Maryland / Regional
Officials unveil procedure for patient escape
(Carroll County Times)
Local health centers
get funding
(Cumberland Times-News)
Class-action status sought in Harford pollution case
(Baltimore Sun)
Domestic violence, pollution bills pass state Senate
(Annapolis Capital)
Treating an Illness Is One Thing. What About a Patient With
Many? (New York Times)
Care
Coordination: Too Expensive for Medicare?
(New York Times)
4th
Circuit upholds Maryland funeral home law
(Daily Record)
National /
International
Court
ends Philip Morris appeal of $79.5M award
(Daily Record)
Avoid pistachios, FDA
warns
(Baltimore Sun)
Tuberculosis: H.I.V. Infection Sharply Raises Risk for TB,
Report Says (New York Times)
For This Health
System, Less Is More
(Washington Post)
The
Checkup
(Washington Post)
Study: Plavix plus aspirin helps prevent strokes
(Washington Post)
Vitamin D Pills May Prevent Fractures in Older Adults
(New York Times)
Opinion
Medical marijuana
(Baltimore Sun)
Maryland / Regional
Officials unveil procedure for patient escape
By Jennifer Jiggetts
Carroll County Times
Tuesday, March 31, 2009
Health officials have released an escape plan for the state’s
controversial Secure Evaluation and Therapeutic Treatment
Program at Springfield Hospital Center’s Muncie Building in
Sykesville. (View the PDF file here)
The plan says that if a resident escapes from the building,
Springfield and Sykesville police will be notified. The county
sheriff’s office and state police will also be called.
And, after consulting with Springfield police, SETT officials
will determine whether or not to contact businesses, the plan
says.
Sykesville Police Chief John R. Williams Jr. didn’t return
several calls Monday.
The program is for patients who are deemed incompetent to stand
trial and therefore unable to be held criminally responsible for
their actions.
Eleven residents from the closing Rosewood Center in Owings
Mills moved into the building in January.
The state also transferred two more residents from the Jessup
Secure Evaluation and Therapeutic Treatment Program. The Muncie
Building’s maximum capacity will be 22.
Gov. Martin O’Malley ordered in January 2008 the Rosewood Center
be closed by June 2009 because of structural problems and
patient safety issues.
A separate facility was supposed to be built at the Clifton T.
Perkins Hospital Center, but state officials said the Muncie
Building was what they were looking for with the SETT program.
The program has been heavily criticized by Sykesville officials,
residents and business owners who had concerns about safety,
money and planning.
The program is located not far from a school, a park and the
Warfield Cultural and Commerce Center.
The state spent about $400,000 to renovate the Muncie Building,
and has budgeted $3.9 million for fiscal year 2009 to house the
residents.
Sykesville Mayor Jonathan Herman criticized state officials for
a lack of leadership and organization.
Herman said the town is still considering annexing the hospital
to have a voice in planning and zoning matters.
He said he hasn’t read the escape plan yet, but said Monday that
he felt confident that the town’s police force would do what it
could to assist Springfield in the event of an escape.
“I know our police chief has been working closely with the
Springfield Hospital police to make sure that everything goes
well,” Herman said.
Reach staff writer Jennifer Jiggetts at 410-857-7873 or
jennifer.jiggetts@carrollcountytimes.com
Copyright 2009 Frederick News-Post.
Local health centers
get funding
Cumberland Times-News
Tuesday, March 31, 2009
OAKLAND — Two area community health centers will receive a total
of $275,839 in federal funding through the American Recovery and
Reinvestment Act.
Western Maryland Health Care Corp., under which Mountain Laurel
Medical Center in Oakland operates, will receive $126,911.
Pendleton Community Care in Franklin, W.Va., will receive
$148,928.
“For decades, community health centers have provided
comprehensive quality primary health care services to medically
under-served communities and vulnerable populations,” Sen. Ben
Cardin said. “I am pleased that the economic recovery package is
providing needed funding to community health centers — centers
that we know work and save lives.”
Those who were selected for grant funding had to submit plans
explaining how funding would be used, which can include
expanding services by adding new providers, extending hours of
operation or widening the variety of services.
Eight counties in Maryland and 26 counties in West Virginia will
receive funding through the economic stimulus package.
“Boldly addressing our nation’s health care issues must be a key
component of any strategy for long-term economic growth and
prosperity,” Sen. Robert C. Byrd said. “In West Virginia, we
grapple with some of the nation’s worst behavioral risk factors
and gaps in access to preventative care and education. This new
funding will have a direct, immediate and positive impact on the
lives of West Virginians, especially in our more rural areas.”
In Maryland, the funds will be distributed through the
Department of Health and Human Services, which supports
community health centers through the Health Resources and
Services Administration.
“Community health centers provide an important safety net for
the people who need it most,” Sen. Barbara Mikulski said. “This
is especially important in these economically trying times when
there is more need and fewer resources. These American Recovery
Act funds will help community health centers keep their doors
open to make sure Maryland families have access to reliable
health care in their communities.”
Copyright © 1999-2008 cnhi, inc.
Class-action status sought in Harford pollution case
Plaintiffs say leak at Exxon station in Fallston tainted wells
By Jonathan Pitts
Baltimore Sun
Tuesday, March 31, 2009
A Harford County judge heard arguments Monday on whether a
lawsuit over a vapor leak at an Exxon gas station in Fallston
should proceed as a class-action case.
The Peter G. Angelos law firm filed the lawsuit as a class
action on behalf of about 150 families and businesses whose
wells were contaminated by the gasoline additive MTBE. Lawyers
for Exxon Mobil Corp. and the operator of the station contended
that the plaintiffs should be required to file individual
lawsuits.
In arguing for class-action status, plaintiffs' lawyers said
their clients shared a common interest in the leak, which
residents learned about in 2004. The lawyers said the station
caused the vast majority of any contamination and polluted a
single aquifer. Lawyers for the oil company said there were
seven sources of contamination.
After a hearing lasting about an hour in Harford County Circuit
Court, Judge William O. Carr said that he would issue a ruling
later.
It is typical for plaintiffs to seek class certification in
cases of this kind, said Donald Gifford, a professor at the
University of Maryland School of Law. "A judgment will be much
larger and much easier to accomplish" as a class action, Gifford
said, which "puts enormous pressure on defendants to settle."
Vapor leaking from the station's underground storage tanks at
Routes 152 and 165 triggered Maryland's largest MTBE
contamination, according to state officials. The plaintiffs are
seeking more than $530 million in individual damages and
billions of dollars in restoration damages.
This month, a Baltimore County jury awarded more than $150
million to residents who sued Exxon Mobil over a 2006 leak at an
Exxon station in Jacksonville in which 26,000 gallons of
gasoline seeped into the groundwater. Those lawsuits were tried
individually.
About 60 people, most of them plaintiffs, attended Monday's
hearing, which was moved to a larger courtroom in the Bel Air
courthouse to accommodate the crowd.
Copyright 2009 Baltimore Sun.
Domestic violence, pollution bills pass state Senate
Associated Press
By Brian Witte
Annapolis Capital
Tuesday, March 31, 2009
ANNAPOLIS, Md. (AP) — The Maryland Senate approved legislation
Monday to protect victims of domestic abuse, and senators barely
pushed through a highly contentious bill to fight Chesapeake Bay
pollution by requiring sewage system upgrades for homeowners who
live near it.
To protect domestic abuse victims, the Senate approved requiring
a judge to order the confiscation of firearms from people who
have final protective orders filed against them. The other
measure to protect victims would give judges discretion to order
the subject of a temporary protective order to give up firearms.
Both bills passed 31-16.
Lt. Gov. Anthony Brown, whose cousin was shot to death last year
by an estranged boyfriend, praised the Senate votes. Gov. Martin
O'Malley's administration has made measures against domestic
violence a priority this session.
"These common sense bills are a big step in that direction,"
Brown said in a statement.
The Senate already had rejected an amendment that would make it
easier for domestic violence victims to get handgun permits. The
House of Delegates already has approved similar legislation, and
rejected a separate attempt to give victims easier access to
handguns.
The legislation to remove nitrogen pollution from the bay was
highly contentious, and it passed by only one vote, 24-23. Even
after the bill passed, Sen. Nathaniel Exum, D-Prince George's,
moved to have the vote reconsidered, but his motion failed on a
22-25 vote.
The bill would require homeowners living within 1,000 feet of
the Chesapeake Bay to install environmentally friendly sewage
systems when their current ones fail.
The bill provides for homeowners to receive state aid to pay for
the new systems, but developers wanting to build new homes in
affected areas within 1,000 feet of the bay would not be
eligible for assistance.
But the measure was sharply criticized by Eastern Shore
lawmakers, who argued that the nitrogen removal technology the
bill requires will still put an unfair burden on rural residents
who could have trouble affording the sewage systems.
It costs about $12,000 to upgrade an existing system. Those who
violate the measure would face fines up to $8,000.
"These are poor people in Somerset County," said Sen. Lowell
Stoltzfus, an Eastern Shore Republican, who noted that more
affluent counties wouldn't be affected. "I ask you to be fair."
But supporters say it won't be as much of a burden as critics
say, and that the measure is needed to clean up nitrogen
pollution in the nation's largest estuary.
Poor water quality caused by pollution from nutrients such as
nitrogen and phosphorous has harmed the blue crab population,
destroyed underwater grasses and hurt fish in the bay.
Sen. Mike Lenett, D-Montgomery, said local health departments
will help homeowners comply with the new regulations to enable
people to avoid fines.
"They get worked out at the local level," Lenett said.
The Senate also approved a bill that would deny state
identification to all illegal immigrants, a big difference from
a House of Delegates bill that would create a two-license
system. Now the two chambers will have to work out a compromise.
In a long night of difficult legislation, the Senate also gave
preliminary approval to a complicated bill that would put
Maryland back on the path to regulating electricity supply.
The Senate voted for an amendment from Sen. Nathaniel McFadden,
D-Baltimore, to require the state's Public Service Commission to
impose a surcharge on large commercial businesses and industry
for benefits they receive in added supply from new power plants
that are built in Maryland, even if they are served by
competitive energy suppliers instead of utilities. Before the
amendment, the measure stipulated that regulators may be
required to pay the surcharge.
Representatives from large commercial businesses have sharply
criticized the bill, saying it would lead to energy cost
overruns for large businesses.
The bill, which is supported by Gov. Martin O'Malley, is facing
serious questions by members of the House of Delegates, who have
said it's too complicated to take up with just two weeks left in
the General Assembly.
Copyright 2009 Annapolis Capital.
Treating an Illness Is One Thing. What About a Patient With
Many?
By Siri Carpenter
New York Times
Tuesday, March 31, 2009
Mazie Piccolo has so many health problems it’s hard to keep
track. Congestive heart failure makes her short of breath and
causes her legs to swell. An abnormal heart rhythm raises her
risk for stroke. Arthritis in her knees makes it hard for her to
get around, and she can no longer drive.
Mrs. Piccolo, 84, of Rosedale, Md., also has osteoporosis, and
she has fallen several times in the past few years, once
breaking her pelvis. On top of all these medical ailments and
others — high cholesterol, high blood pressure, gastric reflux —
she has a history of depression, and it is sometimes hard for
her to care for her husband, who is even frailer than she is.
Strictly by the book, Mrs. Piccolo should be taking 13 different
medications — an expensive, confusing cocktail that has proved
too much for her to manage. Other medications that might be
advisable cause intolerable side effects, and the more drugs she
takes, the greater the risk of dangerous drug interactions.
What is striking about her predicament is not how rare it is,
but how common. Two-thirds of people over age 65, and almost
three-quarters of people over 80, have multiple chronic health
conditions, and 68 percent of Medicare spending goes to people
who have five or more chronic diseases.
As a group, patients like Mrs. Piccolo fare poorly by any
measure. They linger in hospitals longer, experience more
serious preventable health complications and die younger than
patients with less complex medical profiles.
Yet people with multiple health problems — a condition known as
multimorbidity — are largely overlooked both in medical research
and in the nation’s clinics and hospitals. The default position
is to treat complicated patients as collections of
malfunctioning body parts rather than as whole human beings.
“Very often, there is nobody looking at the big picture or
recognizing that what is best for the disease may not be best
for the patient,” said Dr. Mary E. Tinetti, a geriatrician at
the Yale School of Medicine.
And treating one disease in isolation, she added, can make
another disease worse. In controlling diabetes, for example,
doctors often seek to reduce levels of a blood-sugar marker
called hemoglobin A1C. “But we know that for some people with
complicated diseases, that’s not always the best move,” Dr.
Tinetti said.
Mrs. Piccolo is being treated by Dr. Cynthia M. Boyd, a Johns
Hopkins University geriatrician whose research focuses on
patients with multiple chronic conditions.
“Doing right by patients like this is tremendously challenging,”
Dr. Boyd said. “Would she get the most benefit from lowering her
blood pressure or cholesterol level, or from being treated for
her osteoporosis, or from taking warfarin for stroke prevention?
Or is it more important to treat her depression so she can
manage her overall health better, or to try to improve her
ability to physically get around?”
The medical file for Fred Powledge, 74, is four inches thick,
with more than a dozen current diagnoses, including diabetes,
gout, chronic obstructive pulmonary disease, compressed
vertebrae, three replacement joints, two replacement eye lenses
and arthritis.
Mr. Powledge, a Maryland writer, takes almost a dozen pills a
day, as ordered by six physicians.
“Good luck and a lot of sleuthing on my part have given me
doctors whom I trust and who are mostly aware of interactions
among the drugs they prescribe,” he said in an e-mail message.
“But what’s missing is someone who can look at the big picture
and see my health as a whole.
“That falls to me alone, with the help of my very wise wife and
frequent visits to reliable Web sites,” he continued. “As our
population ages, we need some kind of overseer to juggle all the
diagnoses and prescriptions and look for conflicts and
duplications. This would also help to counteract the notion in
many people’s minds that the doctor knows best — because often
the doctor doesn’t.”
In a medical system geared toward individual organs and
diseases, there is no champion for patients with multiple
illnesses — no National Institute on Multimorbidity, no charity
Race for the Multimorbidity Cure, no celebrity pressuring
Capitol Hill for more research.
And because studies involving uncomplicated populations are
cheapest and easiest to interpret, patients with multiple
diseases are routinely shut out of drug trials. A 2007 study
found that 81 percent of the randomized trials published in the
most prestigious medical journals excluded patients because of
coexisting medical problems.
“We often don’t know what the real safety or efficacy is for
patients with multiple illnesses,” said Dr. W. Douglas Weaver,
president of the American College of Cardiology.
Pharmaceutical companies are required to study how well
particular drugs and medical devices work in the real world,
after they’ve gotten government approval. In theory, such
post-marketing studies should shed light on how best to treat
patients who have complex medical problems. But the studies tend
to include only a small fraction of patients receiving
treatment, Dr. Weaver said.
Comprehensive data registries that track all patients at a given
hospital or clinic are more promising, he said. But he added
that unless the federal government stepped in to support such
registries and pay doctors for participating, they might not be
sustainable.
Because so little research includes complicated patients,
physicians have little scientific evidence on which to base
their care. In a 2005 study, Dr. Boyd and colleagues analyzed
influential, evidence-based clinical practice guidelines used to
treat nine of the most common chronic diseases, among them
osteoporosis, arthritis, Type 2 diabetes and high cholesterol.
Fewer than half the guidelines specifically addressed patients
with multiple illnesses, and most were limited to patients with
only one coexisting disease or a small number of closely related
diseases. “We’re so far away from having perfect evidence about
how to help patients with complex health problems,” Dr. Boyd
said.
Lacking solid guidance, doctors make their best guesses about
whether a particular guideline is applicable to the patient,
said Gerard F. Anderson, a professor of health policy and
management at the Bloomberg School of Public Health at Johns
Hopkins. And “their best guesses,” he went on, “vary all over
the map.”
Time pressures intensify the doctors’ predicament. A typical
15-minute appointment leaves too little time to weigh the risks
and benefits of a complex treatment plan, much less to fully
consider the patient’s preferences and priorities.
“We don’t actually know how to weigh evidence across diseases,”
said Dr. Boyd, of Johns Hopkins, “and we also don’t know the
best ways of communicating to patients what we do and don’t
know.”
Quality-improvement measures, which tie doctors’ compensation to
how closely they follow evidence-based practice guidelines,
further complicate matters, and some worry that they provide a
financial incentive for physicians to sacrifice individualized
decision-making.
“Doctors know that it’s not right for someone to be on 15, 18,
20 medications,” said Dr. Tinetti, the Yale geriatrician. “But
they’re being told that that’s what’s necessary in order to
treat each of the diseases that the patients in front of them
have.”
Changing that will require a major investment in research,
guidelines and quality measures that include the kinds of
complicated cases doctors see every day.
“I think everyone realizes that we need to figure out how to
integrate care for our elderly patients with multiple chronic
conditions,” said Dr. Ardis D. Hoven, an internist in Lexington,
Ky., who is a trustee of the American Medical Association. “But
we’ve got a long way to go. We’re just now beginning to
verbalize this.”
Copyright 2009 The New York Times Company.
Care
Coordination: Too Expensive for Medicare?
By Anne Underwood
New York Times
Tuesday, March 31, 2009
James Lo Scalzo for The New York Times Cecilia Daub, left, and
Joanne Philleo.
A former two-pack-a-day smoker, Jude Cashman of Bethesda, Md.,
suffered chronic bronchitis and pneumonia for the last several
years of his life. Repeated hospitalizations were traumatic and
frightening. But help came to Mr. Cashman and his wife, Joanne
Philleo, in the person of Cecilia Daub, a registered nurse with
a program called Guided Care.
Ms. Daub accompanied Mr. Cashman to doctor’s visits. Between
appointments, she was available by phone to answer his questions
about symptoms and treatment. She even came to the house and
coaxed him into doing lung exercises to clear his airways —
exercises that he tended to shirk if Ms. Daub wasn’t there.
Perhaps best of all, when he was hospitalized, Ms. Daub would
come to the ward to make sure staffers knew what medications he
was taking, what allergies he had, and the names and numbers of
his various doctors. “She would comfort us and explain what was
going on,” said Ms. Philleo.
What Ms. Daub did for Mr. Cashman amounts to a radical departure
from what usually happens to patients lost in the maze of U.S.
health care. I remember the helpless feeling I had during my own
mother’s final hospitalizations a year ago. It seemed as if I
was at the wheel of a car that I wasn’t licensed to drive.
Should I authorize more invasive care? Should I agree to
additional tests and procedures that might help or hurt? Should
I put her on hospice care rather than make her suffer any
longer? I made the best decisions I could, but to this day,
wonder if I made the right choices. I would have loved a program
like Guided Care.
Judging by a three-year trial of Guided Care in the
Baltimore-Washington area, so would many others. Results showed
that patients rated the quality of their health care higher,
physicians reported increased satisfaction, and caregivers
registered lower stress levels on a measurement called the
C.S.I. — the Caregiver Strain Index. Overall health care costs
even came down by $75,000 per nurse in the first year, or $1,300
per patient. (Data from the second and third years have not been
analyzed yet.)
Such “care coordination” programs have garnered intense interest
in recent years. But as a recent study in the Journal of the
American Medical Association showed, they’re harder to implement
than you might expect. Of 15 programs included in the study,
only one reduced hospitalizations (though two others also
positively affected patient health). And none brought down
expenditures. “The best was cost neutral,” said Randall Brown,
director of health research at Mathematica Policy Research,
Inc., in Princeton, and senior author of the paper.
That’s too bad, because Medicare is desperately seeking ways to
reduce costs. And the proposed solutions are not going to make
anyone happy — increase payroll taxes, make retirees shoulder
more of the burden, reduce benefits, or cut payments to doctors
and hospitals.
If care coordination could help patients and reduce costs, too,
these programs would be more widely implemented. “We can’t spend
$200 a month to save $190,” says Mr. Brown. “What Medicare is
looking for and needs is ways to generate net savings.”
The JAMA study highlighted features of the most effective
programs, characteristics that caregivers should seek out when
enrolling family members. Among the lessons:
* Care coordinators need to interact in person with patients and
not simply deal with them by telephone.
* They must collaborate closely with the patients’ physicians.
* Services are particularly important during transitions, when
patients are entering and leaving the hospital.
* And when it comes to cost savings, the benefits are greatest
when services are directed to patients with the most complex
problems.
All four are features of Guided Care. But its $1,300 savings per
patient are hardly enough to rescue Medicare. If a program like
this were simply to break even, though, many caregivers would
consider it well worth continuing.
Ms. Philleo, for example, has no doubt that her husband received
better care as a result and possibly dodged further infections
and hospitalizations. “I call Cecilia my miracle worker,” she
said.
Jude Cashman passed away in January at the age of 79. Now Ms.
Philleo is struggling with her own health problems. In addition
to mourning her husband, she’s feeling adrift because she
herself is not part of Guided Care. Being without the assistance
of Ms. Daub, she said, “is like another loss.”
Copyright 2009 The New York Times Company.
4th
Circuit upholds Maryland funeral home law
Staff and Wire reports
Daily Record
Tuesday, March 31, 2009
RICHMOND, Va. — Maryland’s restrictions on funeral home
ownership serve a worthy goal of protecting the public and do
not excessively impair interstate commerce, a federal appeals
court ruled Friday.
The three-judge panel of the 4th U.S. Circuit Court of Appeals
reversed a Baltimore judge’s ruling that the Maryland Morticians
and Funeral Directors Act violates the dormant Commerce Clause
of the U.S. Constitution. The panel also affirmed U.S. District
Judge Richard D. Bennett’s finding that the law does not violate
the due process and equal protection clauses.
Calling the law “discriminatory and protectionist,” Clark Neily,
senior attorney for the Institute for Justice who argued the
case both in Baltimore and in Richmond for the plaintiffs, said
he “respectfully disagree[s]” with multiple aspects of the
appellate panel’s ruling and might ask the U.S. Supreme Court to
hear the case.
Since the Institute of Justice is not charging the plaintiffs in
the case for its services, “it’s not a money issue in terms of
going forward with the case,” Neily said. The libertarian
public-interest law firm, located in Arlington, Va., had also
appealed the district court ruling.
Assistant Attorney General Grant D. Gerber said the Maryland
State Board of Morticians is “very pleased with the result,”
declining to comment further.
No excessive burden
Maryland’s law limits funeral home ownership to licensed funeral
directors and the holders of 58 corporate licenses that were
issued more than 60 years ago. Only a few other states have such
a policy.
The four plaintiffs, two of whom are licensed morticians, want
to get into the funeral home business in the state and have
alleged that the law unconstitutionally stifles competition and
drives up the average cost of a funeral by $800.
Neily said the law would be equivalent to requiring the owner of
a limousine service, not just its drivers, to have a Maryland
driver’s license.
However, the appeals court said the law seeks accountability by
requiring operators to be licensed by the state board. The
plaintiffs, on the other hand, wanted to be insulated from
personal liability for negligence, the court said.
“In short, we conclude that the Morticians Act’s incidental
burden on interstate commerce is not excessive and is justified
by the very real benefits of protecting the public health,
safety and welfare by encouraging familiarity of the owner of a
funeral business with the day-to-day workings of that business
and creating accountability to regulators and to clients,” Judge
Paul V. Niemeyer wrote.
If the plaintiffs want to own funeral homes in Maryland, they
should put in the time to obtain a license or pursue their
desired change in the law through the legislature, wrote
Niemeyer.
Neily said the former option takes months or years of study and
the attendant cost. The latter idea has been tried and has
failed repeatedly — 13 times from 1997 to 2005 according to the
state’s brief. Kathleen Ellis, assistant attorney general and
deputy counsel to the Department of Health and Mental Hygiene,
had said at the district court level that “maybe the law should
be changed.”
“They’ve been going to the legislature for 10 years,” Neily
said, noting Del. Hattie N. Harrison, D-Baltimore City, has
consistently blocked those efforts.
Niemeyer was joined in the opinion by Judges William B. Traxler
and Judge Dennis Shedd, who also wrote a one-paragraph
concurring opinion.
Daily Record Legal Affairs Writer Brendan Kearney and Associated
Press Writer Larry O'Dell contributed to this article.
Copyright 2009 Daily Record.
National / International
Court
ends Philip Morris appeal of $79.5M award
Associated Press
Daily Record
Tuesday, March 31, 2009
WASHINGTON — The Supreme Court on Tuesday threw out a cigarette
maker's appeal of a $79.5 million award to a smoker's widow,
ending a 10-year legal fight to keep her from collecting.
In a one-sentence order, the court left in place a ruling by the
Oregon Supreme Court in favor of Mayola Williams. The state
court has repeatedly upheld a verdict against Altria Group
Inc.'s Philip Morris USA in a fraud trial in 1999.
The judgment has grown to more than $155 million with interest,
and Williams stands to collect between $60 million and $65
million, before taxes and payments to her lawyers, said Robert
Peck, her Washington-based lawyer.
The justices heard arguments in the case in December, but said
Tuesday that they are not passing judgment on the legal issues
that were presented. Instead, it is as if the court had declined
to hear the case at all.
Philip Morris had argued that the award should be thrown out and
a new trial ordered because of flaws in the instructions given
jurors before their deliberations.
Business interests had once hoped the high court would use the
case to set firm limits on the award of punitive damages,
intended to punish a defendant for its behavior and deter a
repeat offense.
Peck said the court has signaled a willingness to allow large
awards in certain circumstances. "I think we can take from this
long tale that if the behavior is sufficiently reprehensible,
then larger awards are merited," Peck said.
Murray Garnick, Altria's associate general counsel, said the
decision does not undo earlier high court rulings setting limits
on punitive damages. "While we had hoped for a different
outcome, the Supreme Court has decided not to review a narrow
procedural ruling by the state court," Garnick said.
The case has bounced around appellate courts since 1999, when
Williams convinced a jury that Philip Morris should be held
accountable for misleading people into thinking cigarettes were
not dangerous or addictive.
Williams' husband Jesse was a janitor in Portland who started
smoking during a 1950s Army hitch and died in 1997, six months
after he was diagnosed with lung cancer.
His widow was awarded $800,000 in actual damages. The punitive
damages are about 97 times greater. A state court previously cut
the compensatory award to $521,000.
The company pegged the size of the award at $143 million a year
ago because of accrued interest. At an interest rate of 9
percent a year, authorized by Oregon law, the pot now exceeds
$155 million. Sixty percent of it would go to an Oregon crime
victims fund, although the company said Tuesday it plans to
contest the portion owed the state.
The Oregon high court made its first decision in 2002, refusing
to hear an appeal from Philip Morris.
Then the U.S. Supreme Court rejected the judgment of nearly $80
million, saying in another case that damages generally should be
held to no more than nine times actual economic damages. It
declined, however, to make that a firm rule.
Next, the Oregon Supreme Court upheld the punitive damages,
citing "extraordinarily reprehensible" conduct by Philip Morris
officials.
Then came the U.S. Supreme Court's second take on the case. In
2007, the court said in a 5-4 decision that jurors may punish a
defendant only for harm done to someone who is suing, not other
smokers who could make similar claims.
The state court was told to reconsider the award in the context
of instructions for the trial jury that Philip Morris proposed
and the trial judge rejected.
In January, the Oregon court said there were other defects in
the instructions that violated Oregon law, and supported the
trial judge's decision not to give the proposed instructions to
the jury.
The case is Philip Morris USA v. Williams, 07-1216.
Copyright 2009 Daily Record.
Avoid pistachios, FDA
warns
Associated Press
Baltimore Sun
Tuesday, March 31, 2009
FRESNO, Calif. - Federal food safety officials warned Monday
that consumers should stop eating all foods containing
pistachios while they figure out the source of a possible
salmonella contamination.
Still reeling from the national salmonella outbreak in peanuts,
the Food and Drug Administration said California-based Setton
Farms, the nation's second-largest pistachio processor, was
voluntarily recalling all of its 2008 crop - more than 1 million
pounds of nuts.
"Our advice to consumers is that they avoid eating pistachio
products, and that they hold onto those products," said Dr.
David Acheson, assistant commissioner for food safety. "The
number of products that are going to be recalled over the coming
days will grow, simply because these pistachio nuts have then
been repackaged into consumer-level containers."
Two people called the FDA, complaining of gastrointestinal
illness that could be associated with the nuts, but the link
hasn't been confirmed, Acheson said. Still, the plant decided to
shut down late last week, officials said.
The recalled nuts represent a small fraction of the 60 million
pounds of pistachios that the company's plant can process each
year and an even smaller portion of the 278 million pounds
produced in the state in the 2008 season, according to the
Fresno-based Administrative Committee for Pistachios.
California is the second-largest producer of pistachios in the
world.
The FDA learned about the problem last Tuesday, when Kraft Foods
Inc. notified the agency that it had detected salmonella in
roasted pistachios through routine product testing. Kraft and
the Georgia Nut Co. recalled their Back to Nature Nantucket
Blend trail mix the next day.
The FDA contacted Setton Farms and California health officials
shortly afterward.
By Friday, grocery operator Kroger Co. recalled one of its lines
of bagged pistachios because of possible salmonella
contamination, saying the California plant also supplied its
nuts. Those nuts were sold in 31 states.
Because Setton Farms shipped 2,000-pound bags of nuts to 36
wholesalers across the country, it will take weeks to figure out
how many products could be affected, said Jeff Farrar, chief of
the Food and Drug Branch of the California Department of Public
Health.
"It will be safe to assume ... that this will be an ingredient
in a lot of different products, and that may possibly include
things like ice cream and cake mixes," he said.
Setton Farms, based in Terra Bella, Calif., did not immediately
respond to calls for comment.
Copyright 2009 Baltimore Sun.
Tuberculosis: H.I.V. Infection Sharply Raises Risk for TB,
Report Says
By Donald G. McNeil Jr.
New York Times Global Update
Tuesday, March 31, 2009
One-quarter of all deaths from tuberculosis are in patients also
infected with the AIDS virus, twice as many as previously
thought, the World Health Organization said last week.
In its annual Global TB Control report, the organization said
that being infected with the virus can increase the risk of
developing tuberculosis by 20 times.
Up to one-third of the world’s people are infected with
tuberculosis bacteria, but the infection usually is dormant
unless the immune system is weakened by malnutrition,
alcoholism, drug abuse, immunosuppressive drugs, AIDS or other
causes.
About 9.3 million people develop TB each year, the report said,
and 1.8 million die. About 456,000 are counted as AIDS deaths
because the victims have both.
The apparent jump in dual cases is not because of a leap in
infections but because African countries are doing a better job
of testing patients for both diseases.
Curing a typical tuberculosis infection requires taking four
different antibiotics daily for six months. But resistance to
those drugs is a growing problem. About 500,000 people now have
multi-drug-resistant tuberculosis, which is common in Eastern
Europe and in the countries of the former Soviet Union, as well
as in China and India. Fewer than 1 percent of them are
receiving care that meets W.H.O. standards, which includes daily
injections of toxic drugs for two years.
More than 50 countries have reported cases of XDR-TB, the
extensively drug-resistant form. Many of those patients die
quickly despite treatment.
Doctors Without Borders said after the report’s release that TB
was “spiraling out of control.”
The headline on an earlier version of this article referred
incorrectly to AIDS. It is the syndrome that is a result of
infection with H.I.V., not the infection itself.
Copyright 2009 The New York Times Company.
For This Health
System, Less Is More
Program That Guarantees Doing Things Right the First Time, for
Flat Fee, Pays Off
By Ceci Connolly
Washington Post
Tuesday, March 31, 2009; A01
DANVILLE, Pa. -- You could think of them as the Maytag repairmen
of health care.
In an industry that makes its money by selling more -- more
tests, more surgeries, more drugs -- Geisinger Health System
officials gambled three years ago that they could succeed by
doing less, but doing it better.
Mimicking the appliance company that advertised its products'
reliability, the health system devised a 90-day warranty on
elective heart surgery, promising to get it right the first
time, for a flat fee. If complications arise or the patient
returns to the hospital, Geisinger bears the additional cost.
The venture has paid off. Heart patients have fared measurably
better, and the health system has cut its bypass surgery costs
by 15 percent. Today, Geisinger has extended the program to half
a dozen other procedures, and initiatives such as the
counterintuitive experiment in Pennsylvania coal country are now
at the heart of efforts in Washington to refashion how care is
delivered across the United States.
Though not identified by name, the Geisinger model tracks
closely with the policy goals of President Obama. A key target
is to reduce expensive errors, duplication, and unnecessary
procedures that do nothing to improve health and may actually
result in worse outcomes.
Nearly 18 percent of hospitalized Medicare patients are
readmitted within 30 days, an expense that experts argue can be
reduced dramatically by doing things right the first time.
Geisinger, which runs the program through its own insurance
unit, is "proving that reliability works," said Donald Berwick,
president of the independent Institute for Healthcare
Improvement.
But its success has been limited. Geisinger also treats patients
who are insured by other companies, and those insurers are not
convinced that the savings would be large enough to make it
worthwhile for them to renegotiate contracts with the health
system. Many still feel more comfortable with the traditional
pay-per-procedure approach, even though they run the risk of
having to pay thousands of dollars to fix surgeries that go
wrong.
Most hospitals are also skeptical of Geisinger's innovation,
saying they would lose money by being unable to bill for
treatment of patients who must return.
"If they do the right thing and keep patients out of the
hospital, it costs them," said Glenn Steele Jr., Geisinger's
president and chief executive.
The budget Obama sent to Congress advances the Geisinger
approach by taking direct aim at hospital readmissions.
Administration officials estimate that "bundling" Medicare
payments for certain procedures such as bypass surgery and
imposing financial penalties on hospitals with high readmission
rates will save taxpayers $26.2 billion over the next decade.
Geisinger, a comprehensive system of 41 clinics, three hospitals
and 650 staff physicians, achieves those goals through
standardization. Science-based protocols are "hard-wired" into
the process, in much the same way that high-end manufacturing
works, said Alfred S. Casale, Geisinger's associate chief
medical officer and a driving force behind the program.
For heart bypass surgery, Geisinger guarantees that every
patient will receive 40 action items it has identified as best
practices. The list includes, for example, properly
administering antibiotics within 30 minutes of the operation.
The wrong dose increases the likelihood of infection, and
infection can lead to a second surgery, prolonged
hospitalization and greater risk of death.
Surgeons can opt out of doing any element if they give a reason,
and an operation is canceled if a single step is missed in the
preparations. Electronic medical records contain built-in
reminders for the surgical team and track the results.
"No one thing on the list is magic," Casale said. "It's the
reliability of knowing that every single one is going to get
done on every single patient. That is the magic."
Cutting Out the Quirks
Just a few years ago, when a patient showed up in the cardiac
unit at one of Geisinger's hospitals, the first question nurses
asked was "Whose patient is he?" -- referring to the six
surgeons on staff.
"What they did next depended more on who the doctor was than on
what was going on with the patient," Casale said. It was not
that one surgeon was better or smarter than the others, but that
each had his own quirks and habits.
"We couldn't even agree on which side of the room the bed should
be on," he said with a laugh.
The Geisinger program, marketed as ProvenCare, eliminates the
guesswork, or "variability," by requiring every employee to
follow an agreed-upon set of best practices. For heart surgery,
many of the steps came from guidelines developed by the American
Heart Association and the American College of Cardiology.
"They have been really smart about not reinventing the wheel,"
Berwick said.
Geisinger doctors initially recoiled at the idea of "cookbook
medicine," believing they already followed best practices,
Casale said.
Far from it, they soon discovered. At the start, three years
ago, only 59 percent of patients received all 40 critical
elements.
Within three months, the cardiac team hit the 100 percent mark,
but three months later it fell to 86 percent. Since then, it has
held at 100 percent, and Geisinger patients spend less time in
intensive care, go home sooner and experience fewer
complications. The in-hospital death rate on elective heart
surgeries has dropped from 1.5 percent to zero.
Standardizing bypass surgery has saved Geisinger money on
ventilators, blood products and staff time. Readmissions, which
can be more expensive than the original surgery, have fallen 44
percent, according to Geisinger's data.
Customers -- namely large employers that purchase Geisinger
insurance -- save money with the guaranteed flat fee. The price
is based on the standard cost of the surgery, plus half the
average cost of complications over the previous two years.
Patients are not charged co-payments for any complications or
readmissions.
"In our industry, if we make a product, we stand behind it,"
said Glenn Salsman, controller for the modular home manufacturer
Integrity Building Systems, which has signed up for ProvenCare.
"Now we know that things are going to cost what they say they
are going to cost."
Repairs on the Spot
Dressed in scrubs and goggles, physician Kimberly Skelding
threads a tube into Nellie Whipple's wrist. With eyes locked on
a computer screen above, Skelding guides the tube through the
patient's vein, up the arm, over the shoulder, across the chest
and into the heart chamber.
Whipple's doctor had suggested the visit to Geisinger's cardiac
catheterization unit after the 56-year-old complained of
shortness of breath and jaw pain. Inside the bustling "cath
lab," Skelding and colleagues use X-ray technology to scan
Whipple's arteries and heart for clots, breakages or other
problems.
As a nurse squeezes a small pump, dye flows through the tube and
brings Whipple's arteries into sharp view on the monitor.
"She has some heart disease, but she doesn't have severe
blockages," Skelding reports, as a technician types the data
into Whipple's digital health record.
About 10 months ago, after implementing the ProvenCare model for
bypass surgery, hip replacements and cataract operations,
Geisinger added cath lab procedures to the program. The list of
best practices includes checking for allergies, monitoring dye
levels and giving bicarbonate to reduce the risk of kidney
failure.
"It's a good idea," said James Roberts, a chief technician who
has been at Geisinger for 21 years. "Honestly, some things get
missed."
It is too soon to measure results in the cath lab, but making
the entire process more efficient has given Geisinger the
ability to repair artery problems on the spot. Most hospitals
require a second procedure, which increases the cost and the
risk of complications.
That was part of what pleased Earl Graham. An athletic retired
professor, Graham was sent to Geisinger's cath lab after a
less-than-stellar stress test.
"I was lying there on the table and they said they'd found a
little obstruction," he recounted. The doctor asked Graham if he
wanted a stent inserted to open the clogged artery. "I said
yes."
The next morning he was heading home, and within a month he was
back on the tennis court. "It was all done quite efficiently,"
he said.
Next on Geisinger's list: prenatal care and treatment of
lower-back pain.
Copyright 2009 Washington Post.
The
Checkup
Health in the News and in Your Life
By Rob Stein
Washington Post
Tuesday, March 31, 2009; HE02
Circumcise Your Son?
There's new evidence that men who are circumcised are less
likely to get infected with sexually transmitted viruses,
according to a study published in the New England Journal of
Medicine.
Previous research had found that men who were circumcised were
50 to 60 percent less likely to get infected with the AIDS
virus. Now, researchers have found that circumcision also
significantly reduces a man's risk of being infected with the
herpes simplex virus type 2 (HSV-2), which causes genital
herpes, and the human papillomavirus (HPV), which can cause
genital warts in men and cervical cancer in women.
Researchers at the Johns Hopkins University Bloomberg School of
Health in Baltimore and at the Rakai Health Sciences Program and
Makerere University in Uganda examined data collected by two
studies involving 3,393 men in Uganda ages 15 to 49.
Copyright 2009 Washington Post.
Study: Plavix plus aspirin helps prevent strokes
Associated Press
By Marilynn Marchione
Washington Post
Tuesday, March 31, 2009
ORLANDO, Fla. - Taking the blood thinner Plavix along with
aspirin helped prevent strokes and heart attacks in people with
a common heartbeat abnormality that puts them at high risk of
these problems, doctors reported Tuesday.
The treatment is for atrial fibrillation, a rhythm disorder that
2.2 million Americans have. It occurs when the upper parts of
the heart quiver instead of beating properly. This allows blood
to pool and form clots that can travel to the brain, causing a
stroke.
The usual treatment is the blood thinner warfarin, sold as
Coumadin and in generic form. But finding the right dose is
tricky - too little and patients can have a stroke; too much and
they can have life-threatening bleeding. Patients on the drug
must go to the doctor often for blood tests to monitor their
dose.
For these reasons, as many as half of patients take aspirin
instead of warfarin, even though aspirin is much less effective
at preventing strokes.
Dr. Stuart Connolly of McMaster University in Hamilton, Ontario,
led a study testing whether adding clopidogrel, sold as Plavix
by French-based Sanofi-Aventis SA, could help.
The study involved 7,554 patients in the United States and 32
other countries who were not able or chose not to take warfarin.
All were treated with aspirin; half also were given Plavix.
After nearly four years of followup, the dual drug treatment
lowered a combined measure - heart attacks, heart-related
deaths, strokes and blood clots - by 11 percent. There were 924
of these problems in patients on aspirin alone but only 832 in
those also getting Plavix.
However, the combination treatment raised the risk of serious
bleeding - 251 cases versus 162 for those on aspirin alone.
Doing the math, patients still come out ahead on the
combination, Connolly said. For every 1,000 patients treated for
three years, it would prevent 28 strokes and six heart attacks,
and lead to 20 bleeding cases. Bleeding often is treated with
transfusions and is not as likely to prove fatal.
"For the first time in 20 years, there's a new treatment for
atrial fibrillation," Connolly said.
Results were presented Tuesday at an American College of
Cardiology conference and published online by the New England
Journal of Medicine.
The study was sponsored by Sanofi, and Connolly and other
authors have consulted for the company. Plavix costs about $4 a
day.
"Warfarin was, and remains, first-line therapy - this does not
change that," said Dr. Richard Page, cardiology chief at the
University of Washington School of Medicine in Seattle and an
American Heart Association spokesman.
But for those who can't tolerate it, the Plavix-aspirin combo
gives a better option than aspirin alone, he said. Page has
consulted for Sanofi in the past.
On Saturday, other doctors at the cardiology conference reported
on another potential treatment for atrial fibrillation - an
experimental heart device called the Watchman aimed at
preventing clots from reaching the brain. A federal Food and
Drug Administration panel meets to consider it on April 23.
On the Net:
Cardiology meeting:http://www.acc.org
Medical journal:http://www.nejm.org
© 2009 The Associated Press.
Vitamin D Pills May Prevent Fractures in Older Adults
By Nicholas Bakalar
New York Times
Friday, March 31, 2009
Vitamin D supplements may help prevent fractures in people over
65, provided they take enough of the right kind. A new review of
clinical trials appears to show a strong dose-dependent effect
for vitamin D in lowering the risk for nonvertebral fractures in
the elderly.
The lead author of the analysis, Heike A. Bischoff-Ferrari, a
professor of medicine at the University of Zurich, said that
“vitamin D in a high enough dose is not only beneficial in the
frail older population, but it also works in those still living
at home and able to take care of themselves.”
The researchers, writing in the March 23 issue of The Archives
of Internal Medicine, reviewed 12 randomized trials that
together included more than 65,000 subjects. Doses under 400
international units a day had no discernible effect, but for
doses larger than that, the pooled data showed a 20 percent
reduction in the risk for all nonvertebral fractures, and an 18
percent reduction for broken hips.
The type of vitamin D made a difference. The effect of vitamin
D3 was significant, with a 23 percent risk reduction, but there
was no significant reduction with vitamin D2. The authors
suggest that D3 is more effective in maintaining blood levels of
25-hydroxyvitamin D, the active form that the supplement takes
in the body.
Copyright 2009 The New York Times Company.
Opinion
Medical marijuana
Our view: Maryland is sending mixed messages about the use of
marijuana for people with serious illnesses who are in need of
relief
Baltimore Sun Editorial
Tuesday, March 31, 2009
For patients suffering from cancer and other debilitating
illnesses, the medical use of marijuana can relieve symptoms
such as pain, inflammation and nausea in many cases. Currently,
13 states, including California, Colorado, Maine, Michigan,
Rhode Island and Vermont, allow the medical use marijuana with a
doctor's approval or certification. And although possession of
the drug remains illegal under federal law, U.S. Attorney
General Eric Holder said last week that the Justice Department
will no longer go after small dispensaries that sell cannabis
for medical use so long as they comply with state laws.
For all these reasons, a bill sponsored by Montgomery County
Del. Henry B. Heller that would require the state Department of
Health and Mental Hygiene to rethink Maryland's policy on
medical marijuana deserves serious consideration.
Delegate Heller's bill does not propose legalizing marijuana; it
would not give drug dealers a license to peddle their wares.
Rather, it would create a task force of health professionals to
study the legal and practical implications of allowing marijuana
to be used solely for medical purposes. At the very least, it
would encourage officials to confront the glaring
inconsistencies in state law so that patients, physicians and
operators of medical marijuana dispensaries would know exactly
where they stood.
Right now, the state is sending mixed signals about the legality
of marijuana for medical use. In 2003, the General Assembly
sharply reduced penalties for patients convicted of marijuana
possession if they could prove a medical necessity in court. But
people with serious illnesses can still be arrested and fined up
to $100 for possession, even if they prove a medical necessity.
Mr. Heller says the 2003 law has had the unintended consequence
of giving people a "false sense of security." He cites
constituents in a senior citizens home who say they want to use
marijuana to relieve symptoms of major illnesses but don't want
to break the law.
As Maryland's population ages and more people experience chronic
health problems that could be successfully treated with medical
marijuana, state officials will need to draw a bright line
between legal and illegal use of the drug that sends a
consistent message to the public. The study proposed by Delegate
Heller is a first step toward a resolution of this matter.
Copyright 2009 Baltimore Sun.
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