Category Archives: second opinion

SURGICAL EXPERIENCE

What is the foremost quality you look for when you are looking for a surgeon? Chances are most of you will say ‘experience’. If there is one thing young surgeons would envy older ones for, it is the fact that the latter are known to have experience.

Isn’t it a given that experience is good, then? Yes and no. Experience has made me a man. But it has also made me a sadder man. It has reduced my expectations from people and from life. It has made me harder and stronger (in the wrong places). It has tempered my emotions, but also made me less receptive to the emotions of others. Experience has not only made my arteries hard, but also my heart harder. It has made me a wiser, but balder, man.

Experience is the sum of one’s mistakes in life, they say. A more discerning person would say ‘no’. There are three kinds of experience:
First hand experience: you have been in battle, and are scarred. No one knows it better than you.
Second hand experience: you have studied the phenomenon of the experience and analysed it.
Third hand experience: you have heard of it from somewhere or someone.

Of the three, which would you prefer your doctor to have? Instinctively, I think we all would prefer to have had first hand experience of the various aspects of life. In the case we started out with (surgery), surgeons would all prefer to have seen complications and disasters in our own lives so as to avoid or solve them in future. This is the best thing for a doc, right? Wrong!

Though it is great for a doc to have first hand experience, it is perfectly likely that he would be biased or plain wrong in the lessons he has learnt from them. In a typical (hypothetical) case, a surgeon uses no mesh to repair his hernia cases because the one time he did use it in 1982, his patient got an infection and lots of problems. This is the main problem with first hand experience. While life must have taught a lesson to the doc, it might have taught him the wrong lesson!

Third hand experience is, obviously, of limited value: who knows what someone told you is right or wrong?
Which brings us to second hand experience.

If you have seen, observed and analysed someone do the right or wrong things, you will have learnt the right lessons. You don’t need to start off with a steep learning curve and create all the complications and make all the mistakes others before you had made. Because you have trained for it. Forewarned is forearmed. It is this second hand experience that is commonly called wisdom. So, it is better to be wise than to be experienced. Therefore, whether it comes to choosing a surgeon or a spouse, better chose a wise, rather than an experienced, one!
Finally, should you not choose a young surgeon? Remember, you can be young once, but you can be immature forever! Hence, young and trained is not a bad combination to have, especially in the present days of changing technology and evolving treatment methods.

(pic source: forgotten. Sorry!)

A NEW FREEDOM FOR THE FUTURE

There is a bomb girl who frequents the same gym I go to. She looks like a movie star, and works ferociously at the various sculpting machines there. She keeps looking back at an imaginary fold of fat at the waist, and keeps whining to the trainer, “I am putting on weight!”
This beauty is spending money, time and effort to beat a non-existent disease: obesity. She is also, potentially, damaging her joints and heart when she pounds the treadmills and pumps the weights. Shouldn’t someone stop her before its too late?
There is another girl I know who wants to trim her inner labia. She seeks a cosmetic gynecologist who does vaginoplasties. And another one who wants a surgery to make her a virgin again, before she gets married a few weeks later. These girls are looking to seek potentially dangerous and complication-prone operations that treat no disease. They are merely expressing some inner wish to change their structure, though there may be nothing fundamentally wrong with them.
I had previously highlighted how the American College of Gynecologists (ACOG) is hotly after the man who has made vaginoplasty a commercial money-spinner. This merely illustrates the fact that there are people in the world, including medical experts, who want to stop procedures that alter one’s physical state. Sex change surgery is another example. There are countries where this is illegal.
The future is fraught with potentially more complex and controversial issues like using genetic engineering and cloning to create a new type of human being that may be peculiarly enhanced. For example, a mother may be able to select a baby who is genetically engineered to see in the dark. Or one who will be free of certain deadly diseases. If you have not read my article on ‘Disruptive Medicine’, this is your lucky day. Check it out.
A Swedish organisation called Eudoxa talks of this morphological freedom, defining it as “an extended right to your own life, including your body.”
Why would a man or woman want to alter his structure for overtly trivial reasons?

We express ourselves through what we are becoming.
Self-development is an intense motivational factor for most humans, and by its
nature this is a very personal and challenging achievement.

Look at tattooing. The way many conservative people see it, it is a kinky and perverse thing to do. It is, however, considered quite cool and contemporary by much of modern society.
It is a personal morphological alteration without specific reasons beyond an individual’s personal choice and freedom of expression.

But wouldn’t genetic modification of children alter society and endanger it? Should we not stop this before it is too late?

Recognizing the right to choose among the many options made available through
morphologic freedom also supports the right not to choose them; the positive and
negative rights are two sides of the same coin.
Purely negative goals like the EU Commission’s directive on children’s right to be
born with unmodified genes will often end up in conflict with positive goals such as
providing children with the best possible medical attention. This right is also
mentioned by the Commission, but is undermined by the negative goal.
One of the many ways this positive goal can be attained is through surgery in the
womb for certain congenital defects. This type of operation changes the body and
the potential person much more than any genetic modification we can bring about.

In other words, apart from the issues of personal freedom and choice, these same disruptive technologies that could change future generations could also save countless lives and improve the lifestyle of the suffering. For example, see the use of intelligent prostheses for amputees that work better than normal limbs.
For more details, check out this link and download a pdf of the statement of Eudoxa.

Whatever be one’s views on this, this issue is a sure one for the future. You haven’t heard anything yet!

SENT HENCE TO DEATH BY DOCTORS!

In this post, I present a fascinating discussion by some experts on the issues surrounding physicians being involved in judicial execution. This is a topic on which I have been thinking of posting for a while, but I will not offer my views on this now. Just read the transcripts of the interview, which I have taken from the New England Journal of Medicine. If you don’t have the ten minutes needed to read this, I suggest you come back when you do.
A video of the same may be seen here.

THE PROTOCOL

Dr. David Waisel: The three-drug protocol is based on what was considered a normal induction of anesthesia when it was developed. [The first drug is] thiopental, also known as sodium thiopental or pentothal, which is a barbiturate, which is designed to put you to sleep, create amnesia and anesthesia. Second comes pancuronium bromide, which is designed to paralyze the muscles. And the third drug, which is not a drug used in anesthesia, is potassium chloride, which is designed to rapidly stop the heart. The doses used are massive compared to the doses that would be used in a normal anesthetic induction.

Dr. Atul Gawande: You raised, Dr. Truog, [the question of] whether these are the right drugs.

Dr. Robert Truog: We’ve taken a pretty strong stand that paralytic agents have no role in end-of-life care. The concern is that they can mask the behavioral signs that we look to, as to whether or not a patient is comfortable. And we are deeply committed to making sure that patients are comfortable and as free of pain and suffering as possible during the dying process. And since we have medications that do relieve pain, that do sedate perfectly adequately, there’s no need to be introducing paralytic agents into end-of-life care. . . . It’s completely inappropriate to treat those signs and symptoms with a paralytic agent. I think that’s just as true in the execution chamber as in the hospital.

Professor Deborah Denno: According to the state, pancuronium bromide is used in order to enhance the dignity of the inmate who’s dying, because without pancuronium, there might be some jerking or involuntary movements that would disturb some of the witnesses. That I find problematic, and Justice Stevens certainly did.

Dr. Truog: From the point of view of the inmate, the argument seems bizarre. Imagine saying to the inmate, “You have a choice. You can either be assured of a pain-free death, and you may have some twitching and grimacing, or we can expose you to the risk of an excruciating death, but we’ll make sure that you don’t twitch or grimace.” I can’t imagine that an inmate would actually consider that to be a real choice.

ALTERNATIVE APPROACHES

Dr. Truog: The number one alternative that’s been proposed has been a very large dose of a barbiturate. A number of experts have said that 2 or 3 or 5 g of pentothal is absolutely going to be lethal. The fact is that, at least in this country, none of us have any experience with this. And if you look at a country where they do have some experience with it, their findings are pretty concerning.

If we go to Holland, where euthanasia is legal, and look at a study from 2000 of 535 cases of euthanasia, in 69% of those cases, they used a paralytic agent. Now, what do they know that we haven’t figured out yet? I think what they know is that it’s actually very difficult to kill someone with just a big dose of a barbiturate. And, in fact, they report that in 6% of those cases, there were problems with completion. And in I think five of those, the person actually woke up, came back out of coma.

LETHAL INJECTION AND THE EIGHTH AMENDMENT

Dr. Gawande: Professor Denno, [you’ve written that] in turning to this three-drug protocol back in 1977, “The law turned to medicine to rescue the death penalty.” What did you mean by that?

Professor Denno: Lethal injection came about in 1977, a year after the United States Supreme Court decided that there would no longer be a moratorium on the death penalty. And there had been acknowledged problems with electrocution and lethal gas, because of the visual side effects of those methods.

By virtue of coming up with a method of execution that makes an inmate look serene, comfortable, and sleeping during the death process, the death penalty in this country was rescued. The presence of doctors, their involvement, and the association with medicalizing the procedure enhanced its Constitutional acceptability.

Dr. Gawande: What does it mean to be not cruel and not unusual punishment [in compliance with the Eighth Amendment]?

Professor Denno: The Eighth Amendment has never said, nor have the petitioners ever argued, that executions are to be pain-free. The question is whether or not that pain is unnecessary, whether there are alternatives.

Dr. Gawande: Chief Justice Roberts asked, “Do you agree that, if the protocol is properly followed, that there is no risk of pain?”

Dr. Waisel: Define “properly followed.” In other words, the protocols list that this should happen and that should happen. But does that mean if everything happens correctly, if there are no problems with insertion of intravenous catheters, if there’s no problem with mixing up the medications, there’s no problem with delivery of the medications? Then, yes, it would be pain-free.

RISK OF ERRORS

Dr. Truog: I think the issue here is that people go to school for a long time and do years of training in order to be able to do this well. And certainly, everything that I’ve read is that the training for the people that are doing it in lethal injection is nowhere near adequate.

Dr. Gawande: In Kentucky, they have responded to the request by physicians not to have physicians involved. And so it’s staffed entirely by phlebotomists and emergency medical technicians. So how likely is it that errors will occur? By one measure, there have been 40 botched executions out of a little over 900, which suggests a 4-to-5% rate of failure.

Dr. Waisel: We have no idea what the error rate is, because there is no oversight, there is no public reporting. And the information [I] hear worries me. For example, I believe the case was from Missouri, in which they pushed the three drugs, and the inmate didn’t go to sleep. And [they] realized the strap holding the arm was functioning as a tourniquet. So they loosened it up, all the drugs came in at once. Now in that case, I’m highly confident that the inmate experienced a great deal of pain from the potassium chloride. And so I think that your 4-to-5% number is dramatically underestimated.

Dr. Truog: Putting an IV in is not as easy as it may sound. And being certain that it continues to remain in the same place also requires quite a bit of experience, because these catheters can become dislodged, they can go into the tissue, and then they won’t work anymore. Furthermore, we know that many of these inmates, by virtue of their history of drug abuse or obesity or being muscular, can be very difficult to start IVs in.

In a hospital setting, we have a lot of different ways of approaching the situation when we can’t get an IV in. Most commonly, we’ll just put in a central venous line. But that requires a great deal of training. The mixing, the administration of the medications [are] routine in any operating room in this country, but far from routine if you haven’t done it before.

One of the mistakes that I know has occurred happened to me early in my training, when I injected the paralytic agent too quickly after the pentothal, and they precipitated in the tubing. The tubing turned into a piece of concrete. Suddenly, I had no IV. And thank goodness, I was surrounded by very experienced anesthesiologists who stepped in, within moments had another IV. But I know that that has happened in executions, and it could be a disaster.

Dr. Gawande: The petitioners [noted that for] the 3 g of thiopental, no one makes 3 g syringes, so you have to constitute it from small vials of 0.5 g of powder. And several times, whether it’s doctors or non-doctors involved, they’ve simply mixed it up wrong and ended up with much lower doses than they thought.

In Kentucky, the risk of IV infiltration is exacerbated, because they use several feet of tubing, and everybody leaves the room and sits behind a screen where you can’t see the IV sites or monitor how well things are flowing in. And finally, they didn’t have a plan to monitor the depth of anesthesia when you don’t have anybody standing there. And to the extent that there is someone there, they’re not used to being able to assess this.

PHYSICIAN INVOLVEMENT

Dr. Gawande: Now we come to this fundamental question of whether physicians should take charge, to make death less painful. Dr. Truog, what’s your take on [Dr. Waisel’s] question: if you were to be executed, wouldn’t you rather have a capable, specialized physician doing this job?

Dr. Truog: If I think of the kind of a hypothetical where you have an inmate who is about to be executed and knows that this execution may involve excruciating suffering, that inmate requests the involvement of a physician, because he knows that the physician can prevent that suffering from occurring, and if there is a physician who is willing to do that, and we know from surveys that many are, I honestly can’t think of any principle of medical ethics that would say that that is an unethical thing for the physician to do.

Professor Denno: If we’re going to be executing people, I would prefer to have a method of execution where medical expertise would not be necessary. If we’re going to, however, have a method that would be cruel and constitute suffering if we didn’t have doctor involvement, then if there are physicians in the country who are willing to be involved, I would like to think that they would not be chastised or lose their license or be punished by the medical profession for volunteering to take part in an execution, to relieve suffering.

Dr. Truog: There’s been a lot written about whether physicians should participate in torture. And of course physicians shouldn’t participate in torture. But fundamentally, it’s because torture is wrong. And this is [similar] to my views about physician involvement in capital punishment. While I think at one level we can justify it, I think it’s to miss the bigger picture. I really believe that capital punishment is ethically wrong.

Living in the bubble of the United States, it’s easy to lose sight of just how much of an outlier our country is. We stand among a small group of countries that still do capital punishment, [and] I really don’t think we want to be in their company.

REMEDIES

Dr. Gawande: When we come to this question of where can the remedy be found, the directions that seem to be posed are: We involve physicians more and let them treat the prisoner as a patient, or we come up with alternative protocols that don’t involve physicians at all.

Professor Denno: My recommendation has been that there be a panel of experts who would propose a viable method of execution.

Dr. Gawande: It makes me deeply concerned, though, imagining us sitting around a table at a conference, trying to figure out various ways of executing people, and then the prospect of what that becomes, that we figure out that physicians have to be continually actively involved, and we create a specialty of the execution physician.

It may not be possible for the court to say that doctors would be allowed to really treat inmates as patients — control protocol, make judgments about how to make the suffering less or more — and leave them free to have that professional role.

Professor Denno: They’ve been doing that for 30 years. There have been physicians involved in lethal injection since the very first execution in 1982 in this country. Because of secrecy, we’ll never know the full involvement of doctors. But we have many examples of doctors having been involved, who have made these kinds of discretionary judgments about drugs or chemicals and what should be done.

Dr. Gawande: If the court says “We need this to go to an expert panel, with physicians, lawyers, public citizens, to determine a new protocol for execution,” would you participate on that panel? And should other physicians participate on that panel?

Dr. Waisel: It should be wholly permissible for physicians to participate if they wish. I would have to think about it very carefully. A large part would depend on the intellectual freedom involved in the panel, the ability to write a dissenting opinion from what the panel comes up with, and moving away from certain constraints that are put around this that seem not to permit what I would consider to be successful ways of nonphysician involvement.

Dr. Truog: I would not participate on that panel, because I don’t think that capital punishment is ethical. I think other physicians should be free to participate on that panel. And while I wouldn’t want to prejudge how they might come out, I can’t imagine that they are going to be able to develop an evidence base for any other approach that is likely to be successful without the immediate presence of a physician. And then I think we have to grapple with the ethics of that.

AN IMPATIENT PATIENT?

This blog author has been up to his usual tricks. The ones where he gets paid. And held accountable. No, not for giving ethereal physical pleasures to beautiful women with hour glass figures. The aforementioned never bills for such activity, as it is done with great reciprocal pleasure. Not to speak of the peculiarly perverse view of the world to it. In other words, I am referring to the tender, loving care of surgical patients. Result: no blogging time. No blog surfing time, etcetera.

Allow me some more blogulent digression:
Man is unique in some fundamental ways, compared to the rest of the animal kingdom. The one I am focussing on in this post is the fact that man is one animal whose tail is not much bigger than his head. Except some privileged women.

Well, this post is aimed to correct this human frailty. I will (for reasons of time) posit this very serious issue here, and I expect you, my dearers readers, to wax eloquent in your comments. I will chip in with my views somewhere in between. The beef of the post should reside in the comments!

A colleague in the Western world has a problem:
“Female 99 yrs old, self inflicted stab LUQ, CT scan confirms splenic laceration with extravasation of contrast. Mildly hypotensive – Patient says she ‘DOES NOT’ want an operation, did not want to come to hospital, ‘let me go, I want to die…..’, knows what she has done and where she is, understands that she will die without an operation.” She also takes aspirin, which makes blood thinner, and may increase bleeding. In other words, she has stabbed herself, and is going to bleed to death, unless the doctors operate on her.

Ambulance workers, her GP, and all concerned say she is compos mentis (of sound and reasonable state of mind). Her husband is not available.

What should the doctor do? Plus, what opinions do you have on aging and death?

Let’s hear your tail!

GETTING TO THE HEART OF ENHANCED CLAIMS

The recent controversy about the ENHANCE study is an important illustration of a serious and long-standing problem with the medical profession, and its allied siblings.

What is the ENHANCE study all about? Surely not a penis-enlargement issue, my readers may be forgiven for wondering even fleetingly. Well, it is a study on two treatment modalities for patients with high lipid (cholesterol, for example) levels. But, first, the basics.

You may have high lipid levels because of genetic reasons, or because you eat, drink, or smoke too much. Many of us are obese, too. Traditionally, if you have high cholesterol, apart from the usually discarded ‘lose weight-do exercise’ kind of advice to the patient, your doctor would give you drugs. These lipid-lowering drugs are called, broadly, statins. One of the most common ones today is Lipitor (atorvastatin).

Why is it important to lower cholesterol? Because high cholesterol can lead to fatty plaques being deposited in the coronary arteries (atherosclerosis), leading to a heart attack.

Statins are prescribed to millions of patients around the world, including those with heart disease, hypertension and diabetes (conditions commonly associated with high lipid levels). All statins act by blocking a liver enzyme that normally results in the formation of cholesterol.

The problems with statins are mostly with their cost and side effects. In addition, in a number of patients, they don’t work well enough. Increasing the dose may increase the side effects. So, what can your doctor do in this kind of scenario?

Enter Ezetimibe. This drug reduces the absorption of cholesterol from the intestines, which bear the brunt of all the cholesterol-rich good things in life that the mouth (along with the mind it carries) chases relentlessly.

With me so far?

So, you have statins that reduce cholesterol, and you have ezetimibe, that also does the same in a different way. Why not combine the two? Will surely work better, and reduce the fatty deposits in your coronary arteries, logically. Merck did that in collaboration with Schering-Plough, with Zetia (ezemitibe) and Vytorin (a $5 billion product).
A 30-day course of Vytorin costs around $100, while Zetia costs $93, compared to $32 for a course of generic simvastatin.

That is what the ENHANCE trial was supposed to prove. Unfortunately, it did not show any such benefit.

However, some experts are discounting the trial, saying it is not a fair representation of the truth, that it is botched, and that they would wait for further trials before changing their prescriptions away from Zetia. Around 60% of doctors, however, are likely to stop prescribing the drug. Obviously, it would be a catastrophe for the company, reeling as it still is from the Vioxx losses. Merck stocks have slid down after this trial has come to light.

The important issue that has come up again in this debate is captured in two quotes:

The main problem is that after six years on the market, there are no data for ezetimibe demonstrating any health outcome benefit. In the absence of any demonstrable effect beyond LDL lowering, nearly one million prescriptions per week are written for ezetimibe. Is this rational?

If the ENHANCE trial had shown regression of atherosclerosis or slowed progression, both the company and advocates of ezetimibe would be trumpeting the results as a landmark study. Now that the trial has failed, they describe ENHANCE as a small and unimportant imaging study. You can’t have it both ways!

THAT, ladies and gentlemen, captures a huge truth. Much of what we do as doctors stems from trials that prove one or the other. Products become available commercially, too, and we are tempted or habituated to use them, especially if treated well at cruises and exotic junkets. However, as clinicians, we would still want to do better for the patient, and refine our treatment methods as evidence improves. Therefore, it is vital that we know which data is proven, and which is putative, suggestive or alleged.

That, however, is a tall order!

(Sources: Heartwire and Medscape)

DEATH BY IMPOTENCE!

ED AND THE MALE WORLD

Erectile Dysfunction (ED), originally from the Latin Impotentia coeundi, is one of the major diseases of mankind, and can be loosely defined as an inability to achieve an erection for successful penetration.

In normal populations, the incidence of major Erectile Dysfunction (ED) is 5 to 20%. Even in the young, ED occurs in around 13%, according to a study on boys between 18 and 25 years. This is remarkable, because ED is known to be seen in older, not younger men, as a rule.

One of the most respected and cited studies on the epidemiology of erectile dysfunction is the Massachusetts Male Aging Study. The study showed that 52% of 1,290 men aged 40 to 70 years had some degree of dysfunction, and almost 10% had total absence of erectile function.

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A new article in The International Journal of Impotence Research has some interesting things to say, based on a large study on the sexual habits of more than four thousand men, both gay and straight.

Most men in the prime of their sexual lives (18 to 44 years) use no drugs for sex, while some do it for recreational use, and fewer because they need to use them medically.

The recreational use of ED drugs is increasing, and seems to have a negative effect. The study says that, on surveying the participants’ perceptions and self assessments after taking ED drugs, their confidence and performance suffered unless they took drugs again.

As lack of confidence in one’s ability to gain and hold erections has been identified as an important psychogenic risk factor for ED, the findings have important implications. Recreational users of ED medications may be vulnerable to becoming psychologically dependent on pharmacologically induced erection.

Therefore, the young kids out for a trip on Viagra are rooting for trouble!

WHO CARES ABOUT ED, A BORING MALE DISEASE?

ED is now more than an andrologist’s way of making bread. It is now a sentinel for a variety of diseases. What are they?

* ED may be the first symptom of coronary heart disease in a young man. In fact, ED is now considered a strong indicator of heart disease, with strong correlation as to severity. In other words, the more severe the heart disease, the greater the liability to be having ED. Men who have less than expected degree of erection, or have it only to lose it midway (lazy erections) are likely to have a cardiovascular cause of ED.

* ED may present in an undetected diabetic.

* It is seen in long-standing smokers, alcoholics (whiskey dick or brewers’ droop), and those with lipid disorders, prostatic diseases, etc.

* Evidence has linked hypertension to ED.

* Drugs used in the treatment of various diseases can also cause ED.

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IMPOTENCE IN INDIA

India has been called the country of unconsummated marriages because of the phenomenon of ‘honeymoon impotence’, when ED manifests on the first attempt. Impotence in India is mainly psychogenic, unlike the rest of the world, where three-fourths of cases are said to be due to organic, not psychological causes. Of course, once a man becomes impotent, he suffers enormous loss of confidence and self-image, leading to further performance anxiety. So the psychological overlay (no pun intended, for once) is also visible here.

HOW DOES ONE TREAT ED?

If you are a man facing ED, the sensible thing is not to hide it, but come out with it to a physician. Screening for hypertension, diabetes and heart disease will follow. Smoking should stop, as should excessive boozing.
Then what?
Based on what is wrong with the patient, the treatment is commenced.
Usually, drugs like Cialis (tadalafil) are the first line of treatment. Among the ED drugs, a lot has changed since Pfizer came out with Viagra. Leftist limpos: please note that Viagra was not invented by a Government pharma company.
Cialis (Tadalafil) is now a preferred drug for ED patients. It works for 36 hours, can be taken irrespective of food, and one does not need to time the drug intake with sex, thereby making for a better experience. In contrast, Viagra (sildenafil) works for only four hours and needs to be taken half an hour or so before sex.
In some cases, the doctor may advise the patient to inject a substance like papaverine or a prostaglandin (Alprostadil) into the penis just before sex. Rigidity is best achieved with injections.
In psychological cases (performance anxiety, depression, schizophrenia, etc.), counselling and appropriate treatment is advised.
Specific cases where the penis loses rigidity due to blood leaking from the veins respond well to vacuum suction devices.

SURGERY FOR IMPOTENCE?

In a small percentage of cases, where there is no response to any of the above, the andrologist might consider implants. These are devices that are implanted inside the penis (and partly in the scrotum). One device (essentially a semi-rigid rod of silicone with metal wires), called the AMS prosthesis, may lead to a permanent semi-erect state. In India, it costs around 60,000 rupees (around 1150 USD). A local version has been made by andrologist Rupin Shah and costs only Rs. 10,000 ($250). The better prostheses (e.g., the three-part inflatable AMS prosthesis) enable erection only during sex (on demand). A pump (implanted in the scrotum) needs to be activated to push in fluid inside an implant in the penis. The implant fills with water, and the penis becomes hard. This costs around Rs.220,000 ($5050).

One problem with the penile implant is that any infection is disastrous, leads to removal of the device, and permanent impotence. Hard luck!

It should also be remembered that any treatment of ED, like drugs or injections, may cause a persistent, painful, permanent state of erection, called priapism. This condition is an emergency.
Unless treated within four hours, it leads to permanent impotence.

To sum up, a man’s inability to achieve a satisfactory erection is not a laughing matter. It may be a sign of serious underlying disease which can eventually kill him.

Note: pictures are mine!

NEEDLE OF SUSPICION

From Journal Watch:

Acupuncture may be better than conventional therapy for the treatment of chronic low back pain, but it seems to offer no benefit over sham acupuncture, according to a study in Archives of Internal Medicine.

Nearly 1200 adults with chronic back pain for at least 6 months were randomized to undergo acupuncture, sham acupuncture, or conventional therapy that included physiotherapy, exercise, and medication. All interventions involved ten 30-minute treatment sessions, with five additional sessions for patients who experienced pain reduction after the first ten.

At 6 months, the response rate was significantly higher with real acupuncture (48%) and sham acupuncture (44%) than with conventional therapy (27%). The difference between the two acupuncture groups was not significant.

The authors say the lack of difference between acupuncture groups “forces us to question the underlying action mechanism of acupuncture and to ask whether the emphasis placed on … traditional Chinese acupuncture points may be superfluous.

That is my point! In several instances, we have seen that any procedure has a temporary benefit arising from its placebo value. The fact that something has been seen to be done itself has a role in providing symptomatic relief.
Doctors who disregard this in their practice tend to believe in their awesome healing prowess, and are likely to be pretentious pricks!

IS THE FALUN GONG GOING WRONG?

http://www.falundafa.org

*Warning: this article links to others that may have graphic content. Discretion advised.*

I think it was a featured post in the WordPress.com website that took me there. The blog was fascinating and morbid. It was an eye opener to read the exhaustive and graphic details of the myriad ways the Chinese officialdom tortures, rapes and murders the members of the Falun Gong sect.

While none of this is fresh, hot news, going into these sites for the last couple of days helped me form some impressions.
These people are committed. No question about this. It is awe-inspiring to see how painstakingly they have documented the list of crimes by the government, as well as the names of the practitioners who have succumbed to the State’s malevolence.

However, one article surprised me. It was a ghastly story of a woman who was tortured with electrical batons held to her breast, and the pictures were supposedly of an electrocuted breast with infection. Naturally, the surgeon in me had an understandable curiosity to see this, and I clicked on the links. I was taken aback to see pictures of a woman with advanced breast cancer.
Many other pictures were on display, quite horrifying for all but the hardened and the trained. However, some of the pictures did not really gel with the textual explanations of the injuries.
In the case of Ms. Gao Rongrong, who was allegedly tortured with an electric baton held inside her mouth for hours, the pictures seem to be surprisingly benign. Medically, a trauma of that severity would have led to tongue swelling to the point of causing obstruction in breathing, and a phenomenal facial swelling would also be seen. Electrical burns also cause scars, the kind of which are lacking in the pictures.
I asked Ken Mattox, a senior American surgeon and an editor of a major international surgical textbook, to opine on these images.
Mattox says, “Photographs can be deceiving. While some of the apparent injuries and conditions might have been caused by torture, it appears that some of the photographs are from conditions which are sometimes seen in a hospital. The photographs could have been from rigor mortis in a dead body, advanced cirrhosis of the liver, portal hypertension, advanced necrotic breast cancer, donor site for a skin graft, routine acute electrical and thermal burns, and sacral decubitus ulcer.”

http://fdkansas.net

The picture of breast electrocution is, quite clearly, a misrepresentation. It fooled none of the group of surgeons I asked to inspect.
I found other Falun Gong sites that also alleged similar torture-induced diseases. Here are two samples:

*Her nose was injured as a result of the brutal force-feeding, turned into an abscess, and became cancerous in 2003. She died on July 12, 2007 at the age of 42.

*She developed cancer after being subjected to severe physical abuse.

Medically speaking, this falls close to the category of myth or rubbish. I wrote to the organisation seeking clarifications on the specific points, but have not yet received a reply.

In view of the long term struggle that the Falun Gong movement is undertaking, and the fact that the struggle is clearly a just and moral one (the struggle to be free, to speak freely and practise one’s beliefs freely), I wish the movement takes note of the fact that it is difficult to regain credibility once lost. The need to be graphic to expose the horrible and inhuman animals who perpetrate these tortures on the Falun Gong is understandable.
However, the truth is great, and shall prevail.
Hence, the Falun Gong should clearly identify the mistakes and the fakes and remove them. They owe this to their own struggle, their own people.

Recommended reading:
1. Bloody Harvest, a treatise on forced organ transplantation.
2. Harry Wu’s take on the Falun media.

SECOND OPINION: 101

http://www.childrenshospital.org/arthur/pop_surgeon_en.html

CNN Health reports that there are five situations where you should take a second medical opinion. These include brain tumors, hysterectomy, medical termination of pregnancy in fetal abnormalities, varicose vein surgery and heart bypass surgery.
I think this is silly pop stuff. What about a diagnosis of tuberculosis versus lymphoma, or cancer, or Crohns’ disease? What about whether a hernia or a gallbladder needs a surgery or not?
There are three main reasons I think a second opinion is important:
1. What is it?
Recently I saw a young girl who was being treated for several months for proven tuberculosis of her lymph glands in her neck. In spite of the treatment, her glands were increasing in size, and I removed a piece, thinking it to be a case of drug-resistant tuberculosis, which is an important health issue all over the world. When the biopsy report came, I was surprised to read the report stating that there was no tuberculosis at all. What would one do now? One report was clearly declaring the presence of TB, and the other (from an equally reliable lab) was refuting it. In the past, I have found a diagnosis changing from TB to cancer! Similarly, TB of the intestines (a very common Asian disease) may be confused with cancer or Crohns’ disease, which, though uncommon, are important diagnoses.
In these cases, it is important to get an experienced specialist to decide further course of action.
2. To treat or not to treat?
Investigations have become commonplace these days, with people going for comprehensive check-ups just to find out if they are okay or not. In addition, people go for thorough health check-ups before they are hired for new jobs, or prior to getting life insurance. These tests are throwing up diagnoses of diseases. People get worried about these findings and queue up for treatment, including surgery. A common example is a young man who is found to have gallstones, or a sailor with a small hydrocele.
It is very important not to treat these people unnecessarily. “You can’t get better than asymptomatic” is a truism for the over-enthusiastic doctor. The patient should earn the surgery, and the surgeon should not sell it. So, in case a doctor recommends surgery or another invasive procedure (like an angiogram) for something that is not troubling you too much, it is good to get a second opinion.
Another example is appendectomy for chronic pain in the right side of the tummy. This is a total no-no, in most cases. Surgery is not needed in more than 90% of cases, as the diagnosis itself is not appendicitis! This is so common that I find it ridiculous that CNN does not talk about it, dealing instead with rare stuff like birth defects detected in pregnancy.
3. What treatment to follow?
Let us take the operation of hysterectomy (removal of uterus). Recently a young woman of 39 years came to me with a tumor (myoma) in her uterus. She had heard that I do laparoscopic surgery, and wanted to hear from me that I would be able to remove this by the keyhole method.
She showed me a previous consultation with a gynecologist (note that I am not one), and this guy (with international degrees, working in one of India’s best hospitals) had told her, “You need an open operation to remove your tumor, because it has become very big.”
In this day and age, I thought, my Gawd!
Here is why I was shocked: it is now established by science that most uterine tumors (and we are not talking of cancer) do NOT need surgery. If treatment is needed at all, it can be something even less invasive than keyhole surgery. In other words, uterine artery embolisation, a procedure whereby a tiny tube is placed from the groin into the artery of the uterus and the blood supply to the tumor cut off by injecting some magic materials. The tumor shrinks because its blood vessels get clogged. End of story. But, no, this is not good enough for many of the gynecs, who want to get their hands into blood, and feel they are actually doing something.
This is another example of when a second opinion should be solicited, and CNN does mention it, to its credit.
So what should you do when faced with a new disease, or with a surgery for something you are scared of? Chances are that the second opinion you take will be equally wrong, or end up confusing you thoroughly. This may be less so in the US or in Europe, for example. In India, it would be most likely! For example, those people who come to me for getting their appendixes removed have already got the same opinion from three other doctors, including medicine specialists and gynecologists. They get shocked when told that no surgery would be needed. It is only because they trust my opinion that their confusion is resolved. If not, they probably get the surgery done by someone else, and, much later, when the pain recurs, remember my opinion.
So, the thing to do in the situation I described is to read. Doctor Google. Web MD.
And some doctors’ blogs!