KOLAHUN

The Dream Life of Pills (Part 1 of 3)

At our clinic, we had many questions about what to do with all the returned medications we collect from our patients and that’s when I began to wonder about the lives of pills...(in three parts).

Do pills get old?  Do they die?  Do pills dream of ambiem sheep?

Considering the billions of dollars spent on medications and the hundreds of millions of dollars lost to unused, expired and discarded medications each year – understanding the life of pills is important to us, for many reasons.

Do Pills Get Old? - Expired meds maybe younger than you think.

Expiration dates on medication's full potency are often determined by the manufacturer, usually a 2-3 year period for an unopened container. Once the original container is opened, the expiration date no longer applies. The "beyond use" date, issued by the pharmacy, usually extends the life of the pill's 100% potency to a 12 month period of after a medication is prescribed (presumably when the container is also unsealed). But there is evidence that the efficacy of a drug may be a lot longer than both the expiration date and beyond use date.  An FDA study showed that expired US military drugs, when stored under optimal conditions, retain 90% or more of their potency for about five years past their expiration date. But no rigorous studies have been done to measure the long term potency of the vast majoirty of the thousands of drugs on the market; and 90% potency might be good enough for Tylenol but suboptimal for life saving medications.

Here’s a link to the Medical Letter's report on the use of expired medications…

http://www.medicalletter.com/freedocs/expdrugs.pdf

Next Time…Do Pills Die?

The Lancet

A sharp, small surgical instrument...or, from an American-o-centric mentality, an oft unread, but awesome journal of medicine.  Recently, the Lancet published an early abstract which may likely change the way we prevent serious heart problems during non-heart surgeries.  It has also published an article on the uselessness of a new term in medicine (the blandly named 'multiple metabolic syndrome).  And, to boot...it's even got its own blog. 

Of course, MSF has had some harsh criticism of the Lancet's stance on malnutrition. 

Simplicity and the Essential Drug List

The vast and seemingly redundant number of medicines in the US adds unnecessary complexity.  On a basic level, most people really can't remember a list longer than ten items.  To simplify their lives, they end up creating heuristics and taking reasonable shortcuts.  This leads to clinicians prescribing about 20 drugs for the vast majority of patients they see, regardless of which field they practice.

More insidiously, however, this leads to relatively robust and meaningless arguments on the benefits of medicines in the same class without regard to the larger class differentials.  A couple of residents recently argued that one type of statin (a cholesterol lowering medicine) was better than another one - which happened to be less expensive.  However, in looking up the literature, there weren't any non-industry sponsored studies to back these claims.  More likely, the drug reps of the more expensive drug ingrained in the residents, possibly even with drug-company tainted studies, that one was better than the other. 

All of this contrasts sharply with the limitations of medicines by financial constraints in much of the world.  The WHO has necessarily, then, compiled a list of the Essential Medicines needed for treating the predominant diseases in each country.  Strikingly, there are only about 80 or so drugs on the list.  The obvious attraction is that this list comprises effective and inexpensive medicines.  the secondary benefit, however, is that given its simplicity, the list can be leveraged by public health officials for use by non-physician practitioners - i.e. non-doctors. 

The prevailing question then: are health outcomes improved through this simplicity or do we need the wisdom of highly trained practitioners making nuanced decisions? 

SWINGERS

I was looking at the latest map of 2008 Democratic primary victories when it struck me – that if we were talking about electoral votes and not the number of primaries won, delegates, super delegates – then Hillary Clinton would be way ahead.  If the nominee where chosen based on how the president gets elected (by the number of electoral votes for each state they won), then by now Clinton would have 300 electoral votes to Obama’s 217.  In the General Election, 270 are needed to be elected President.

John Kerry had 257 electoral votes in 2004. In 2000, Gore had 266.  In those close races, most would agree that in the 2000 and 2008 elections the choice came down to one state, Florida and Ohio, respectively and there was no prize for second place.

This year, it might be any one of the “swing states” who’s winner-takes-all electoral votes decide the national contest … Florida (27), Pennsylvania (21), Ohio (20), Michigan (17), New Jersey (15), N. Carolina (15), Virginia (13), Missouri (11), Minnesota (10), Wisconsin (10), Colorado (9), Connecticut (7), Iowa (7), New Mexico (5), Nevada (5) and New Hampshire (4).

Yes, Obama has won more delegates, more super delegates and more primaries and caucuses.  But when facing Hillary Clinton in the 16 swing states above, they both won 8, but her 8 translate into 114 electoral votes to his 82.  What will happen against McCain, in those same states? – Hard to say (but here goes…).

More Natural Disasters - the Chengdu Earthquake

Cyclone Nargis in Myanmar (Burma)

One of the first places to start understanding the Myanmar cyclone is through the map site of the University of Texas library.  From that link, one gets referred to ReliefWeb and to the following simple map of the onset of destruction:

a fesnying of ferrets

Several laguages use collective nouns (a noun that refers to more than one things, animals or persons) in their grammar, but we are sure none more so than the English laguage.  Like "a SHOWER of Bullets", "a BALE of Hay", for example. Some get pretty specific, like "a SHEAF of corn" is the bunble you have after reaping, but a "BUSHELL of corn" is the dry weight of the grain, itself; and pheasants on the ground are called a "nide", those in flight a "nye" and when flushed from the ground into flight a "bouquet".

Test your knowledge of animal collective nouns (some more commonly used than others).

MATCHING
Match the collective noun with the animal group it describes.
Click on the link for the answers.

1. a down                            a. of apes
2. a flamboyance                 b. of beavers
3. a gaggle                          c. of boar
4. a colony                          d. of boy/girl scouts
5. a murder                         e. of cattle (two)
6. a parliament                   f. of crows
7. a pod                              g. of fish
8. a school                          h. of flamingos
9. a shrewdness                  i. of foxes
10. a skulk                          j. of hares
11. a sounder                      k. of geese
12. a troop                          l. of geese (in flight)
13. a wedge                        m. of owls
14. a yoke                           n. of whales

You'll be the smartest hedgehog in your prickle, thanks to another public service message brought to you by...

The Ministry of Information

“more power to the misinformed”

And the Beast Replies

In response to the heparin contamination outbreak, a lot of criticism pointed towards the lax FDA oversight.  Last week's NEJM carried a retort from Dr. Alastair J.J. Wood, where he argues that fault doesn't solely lie with the FDA, but can be pointed back at the accusers: Congress and the media.  He concludes:

"It is easier to attack the FDA than to assume one's own share of responsibility. The press, for its part, frequently reports legislators' criticisms of the agency without providing any analysis of their voting records on FDA appropriations. But the bigger scandal is Congress's grossly inadequate funding of the agency, which demands swift and decisive action. No longer should our legislators be able to publicly excoriate FDA employees while ignoring their own complicity. No longer should any of us berate the FDA while failing to acknowledge that we are asking it to do more and more work with fewer and fewer resources. No longer should manufacturers be able to imply that inadequate FDA inspection is an excuse for adulteration of their product during manufacture. We must stop allowing the game of "kick the FDA" to be risk-free to participants. The public's health is at stake, and the time for adequate federal funding of the FDA is now." (emphasis added.)

That seems reasonable.  I'd agree with massively increasing FDA funding and even removing the Prescription Drug Users fee, which creates a wholly conflicting situation where the drug companies fund, in large part, the salaries of the FDA.  And I even agree with increasing powers given to the FDA, to regulate the safety of medical drugs, biologics, technology, foods, et. al.  And maybe then, we won't have the cause to dump on the FDA. 

But is this really what the good Dr. Wood wants?  At the bottom of his letter is this disclaimer: "Dr. Wood reports receiving lecture fees from the Pharmaceutical Research and Manufacturers of America, serving on the board of directors of Antigenics, and serving on the scientific advisory board of Sapphire Therapeutics, in which he holds stock options."  Gaining personal wealth from drug companies and PhRMA, does he really want further regulation and oversight of those companies and industry?  Or is his letter a simple deflection of the proportional blame that must go to these companies? 

I'd say the latter.