aging[/tags]

I had a physical last week that lasted an hour(!). My doctor (who I just started seeing) did two extra things that I’ve never had done before during the course of a routine physical: an EKG and a hearing test. Both of them made me scratch my head inwardly, and they were performed at the end of the physical by a nurse.

I’m a healthy male, in my mid-to-early twenties, with no history of heart problems, and I’ve not complained about anything hearing-related, save twice-a-year ear infections. I’m convinced the hearing test is part of what he does at every physical, because I mentioned my ear infection as an afterthought, after he’d already told me about the hearing test…

Is this normal for physical exams now? Or is it just so he can bill for a bit more from my insurance company?

Back in July, CVS bought MinuteClinic, thinking to get a jump on the coming retail health clinic boom. If you’re like me, and you oppose the fast-food medicine phenomenon, you’re probably against the whole idea.

What I can’t argue against is the convenience, and that’s what’s going to be the big thing. People aren’t going to utilize them for the management of chronic illness, they’re going to use it for the one-off things: Hey I’ve got an ear infection. Hey I’ve been hacking my lungs out for the last 3 days. Hey my sinuses are about to explode and I’m ready to go postal on anyone who f’n looks at me. That sort of thing. (“Zpak, next!” “Zpak, next!” “Amoxicillin, next!…” etc. etc. ad inifinitum) Anyways, what’s better than stopping by CVS, seeing the PA (or NP), doing some shopping, then stopping by the pharmacy to pick up your Zpak? One-stop shopping at it’s finest.

Anyway I spoke at some length with a CVS district manager two weeks ago about the MinuteClinic thing, asking for some details on how they’re run. Who are they staffed by? (An MD? Probably not.) He didn’t know, which sort of irritated me. He was thinking in terms of revenue, and I’m thinking in terms of what’s best for the patient. I guess my main question is how you’re going to have someone diagnosing and prescribing without an MD on staff. PAs and NPs, of course are able to prescribe, so long as they have a supervising physician. (In the two states I’m familiar with, anyway.) So where’s the incentive for the MD to “supervise” a clinician at a retail-based health clinic that’s taking revenue away from their own practice, regardless of whether they own their own shop, or are part of a bigger whole? From a pure business perspective, it doesn’t make sense to me, unless CVS plans to share part of the revenue from their health clinics with these practices. (Which I don’t see CVS doing.)

Maybe they’ll higher one supervising MD per district and have all their NPs or PAs report to him? That’s really the only way I could see a system like that working, but it would seem like a terribly kludgy system. Does anyone know?

In any event, retail health clinics will not be coming to New Hampshire or Massachusetts in 2007, according to aforementioned DM. There hasn’t been any money allocated to open clinics. They will be popping up in Maine, particularly in the uniquely urban-rural areas like Bangor. Apparently there’s more money to be made there than in southern NH and Massachusetts, which really isn’t terribly surprising given the relative density of clinicians to the general populace.

[tags]Medicine, pharmacy, CVS[/tags]

Disclaimer: none of the stores I’ve worked in have ever been held up. I’ve never had anyone shove any weapons into my face and demand XYZ controlled substance. Those of you who have experienced this may think differently.

All of the pharmacies I work in, save my home store, have mandatory 24 hour OxyContin waiting periods. I used to be envious of these stores, but the more I learn think about it, and about pain management in general, the more I think maybe it’s a stupid rule. Why was I envious of those other stores at first?

Well people that bring in scripts for CIIs — especially OxyContin — seem to bring in 2 or 3 at a time. And they usually come in packs of 2-3 people at a time. Almost like they’re all friends or something. (“Hey guys let’s hang out and take some Oxies tonight!” “Yeah, OK!”) I have no idea why. Maybe it’s just my area. Anyway, that means you’ve got anywhere between 6 and 9 OxyContin scripts to fill. These people often choose to wait. Filling 9 prescriptions for CIIs really gums up the works. Most retail pharmacies keep their CIIs in a safe, and only a pharmacist has access to them for theft reasons. This means that the pharmacist is tied up for about 15-20 minutes doing nothing but working on these prescriptions. That’s a royal pain in the ass for everyone else. Those of you familiar with retail pharmacy understand that ours is an interrupt-driven business. You just don’t have time to concentrate exclusively on one task for 15 or 20 minutes to the exlusion of all else. The rest of the place falls apart because the pharmacist is the bottleneck through which all prescriptions must pass.

It’s easier if there are two pharmacists on, because one can pick up the slack, but at most smaller retail pharmacies, there is no pharmacist overlap.

Anyway, as I said, my attitudes have changed. While I don’t think it’s often necessary for these people who wait for their Oxy scripts to do so, I do think retail pharmacies should re-think the “mandatory” 24 hour wait period so that (ostensibly) we can order OxyContin for the next day.

Random aside: Ordering OxyContin for the next day is complete and utter BS anyway, as you pharmacists will know. It takes at least two days for the requisite 222 form to make it to the supplier. In fact, there’s just one pharmacist per pharmacy allowed to sign off on a CII order, and s/he doesn’t work 7 days a week, usually. So next-day ordering is out most of the time. The idea is that this policy will trick people into thinking that your retail store doesn’t actually have any OxyContin on the premises for safety reasons.

Back on topic: people who are on maintenance doses of OxyContin don’t usually need to wait. In stores where there’s a 24-hour wait policy, these people happily drop off their prescriptions and pick them up the next day.

Last night we had a person who had been in a serious accident involving a tractor trailer get released from the hospital. She had 3 prescriptions, one of which was for OxyContin. I had to turn her away — which made me mad because we had it in stock, and I sent her up the street to my home store where we don’t have any waiting rules — for what amounted to no reason. I guess this “rule” is in place for “safety” reasons. Though any criminal is going to know — not guess — that this rule is complete BS, which isn’t going to prevent him from holding you up in the first place.

If you’re at one of these 24-hour wait stores, are you really going to try to convince some dude sticking a .44 magnum in your face that you really don’t have any OxyContin in the safe? Somehow I doubt it. It’s just not worth the risk.

So we’ve created a rule that merely offers the illusion of protection. It keeps the honest opioid users honest, won’t deter those bent on breaking the law, and prevents those who may legitimately need a prescription for OxyContin today (first-time fillers) from getting their medication.

What a wonderful, pointless system we’ve created. I think it would be more effective if we simply advertised the fact that we keep less than 100 tablets of OxyContin in the store at all times. That, at least, sounds somewhat believable.

While this post was more introspective and rant-ish, I have lots more to say about the clinical aspects of pain management in the near future, especially about the castigation of opioid users by pharmacy staff, and the backwards attitudes of (usually older) pharmacists when it comes to pain management.

[tags]Medicine, pharmacy, OxyContin[/tags]

So it looks like at the end of next week, we’re going to run out of generic Plavix. I’ve not followed the business drama of Big Pharma in a little while because I find it dull, so I have no commentary on the outcome of the lawsuit, which I presume has been settled in S-A and BMS’s favor. Apotex had a good run while it lasted. I mentioned in September that we were warned that this might happen.

In any event, it looks like it’s for real. As far as I know, this is the only time in recent history where a generic has been withdrawn. I think I recall similar things happening for Lanoxin (digoxin) and Synthroid (levothyroxine), but generics for those drugs were withdrawn because of problems with bioequivalence rather than as a result of litigation.

It’s going to suck explaining the reasons why clopidogrel is temporarily going the way of the Dodo. People don’t take too kindly to the idea of their copayments doubling (or more). I’m thinking I should write a little handout for people explaining what happened so we don’t have to have the same conversation 500 times. After telling something a dozen or so times, you’ve heard all the wisecracks and complaints that such a topic engenders, and it just gets redundant and tiresome.

I also think the idea of jerking patients/consumers around like this is ethically wrong, patents and the justice system be damned. But then morality is entirely dependent on one’s point of view, now isn’t it?

[tags]Medicine, pharmacy, big pharma, plavix, clopidogrel, ethics[/tags]

As I mentioned about six weeks ago, I ended up going to the hospital while I was on vacation in California. Of course one of the hospitals lost my insurance info so they sent me an itemized bill instead. I’ve posted it here so we can all laugh together at how much they’ve charged me for a few things. I’ve not included a couple of things because they didn’t seem terribly unreasonable to me.

Promethazine 25AMP: $37.88
Sublimaze (fentanyl) 100mcg injection: $47.50
1000mL Normal Saline: $99.01
Contrast with Exam: $412.00

CT scan/body:
CT W/W/O Contrast: $2629.69
CT Pelvis W/W/O Contrast: $2355.70

Emergency Room
Level 3 w/ MD/Nurse procedure: $699.43
Admin of IV Injection: $184.71

——————————

Self-pay adjustment: -$1321.54

Continue reading On the absurdity of not having health insurance →

I’ve got a soft spot in my heart for GI disorders since I suffer from one myself. They suck. So when I read this the other day I was a bit surprised.

“For people with active ulcerative colitis who do not respond to corticosteroids or immunosuppressive agents, infliximab is effective in inducing clinical remission, inducing clinical response, promoting mucosal healing and reducing the need for colectomy, at least in the short term,” said review co-author Dr. Anthony Kwaku Akobeng.

[…]

“Infliximab is another option if steroids fail,” said Peter Higgins, M.D., an assistant professor in gastroenterology at the University of Michigan Medical Center in Ann Arbor.

And here I was, thinking this was common knowledge. In fact I during my hospitalization a few weeks ago whilst on vacation I had a discussion about UC with the tech doing my CT scan. She was telling me one of her friends had severe UC, and that he was on steroids. I distinctly remember suggesting Remicade or Humira instead of prednisone through my drug-induced stupor. She was telling me he hated the side effects. What a surprise. Then I think I started rambling about monoclonals and the lack of a generic approval pathway for biologics in general. She stopped talking to me after that.

She was cute, too. Really cute.

But hey, more studies are always good. Too bad Remicade is WAY more expensive than prednisone…

[tags]Medicine, pharmacy, Remicade, infliximab, ulcerative colitis[/tags]