Testosterone has other important functions

Bowing to public pressure the R.J. Reynolds Tobacco Co. of Winston-Salem N.C. has recently announced it will retire its controversial Joe Camel advertising character (seen here on a special “collector’s pack” of Camel cigarettes).  Anti-tobacco activists have roundly condemned R.J. Reynolds for its Joe Camel advertising which they say is clearly aimed at children and adolescents. A survey in a December 1991 issue of the Journal of the American Medical Association found the Joe Camel character was as recognizable to six-year-olds as Mickey Mouse.  This past May the U.S. Federal Trade Commission a U.S. advisory body threatened to take the tobacco manufacturer to court if it did not stop using Joe Camel in its advertising.
Hamilton – More explicit and sophisticated health care contracts with shorter life spans are likely to become de rigeur when it comes to ensuring adequate provision of services says an international expert in the field.  In Canada though where contracts between doctors and provincial governments are often the cause of much dispute and ill-will it’s clear this will present significant dangers.  Dr. Chris Ham a U.K. health service adviser and director of Birmingham University’s Health Services Management Centre said governments and politicians have no choice but to use “practical previous experience” to develop new more effective relations between those who provide health services and those who purchase them.  “There are ideological preferences for market-based solutions rather than planning as a tool of resource allocation” he told the 10th annual policy conference at McMaster University’s Centre for Health Economics and Policy Analysis (CHEPA).  The reasons for this include centre-right politics changes in private sector practices and new ideas for delivery of different types of services he said.  “(Health reforms through contracts) are symptomatic of the new public management and the attempt at least in part to borrow ideas from the private sector by reforming and reinventing public services” Dr. Ham added. “After initial enthusiasm policy-makers are having second thoughts about the shift.”   Creeping regionalization   Well-known University of Toronto political scientist Carolyn Tuohy said she thinks there’s little doubt in an era of creeping regionalization and devolved decision-making that contracts are gaining popularity – and significance – “at least as an idea.”  There’s even less doubt anything can turn back the clock. “Expect to see bargaining between providers and purchasers to become more explicit” she told CHEPA delegates.  Whether contracting is ultimately successful she also noted rests on the availability of more reliable data dealing with important concepts of health economics and policy analysis as well as continuing interest in health regions.  To date contracting has been hampered by a lack of reliable data a number of speakers noted. As more and more trustworthy statistics are developed however interest in contracts is bound to grow they believe.  The trend can be seen in the Ontario Medical Association’s recent agreement which features a number of special committees to study issues ranging from physician resources and new health care delivery systems to changing the schedule of benefits and malpractice insurance.

“There’s already quite a bit of contracting going on in Canadian health care” said Steven Globerman of Simon Fraser University’s department of economics in Vancouver. It’s happening at organizational nonmedical medical and institutional levels he pointed out for many reasons including utilization control quality assurance and limiting the so-called “transaction” and “opportunism” costs associated with bargaining.   Managed care   As good as contracting might sound Dr. Jeffrey Harris of Massachusetts General Hospital presented what most Canadian doctors would consider a chilling scenario describing the nightmarish lengths contracting has reached in the U.S.  His talk centred on who owns patients and for how long. Dr. Harris listed a litany of inefficiencies resulting from “contract-focused” U.S. care.  “The growing market penetration of managed care organizations in the U.S. has produced fundamental changes in the contractual relationships between doctors and their patients and between doctors and their colleagues” he said. “Managed care organizations not doctors now own patients.”  Traditional long-term informal relationships between primary care physicians coupled with “informal reciprocal contracts” among generalists and specialists have been replaced by a formal system of short-term market contracts Dr. Harris added.  The effects of the changes on cost and quality of medical care as more patients in the U.S. have “a sequence of physicians” rather than traditional long-term relations with one doctor are “poorly documented and poorly understood” he admitted.  The presentation gave many Canadian policy-makers at the CHEPA conference pause. How do we know if we’ve travelled too far down the contracting road one asked. Sometimes the answer comes far too late he was told.
London – A top police official here is calling for Britain to institute a system similar to that in the Netherlands where drug users can have their stash tested for dangerous impurities.  Richard Wells chief constable for South Yorkshire said he did not think Britain could adopt wholesale the policy of Dutch “safe houses” where users have their compounds tested “but we need to at least see” if something along those lines would work he said.  Wells pointed out hundreds of thousands of ecstasy tablets are taken each weekend by British teens and young adults at dance “raves” around the country. Tablets tested by police have contained amphetamine along with heroin bath scouring powder and even fish tank cleaner.  The use of ecstasy or MDMA is now endemic and almost every weekend there are reports of teens who die from an overdose.
EFFECT WITH PROTEASE SHOULD BE WATCHED    TORONTO – Protease inhibitors (PIs) may slow the metabolism of methadone but not all of them produce the same effect according to in vitro work done in France.   While the results need to be confirmed by clinical studies they suggest HIV-infected patients who are taking PIs and are also on methadone maintenance therapy should have their methadone plasma concentrations closely monitored the researchers said.  They presented their findings at the recent Interscience Conference on Antimicrobial Agents and Chemotherapy here.  Headed by Dr. Anne-Marie Taburet (PharmD) of the clinical pharmacy department at HÙpital BicÍtre in Paris they examined the question of PI-methadone interaction because the two drugs are both metabolized in the liver by the isoenzyme cytochrome P4503A4 (CYP3A4).  They assessed the extent of the interaction using healthy human liver microsomes from grafts. They measured the rate of formation of EDDP the major primary metabolite of methadone in the presence and absence of ketoconazole a known inhibitor of CYP3A4 and each of three PIs – ritonavir indinavir and saquinavir.  To predict the effect of the PIs on methadone pharmacokinetics they also factored in average plasma concentrations of the PIs as measured in HIV patients after taking standard doses of the drugs.  Assuming that the same concentrations would be found in hepatocytes ritonavir might be expected to produce a 50% increase in methadone concentration – similar to that seen with ketoconazole Dr. Taburet said.  Indinavir could produce a 30% increase in methadone concentration but saquinavir appeared unlikely to inhibit methadone metabolism.  “A clinical trial should validate these data as in vivo other factors such as enzyme induction and the effects of endogenous compounds could influence the importance of drug-drug interactions” Dr. Taburet said.
London – A government priority for National Health Service (NHS) funding for evidence-based medicine is colliding with growing public interest in alternative medicine.  The situation creates a dilemma for physicians confronted with patients who want to try alternative medicine according to those attending a conference on science-based complementary medicine held by the Royal College of Physicians of London.  One of the most worrying aspects of homeopathy in Britain is not what practitioners sell their clients but what they tell them said Dr. Ezard Ernst director of the department of complementary medicine at the University of Exeter Postgraduate medical school.  He noted evidence that many homeopaths advise clients not to immunize their children. “In Britain it is the most prominent cause for nonimmunization of children” he said. “On a large scale this behavior endangers all of us and raises the question of whether complementary medicine saves or costs money.”  Dr. Ernst’s latest study reported in the Journal of the Royal Society of Medicine found the perceived quality of therapeutic encounters was the basis for high patient satisfaction with alternative medicine.   Therapies analysed   Dr. Ernst analysed 333 replies from more than 1000 received from arthritis patients who responded to a story in a national women’s magazine and had received both traditional treatment and alternative therapy.  Dr. Ernst and colleagues found the patient-therapist encounter was perceived to be more satisfying with alternative medicine practitioners and ought to remind physicians “how much a good bedside manner can achieve” said Dr. Ernst.  Dr. George Lewith director of the Center for the Study of Complementary Medicine at the University of Southampton has been designing alternative therapy clinical trials for 15 years.  He currently has 270 asthma patients randomized into an alternative/placebo-controlled trial. He recently started a trial involving acupuncture/placebo for nasal airway resistance in rhinitis.  Dr. Lewith said that within the NHS more than one million consultations a year involve alternative therapies “so if we are going to use it more widely it should be based on evidence of its efficacy.”   Claims ‘ludicrous’   Dr. Stephen Holgate professor of cell and molecular biology at the University of Southampton dismissed as “ludicrous” claims that a homeopathic remedy leaves a “footprint” that marks its healing power.  It is becoming clear he said that “alternative medicine practitioners are simply offering something the conventional health service is not: time and understanding.”  Dr. Helen Gelband who directed a study into unconventional cancer treatments for the U.S. Office of Technology Assessment and is now a consultant in Rockville Md. said that after years of discussion with proponents of alternative treatments little was achieved.  While mainstream cancer therapies undergo intensive clinical trials “alternative medicines are simply handed to patients for treatment” said Dr. Gelband. “However I can’t think of one alternative cancer therapy success story.”  However even clinical trial results do not dissuade people in search of a cure. Demand in the United States for laetrile ceased when clinical trials in the late 1970s proved it ineffective but the compound is still sought by patients in Mexico.
New Orleans – Brachytherapy is an effective treatment for penile carcinoma as it avoids amputation and offers good five-year survival according to researchers from the Ottawa Regional Cancer Centre.  Dr. Juanita Crook told the American Urological Association that 10 of 12 patients receiving this conservative therapy between 1987 and 1996 are still alive without evidence of disease. Six out of seven men who were sexually active before therapy continue to be potent today. Average follow-up was 3.5 years (ranging from four to 85 months).  One patient died from metastatic cancer 15 months after therapy in spite of local tumor control and another died at age 84 without evidence of cancer.  Brachytherapy is an important option to amputation for squamous cell carcinoma of the penis a relatively rare form of cancer occurring once in 100000 men.  “One of the goals of cancer management is to preserve the function of the organ involved. That’s obviously important in cases of penile cancer” said Dr. Crook a radiation oncologist at the Ottawa centre and principal investigator on the study.  Brachytherapy involves the placement of needles through the tumor site which are held in place with templates. Radioactive iridium wire is loaded into the needles and left in place for about five days. During delivery of the radiation the patient is confined to a hospital bed. The therapy is more effective than conventional irradiation because it delivers radiation directly to the tumor rather than relying on beams of external radiation to penetrate surrounding tissue Dr. Crook said.


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