All JAMAd up

It is a continuing annoyance that the important medical and public health journals are available by subscription only, and subscriptions cost hundreds of dollars a year. A lot of what is in there really matters to you, but the public has to depend on the corporate media to tell them about it. The criteria for what stories make it into your newspaper or your local TV "Healthcast" or whatever they call it are not closely related to how much it actually matters for the public to know about the subject. What's worse, the reporters usually don't understand the studies or their context and they get the information wrong, or they miss the real point.

Here are some highlights from the new JAMA (which used to stand for Journal of the American Medical Association but now apparently doesn't stand for anything).

1. A bit of a theme on opioid dependence and treatment. Bridget Kuehn reviews the 40th anniversary of methadone maintenance, Collins and colleagues report on a study comparing detoxification under anaesthesia with standard methods (not safe, not effective), and Patrick O'Connor discusses what he calls detoxification vs. methadone maintenance as treatment. (It's actually a false dichotomy -- people who go onto methadone maintenance commonly go through detoxification first. What he really means is abstinent recovery vs. maintenance.) The bottom line is clear: only a small percentage of opioid addicts succeed without methadone or a newer alternative, buprenorphine. Unfortunately, like all questions concerning addiction, this undeniable reality runs up against ideology. Maintenance therapy is just morally offensive to some people. Sure, you don't get high, you function perfectly well, you can work, take care of your kids, go to school -- but you're on drugs, and that's bad! Access to these therapies is therefore restricted in many ways. Result? People relapse.
   
2. William Maisel reviews regulation of medical devices in the context of the recent flap about malfunctioning defibrillators. Implantable defibrillators do work, and do save lives. Like any machine, they aren't perfect and sometimes they don't work. Amazingly, it took decades for Congress to give the FDA authority to regulate and approve medical devices prior to marketing. Today, manufacturers still don't have to publish useful data on the reliability of their devices; they have to report malfunctions to the FDA but not to physicians or patients; and physicians, as a result, do not know how reliable the devices are. As a matter of fact, physicians have false beliefs about this. Patients are not notified if the device in their chest has been recalled! A million people have been affected by advisories about implantable defibrillators and pacemakers in the past 15 years, but there are no standards for how to report on these advisories or how to inform the public.
   
3. Ah yes, those good old nosocomial infections. Hospitals are full of the nastiest bugs anywhere. With a lot of debilitated people who have holes in them and tubes going into the holes, the bugs get around. In the antibiotic saturated environment, they get drug resistant. In the U.S. each year, there are 2 million nosocomial infections, that kill 88,000 people and cost $4.5 billion. Youch. Now there are recommendations for public reporting of nocosocomial infections, with process and outcome measures, endorsed by the leading relevant associations. Now let's do it!
   
4. Mike Bamshad discusses race, actual geographic ancestry (somewhat correlated but not the same thing since race is a social construction) and how much this actually has to do with frequencies of specific genetic characterstics that have something to do with health and drug efficacy. Complicated. Bottom line: "Race" is pretty vaguely associated with what's actually in your genes. Better to find out what your individual characterstics are, and proceed accordingly.
   
5. At last, the one you may already have heard about. Susan Lee and colleagues, with senior author Mark Rosen, figure out when human fetuses may be able to feel pain, based on when the necessary brain structures develop. Their bottom line? 29-30 weeks gestation. This conclusion is uncongenial to opponents of abortion, who are trying to pass laws requiring that fetuses be anesthetized prior to abortion (which is dangerous to the mother, the real agenda being to discourage her from the decision), so we have yet another public argument over scientific conclusions in which the desired outcome (whether it be the literal truth of the Bible or the contribution of burning fossil fuels to global warming) trumps the truth for one camp.

Funny how it's always the conservative position that is in opposition to scientific conclusions. Reality has a liberal bias. We have to balance all those liberals in the universities, who believe in reality, with conservatives, who can provide students with the alternative viewpoint to reality.