Grand Rounds Vol 3, No 29

The always entertaining Dr Dork hosts this week's Grand Rounds of the best of the Medical Blog-o-sphere and did an outstanding job editing. Be sure to check it out.

-Wes

UnitedHealth's Self-Referral

The line has been crossed. UnitedHealth, the health largest insurance provider in America, not only has officially decided who, when and where patients should get care, they've decided that if physician's don't comply, they'll be fined and removed from their network, forcing patients to switch providers:

(WSJ) Most health plans are designed so their members pay more when they go to an out-of-network doctor or take a nonpreferred medication. But the financial sanctions -- which UnitedHealth has yet to impose -- mark the first time a physician could be fined by a health insurer if he or she directs a patient to seek out-of-network care or testing, the American Medical Association says.

The threats stem from a 10-year deal that UnitedHealth struck late last year with Laboratory Corp. of America Holdings to become its national in-network laboratory. With 28.5 million health-plan members and growing, UnitedHealth has been using its heft more and more in recent years to negotiate cut-rate fees with doctors, drug makers and other suppliers. In the same vein, it signed on Lab Corp. after its longtime lab partner, Quest Diagnostics Inc., said it couldn't accept new terms that UnitedHealth wanted and dropped out of contract negotiations.

To squeeze as much savings as possible out of the Lab Corp. deal, UnitedHealth sent a not-so-friendly reminder to doctors to play along. If doctors consistently failed to refer patients to Lab Corp. or other local in-network lab facilities as of March 1, UnitedHealth said it reserved the right to fine them $50, cut their fees or oust them from the network.

Is this where we're going to cut health care costs in America? Fine the doctor. As if we set the lab prices. Is the monopolization and WalMart-ization of health care always in the patient's best interest? Or could there just be, in the interest of corporate profits, an ulterior motive? I can just see UnitedHealth's Directors and Board Members sitting around the board room table:

Hey Donna! I gotta idea how the heck we can pay for ol' McGuire's accountant fees and post-retirement corporate jet! We'll just tack on a fine to those pesky physicians! Imagine. 520,000 of 'em ordering way too many tests, say twenty a day, about five of which we can find as improper, times fifty bucks. Hell, that'd be a cool $130 mil! Yeeeeeee Haaaaaa! That'd pay for his jet with a little left over for us! Whatd'ya think, girl?"

"Oh Steve, I love it when you talk dirty!"

I love the double standard. Physicians can't refer to their labs due to concerns over conflicts of interest due to the Stark laws, but insurers can help themselves and do even one better: threaten physicians if they fail to make such a financially-motivated referral that lines the insurance company's coffers.

Oh, but certain self-interested physicians don't seem to mind, especially those in leadership positions poised to profit:

Not all doctors are upset. The American Academy of Family Physicians wrote a letter of concern to UnitedHealth in February. But it told members that the health insurer had eased its worries after clarifying that it would not punish doctors for patient's decisions and only apply the sanctions in rare cases where a doctor repeatedly defied the policy. "This doesn't look as bad as it originally did," says Bruce Bagley, the academy's medical director for quality and improvement. Dr. Bagley also serves on a physician-advisory committee for UnitedHealth.

I wonder how much they payed Dr. Bagley for his time to sit on their committee?

-Wes

When a Medical Device Advisory is Not an Advisory

I noticed something interesting in the medical device industry this week. It seems companies who make pacemakers and defibrillators are using a “non-advisory” to notify physicians about problems with their devices.

What is a "non-advisory?" Well it’s a “Dear Doctor” letter informing the doctor about a problem they have identified in a small number of their devices. But unlike advisories, these notifications are not published in the company’s websites, but details about them are told to doctors, with some specifics not forthcoming since they might be “works in progress.” In the last two weeks, I have received two such "non-advisories:"

• Medtronic: Seems there is a problem with their premier defibrillator lead, the ultra-small Sprint Fidelis 7Fr defibrillator leads. The problem, they think, is possibly due to implanter technique since it has not been seen across all centers across the nation. It seems these leads are subject to fracture at either the tie-down sleeve or the distal tip of the device if there’s a bend at the end of the device, or if the distal portion of the lead becomes bent during the implant process. The exact distribution of centers with this problem was not reported. (To my knowledge, we have not seen this fracture yet).



• Boston Scientific: Yep, today I was notified about another small capacitor problem in their ICD line, the Vitality and Latitude defibrillator lines that occurs after the battery is connected to these faulty capacitors – a small percentage of them go through a chemical degradation process, I was told. This process can cause a small percentage of them to rapidly deplete the battery of the defibrillator, shortening the time between its Elective Replacement Indicator and its End-of-Life Indicator. Usually, the time between these two indicators is separated by about 3 months, but this might be shortened to as little as one month in devices with these faulty capacitors. They have found this in 19 of 73,000 devices so far and fortunately no injuries have been reported. But it is thought this defect may occur in up to 2% of their implanted devices. Boston Scientific is no longer using that capacitor supplier in their manufacturing process, fortunately.

So, are these product advisories or “non-advisories?” I’m not sure. But it is clear companies are “bringing it to doctors’ attention” when such device issues are identified. But it is VERY clear that these notifications will not be provided to the lay press. This is probably a good thing, since the management of the issues is best left up to physicians savvy in devices, I believe. But there should be a central location of these “non-advisory” ‘Dear Doctor’ letters on the companies' websites that can be found by those managing these devices, since, at their current rate, it looks like doctors will receive about 52 of these notices per year.

-Wes

Medtronic's Carelink Remote Device Follow-up "Free"

Today I received a letter from Stephen H. Mahle, Executive Vice President and President of Medtronic's Cardiac Rhythm Disease Management division, notifying me that their Carelink remote device check technology no longer has quarterly service charges.

"You will not be charged for patient transmissions that occurred on or after January 1, 2007. You will receive a final, zero-dollar invoice for transmissions occurring through March 31, 2007. In the next few days, your contract administrator will receive more information about this pricing change."

It seems Boston Scientific's Latitude system, which rolls up the cost of continuous remote device checks in to the cost of their device, is a better business model. People already perceive the cost of these devices as high, and to pay additional costs for ongoing monitoring consumed too many hospital (and Medtronic) resources and resulted in a competitive disadvantage to Medtronic. Furthermore, this is in line with the Heart Rhythm Society's mandate to provide this service as part of continuing quality assurance monitoring.

This is not good news for St. Jude, since there will be additional pressure on their ICD and pacemaker technology platforms to provide similar services at no charge to their customers.

-Wes

Blog Break

Took a bit of time off for Easter - hope others did the same. Happy, happy Easter to all. Back soon.

-Wes

A New Twist to the Medical Tourism Debate

The sign outside the Holocaust museum in Dachau, Germany says "Never Again."

Although I've spoken about the problem with Medical Tours regarding its economics to our health care system, now there is another more pressing ethical issue regarding this practice reported in the Wall Street Journal:

Rising demand for organ transplants in developed countries, coupled with the spread of transplant technology to the developing world, is fueling a global commerce in body parts between the rich and the poor. Israel is one of the only nations where insurance companies cover the cost of foreign transplants, and several companies there have built businesses around helping people like Mr. Abelson to arrange organ transplants in China. Plenty of people are willing to pay out of their own pockets, and transplant patients have also been streaming into China from the U.S., Germany, the Middle East, Japan, South Korea and Singapore. (In the U.S., insurance companies generally won't pay for such procedures.)

In recent months, however, controversy over the ethical issues surrounding the practice has come to a head in China, Israel and elsewhere in the global medical community. China's Ministry of Health recently instructed hospitals to stop performing transplants for foreigners, arguing that patients from wealthy foreign countries shouldn't be getting organs when not enough are available for Chinese citizens who need them. But it's not yet clear how rigorously the new rule will be enforced.

Amazing that Mr. Abelson, an Israeli, is supporting transplantation of organs without regard to their origin. Many of the people of Israel are relatives of Holocaust survivors who endured forced medical experimentation as prisoners of the Nazis. Are we really comfortable that prisoners will never be executed unjustly for economic incentive? With China's human rights record, are these kinds of questions relevant only when it is convenient to our needs? Who should understand the dangers of moral expedience more than Israel?

Lets hope this discussion will lead to an end to this practice of transplant tourism.

-Wes

Really Helping Our Needy

This evening, I saw a spot on the news about a new Illinois "comprehensive" health website to serve as a safety net for those without insurance in our state. I decided to peruse some of the offerings and had to check out the I-Save Rx link which promises to save our needy folks up to 40% on the cost of heart medications. Just dial 1-866-I-SAVE33 and earn a whopping 44% off your next prescription of Zocor imported from Australia, England, New Zealand or Canada!

Never mind that 100 pills (a 3-month, 10 day supply of 100 tablets of 40mg tablets of generic simvastatin from the USA) can be obtained at CostCo for $28.15 - a 93% savings.

Although some have certainly found benefit with the I-Save program, if we really want to help out the needy, why not make such information about generic drug alternatives available on the website as well?

Or could it be that special interests that contribute to governmental coffers might be making a killing on this program at the little guy's expense?

-Wes

Regrouping

“Come on, baby, breathe, please breathe, baby. Come on! You can do it! Please! Come on, honey, do it for mama! Breathe!”

He never did. Despite all of the work, all of the effort of hordes of the best-trained nurses, emergency medical technicians, doctors. Monitors, compressions, tubes, drugs, defibrillations. Two hours hoping beyond hope that something would work. Electromechanical dissociation. And then the deafening wail of a young mother as she realizes that all efforts have failed to bring her baby back.

Glances left, then right. A tear. A glance away. A hug. Clean up. Where’s the family? More tears. The chaplain. Burying the nose back in work. Try to forget. Disconnect. Stay busy. Think. Move on. “Go home and hug your kids.” “I’ve got clinic patients waiting for me.” “Breathe.” “Why?” “We did everything we could.” “What do you think happened?”

Then quiet. No monitors, no hiss of oxygen, no wrappers opening, no words. Just quiet.

Tiny relaxed blue fingers pointed skyward and gripped my soul.


“Doctor, your next patient is in Room 4.”

Sudden Cardiac Death Preparedness in School Athletic Programs

Despite these new guidelines published in the April issue of the journal Heart Rhythm that addresses preparedness for cardiac arrest in high school and college athletic programs, many schools still have no automatic external defibrillators (AEDs) on site. But the guideline's lead author, Dr. Jonathan Drezner (University of Washington, Seattle), makes an important point on TheHeart.org:

"Many schools are acquiring defibrillators through donations, and while that's not a bad thing, it's solving only half the problem," said Drezner. "You have the equipment, but do you have the plan that goes with it? If the defibrillator is kept in the nurses' office in a locked cabinet, it doesn't really do you much good if a player has a cardiac arrest on the football field or the basketball court."

After communication, personnel, and equipment, the emergency action plan must be ready to work smoothly when the situation arises. "This is something that has to be practiced," emphasized Drezner. "You have to get your likely first responders, your athletic trainers, your team physicians, your school nurses, coaches, and administrators, and bring them out to the practice field and simulate a cardiac arrest. Go over that emergency practice plan, and go over it at least once a year."

But why stop with high schools and colleges? In my view, elementary schools should have a similar plan and equipment in place.

It just makes sense for our kids.

-Wes

Belated Grand Rounds Referral

Geez, I forgot to mention that Grand Rounds (Vol 3, No. 28) are up over at Urostream. Check it out for some of this week's medical blogging best.

-Wes

New Drugs (updated)

DAMNITOL: Take 2 and the rest of the world can go to hell for up to 8 full hours.

EMPTYNESTROGEN: Suppository that eliminates melancholy and loneliness by reminding you of how awful they were as teenagers and how you couldn't wait till they moved out!

ST. MOMMA'S WORT: Plant extract that treats mom's depression by rendering preschoolers unconscious for up to two days

PEPTOBIMBO: Liquid silicone drink for single women. Two full cups swallowed before an evening out increases breast size, decreases intelligence, and prevents conception.

DUMBEROL: When taken with Peptobimbo, can cause dangerously low IQ, resulting in enjoyment of country music and pickup trucks.

FLIPITOR: Increases life expectancy of commuters by controlling road rage and the urge to flip off other drivers.

MENICILLIN: Potent anti-boy-otic for older women. Increases resistance to such lethal lines as, "You make me want to be a better person."

BUYAGRA: Injectable stimulant taken prior to shopping. Increases potency, duration, and credit limit of spending spree.

JACKASSPIRIN: Relieves headache caused by a man who can't remember your birthday, anniversary, phone number, or to lift the toilet seat.

ANTI-TALKSIDENT: A spray carried in a purse or wallet to be used on anyone too eager to share their life stories with total strangers in elevators.

NAGAMENT: When administered to a boyfriend or husband, provides the same irritation level as nagging him, without opening your mouth.

-Wes

Hat tip: A Faithful Reader, Armonde.

18:38 PM CST: Oh, and one more for your dog (my favorite): BONERAL.

Drugs on a Chip

The world of implantable devices, like pacemakers and defibrillators, may become more interesting soon.

MicroCHIPS, Inc., a developer of innovative drug delivery and biosensing devices, has announced a $13.4 million dollar round of investment funding led by Novartis Venture Fund. Reinhard Ambros, Global Head of Novartis Venture Fund, has joined the company's board of directors. CSK Venture Capital of Japan also joined existing MicroCHIPS investors Polaris Venture Partners, IDG Ventures, Medtronic, Boston Scientific, Intersouth Partners and Boston University Community Technology Fund in this round of financing.

The chip they've developed uses micro-reservoirs sealed by a small metal filament that can be heated to cause a "short" much like a fuse, and thereby releases the contents of the microreservoir. A study in dogs demonstrated consistent drug delivery over six months.

Cool. Very cool.

-Wes

References:
Microchips Press Release
Technology Review article.

Reconciliations

reconciliation
noun
1. the reestablishing of cordial relations
2. getting two things to correspond; "the reconciliation of his checkbook and the bank statement"

* * *
About a week ago, it was time to sit down and pay the bills. Being a computer nerd, I generally find that paying by bills on-line is quick and efficient. I use Quicken and pay bill after bill fairly quickly. The program then logs on to my bank and uploads by payment requests and downloads mysterious transactions that my wife performs throughout the week. I am glad she handles many of the family chores as efficiently as she does.

But the other day a great big “cash advance” was noted on my debit card. Hmmm. “This just happened yesterday,” I thought. Wow, it’s for an awful lot of money – way more than I thought I could withdraw on my card. And it was cashed at a USAA Bank. Hmmm.

“Honey?”

“Yes, dear?”

“Did you withdraw some cash (to the tune of well over a $1000 – exact amount not to be disclosed) to a USAA Bank?”

“No.”

So I called USAA Bank and gave them the cryptic series of numbers on the electronic transfer and asked if I happened to be at their bank yesterday if I received a cash advance. They had no recollection of such a transaction and noted I did not have an account with them.

“And where are your banks?”

“We only have branches in Texas.” Hmmm. Now maybe this was the same yahoo that tapped into GruntDoc’s account, I don’t know, but I live in Illinois.

“We suggest you call your credit card company.”

Which I did. St. Elsewhere Bank in St. Elsewhere. I gave them that cryptic number on my bank statement.

“Just a moment,” the helpful person said on the other end of the line. A few minutes later she said, “this is was withdrawn from your credit card that ends in the digits, 2212 (not the real numbers).”

“Uh, I don’t have such a credit card from you.”

“Just a moment.”

Well now I’m pissed. But it could have been much worse. I luckily learned that my account had been violated under 24 hours prior. By mere luck, I had logged on and noticed the transaction and called my bank. I learned in all my escapades that debit cards (even debit cards you don’t own) have a limit on how long you can be before notifying the bank about fraudulent charges – 48 hours. Unlike credit cards, they are not as “secure” and the odds of getting any money back after using a non-signature card is much less likely than with a signature card. Fortunately, my card company has credited by account with a “provisional deposit” pending the investigation for the amount transferred, but I was lucky. And I also have learned about this problem with TJX Companies (TJ Max, Marshalls, HomeGoods, etc) - it seems they had a massive intrusion into their computer systems. My wife shops often at these stores. And her name, address, driver's license number and social security number and 45.7 million credit cards have likely been lifted. Needless to say a police report has been filed (may they please see who did this on the USAA Bank video…).

SOOOOO, what the heck does all of this have to do with MEDICINE???

Well, yes Virginia, there’s more. It seems we ALL have to do more reconciling – every day. Oh, not of bank accounts. No.

Of medications.

Yep. In case you haven’t heard, the Joint Commission has decided that ALL patient medication lists must be reconciled ANY time there is a transfer of patients between ANY facilities, care units, or providers. It’s part of their 2007 National Patient Safety Goals. Sections 8A and 8B, to be specific. And we’ve heard their “dropping in” on facilities around our area to see how well folks are complying.

What, you don’t know about this? Either did I until today, when the 17-page ’frequently asked questions’ about this initiative landed in my hands from a nurse. She was “pleased” to say the least.

“What are we gonna do about this? It says we have to give the patient a printed list of all of their medications with easy-to-read instructions when they leave the clinic or hospital any time there is a change to those medications. How are you going to DO this, doctor? Why does this fall on US?”

Well, I certainly understand the need to reconcile things, especially after my bank statement fiasco, but boy, have we got another time-consuming and tedious task just handed to us. Many of my patients have over 12 medications, not to mention vitamins, and occasional vaccinations, and in some cases, even fluoride treatments, that we are supposed to reconcile EVERY TIME a patient leaves our clinic or hospital. I’m not kidding. There’s even a flow chart on what to do. Will patient’s even want this list? Worse still, what impact will repetitive lists sent to referring physicians have in the outpatient care arena – will these notifications eventually be treated as spam in their inbox? Delete. Delete. Delete.

But it’s all in the name of safety and all during a 20-minute follow-up patient visit or every time a patient transfers between care arenas.

But perhaps there is a tacit agenda at play here. Perhaps this initiative is another means of driving a stake into the heart of the paper medical record. After all, only an electronic form of information can make this initiative even possible. Who the heck has the time to manually write a long list of medications each time the patient leaves their office after a single medication change?

While many of the 2007 National Patient Safety Goals of the Joint Commission are based on a sound premise, that is, reduced medical errors and improved safety for our patients, every one of these initiatives has the potential to impact other areas of health care delivery. This requirement, while noble, may also drive a stake in what little remains of the doctor-patient relationship and in effect, be anti-reconciliatory, since doctors will spend more time documenting and less time looking and speaking to their patients.

-Wes

Your 10-year Heart Disease Risk

It was great to be back in clinic yesterday. I saw lot's of interesting new patients with a variety of heart arrhythmias and a few patient's with coronary disease. One younger patient commented that he had his cholesterol checked, but had no clue what the numbers meant.

Oh he knew something about "good choleterol" (HDL) and "bad cholesterol" (LDL) but he was more concerned about what those numbers on his panel meant to him, as far as heart attack risk was concerned.

So I referred him to this handy calculator. It plugs in some very basic information and calculates (based on a nomogram of a large database of subject), what the percentage likelihood that someone will have a heart attack in the next 10 years. Realize the data for this risk calculator may be somewhat limited because they were obtained at a time before so many of us were obese and before the wide-spread penetration of statin drugs in the population, but it still gives meaning to your cholesterol level based on your age and gender.

So, what's your risk?

Heart Valve Grown From Stem Cells

Although not yet applicable to man, things are getting closer.

-Wes

10:00 AM Addendum: It seems growing heart valve cells derived from bone marrow progenitor cells on collegen matrix is being called a "heart valve."

The scientists first coaxed stem cells extracted from bone marrow to grow into heart valve cells by using chemical and physical nudges.

Then, by placing these cells into scaffolds made of collagen, they grew small 3cm wide discs of heart valve tissue.

Later this year the tissue will be implanted into animals - probably sheep or pigs - and monitored to see how well it works as part of a circulatory system.

I'm becoming a bit more skeptical for many of the reasons others have pointed out on a earlier post about growing vascularized heart cells by researchers in Israel.

Solipsism

We doctor bloggers are a solipsistic bunch: eager to indulge our egoistic self-absorption.

We are rule-followers after all. We have followed the rules, taken the required courses, marched lock-step to the corporately-mandated requirements for medical school, residency, fellowship, and beyond to get to our final goal as doctor of whatever specialty.

So when one reads the well-written trilogy by Panda Bear, MD outlining the problems with the single payer system being proposed by many, I ask myself: “Now what?”

Never has there been a push for a single payer system like there is now. And yet, we're like prisoners in jail snickering about the guards. The problem? We're still prisoners, aren't we?

How many of us know how to take such an articulate point of view, and take it to the next level? How many of us know our congressman’s or senator’s e-mail, phone number or address? How many of us will take our opinions to our elected legislator? Probably very few: solipsism requires we remain mute and ineffectual, hoping that the media will pick up what we have started.

But these issues are too complicated and important to leave to the media. The issues at hand are not served well by 30-second sound-bites on the news. We must do better.

So if you feel strongly about what people say out here on the blog-o-sphere, here’s a suggestion: contact your senator or congressman. Send them the link to the blog that matters to you. Write your own comments. Contact the Senate Subcommittee on Health Care. After all, using the Panda Bear anology: they’re the “junk-yard dog.”

So irrespective of your take on the issues, make your comments heard.

-Wes

Reference: Panda Bear MD’s Trilogy: Part 1, Part 2, and Part 3.

Are Smokers Slackers?

At least one study thinks so.

The research team analysed nationally representative registry data on sickness absence among more than 14,000 workers in Sweden between 1988 and 1991.

Of the sample included in the study, 45 percent had never smoked.

Of the remainder, 29 percent were current smokers and 26 percent former smokers.

Non-smokers took the fewest days off sick; smokers took the most.

Across the whole sample, the average number of days taken as sick leave was 25.

But smokers took almost 11 extra days off sick compared with their non-smoking colleagues, equal to 43 percent of all sick leave taken every year among the sample, say the authors.

There was little difference in the number of additional days taken as sick leave between male and female workers.

-Wes

Source reference from British Medical Journal's Tobacco Control.

Implications of Zelnorm's Withdrawl

Zelnorm (tegaserod maleate), a serotonin 5-HT4 receptor partial agonist indicated for the short-term treatment of women with irritable bowel syndrome (IBS) whose primary bowel symptom is constipation, was pulled today from the market by Novartis on the recommendation of the FDA. It had previously been reported to have rare instances of ischemic bowel associated with the drug's use and now appears to have rare, but significant, problems with ischemic cardiovascular disease after a retrospective review of 29 studies of the drug.

(CBS News) Earlier this year, Novartis gave the FDA the results of 29 clinical studies of Zelnorm for treatment of a variety of gastrointestinal tract conditions. The analyses showed 13 of 11,614 patients given Zelnorm had serious and life-threatening cardiovascular side effects, while just one of the 7,031 patients given dummy pills did, the FDA and Novartis said in separate statements.

This drug follows closely the pulling of Pergolide yesterday two months after reports in the New England Journal of Medicine demonstrated the problems with this drug causing valvular regurgitation (leakage). It seems we'll be seeing more and more drugs pulled after the Vioxx fiasco and closer scruitiny by the media and Congress. But the incidence of problems (0.012%) vs (0.0014%) is mighty small, especially when one considers that acetominophen (Tylenol®) liver toxicity approaches a 4% incidence in emergency rooms in the US and England. Will Tylenol® be next?

These withdrawls suggest that even retrospective meta-analyses of outcomes that demonstrate almost no side effects will be the expected norm for drug safety in the post-market drug survellance era we have entered. Certainly, the potential for litigation is significant if side effects and potential complications are not disclosed. However, while patient safety is always paramount, the risk/benefit ratio of any drug should be considered when it is prescribed and there may be circumstances when certain drugs with higher side effects are in the patient's best interest.

So now I'm confused. How do we compare the incidence rate of side effects of drugs we prescribe? Are some drugs held to a double standard? What drug safety level should doctors tolerate?

-Wes

via KevinMD.

UNICEF's Virtual Smokescreen

This week’s Lancet had a short spot of Teen Second Life – virtual on-line world restricted to 13-17 year olds that allows them to “build” a virtual environment and interact with other teens on-line.

I don’t like these games because I think their motivation for existence is not altruistic, but financial.

You see, these games are all structured about the same way. They all hook kids by telling them they can join and get a “basic” membership to the on-line world for free. Later, as they get hooked on the game, then only allow them to go further in the game by purchasing a “premium” membership. And to be successful socially in these worlds, the coolest kids own stuff that must be purchased.

And here’s my beef. Teens know that their parents don’t like them to be sitting at a computer all day. So in order to be successful at these on-line virtual worlds with their on-line peers, most kids have to stretch a very important line with their parents: they must use their parent’s credit card to purchase the “premium” package to gain access to new "powers" or (in the case of Teen Send Life) "land" – often without their knowledge. You see, when you can’t see the cash, it’s virtual, too.

I know this from personal experience. Kids are savvy and know how easy it is to enter the data on the front and back of a credit card to purchase whatever they want on-line. They know it’s not permitted to use their parent’s credit card, but their virtual world can become more important to them than their real-world relationship with their parents. And once the charge is made once, it shows up month after month on the parent’s credit card as a recurrent charge. Breaking this addiction can be difficult, to say the least.

So to find out that UNICEF is using Teen Second Life to promote their ’World Fit for Children’ festival as part of their ‘Global Kids Digital Media Initiative,’ raised concerns, to say the least:

In December, 2006, Global Kids, a non-profit organisation (sic) based in New York, teamed up with the United Nations Children's Fund (UNICEF) to put together a World Fit for Children Festival in Teen Second Life's virtual world. The teenage participants attended workshops about UNICEF and then constructed virtual buildings that could, in theory at least, help alleviate poverty, poor education, or HIV/AIDS. The winning team of teenagers from Finland was awarded $200 for their building—an African school where children could learn safely. UNICEF believes that more than 1000 teenagers visited their virtual festival.

But there were interesting findings, like kids that can fly, or have a playboy logo as their “flag,” (see their video) or smoke behind a virtual bike sheds. If this the way we want to promote real-life solutions for real life-and-death issues like HIV and AIDS? What does the message does the Playboy flag send in this regard – that AIDS is just a big joke?

I take real issue with the Lancet author James Butcher’s assessment of the virtual world to teach real-world values:

Parents will have concerns about this virtual world, but the benefits in terms of creativity and socialisation (sic) surely outweigh the risks. The only real concern should be whether parents can keep up with teens reared in our digital world.

No Mr. Butcher, we can keep up. It’s the fraud engendered by these sites and the mixed messages they portray that has me concerned, especially when Global Kids and UNICEF uses these venues to promote their agenda.

-Wes

References: James Butcher, "Smoking Behind Virtual Bike Sheds," The Lancet, Volume 369, Issue 9567 , 31 March 2007-6 April 2007, Page 1074.

Global Kids/Unicef Festival Promotional Video on YouTube

Global Kids Digital Media Initiative Website.

Stem Cell Therapies for Weakened Hearts

Now that the American College of Cardiology meeting has come to a close, a number of interesting reports have surfaced that promise to attack the weakened heart using stem cells. Even stem cells on stents are being evaluated.

While the results are exciting, careful evaluation of the very preliminary data is warranted. For instance, echo measurements demonstrating improvements of "1 mm" more of systolic contraction in 23 patients can hardly be classified as significant, since the resolution of reproducible measurement exceeds this amount. Also, the data suggest a trend (though again, not significant), of other possible issues with immune disorders or infections. Nonetheless, what was encouraging was that the authors found that their data did not demonstrate a worstened outcome in any patient so far.

Perhaps the best review of the current state of the art in this area has appeared recently in the New England Journal of Medicine. This report sheds light on the difficulties demonstrating long-term improvement in patients to date. Additionally, delivery of cells to their target has also been complicated:

Some of the complications of delivering cells or drugs locally to the heart are the inherent motion of the organ, the compatibility of the device with the treatment being injected, and the distribution of the therapy within the tissue. Other potential routes of cardiac delivery include intracoronary injection, adventitial delivery, epicardial injection, and pericardial injection.

The development of methods for delivering stem cell therapies to the heart is not straightforward. There are many complications and contradictions. Animal studies show that the success of a delivery method is different for a healthy heart than it is for a diseased heart.

There may be an additional mechanism where cells can find their way into the heart, which is not available for a normal heart, said Dr. Palasis. Many delivery devices in development for cardiac cell therapy are actually angioplasty catheters, and these devices come with their own complications.

If angioplasty catheters are going to be used for cell therapies, its important to look at potential for catheter materials to affect viability of cells. Guidewire lumens could be covered with lubricants. The FDA is aware of the compatibility issues. Both acute cell delivery and cell engraftment depend on the delivery method used.

And while early results of the more recent works may suggest a benefit to these therapies, they certainly have a long way to go before they can be applied to the populace at large. Perhaps the best advise came from the NEJM article:

Recent randomized studies of cell therapy for heart disease represent a milestone in this rapidly developing field while serving as a cogent reminder that many important clinical and fundamental questions have yet to be addressed. We should guard against both premature declarations of victory and premature abandonment of a promising therapeutic strategy. The ultimate success of this strategy is likely to depend on continued and effective coordination of rigorous basic and clinical investigations.

-Wes