Monday, November 30, 2009
Hopefully by now people are realizing that more is not necessarily better. A new study reported at the American Heart Association 2009 Scientific Sessions showed that patients with acute myocardial infarction (AMI) receive large doses of ionizing radiation per hospital admission.
They looked at patients treated at 55 academic hospitals and found, on average, each patient received seven studies per AMI admission. The studies included chest X-rays, chest CT, head CT, nuclear perfusion testing and cardiac catheterization, which added up to about 17.31 mSV of ionizing radiation. The average American receives 3mSV annual radiation from natural sources and 50 is the max exposure allowed in the workplace.
Ionizing radiation has the ability to affect the large chemical molecules of which all living things are made and cause changes which are biologically important.
The researchers did not say that the tests were not indicated. But they pointed out that physicians need to carefully evaluate the indications for tests involving radiation and consider decreasing the dose based on the admitting diagnosis.
With various specialists ordering tests looking at their specific body part, someone needs to be tracking the patient's total radiation dose. We have learned that there is great variation across the country in testing and procedures done, depending upon where the patient is and where the doctor trained. It may be time to take a look at cardiovascular imaging tests and determine if over testing is occurring.
Saturday, November 28, 2009
After a holiday weekend of movie-going and eating that popcorn that smells so good in the theater, it was a shock to read the report from the Center for Science in the Public Interest that shows just how bad theater popcorn is. The researchers studied medium size popcorn from three large movie chains; Regal Entertainment Group, AMC and Cinemark.
The analysis showed that a Regal medium popcorn contains 1,200 calories and 60 grams of saturated fat. AMC popcorn was a "smaller" medium and contained 590 calories and 33 grams of saturated fat. This was before adding the butter topping. Cinemark wasn't much better at 760 calories but it only had 3 grams of saturated fat.
Kudos to Cinemark for popping their corn in canola oil with less saturated fat. The other chains use heart unhealthy coconut oil, which is about 90% saturated fat. Lard is 40% saturated!
The study showed that a $12 medium popcorn and soda combination at a Regal movie would be the equivalent of three McDonald's Quarter Pounders with 12 pats of butter.
Do you want soda with your popcorn? A 54 ounce large soda at Regal has 33 teaspoons of sugar and 500 empty calories.
Taking the family to a movie should be a treat. Giant portions of heart unhealthy food are making us fat. See the movie, skip the snacks.
Great movie tip: "Precious". See it for the academy award performances and the amazing, heartrending story.
Tuesday, November 24, 2009
Here is an idea of how to kick off the Holiday and Thanksgiving season. Take the 29 Day Giving Challenge! The idea comes from Cami Walker, the young woman who founded 29 Gifts. The principle is easy. Commit to giving 29 gifts in 29 days. The gifts can be time, money, objects, advice, kindness, something you think you can't live without. There are no rules.
Can giving to others change your life and health? Can we make a shift in our thinking by changing our behavior? Cami Walker says it is a powerful way to change ourselves as we change the world, one gift at a time. It makes sense that just staying in a conscious mode of "giving" and deciding what to give each day could make a real difference in how one views the world.
I'm going to do it. If you start on Thanksgiving day...it is 29 days until Christmas Eve. Lovely.
The movement for physicians to say "I'm sorry" when things go wrong in patient care has been under debate for the past few years. In the past, physicians were advised to never admit to a problem or to apologize for clinical errors with the thought that it would lead to more lawsuits. Saying "I'm sorry" might be taken by a lawyer as an admission of guilt and malpractice. Attorneys advised, "Say nothing" but that left patients with unanswered questions and often the feeling that the doctor just didn't care.
Numerous studies have shown that patients want physicians to disclose harmful errors and they want information about what happened, why it happened and if something has been done to keep it from happening again. There has been a gap between what patients want and what actually occurs.
Physicians are not trained to disclose mistakes and being stoic is rewarded more than empathy in medical training. Many lawsuits are filed against doctors because of anger so the silent approach that physicians have taken may actually be backfiring.
There is a group called "Sorry Works" that teaches doctors and nurses to be empathetic, caring and stay connected with patients and families when an adverse event occurs. The honest approach reduces anger and blame and often removes the urge to pursue litigation.
Thirty-five states have passed apology immunity laws that say "sorry" cannot be used as evidence of wrong doing.
There is certainly no way anyone can prevent a lawsuit. Saying "I'm sorry", without admitting guilt should be in the doctors professional code of ethics and behavior.
Thanks to KM for alerting me to the Massachusetts woman who wants help to pay for eye surgery for her pet turkey named Jerry. It seems Jerry has cataracts and he can't see his food to eat independently or fly with his girlfriend turkey, Penelope.
The cataract surgery for Jerry could cost up to $2,600, according to his owner. Medicare pays $2,338 total (including surgeon, facility fee and anesthesia) for a cataract extraction.
Jerry is one lucky turkey, especially this close to Thanksgiving.
Sunday, November 22, 2009
One of the best things you can do for your aging granny or grandpa is get them online. Ninety two percent of American ages 18-29 use the internet and email. But for folks older than 65, the rate falls to 42%.
Why is it important to get seniors on line? A recent study by the Phoenix Center for Advanced Legal and Economic Public Policy Studies (they need a better name), a non-profit Washington think tank, shows that seniors who are on the computer cut the incidence of depression by 20%.
Another recent study from UCLA showed that first time use of the internet by older people enhanced brain function and cognition. Even performing internet searches changed brain activity patterns and enhanced neuro function. They performed brain scans on participants after they were on line and found enhancement in the areas known to be important in working memory and decision-making.
So if you are wondering about that perfect gift for your grandparents...think about a computer with internet access. Soon they'll be twittering up a storm and maybe even posting their own blogs.
Saturday, November 21, 2009
Neckties worn by physicians may be contaminated with dangerous bacteria and viruses that are transported from patient to patient. The British Medical Association made a decision in 2006 that doctors should forgo wearing neckties because they carry germs and bacteria. The American Medical Association is looking at the same issue.
Stethoscopes are draped across ties, patients sneeze on them and neckties are worn repeatedly without being washed. A study from 2004 at New York Hospital Medical Center at Queens showed half of the neckties worn by the study doctors harbored bacteria, including MRSA.
If an article of clothing has no function and may be contaminated, I say why wear it? I doubt that given the choice of a dressed up doctor vs a clean doctor, patients would choose the necktie.
Personally, I think we should all be wearing scrubs in the hospital and in the office. They are comfortable, professional and clean. I would welcome saving $$ on clothes and dry cleaning. Or what about the old Dr. Kildare look?
What do you think? Is it time for men physicians to lose the tie?
Friday, November 20, 2009
We have been talking about women's health for the past week. Now it is time to discuss men's health. The Sexual Medicine Society of North America met in San Diego and heard reports on a new spray to prevent premature ejaculation in men.
The drug maker Sciele Pharma, Inc, a division of Japan's Shinogi has been testing the new spray that contains the numbing agents lidocaine and prilocaine. The researchers from San Francisco tested 300 men who used the spray on their penis five minutes before intercourse. The men were able to last 2.6 minutes. (compared to less than a minute without the spray).
They did not address what happened to the woman, who probably experienced some of the topical spray anesthetic herself via contact! I don't mean to sound glib, but the new spray strikes me as a biochemical fail! It is hard for me to see how this would be considered a success.
Sciele Pharma plans to file for U.S. approval next year.
Right in the middle of the national firestorm about Mammogram recommendations, the American College of Gynecologists (ACOG) has issued new guidelines for screening of cervical cancer. After 40 years of successfully convincing women to get pap smears annually, the new recommendations say women should not get their first pap test until age 21 and the intervals for testing can then be stretched out.
The new recommendations say that women should start pap screening at age 21 (not teens who are sexually active as previously recommended) and then every two years through age 29. Women age 30 and over with three negative pap smears can stretch it out for three years. Women over age 65 can stop getting pap tests if their previous tests have been negative. Women who have had a hysterectomy for non-cancer reasons never need a pap smear.
The study experts looked at pooled data from around the world. We now know that cervical cancer is caused by certain strains of Human Papillomavirus (HPV), however most women infected with HPV will not develop cervical abnormalities. Most women who contract HPV have an effective immune system that clears the virus. Paps that are done too frequently can show abnormalities that would, in the majority of cases, clear spontaneously.
The researchers also found that pap tests are difficult to interpret and there is inconsistency among cytologists reading the slide. Upon a second review, most results that were reported as showing abnormalities were downgraded to normal.
The study points out that abnormal pap tests lead to a sequence of further testing, biopsies and excisional procedures that can adversely affect a young woman's reproductive health.
In summary, the new guidelines recommend:
- Start pap smears at age 21 regardless of prior sexual activity (no need at all in virgins).
- Test every 2 years to age 30
- After age 30, test every 3 years if prior tests are normal
- Stop at age 65 if prior tests have been negative.
- No paps needed for women who have had hysterectomy if there was no cancer
The 12 page recommendations from ACOG can be found here.
Thursday, November 19, 2009
As I predicted, the controversy and backlash against the recommendation to change mammogram screening to women over age 50 is huge. Special interest groups are coming out of the woodwork and every woman who found a breast cancer by mammogram has been interviewed by CNN and Fox news. Here is my 2¢.
We have thousands of tests we can perform on people. Why not perform these tests on everyone? Lung cancer is more prevalent than breast cancer and it shows up in young women with no risk factors. Why don't we get Chest X Rays on everyone every year? Why don't we get EKGs or thyroid scans on everyone every year to find silent heart attacks or thyroid nodules? Why not get CT scans annually? That way we could find early adrenal, kidney, brain or pancreatic cancer.
The decisions about screening exams for the population are made by scientific groups like the USPSTF. There is often confusion because other groups like the American Cancer Society and other specialty medical groups (Radiologists, Surgeons, Urologists, Cardiologists, Republicans and Democrats) also offer their own recommendations. Those groups are not impartial and can be influenced by politics or gain.
The impartial and independent physicians and scientists are crucial for making recommendations for the Nation.
The USPSTF studied over 500,000 women for more than a decade. They found that yearly Mammograms in women under 50 could possibly be detrimental to health. The effects of excessive radiation have been known for decades. They based their screening recommendation on the best and current science that is now available.
Mammograms do save lives by detecting early cancer. Other tests can also detect early cancer but determining where the benefit of the tests exceed the risk (in both $$ and health ) is the goal before we recommend mass screening. Some women have breast cancer in their 30's. Why not start screening at age 30? It is because we have determined that the risk exceeds the benefit. The new recommendations are saying the same thing for under age 50.
I will continue to prescribe mammograms to women younger than 50 if the woman wants it. I have never believed there is a magic age (40?, 41?) that made logical sense. We must keep in mind that detecting cancer is not the same as preventing cancer. We have not yet found a way to do that.
Wednesday, November 18, 2009
This weeks medical challenge should be pretty easy for readers of EverythingHealth. Which one of the following drugs of abuse causes the abnormality in the photo? (click on image for a better view). Show us how smart you are!
The answer will be posted tomorrow.
Tuesday, November 17, 2009
For years women have been advised to have an annual mammogram starting at age 40. The advice and insurance coverage for mammograms has been so effective that nearly 2/3 of women over age 40 had mammograms. Scratch that advice. The new guidelines, published in the Annals of Internal Medicine will spark a wave of controversy. Women are now advised NOT to have screening mammograms until age 50 and then to space them every other year. The United States Preventive Services Task Force, an independent panel of experts, says the new guidelines were based on new data and analysis and were aimed at reducing the harm of overscreening.
Why the switch? The report says the risk/benefit of mammogram just doesn't pan out for women age 40-49. The task force said that once cancer death is prevented for every 1,904 women who are screened for 10 years in the 40-49 age range. As a woman ages, her risk of cancer increases so one death is prevented for every 377 women screened at age 60-69.
Mammograms often detect abnormalities that are not serious. These false positives cause women to undergo more testing and biopsies that can cause harm. The Task Force recommends the way to get the most benefit and the least harm is to start screening at age 50 and have approximately 10 mammograms in a lifetime.
The new advice will undoubtedly change the insurance and Medicare coverage for mammograms. Already the group that "grades" health plans on quality, the NCQA, is changing the measure for mammograms to women over age 50, every two years.
We can expect an outcry from women who had an early mammogram and it "saved my life". People will say it is part of "Obamacare" and meant to save billions of dollars ( BTW, it will save $billions) but they would be wrong as the USPSTF is probably the most impartial scientific group around.
The new guidelines do not apply to women with genetic markers or family history of early breast cancer. Let the debates begin.
Monday, November 16, 2009
It was interesting to read the results of my little poll, "Do You Have Health Insurance". The readers of EverythingHealth that chose to participate don't exactly match the population at large.
40% have insurance through their employer
10% buy their own insurance coverage and another 10% have a high deductible so that means they most likely pay the full cost of claims too.
12% are covered by Medicare, Medicaid or the VA. (In the normal population it is about 50%).
22% have no coverage. That is about average for the U.S.
4% of readers have government coverage (probably foreign).
So, 42% of readers are paying their own health costs through buying insurance or paying out of pocket for medical costs. 52% of readers have government or employer based insurance. It doesn't quite add up to 100% but you get the drift.
Saturday, November 14, 2009
When patients see a medical license framed on a doctor's wall, they assume his credentials have been checked and that the state has done due diligence about his practice behavior. That wasn't the case for patients who saw Dr. Ben D. Ramaley in Greenwich, Conn. In 2002 he performed insemination on a woman patient, but he did not use the husbands sperm. Twins were born but the husband was black and the mom was white and the twins did not look bi-racial. The couple did a paternity test that proved the husband was not the father. The couple filed a lawsuit months later and charged the doctor with using HIS OWN SPERM. The lawsuit was settled in 2005 without the doctor ever undergoing a DNA test. He did admit to using "the wrong sperm" for the insemination.
In 2006, the Dept of Public Health launched an investigation into his care practices. They found numerous problems including other instances where the standard of care had been seriously violated. His record keeping was poor and there was no systems to verify and maintain identity of the sperm sample. No DNA analysis was done on him to confirm if he used his own sperm.
In 2008, Dr. Ramaley received a $10,000 fine from the state and was allowed to continue practicing medicine. He has a unrestricted license. He continues to practice in Southport, Conn. There would really be no way any of his patients would know about this case or assume he is anything but a wonderful fertility doctor.
I have no idea if Dr. Ramaley used his own sperm to inseminate a patient. We cannot know if the fact that the husband was black played any role in the "accidental" switch of sperm. What we do know is that a physician did not practice to the standards that are expected and the error was an "extreme and outrageous act".
Doctors rights to fair process are paramount in a democratic society. But patients have rights too and it is up to the State to protect the rights of patients to know that a doctor's license meets certain standards of care.
Friday, November 13, 2009
The FDA's Arthritis Advisory Committee has approved a new treatment for treating advanced Dupuytren's disease. If approved, this would be the first nonsurgical therapy for the disorder.
Dupuytren's disease (named for Guillaume Dupuytren, 1778, of course) is a formation of scar tissue under the skin of the palm of the hand. This scar tissue pulls the flexor tendon of the fingers and causes the fingers to slowly be pulled into a grip. Over time, the contracture progresses and the skin is pulled in a fixed flexed position. Dupuytren's disease is inherited and it occurs mainly in males.
When the Dupuytren contracture was bad enough, the only treatment previously was surgical release of the scar tissue. (see image above...yikes) Even after surgery, the disease can recur. The new treatment is an injectable biologic treatment that breaks down collagen. The bacterium Clostridium histolyticum, is injected into the cord at 4 week intervals for three injections. In double blind studies, patients treated with collagenase clostridium had almost a complete reduction in contractures compared with those who received placebo.
Ain't science wonderful?
Thursday, November 12, 2009
The readers of EverythingHealth are so darn smart! Most of you knew that the swollen finger joint with the yellowish white material under the skin was gout. Gout is a disease with elevated levels of uric acid in the bloodstream. The crystals of urate are deposited in joint cartilage and cause painful attacks of acute arthritis. Any joint can be affected but the large toe is the most common. Approximately 75% of first attacks are in the large toe.
Gout occurs more often in men than in women. There are probably some genetic causes of gout as well as excessive alcohol use and untreated hypertension, hyperlipidemia and certain medications.
I have blogged before about the association of high fructose corn syrup and gout attacks. There is also evidence that Vitamin C supplements can prevent gout.
Wednesday, November 11, 2009
This weeks image challenge is a good one. Click on the photo for a better view. This 52 year old man has a painful index finger. What is the diagnosis?
4. Rheumatoid Arthritis
5. Septic Arthritis
Be brave and make your best diagnostic comment. Check back tomorrow for the answer.
Tuesday, November 10, 2009
Marlene is a single stepmom who is raising the two children of her deceased sister. They live in a cramped apartment and stretch a dollar as far as they can. She is extremely responsible about health care for herself and her stepkids. Since I don't contract with United Health Care, she pays me and sends the bill to United for them to reimburse her. Over the last two years, they have reimbursed her ZERO for health visits and illnesses for herself and the teenage kids.
Under the contract with United, they should pay a portion of "out of network" care. United has a pattern of delay and hassle that is repeated over and over. United sends me forms to fill out after each visit, even though they have the information in full on the bill I give her to submit. They want a complete duplicate of the information that they already have. When I resubmit the forms they stall and after 90 days they send a denial, stating they did not receive proper information and allowing me to "appeal" on the patient's behalf. When I send the appeal letter with copies of everything, nothing more happens. This cycle can take about a year to complete. There is no phone number to call on the letters and phone calls to United Health Care corporate puts you on a recording loop.
United Healthcare is truly a shameless corporation. Despite the fact that my patient has insurance that should cover her and her step-children, I provide heavily discounted care because I know she will never be paid a dime by United.
The CEO of United Health Group was paid $3,241,042 last year and has a retirement account of $10,703,229. The prior CEO of United was paid $342 million over 5 years. I don't know what his retirement is.
Monday, November 9, 2009
- The vast majority (69 percent) of U.S. respondents report that their practices have no provisions for after-hours care, leaving their patients no choice but the emergency room. The U.S. was behind every other country surveyed on this finding.
- Fifty-eight percent of U.S. primary care physicians say their patients often have trouble paying for their medications and care, compared to 5- 37 percent in the other ten countries.
- While 99 percent of doctors in the Netherlands and 97 percent of doctors in New Zealand and Norway use electronic medical records (EMRs), only 46 percent of U.S. doctors report EMR use.
- One-third of U.S. physicians report receiving any financial incentives for the quality improvement measures tracked in the survey. By contrast, 89 percent of doctors in the U.K. and sizable majorities of their counterparts in the Netherlands, New Zealand, Italy, and Australia report financial incentives tied to quality.
Primary care forms the foundation of a quality health delivery system, coordinating care and holding down prices.
The authors conclude, "Overall, the survey highlights the lack of national policies focused on U.S. primary care. Unless primary care practices are part of more integrated care systems, they are on their own facing multiple payers with uncoordinated policies. In contrast, other countries with multiple payers seek coherent payment and coverage policies. As the United States looks to develop new primary care models that could work well for patients and physicians, policymakers can learn a great deal from diverse initiatives under way in other countries."
Saturday, November 7, 2009
With the H1N1 flu season hitting most communities, the question of when to give patients Tamiflu comes up for physicians. Tamiflu is the antiviral medication that can shorten the severity of flu symptoms by...drumroll...one day. To be effective it should be given within the first 48 hours of symptoms.
There are no medical guidelines for who should take Tamiflu. If patients have symptoms severe enough for hospitalization or have a chronic condition or asthma, Tamiflu should definitely be prescribed. Pregnant women and young children are at more risk for severe flu so they should be given Tamiflu when symptoms present, but what about everyone else?
Is shortening the illness by one day worth the $100 Tamiflu costs? Some doctors are concerned about creating resistant strains of influenza if Tamiflu is overused. And giving Tamiflu to "prevent" flu is not recommended because people who live in a household with a flu victim have only a 15-27% chance of catching flu anyway. That said, if a person with high risk factors is exposed to the flu, giving Tamiflu is likely to prevent illness.
As with any medication, adverse events can occur. With Tamiflu adverse event reports were primarily related to unusual neurologic or psychiatric events such as delirium, hallucinations, confusion, abnormal behavior, convulsions, and encephalitis. Most of the reports come from Japan.
I am not prescribing Tamiflu routinely for people with flu symptoms. If they ask for it, and understand how it works and the small risks of taking it, I will write the prescription. Tamiflu is not a substitute for the flu shot.
Thursday, November 5, 2009
There are a lot of myths out there about which patients are most likely to sue a doctor for malpractice. Many doctors think it is "poor patients on welfare." They would be wrong. Evidence shows that low income patients on Medicaid are actually less likely to sue than others. But there are some patients and situations that should raise a red flag for physicians that they could bring a lawsuit.
- Angry patients: A patient who is upset about the doctor-patient relationship, either because something didn't work out or they perceived a lack of caring, is more likely to sue the doctor. Plaintiff attorneys say that the majority of their calls come from patients who had poor rapport with their physicians. What works in a medical error? An explanation of what went wrong and, if appropriate, an apology!
- Money Issues: Now that more patients are paying out of pocket costs, if they feel overcharged they become less tolerant of errors. If patients know the approximate costs up front, they aren't surprised and outraged when that big bill arrives. We all know, however, how hard it is to find out anything about costs in advance. Big problem!
- Doctors Dissing Others: So many lawsuits have been filed because of one doctor or nurse making disparaging remarks about another; "How did such a thing happen to you?" It's easy to be a Monday morning quarterback.
- Lousy Service: Bad service goes along with poor doctor-patient rapport. It is hard for someone to feel respected and cared for, if they get bad service or the rooms are dirty or the phone call isn't returned. If a mistake happens, the doctor must be available to discuss it. An absent doctor or poor service turns patients and family members into "angry patients" (see number 1).
Medical mistakes happen because the human body is complex, treatments are complex and there are no guarantees in life. Most patients don't sue their doctors when a bad outcome occurs. The experts in risk warn us that the relationship is the most important prevention for lawsuits, followed by meticulous documentation in the medical record.
Wednesday, November 4, 2009
J&J is one of the most admired and diversified health conglomerates with a consumer division, diagnostic/devise equipment, pharmaceutical drugs and R&D arm. Johnson and Johnson is present in 57 Countries around the world.
If a company like J&J is cutting back this much, it shows the economic recovery will be long and hard.
I took my son to the ER for a broken thumb. It was a minor injury but the thumb is the most important digit on the hand. The ER care was just fine...a quick look, an Xray and a small splint. We didn't have to wait long and everyone was courteous.
Imagine my surprise to receive the bill from the hospital. Yes, I have insurance. My out of pocket expense was minimal but here is what the insurance company was charged:
- Hospital Misc.- $56.00 (could this be the splint?)
- Diagnostic Xray - $342.00
- Emergency Care- $952.00
- Surgery - $570.00
This bill is unreal and is comprised of unreal health care costs. The insurance paid a component of the bill. They have a cap on what they will pay for each element.
I am an informed consumer so I will be calling the hospital billing office to discuss the unreal charges. I doubt that most patients would do that if they had insurance. It would be "somebody else's problem". We need to bring the patient back into the loop to control costs. We all pay in the end anyway.
The Doctor and Radiologist bill will be separate.
Sunday, November 1, 2009
Universoul Productions has compiled a fascinating look at what one family from different countries eats during one week. Take a good look at the family size and diet of each country. I found this amazing. Starting at the top:
#1 - Chad, cost $1.23 U.S.
#2- Bhutan, cost $5.03 U.S.
#3- Ecuador, cost $31.55 U.S.
#4- Egypt, cost $68.53 U.S.
#5- Poland, cost $151.27 U.S.
#6- Mexico, cost $189.09 U.S.
#7- United States $341.98 U.S.
#8- Germany, $500.07 U.S.
#9- Italy, $260.11 U.S.
I think the photos and the cost of food speak for themselves. Which country has the best diet?
As a physician, I see a lot of strange things and meet lots of interesting people. I guess I shouldn't be surprised when the oppression of women in many countries across the globe has created a market for fake hymens for non-virginal women. Since virginity is valued above all else in many religions, it was only a matter of time when the artificial hymen would be manufactured and sold. Now with the internet, fathers and mothers in Sudan and Egypt and anywhere else, can order online for their little bride.
For $15-$29.00, a family can obtain a Chinese-made artificial hymen that might (?) fool a groom or at least the groom's family. The "hymen" is a 5X7cm folded piece of albumen covered on one side by dark red ink. Place in the vagina before sex, the plastic hardens slightly and rips upon intercourse. Voila! A few drops of "blood" and everyone is happy.
Why would a product like this be in demand? In Muslim countries a girl who is not a virgin will have hell to play after the wedding. Her husband can divorce her or the family can keep the dowry and disown her. It is such hypocrisy that 50% of the population can be discriminated against. There is no such obsession with the man's virginity.
The whole issue of a woman's virginity is a carry over from ancient times and religious texts. "Then the wedding night sheets were hung over the balconies in the morning, to let the rest of the world know how virginal the bride was, altho rumours of sheep's blood and substitutions have been heard." A visitor to Rome in the mid-20th century remarked on how virginity could be faked.
The "fake hymen" is just a modern day version of ancient misogyny. It goes along with the horrendous practice of marrying off pubescent girls to older men who want "virgins". I guess there is more success in finding a 12 year old virgin. Sick, sick, sick.
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