Medical school in blog form May 21 2013
Why go to medical school when you can just read this Medical School tumblr blog? Includes posts on open heart surgery, sickle cell anemia, and a simple suturing demonstration:
Why go to medical school when you can just read this Medical School tumblr blog? Includes posts on open heart surgery, sickle cell anemia, and a simple suturing demonstration:
"Give me your tired, your poor, your huddled masses yearning to breathe free." And I'll give them heart disease, high blood pressure, diabetes, and a shorter lifespan. A growing body of research suggests that there is often a high health toll when it comes to coming to America.
A growing body of mortality research on immigrants has shown that the longer they live in this country, the worse their rates of heart disease, high blood pressure and diabetes. And while their American-born children may have more money, they tend to live shorter lives than the parents.
The pattern goes against any notion that moving to America improves every aspect of life. It also demonstrates that at least in terms of health, worries about assimilation for the country's 11 million illegal immigrants are mistaken. In fact, it is happening all too quickly.
In this morning's NY Times, Angelina Jolie writes about her decision to have a preventive double mastectomy to hopefully ward off cancer.
My mother fought cancer for almost a decade and died at 56. She held out long enough to meet the first of her grandchildren and to hold them in her arms. But my other children will never have the chance to know her and experience how loving and gracious she was.
We often speak of "Mommy's mommy," and I find myself trying to explain the illness that took her away from us. They have asked if the same could happen to me. I have always told them not to worry, but the truth is I carry a "faulty" gene, BRCA1, which sharply increases my risk of developing breast cancer and ovarian cancer.
It happens that just last night I read about the BRCA-1 gene in Siddhartha Mukhergee's excellent biography of cancer, The Emperor of All Maladies. This part is right near the end of the book:
Like cancer prevention, cancer screening will also be reinvigorated by the molecular understanding of cancer. Indeed, it has already been. The discovery of the BRCA genes for breast cancer epitomizes the integration of cancer screening and cancer genetics. In the mid-1990s, building on the prior decade's advances, researchers isolated two related genes, BRCA-1 and BRCA-2, that vastly increase the risk of developing breast cancer. A woman with an inherited mutation in BRCA-1 has a 50 to 80 percent chance of developing breast cancer in her lifetime (the gene also increases the risk for ovarian cancer), about three to five times the normal risk. Today, testing for this gene mutation has been integrated into prevention efforts. Women found positive for a mutation in the two genes are screened more intensively using more sensitive imaging techniques such as breast MRI. Women with BRCA mutations might choose to take the drug tamoxifen to prevent breast cancer, a strategy shown effective in clinical trials. Or, perhaps most radically, women with BRCA mutations might choose a prophylactic mastectomy of both breasts and ovaries before cancer develops, another strategy that dramatically decreases the chances of developing breast cancer.
Radical is an understatement...what a tough and brave decision to make. Again from the book, I liked this woman's take on it:
An Israeli woman with a BRCA-1 mutation who chose this strategy after developing cancer in one breast told me that at least part of her choice was symbolic. "I am rejecting cancer from my body," she said. "My breasts had become no more to me than a site for my cancer. They were of no more use to me. They harmed my body, my survival. I went to the surgeon and asked him to remove them."
The genetic testing company 23andme screens for three common types of mutation in the BRCA1 or BRCA2 genes:
Five to 10 percent of breast cancers occur in women with a genetic predisposition for the disease, usually due to mutations in either the BRCA1 or BRCA2 genes. These mutations greatly increase not only the risk for breast cancer in women, but also the risk for ovarian cancer in women as well as prostate and breast cancer among men. Hundreds of cancer-associated BRCA1 and BRCA2 mutations have been documented, but three specific BRCA mutations are worthy of note because they are responsible for a substantial fraction of hereditary breast cancers and ovarian cancers among women with Ashkenazi Jewish ancestry. The three mutations have also been found in individuals not known to have Ashkenazi Jewish ancestry, but such cases are rare.
23andme testing kits are only $99.
Update: Two things. First, and I hope this isn't actually necessary because you are all intelligent people who can read things and make up your own minds, but let me just state for the official record that you should never never never never NEVER take medical advice, inferred or otherwise, from celebrities or bloggers. Come on, seriously. If you're concerned, go see a doctor.
Two: I have no idea what the $99 23andme test covers with regard to BRCA1 and BRCA2 gene mutations beyond what the company states. The most comprehensive test for BRCA1 and BRCA2 mutations was developed by a company called Myriad Genetics and costs about $3000. Myriad has patented the genes, a decision that has been sharply criticized and is currently being decided by the Supreme Court.
But many doctors, patients and scientists aren't happy with the situation.
Some are offended by the very notion that a private company can own a patent based on a gene that was invented not by researchers in a lab but by Mother Nature. Every single cell in every single person has copies of the BRCA1 and BRCA2 genes.
Myriad officials say they deserves the patent because they invested a great deal of money to figure out the sequence and develop "synthetic molecules" based on that sequence that can be used to test the variants in a patient.
"We think it is right for a company to be able to own its discoveries, earn back its investment, and make a reasonable profit," the company wrote on its blog.
I do know the 23andme test covers something related to the BRCA1 and BRCA2 mutations...a friend of a friend did the 23andme test, tested positive for the BRCA1 mutation, and decided to have a preventive double mastectomy after consulting her doctor and further tests. (thx, mark, allison, and ★spavis)
An article from a mother who was anti-vaccine until her daughter (and then the rest of the family) got the whooping cough. And still she feels "funny" about vaccination.
And yet I still wondered about that list of things that I would now, I suppose, have to surrender to and immunise my child against. Polio, for one -- a couple of my parents' pensioner friends still carry the limp left by their childhood polio, but none of my friends do, because it isn't around any more. And diphtheria -- what was that, even? I knew it had killed one of Queen Victoria's daughters, but that wasn't our reality.
The reason it wasn't our reality was, of course, due to a continuous programme of immunisation. Duh. Diphtheria is a disease that still kills one in five infants it meets, even if they get treatment, their necks swelling up until they can no longer breathe. I have now seen a picture of a child whose neck was ravaged by diphtheria, bloated like a foie gras goose about to burst. I wish I could unsee it.
Duh, indeed. This anti-vaccination nonsense is an instance in which the public's lack of knowledge about how science works (and not just their lack of recall of scientific facts) is truly harmful. (via @CharlesCMann)
Or at least unbeneficial. A comprehensive study out of Croatia complements other evidence that stretching your muscles before exercise results in less strength, power, and performance than if you hadn't stretched.
The numbers, especially for competitive athletes, are sobering. According to their calculations, static stretching reduces strength in the stretched muscles by almost 5.5 percent, with the impact increasing in people who hold individual stretches for 90 seconds or more. While the effect is reduced somewhat when people's stretches last less than 45 seconds, stretched muscles are, in general, substantially less strong.
They also are less powerful, with power being a measure of the muscle's ability to produce force during contractions, according to Goran Markovic, a professor of kinesiology at the University of Zagreb and the study's senior author. In Dr. Markovic and his colleagues' re-analysis of past data, they determined that muscle power generally falls by about 2 percent after stretching.
And as a result, they found, explosive muscular performance also drops off significantly, by as much as 2.8 percent. That means that someone trying to burst from the starting blocks, blast out a ballistic first tennis serve, clean and jerk a laden barbell, block a basketball shot, or even tick off a fleet opening mile in a marathon will be ill served by stretching first. Their performance after warming up with stretching is likely to be worse than if they hadn't warmed up at all.
I'm currently reading The Emperor of All Maladies: A Biography of Cancer (which is excellent) and I'm up to the chapters on prevention, specifically the prevention of lung cancer through reduction of cigarette smoking. I had no idea cigarette smoking was so uncommon in the US as recently as 1870...but we caught up quickly.
In 1870, the per capita consumption in America was less than one cigarette per year. A mere thirty years later, Americans were consuming 3.5 billion cigarettes and 6 billion cigars every year. By 1953, the average annual consumption of cigarettes had reached thirty-five hundred per person. On average, an adult American smoked ten cigarettes every day, an average Englishman twelve, and a Scotsman nearly twenty.
For some context on that 3500/yr per person number (and the unbelievable 7000/yr Scottish rate), the current rate in the US is around 1000/yr and the highest current rate in the world is in Serbia at almost 2900/yr per person.
Whenever I start to feel sick, I hit the Internet and start searching for more information about my symptoms. When a doctor writes me a prescription and I start feeling something unexpected, I search the web for side effects. And I'm not the only one whose first instinct is to turn my head and search. So many of us have adopted this behavior that researchers are gathering valuable information by studying our search queries and "have for the first time been able to detect evidence of unreported prescription drug side effects before they were found by the Food and Drug Administration's warning system."
A baby in Mississippi may have been cured of HIV by an early treatment of standard HIV drugs.
After starting on treatment, the baby's immune system responded and tests showed diminishing levels of the virus until it was undetectable 29 days after birth. Ten months later, when the baby returned to the hospital (her mother stopped bringing her, without explanation) the researchers tested her again for HIV and found no sign of the virus. It appeared she had been functionally cured.
From back in August, Atul Gawande visits a Cheesecake Factory and wonders if the combination of "quality control, cost control, and innovation" achieved by chain restaurants can offer lessons to hospitals and other health care organizations.
The company's target last year was at least 97.5-per-cent efficiency: the managers aimed at throwing away no more than 2.5 per cent of the groceries they bought, without running out. This seemed to me an absurd target. Achieving it would require knowing in advance almost exactly how many customers would be coming in and what they were going to want, then insuring that the cooks didn't spill or toss or waste anything. Yet this is precisely what the organization has learned to do. The chain-restaurant industry has produced a field of computer analytics known as "guest forecasting."
"We have forecasting models based on historical data-the trend of the past six weeks and also the trend of the previous year," Gordon told me. "The predictability of the business has become astounding." The company has even learned how to make adjustments for the weather or for scheduled events like playoff games that keep people at home.
A computer program known as Net Chef showed Luz that for this one restaurant food costs accounted for 28.73 per cent of expenses the previous week. It also showed exactly how many chicken breasts were ordered that week ($1,614 worth), the volume sold, the volume on hand, and how much of last week's order had been wasted (three dollars' worth). Chain production requires control, and they'd figured out how to achieve it on a mass scale.
As a doctor, I found such control alien-possibly from a hostile planet. We don't have patient forecasting in my office, push-button waste monitoring, or such stringent, hour-by-hour oversight of the work we do, and we don't want to. I asked Luz if he had ever thought about the contrast when he went to see a doctor. We were standing amid the bustle of the kitchen, and the look on his face shifted before he answered.
"I have," he said. His mother was seventy-eight. She had early Alzheimer's disease, and required a caretaker at home. Getting her adequate medical care was, he said, a constant battle.
This piece was on several best-of-the-year longreads lists and deservedly so. But the Factory's 3000-calorie plate of pasta will probably not help the state of American health care.
The deceased former NFL player's family joins more than 6000 people who have sued the NFL over head injuries in the past few years.
"We were saddened to learn that Junior, a loving father and teammate, suffered from CTE," the family said in a statement released to the AP. "While Junior always expected to have aches and pains from his playing days, none of us ever fathomed that he would suffer a debilitating brain disease that would cause him to leave us too soon.
"We know this lawsuit will not bring back Junior. But it will send a message that the NFL needs to care for its former players, acknowledge its decades of deception on the issue of head injuries and player safety, and make the game safer for future generations."
Plaintiffs are listed as Gina Seau, Junior's ex-wife; Junior's children Tyler, Sydney, Jake and Hunter, and Bette Hoffman, trustee of Seau's estate.
The lawsuit accuses the league of glorifying the violence in pro football, and creating the impression that delivering big hits "is a badge of courage which does not seriously threaten one's health."
It singles out NFL Films and some of its videos for promoting the brutality of the game.
Seau is a pretty boldfaced name...I wonder what effect this will have on public perception, etc.
CTE (chronic traumatic encephalopathy), the degenerative brain disease that could dramatically change the way pro football is played in the future (if it's played at all), can't be identified in victims until after death. That makes it difficult to prove (or disprove) the connection between pro football, concussions, and death from CTE. But researchers have discovered a possible technique that could diagnose CTE in living patients.
Last year five retired N.F.L. players who were 45 years and older and suffered from mood swings, depression and cognitive problems were given PET, or positron emission tomography, scans. The authors of the study said those scans revealed tau protein deposits in their brains, a signature of C.T.E. While not definitive, the distribution of tau in the retired players was consistent with those found in the autopsies of players who had C.T.E.
If it's actually possible, this could be huge. Many more players, current and former, can be tested and diagnosed and if CTE was found regularly and consistently, you'd think that insurance companies would flee from the NFL like rats leaving a sinking ship and football would have to adapt (to be more like soccer? flag football?) or die.
"The worst injury I've ever had on the field -- for my wife and kids, at least, and my mom and dad -- was an injury I got against the 49ers," says Matt Hasselbeck. "Patrick Willis hit me as I was diving for the goal line. He hit me, and twenty minutes later I'm in an ambulance on my way to Stanford Medical. I'd broken a rib on the left and I'd broken a rib on the right. The rib on the right was right next to my aorta, and it was really dangerous for my health. I couldn't breathe. It was like there was a weight on top of me. It's a scary thing, because it feels like you're drowning. I couldn't breathe at all, and I got up off the field because it was a two-minute situation - I didn't want the team to have to take a time-out. I tried to run off the field, and when the trainers met me they saw I was, like, purple in the face. And they immediately put me on the ground. Sometimes they'll put you on the ground to evaluate you and sometimes to give the backup quarterback a chance to get loose. They put me on the ground because I was purple."
That instinct - the instinct to run when you can't breathe in order to save your team a time-out - is not one often encountered in civilian life. Indeed, it is one encountered almost exclusively in war, in which people's lives, rather than simply their livelihoods, are at stake. Now, the NFL is replete with military symbolism, not to mention military pretensions. But the reality of injury is what makes it more than fantasy football, more than professional wrestling, more than an action movie, more than a video game played with moving parts who happen to be human. The reality of injury - and the phantasmagoric world of pain - is what makes it, legitimately, a blood sport. And it is what makes Dr. Yates, the Steelers' team doctor, define his job simply and bluntly: "My job is to protect players from themselves."
Junod adds, via Twitter:
Concussion: the global warming of the NFL. We feel bad about it. But what we really worry about is someone taking our football away.
Former NFL star Jason Taylor was so injured (and yet still playing every week) that for a period of two years, the 6'6" 240-pound linebacker couldn't lift his kids into bed. So how did he play? Shots to kill the pain and then more shots to kill the pain of the first shots. And so on. Until he almost had to have his leg amputated.
The trainer rushed to Taylor's house. Taylor thought he was overreacting. The trainer told him they were immediately going to the hospital. A test kit came out. Taylor's blood pressure was so high that the doctors thought the test kit was faulty. Another test. Same crazy numbers. Doctors demanded immediate surgery. Taylor said absolutely not, that he wanted to call his wife and his agent and the famed Dr. James Andrews for a second opinion. Andrews also recommended surgery, and fast. Taylor said, fine, he'd fly out in owner Daniel Snyder's private jet in the morning. Andrews said that was fine but that he'd have to cut off Taylor's leg upon arrival. Taylor thought he was joking. Andrews wasn't. Compartment syndrome. Muscle bleeds into the cavity, causing nerve damage. Two more hours, and Taylor would have had one fewer leg. Fans later sent him supportive notes about their own compartment syndrome, many of them in wheelchairs.
"I was mad because I had to sit out three weeks," he says. "I was hot."
He had seven to nine inches of nerve damage.
"The things we do," he explains. "Players play. It is who we are. We always think we can overcome."
At the New Yorker, Reeves Wiedeman reminds us that the NFL is unlikely to change because so much of what happens with injuries is hidden from view.
As we watch a game that we know is dangerous, we soothe ourselves with the idea that these men must be aware of the risks, too; that they are being well compensated to take on those risks; and that, at least when they're on the field, in front of the cameras, they are living the dream that we all craved as kids, and they're having fun.
But what we can take from this story, and from the fact that, on the surface, this weekend's games were filled with such excitement, is the fact that so much of football's barbarism takes place beyond our vision and behind closed doors.
Flu season is here and it's horrible. Jennifer Cain at Kicker has written a No-Nonsense, Non-Alarmist, Essential Guide to the Flu. The sections on how to tell the flu from other illnesses and what to do to avoid the flu are especially helpful.
There are four big telltale signs that can help you distinguish among a cold, a flu, norovirus and whooping cough:
#1. Fever equals flu. You might get a slight temperature from a cold, but if you're really heating up, it's probably the flu.
#2. Colds are mild and long lasting. Colds usually start with a sore throat, then progress to symptoms like a runny nose and congestion, followed by a cough that won't go away. And they don't usually cause fevers. Sometimes it can take up to 3 weeks to get rid of a cold entirely. The flu, though, tends to come on quickly all at once and be more intense, but it doesn't linger. If you're running a fever and your body aches and you can't get out of bed and don't feel like eating anything, it's flu time.
Recent analysis by specialists shows that Junior Seau, the former stand-out NFL linebacker who committed suicide last year, suffered from chronic traumatic encephalopathy (CTE) at the time of his death. CTE is associated with repeated trauma to the head and has been found in many ex-NFL players, including a few that have committed suicide.
"I think it's important for everyone to know that Junior did indeed suffer from CTE," Gina Seau said. "It's important that we take steps to help these players. We certainly don't want to see anything like this happen again to any of our athletes."
She said the family was told that Seau's disease resulted from "a lot of head-to-head collisions over the course of 20 years of playing in the NFL. And that it gradually, you know, developed the deterioration of his brain and his ability to think logically."
Experts caution that correlation is not causation, but as these incidents mount, the NFL is going to come under increasing pressure to act, causation or no.
Studies have long shown evidence of placebos doing something to help ill patients. Harvard Medical School's Ted Kaptchuk is studying this effect to determine how and why it works.
Two weeks into Ted Kaptchuk's first randomized clinical drug trial, nearly a third of his 270 subjects complained of awful side effects. All the patients had joined the study hoping to alleviate severe arm pain: carpal tunnel, tendinitis, chronic pain in the elbow, shoulder, wrist. In one part of the study, half the subjects received pain-reducing pills; the others were offered acupuncture treatments. And in both cases, people began to call in, saying they couldn't get out of bed. The pills were making them sluggish, the needles caused swelling and redness; some patients' pain ballooned to nightmarish levels. "The side effects were simply amazing," Kaptchuk explains; curiously, they were exactly what patients had been warned their treatment might produce. But even more astounding, most of the other patients reported real relief, and those who received acupuncture felt even better than those on the anti-pain pill. These were exceptional findings: no one had ever proven that acupuncture worked better than painkillers. But Kaptchuk's study didn't prove it, either. The pills his team had given patients were actually made of cornstarch; the "acupuncture" needles were retractable shams that never pierced the skin. The study wasn't aimed at comparing two treatments. It was designed to compare two fakes.
According to Google's search tracking, this is the worst flu season in more than 6 years.
Google's trends tend to follow the official CDC data closely and indeed the CDC concurs about the scope of the flu this year but their data is lagging behind Google's by what looks like about 2 weeks. See also my post on how flu vaccines are made. (via @kellan)
In an op-ed piece for the NY Times, Dr. David Newman bears witness to the effects of gun violence he sees at his hospital.
I have sworn an oath to heal and to protect humans. Guns, invented to maim and destroy, are my natural enemy.
We've spent the two dozen years putting computers in everything from our bodies to our cars. Now those devices increasingly have wireless connections to the outside world. Throw in a little lax security and the whole world becomes hackable.
Hospital equipment like external defibrillators and fetal monitors can at least be picked up, taken apart, or carted away. Implanted devices -- equipment surgically implanted into the body -- are vastly more difficult to remove but not all that much harder to attack.
You don't even have to know anything about medical devices' software to attack them remotely, Fu says. You simply have to call them repeatedly, waking them up so many times that they exhaust their batteries-a medical version of the online "denial of service" attack, in which botnets overwhelm Web sites with millions of phony messages. On a more complex level, pacemaker-subverter Barnaby Jack has been developing Electric Feel, software that scans for medical devices in crowds, compromising all within range. Although Jack emphasizes that Electric Feel "was created for research purposes, in the wrong hands it could have deadly consequences." (A General Accounting Office report noted in August that Uncle Sam had never systematically analyzed medical devices for their hackability, and recommended that the F.D.A. take action.)
Denis Duthie was recently struck blind by vodka reacting poorly to his diabetes medication. Doctors in his native New Zealand thought he might have formaldehyde poisoning, which you can get from drinking methanol. The cure? More
cowbell, er, ethanol. Since the hospital didn't have enough medical ethanol for treatment, a nurse went to the liquor store for Johnnie Walker Black, which was then dripped directly into Duthie's stomach.
It worked because the ethanol competed with the methanol and prevented it from being metabolised into harmful formaldehyde, which can cause blindness.
"There are two potential ways of doing it: one is to give intravenous ethanol through a drip, but that is not available in all hospitals. There is also nothing wrong with supplying that alcohol via the gastro-intestinal tract, which is what they've chosen to do in this circumstance, and that's a well established treatment. If the patient's awake they can just drink it."
Ashlyn Blocker does not feel pain, a condition called 'Congenital insensitivity to pain.' Although she can feel pressure, and warm or cool, she can't feel extreme heat or cold. In this profile in the NY Times Magazine, though, she seems like a relatively well-adjusted 13 year-old girl, which is a credit to her and her parents. Pretty fascinating story.
Tara and John weren't completely comfortable leaving Ashlyn alone in the kitchen, but it was something they felt they had to do, a concession to her growing independence. They made a point of telling stories about how responsible she is, but every one came with a companion anecdote that was painful to hear. There was the time she burned the flesh off the palms of her hands when she was 2. John was using a pressure-washer in the driveway and left its motor running; in the moments that they took their eyes off her, Ashlyn walked over and put her hands on the muffler. When she lifted them up the skin was seared away. There was the one about the fire ants that swarmed her in the backyard, biting her over a hundred times while she looked at them and yelled: "Bugs! Bugs!" There was the time she broke her ankle and ran around on it for two days before her parents realized something was wrong. They told these stories as casually as they talked about Tristen's softball games or their son Dereck's golf skills, but it was clear they were still struggling after all these years with how to keep Ashlyn safe.
"It is an extraordinary disorder," Woods said. "Boys die at a younger age because of more risky behavior. It's quite interesting, because it makes you realize pain is there for a number of reasons, and one of them is to use your body correctly without damaging it and modulating what you do."
Matter, a new publication that raised funds on Kickstarter, has launched and their first story is fantastic. Do No Harm by Anil Ananthaswamy profiles those suffering from Body Integrity Identity Disorder...people who believe that one or more of their limbs don't belong to them and want them amputated.
Sitting at home in a small, somewhat rural American town not too far from the ocean, Patrick recalled the day his wife found out about his obsession. It was during the mid-'90s. As with almost all BIID sufferers, Patrick was fascinated with amputees, so he began downloading pictures of them off the Internet and printing them out. One day his wife was sitting in front of their computer, while Patrick sat in a wingback chair. She noticed a pile of printouts. They were images of men, but "completely clothed, no nudes or anything like that." It was an awkward moment. "She was thinking that maybe I was gay," Patrick recalls. "I must have been crimson." Patrick asked her to take a closer look. She did, and soon realised that the men were all amputees.
Patrick told his wife that he had felt odd about his leg since he was four years old, a feeling that eventually grew into an all-consuming desire to be rid of it. It was a shock: they had been married for decades, and the revelation that he had been hiding something was hard to take. But his confession also brought relief. For more than four decades he had suffered alone. Growing up in small-town America, with conservative parents, in an era when "people didn't believe in going and seeing mental health professionals," Patrick was mystified by what he felt.
The last third of the piece, in which Ananthaswamy accompanies a BIID sufferer to have an amputation in Asia, was really difficult to read...powerful stuff. The piece is 99 cents for web/ePub/Kindle versions.
Ever since St. Vincent's closed in 2010 (I walk past it every morning taking my son to school and they are ripping the shit out of the building to turn it into condos), lower Manhattan has been short more than a few hospital beds. In the aftermath of hurricane Sandy, Manhattan has been left with zero high-level trauma centers south of 68th Street.
Now, the nearest Level One trauma centers for residents of lower Manhattan aren't all that close: New York Presbyterian/Weill Cornell Medical Center is on the Upper East Side at East 68th Street and St. Luke's/Roosevelt Hospital is on the Upper West Side.
Officials say there's no reason to think that, for now, trauma victims in lower Manhattan will be any worse off than those in other parts of the city. The response speed is still acceptable, they say. And if a trauma victim is in an immediately life-threatening situation, such as a traumatic cardiac arrest, ambulances bring them to the closest hospital, regardless of whether it's a trauma center.
But the fear is that there won't be enough surge capacity at other hospitals if there is a major disaster, or that overworked staff at other hospitals will grow fatigued under the load and patient care could suffer.
Well, I'm sure the free market will sort all of this out. (via @Atul_Gawande)
Uroscopy is the now obsolete practice of using the smell, taste, and color of urine to diagnose illness. There were even charts to help doctors and other healers identify different types of urine.
Many diseases affect metabolism and many changes in metabolism can be detected in the urine. For example, diabetics will excrete sugar in their urine -- sometimes enough sugar that it can be fermented into whisky. There are many other diseases that change the smell of a person's urine, including the very descriptively named Maple Syrup Urine Disease or Sweaty Feet Syndrome, now much more likely to be diagnosed by electronic sensor arrays than actually tasting the urine.
(via edible geography)
Over the past few years, we've seen an endless parade of stories debunking the value of many of the products that line the shelves of our local pharmacies. Well, here's a different kind of story. A massive study that included more than 15,000 men and lasted more than 13 years found that taking a daily multivitamin (in this case Centrum Silver) reduced the risk of cancer. It looks like there's something to taking one multivitamin as opposed to swallowing high doses of individual vitamins.
Because of the frequent testing and safety measures, adult film stars are perhaps the world's safest community, STD-wise. No one in the industry has been infected with HIV since 2004. Porn star Stoya explains:
The production manager printed out a copy of each performer's page in the APHSS database. I signed my own copy and James's, indicating that my results were mine and accurate and that I had seen James's and was comfortable working with him and his clean test which had been taken less than 14 days prior. He did the same. Then the production manager performed an inspection. He looked in our mouths, at both sides of our hands, and at our genitals to make sure there were no visible sores or open wounds. There was another paper to sign stating that we have no sores or open wounds on or in our mouths, hands, and genitals and had been inspected. We also looked at each others genitals, mostly for fun but if either of us had seen (or smelled) something odd we would have called off the scene ourselves.
In No Evidence of Disease, Maciej Cegłowski writes about his girlfriend's cervical cancer and the appearance of a new friend in her life, fellow cancer patient Stephanie. Except that, well, that's not the whole story.
Cancer comes with an entourage: fear, loneliness, and isolation. Diane didn't go to the makeup event expecting to make a new friend, but it was a way to get out of the house. She came home excited about having met Stephanie.
Stephanie was ten years younger than Diane. Her illness was acute myeloid leukemia (AML), a type of blood cancer in which cancerous precursor cells completely take over the bone marrow. Steph had gotten her diagnosis while studying abroad in Spain, and had been treated there long enough to put her into remission and send her home. Now her life was on hold, and the cancer was coming back.
Her long-term prognosis was poor. Steph was reticent in talking about it straight out, but after she and Diane became better friends, it became clear that she did not expect to survive a year. Her only hope lay in a difficult and risky transplant procedure. I couldn't imagine having to face this at 23, but of course no one gets to make the choice.
Maciej is a great writer and this is a crazy-ass story and I don't know exactly what you're supposed to feel after reading this piece (sad? mad? defeated?), but you'll definitely feel something. (via @sippey)
Using just the camera on your iPhone, the Cardiio app can accurately measure your heart rate. Here's how it works:
Every time your heart beats, more blood is pumped into your face. This slight increase in blood volume causes more light to be absorbed, and hence less light is reflected from your face. Using sophisticated software, your iPhone's front camera can track these tiny changes in reflected light that are not visible to the human eye and calculate your heart beat!
This video shows this process in action (with a short explanatory intro of the mathematical technique):
That is flat-out amazing. (via @delfuego)
Three people are HIV-free due to bone marrow transplants and that's providing scientists with hope for a possible AIDS cure.
AIDS patients are susceptible to cancers, but they usually stop taking HIV drugs before receiving cancer treatment. "That allows the virus to come back and it infects their donor cells," Kuritzkes said.
About 34 million people are infected with HIV, the virus that causes AIDS, globally; 25 million have died from it. While there's no vaccine, cocktails of powerful antiviral drugs called antiretroviral therapy (ART) can keep the virus suppressed and keep patients healthy. No matter how long patients take ART, however, they are never cured. The virus lurks in the body and comes back if the drugs are stopped. Scientists want to flush out these so-called reservoirs and find a way to kill the virus for good.
Brown, and now these two other men, offer some real hope.
Dr. Timothy Henrich and colleagues at Brigham and Women's Hospital launched a search about a year ago for HIV patients with leukemia or lymphoma who had received bone marrow stem cell transplants. Bone marrow is the body's source of immune system cells that HIV infects and it's a likely place to look for HIV's reservoirs.
"If you took an HIV patient getting treated for various cancers, you can check the effect on the viral reservoirs of various cancer treatments," Kuritzkes, who works with Henrich, said. They found the two patients by asking colleagues at Dana-Farber Cancer Institute in Boston which, like Brigham and Women's, is associated with Harvard Medical School.
Both men had endured multiple rounds of treatment for lymphoma, both had stem cell treatments and both had stayed on their HIV drugs throughout. "They went through the transplants on therapy," Kuritzkes said.
It turns out that was key.
"We found that immediately before the transplant and after the transplant, HIV DNA was in the cells. As the patients' cells were replaced by the donor cells, the HIV DNA disappeared," Kuritzkes said. The donor cells, it appears, killed off and replaced the infected cells. And the HIV drugs protected the donor cells while they did it.
The two men have been HIV-free for two years and three-and-a-half years, respectively. Another man who benefited from a bone marrow transplant from a donor whose immune cells resist HIV infection has been free of HIV for five years. (via @gavinpurcell)
A team in Boston is working on a method for injecting oxygen straight into a person's bloodstream, which is faster than the more traditional method (you know, breathing).
Researchers led by Harvard Medical School's John N. Kheir engineered tiny, gas-filled microparticles, which were about three micrometers in size and invisible to the naked eye. They used a device called a sonicator, which uses high-intensity sound waves, to produce a foamy liquid solution with microparticles that consist of a single layer of lipids that trap a tiny pocket of oxygen gas. They then injected the resulting mixture directly into the bloodstream of rabbits that were severely oxygen-deprived.
Within seconds, infusions of the microparticles restored the blood oxygen saturation of these mammals to near-normal levels. When the rabbits' windpipes were completely blocked, the solution kept them alive for 15 minutes without a single breath and reduced the likelihood of cardiac arrest and organ injury.
Writing for The New England Journal of Medicine, Atul Gawande reviews the history of surgery. The utility and efficacy of surgical procedures increased sharply with the use of anesthesia and antiseptic practices.
Before anesthesia, the sounds of patients thrashing and screaming filled operating rooms. So, from the first use of surgical anesthesia, observers were struck by the stillness and silence. In London, Liston called ether anesthesia a "Yankee dodge" - having seen fads such as hypnotism come and go - but he tried it nonetheless, performing the first amputation with the use of anesthesia, in a 36-year-old butler with a septic knee, 2 months after the publication of Bigelow's report. As the historian Richard Hollingham recounts, from the case records, a rubber tube was connected to a flask of ether gas, and the patient was told to breathe through it for 2 or 3 minutes. He became motionless and quiet. Throughout the procedure, he did not make a sound or even grimace. "When are you going to begin?" asked the patient a few moments later. He had felt nothing. "This Yankee dodge beats mesmerism hollow," Liston exclaimed.
It would take a little while for surgeons to discover that the use of anesthesia allowed them time to be meticulous. Despite the advantages of anesthesia, Liston, like many other surgeons, proceeded in his usual lightning-quick and bloody way. Spectators in the operating-theater gallery would still get out their pocket watches to time him. The butler's operation, for instance, took an astonishing 25 seconds from incision to wound closure. (Liston operated so fast that he once accidentally amputated an assistant's fingers along with a patient's leg, according to Hollingham. The patient and the assistant both died of sepsis, and a spectator reportedly died of shock, resulting in the only known procedure with a 300% mortality.)
The New England Journal of Medicine recently reported on the 69 year-old man in the photo above. Constant sun exposure to one side of his face resulted in premature aging, though, the other side doesn't look too bad for 69. The condition is called unilateral dermatoheliosis, which I think is Greek for make sure to wear sunblock.
The patient reported that he had driven a delivery truck for 28 years. Ultraviolet A (UVA) rays transmit through window glass, penetrating the epidermis and upper layers of dermis. Chronic UVA exposure can result in thickening of the epidermis and stratum corneum, as well as destruction of elastic fibers. This photoaging effect of UVA is contrasted with photocarcinogenesis.
The Jenny McCarthy Body Count site tracks the number of vaccine-preventable illnesses and deaths in the US since June 2007.
In June 2007 Jenny McCarthy began promoting anti-vaccination rhetoric. Because of her celebrity status she has appeared on several television shows and has published multiple books advising parents not to vaccinate their children. This has led to an increase in the number of vaccine preventable illnesses as well as an increase in the number of vaccine preventable deaths.
Indigo children is a term used to describe children who are believed to possess special, unusual and sometimes supernatural traits or abilities. The term is pseudoscientific. The idea is based on New Age concepts developed in the 1970s by Nancy Ann Tappe and further developed by Jan Tober and Lee Carroll. The concept of indigo children gained popular interest with the publication of a series of books in the late 1990s and the release of several films in the following decade. A variety of books, conferences and related materials have been created surrounding belief in the idea of indigo children and their nature and abilities. The interpretations of these beliefs range from their being the next stage in human evolution, in some cases possessing paranormal abilities such as telepathy, to the belief that they are more empathic and creative than their peers.
Alive Inside is a documentary that follows social worker Dan Cohen as he discovers that music can "awaken" people suffering from degenerative memory loss (Alzheimer's, etc.). Here's a clip in which a man goes from a near-coma state to talking about his favorite songs after listening to music for awhile on headphones.
You never really quite appreciate just what a cornucopia of food alternatives exists -- just how many culinary directions you can set off in -- until a few are cut off and you're forced to re-route yourself. That's a lesson that people with celiac disease and with diabetes have learned. It's what vegetarians have long asserted. And it's what gout is teaching me. In diet books, the word "substitution" comes across as some pathetic euphemism for "sacrifice" and "compromise," a positive-spin noun born of negative circumstances. But substitution is indeed a plausible course, and not necessarily a punitive one. At breakfast, oatmeal thickened with a heaping tablespoon of peanut butter can provide the same wicked indulgence that pork sausage does. At dinnertime, chicken prepared with care and ingenuity can go a long way toward replacing lamb, and the right kind of omelet can be wholly satisfying.
This is your classic "boy meets girl, boy and girl go back to her place, and he breaks his penis having sex" story. It also might be the best medical love story you'll read all month.
Somehow the conversation turns to Margaret Thatcher. Somehow Margaret Thatcher becomes a recurring topic. Somehow Margaret Thatcher becomes our go-to sexual depressant. Somehow Margaret Thatcher ends up sitting naked on a suburban fence, legs swinging and twirling a top hat. Occasionally Reagan makes an appearance, too. There's a lot of glitter involved. I invoke the former Prime Minister whenever I need to cool off. For emergency purposes only.
Also from The Awl, A Treasury of the World's Worst Online Dating Stories. Warning, contains doozies.
In Infinite Jest, David Foster Wallace wrote that videophone technology wasn't popular due in part to vanity.
And the videophonic stress was even worse if you were at all vain. I.e. if you worried at all about how you looked. As in to other people. Which all kidding aside who doesn't. Good old aural telephone calls could be fielded without makeup, toupee, surgical prostheses, etc. Even without clothes, if that sort of thing rattled your saber. But for the image-conscious, there was of course no answer-as-you-are informality about visual-video telephone calls, which consumers began to see were less like having the good old phone ring than having the doorbell ring and having to throw on clothes and attach prostheses and do hair-checks in the foyer mirror before answering the door.
Now DC-area plastic surgeon Dr. Robert Sigal is offering what he calls the "FaceTime Facelift".
"Patients come in with their iPhones and show me how they look on [Apple's video calling application] FaceTime," says Dr. Sigal. "The angle at which the phone is held, with the caller looking downward into the camera, really captures any heaviness, fullness and sagging of the face and neck. People say 'I never knew I looked like that! I need to do something!' I've started calling it the 'FaceTime Facelift' effect. And we've developed procedures to specifically address it."
There is increasing evidence that a parasite called Toxoplasma gondii, which many humans have gotten from cat feces, can rewire our brains and modify human behavior in unexpected ways.
The parasite, which is excreted by cats in their feces, is called Toxoplasma gondii (T. gondii or Toxo for short) and is the microbe that causes toxoplasmosis-the reason pregnant women are told to avoid cats' litter boxes. Since the 1920s, doctors have recognized that a woman who becomes infected during pregnancy can transmit the disease to the fetus, in some cases resulting in severe brain damage or death. T. gondii is also a major threat to people with weakened immunity: in the early days of the AIDS epidemic, before good antiretroviral drugs were developed, it was to blame for the dementia that afflicted many patients at the disease's end stage. Healthy children and adults, however, usually experience nothing worse than brief flu-like symptoms before quickly fighting off the protozoan, which thereafter lies dormant inside brain cells-or at least that's the standard medical wisdom.
But if Flegr is right, the "latent" parasite may be quietly tweaking the connections between our neurons, changing our response to frightening situations, our trust in others, how outgoing we are, and even our preference for certain scents. And that's not all. He also believes that the organism contributes to car crashes, suicides, and mental disorders such as schizophrenia. When you add up all the different ways it can harm us, says Flegr, "Toxoplasma might even kill as many people as malaria, or at least a million people a year."
Some pediatricians are asking families who refuse to vaccinate their children to leave their practices.
For Allan LaReau of Kalamazoo, Mich., and his 11 colleagues at Bronson Rambling Road Pediatrics, who chose in 2010 to stop working with vaccine-refusing families, a major factor was the concern that unimmunized children could pose a danger in the waiting room to infants or sick children who haven't yet been fully vaccinated.
In one case, an unvaccinated child came in with a high fever and Dr. LaReau feared the patient might have meningitis, a contagious, potentially deadly infection of the brain and spinal cord for which a vaccine commonly is given. "I lost a lot more sleep than I usually do" worrying about the situation, he said.
"You feel badly about losing a nice family from the practice," added Dr. LaReau, but families who refused to vaccinate their kids were told that "this is going to be a difficult relationship without this core part of pediatrics." Some families chose to go elsewhere while others agreed to have their kids inoculated.
Writing for Grantland, economists Tyler Cowen and Kevin Grier imagine how the NFL might end due to the increasing visibility of head injuries.
This slow death march could easily take 10 to 15 years. Imagine the timeline. A couple more college players -- or worse, high schoolers -- commit suicide with autopsies showing CTE. A jury makes a huge award of $20 million to a family. A class-action suit shapes up with real legs, the NFL keeps changing its rules, but it turns out that less than concussion levels of constant head contact still produce CTE. Technological solutions (new helmets, pads) are tried and they fail to solve the problem. Soon high schools decide it isn't worth it. The Ivy League quits football, then California shuts down its participation, busting up the Pac-12. Then the Big Ten calls it quits, followed by the East Coast schools. Now it's mainly a regional sport in the southeast and Texas/Oklahoma. The socioeconomic picture of a football player becomes more homogeneous: poor, weak home life, poorly educated. Ford and Chevy pull their advertising, as does IBM and eventually the beer companies.
Is this how soccer finally conquers America? Not that soccer doesn't have its own concussion-related problems.
According to Dr. Ken Murray, doctors don't die like the rest of us.
It's not a frequent topic of discussion, but doctors die, too. And they don't die like the rest of us. What's unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
Of course, doctors don't want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They've talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen-that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that's what happens if CPR is done right).
People don't know how to die anymore...advances in technology and medicine have lulled us into believing we can fix anything that's wrong with our bodies, pain and expense be damned. And sometimes we can and do, and it's that "what if" that makes it so difficult when thinking about what to do.
This has been happening for awhile but I hadn't heard about it before: some coma patients are being awoken by Ativan and Ambien and paradoxically so...both are sedative drugs used for treating insomnia.
The first report of a zolpidem [aka Ambien] awakening came from South Africa, in 1999. A patient named Louis Viljoen, who, three years before, was declared vegetative after he was hit by a truck, had taken to clawing at his mattress during the night. Thinking he was suffering from insomnia, his family doctor suggested zolpidem to help him sleep. But 20 minutes after his mother ground the tablet up and fed it to him through a straw, Viljoen began to stir. His eyes, which normally wandered the room, vacant and unfocused, flickered with the light of consciousness. And then he began to talk (his first words were "Hello, Mummy"), and move (he could control his limbs and facial muscles). A few hours later he became unresponsive. But the next day, and for many days after that, zolpidem revived him, a few hours at a time.
Here was a case worthy of Hollywood: three years was well past the point at which doctors would expect any sort of spontaneous recovery. Viljoen awoke with the ability to speak in complete sentences. Not only did he recognize his mother, but he also recognized the voices of people who had spoken to him only when he was apparently vegetative. He remembered nothing of the mysterious realm he kept receding back into. When doctors asked him what it was like to slip away, he said he felt no changes at all. But he could recall conversations from the previous day's awakening, along with bits and pieces of his former life: his favorite rugby team, specific matches he attended, players that he rooted for and against. As time passed, his cognition improved. He could laugh at jokes, and his awakenings stretched from a few hours to entire days. Eventually, he no longer needed zolpidem.
Sour candy is sour because of the acidity level. The Minnesota Dental Association has compiled a chart listing several popular sour candies, all of which are acidic enough to cause tooth enamel loss and some of which are almost as acidic as battery acid! Here's part of the chart:
Update: I meant to add that the ph scale is logarithmic (like the Richter scale) so that a pH of 3.0 is 10 times more acidic than a pH of 4.0. That means that even the pH 1.6 & 1.8 candies on the list aren't quite battery acid, but it also means that a pH 2.0 candy has 100x more acidity than is required to cause enamel loss, not just 2x.
This is good news in the fight against malaria, which kills almost 800,000 people annually (that's a San Francisco, every single year).
An experimental vaccine from GlaxoSmithKline halved the risk of African children getting malaria in a major clinical trial, making it likely to become the world's first shot against the deadly disease.
Final-stage trial data released on Tuesday showed it gave protection against clinical and severe malaria in five- to 17-month-olds in Africa, where the mosquito-borne disease kills hundreds of thousands of children a year.
"These data bring us to the cusp of having the world's first malaria vaccine," said Andrew Witty, chief executive of the British drugmaker that developed the vaccine along with the nonprofit PATH Malaria Vaccine Initiative (MVI).
While hailing an unprecedented achievement, Witty, malaria scientists and global health experts stressed that the vaccine, known as RTS,S or Mosquirix, was no quick fix for eradicating malaria. The new shot is less effective against the disease than other vaccines are against common infections such as polio and measles.
GlaxoSmithKline has previously stated that they will sell the vaccine for cost + a 5% markup that will be put back into tropical disease research.
Scientists have developed a spray gun that sprays the burn victim's own skin cells onto the affected area heals them within a matter of days, not weeks or months.
The guy doesn't even look like he got burned. (via @delfuego)
Internet sensation Amit Gupta was recently diagnosed with leukemia and needs a bone marrow transplant. Problem is that he needs a transplant from someone of South Asian descent.
To aid him in his fight, Amit is going to need a bone marrow transfusion. Unlike blood transfusions, finding a genetic match for bone marrow that his body will accept is no easy task. The national bone marrow registry has 9.5 million records on file, yet the chances of someone from South Asian descent of finding a match are only 1 in 20,000.
This is where we come in. We're going to destroy those odds.
How? By finding and registering as many people of South Asian descent as we possibly can.
Tests are easy -- a simple swab of the cheek. If someone is determined to be a match, that person would have to be willing to undergo an outpatient procedure in which marrow is extracted from bones in the back by a special needle. It's not a fun procedure, but it's not dangerous either. And doing it could save a life.
If you're interested in helping, read on.
This crazy-experimental therapy uses a modified HIV virus to attack cancer cells in humans. Only three people have tried this therapy for chronic lymphocytic leukemia; two are in complete remission and one showed improvement.
Doctors removed a billion of his T-cells -- a type of white blood cell that fights viruses and tumors -- and gave them new genes that would program the cells to attack his cancer. Then the altered cells were dripped back into Mr. Ludwig's veins.
At first, nothing happened. But after 10 days, hell broke loose in his hospital room. He began shaking with chills. His temperature shot up. His blood pressure shot down. He became so ill that doctors moved him into intensive care and warned that he might die. His family gathered at the hospital, fearing the worst.
A few weeks later, the fevers were gone. And so was the leukemia.
There was no trace of it anywhere -- no leukemic cells in his blood or bone marrow, no more bulging lymph nodes on his CT scan. His doctors calculated that the treatment had killed off two pounds of cancer cells.
A year later, Mr. Ludwig is still in complete remission. Before, there were days when he could barely get out of bed; now, he plays golf and does yard work.
Using a modified iPhone and a fluorescing nanoparticle tattoo, researchers at Northeastern University have found a way to monitor chemicals in the blood without drawing blood.
The team begins by injecting a solution containing carefully chosen nanoparticles into the skin. This leaves no visible mark, but the nanoparticles will fluoresce when exposed to a target molecule, such as sodium or glucose. A modified iPhone then tracks changes in the level of fluorescence, which indicates the amount of sodium or glucose present. Clark presented this work at the BioMethods Boston conference at Harvard Medical School last week.
The tattoos were originally designed as a way around the finger-prick bloodletting that is the standard technique for measuring glucose levels in those with diabetes. But Clark says they could be used to track many things besides glucose and sodium, offering a simpler, less painful, and more accurate way for many people to track many important biomarkers.
Dudley Clendinen has ALS, aka Lou Gehrig's disease, and has a short time to live. Which is fine by him; he's got a plan.
There is no meaningful treatment. No cure. There is one medication, Rilutek, which might make a few months' difference. It retails for about $14,000 a year. That doesn't seem worthwhile to me. If I let this run the whole course, with all the human, medical, technological and loving support I will start to need just months from now, it will leave me, in 5 or 8 or 12 or more years, a conscious but motionless, mute, withered, incontinent mummy of my former self. Maintained by feeding and waste tubes, breathing and suctioning machines.
No, thank you. I hate being a drag. I don't think I'll stick around for the back half of Lou.
I think it's important to say that. We obsess in this country about how to eat and dress and drink, about finding a job and a mate. About having sex and children. About how to live. But we don't talk about how to die. We act as if facing death weren't one of life's greatest, most absorbing thrills and challenges. Believe me, it is. This is not dull. But we have to be able to see doctors and machines, medical and insurance systems, family and friends and religions as informative - not governing - in order to be free.
And that's the point. This is not about one particular disease or even about Death. It's about Life, when you know there's not much left. That is the weird blessing of Lou. There is no escape, and nothing much to do. It's liberating.
In his recent commencement address at Harvard Medical School, Atul Gawande argued that medical practitioners need to shift from thinking of themselves as cowboys to thinking of themselves as pit crews.
Two million patients pick up infections in American hospitals, most because someone didn't follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It's like no one's in charge-because no one is. The public's experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it's pit crews people need.
Instead of amputating entirely, doctors removed the cancer from Dugan Smith's leg and put it back on backwards.
Now Smith wears a prosthesis, uses his ankle as a knee, and plays sports.
When former NFL player Dave Duerson shot and killed himself the other day, he aimed for his chest and not his head because he wanted his brain to be in one piece and therefore available for study for signs of chronic traumatic encephalopathy, which may have led to Duerson's suicide in the first place.
Players who began their careers knowing the likely costs to their knees and shoulders are only now learning about the cognitive risks, too. After years of denying or discrediting evidence of football's impact on the brain -- from C.T.E. in deceased players to an increasing number of retirees found to have dementia or other memory-related disease -- the N.F.L. has spent the last year addressing the issue, mostly through changes in concussion management and playing rules.
Duerson sent text messages to his family before he shot himself specifically requesting that his brain be examined for damage, two people aware of the messages said. Another person close to Duerson, who spoke on the condition of anonymity, said that Duerson had commented to him in recent months that he might have C.T.E., an incurable disease linked to depression, impaired impulse control and cognitive decline.
There's nothing good about that story at all.
You may have seen a reference to this last week, but the New Yorker just posted the full text of Atul Gawande's latest article on their site. The article is about efforts to lower healthcare costs by focusing on the patients who use (and often misuse) healthcare the most. Like many of Gawande's other articles, this is a must-read.
"Let's do the E.R.-visit game," he went on. "This is a fun one." He sorted the patients by number of visits, much as Jeff Brenner had done for Camden. In this employed population, the No. 1 patient was a twenty-five-year-old woman. In the past ten months, she'd had twenty-nine E.R. visits, fifty-one doctor's office visits, and a hospital admission.
"I can actually drill into these claims," he said, squinting at the screen. "All these claims here are migraine, migraine, migraine, migraine, headache, headache, headache." For a twenty-five-year-old with her profile, he said, medical payments for the previous ten months would be expected to total twenty-eight hundred dollars. Her actual payments came to more than fifty-two thousand dollars -- for "headaches."
Was she a drug seeker? He pulled up her prescription profile, looking for narcotic prescriptions. Instead, he found prescriptions for insulin (she was apparently diabetic) and imipramine, an anti-migraine treatment. Gunn was struck by how faithfully she filled her prescriptions. She hadn't missed a single renewal -- "which is actually interesting," he said. That's not what you usually find at the extreme of the cost curve.
The story now became clear to him. She suffered from terrible migraines. She took her medicine, but it wasn't working. When the headaches got bad, she'd go to the emergency room or to urgent care. The doctors would do CT and MRI scans, satisfy themselves that she didn't have a brain tumor or an aneurysm, give her a narcotic injection to stop the headache temporarily, maybe renew her imipramine prescription, and send her home, only to have her return a couple of weeks later and see whoever the next doctor on duty was. She wasn't getting what she needed for adequate migraine care -- a primary physician taking her in hand, trying different medications in a systematic way, and figuring out how to better keep her headaches at bay.
As if there was actually more evidence needed that vaccines don't cause autism, the 1998 British study that linked autism to childhood vaccines was recently discovered to be an elaborate fraud. Not just incorrect, a fraud.
An investigation published by the British medical journal BMJ concludes the study's author, Dr. Andrew Wakefield, misrepresented or altered the medical histories of all 12 of the patients whose cases formed the basis of the 1998 study -- and that there was "no doubt" Wakefield was responsible.
"It's one thing to have a bad study, a study full of error, and for the authors then to admit that they made errors," Fiona Godlee, BMJ's editor-in-chief, told CNN. "But in this case, we have a very different picture of what seems to be a deliberate attempt to create an impression that there was a link by falsifying the data."
According to his doctors, a Berlin man has been cured of HIV because of a stem cell transplant.
Doctors who carried out a stem cell transplant on an HIV-infected man with leukaemia in 2007 say they now believe the man to have been cured of HIV infection as a result of the treatment, which introduced stem cells which happened to be resistant to HIV infection.
The man received bone marrow from a donor who had natural resistance to HIV infection; this was due to a genetic profile which led to the CCR5 co-receptor being absent from his cells. The most common variety of HIV uses CCR5 as its 'docking station', attaching to it in order to enter and infect CD4 cells, and people with this mutation are almost completely protected against infection.
With the current popularity of the craft cocktail bar, massive ice cubes, and vigorous cocktail shaking techniques, comes the risk of injury.
"When they're shaking a drink, it's very similar to the motion of a pitcher, or a tennis serve or throwing a football," said Lisa Raymond-Tolan, an occupational therapist in New York. "It's the same motion, back and forth, back and forth, rotating up high. You have a heavy weight at the end of the arm, out in the air. It's not just the shoulder. It's the wrist as well."
One of the bartenders at Varnish, Chris Bostick, shook his cocktails so vigorously that he ripped out the screws that had been inserted in his clavicle after a snowboarding injury. He was sidelined for weeks.
Maybe instead of Tommy John surgery, they'll start calling it Johnny Walker surgery.
In the New Yorker, Michael Specter reports on tuberculosis, the world's deadliest infectious disease -- worldwide, more than 5000 people die from it every day. In India, misdiagnosis and improper treatment result in tens of thousands of unnecessary deaths a month and even new genetic screening machines might not help matters.
Since late 2009, the hospital has had one unique asset: a piece of equipment called a P.C.R., which can multiply tiny samples of DNA and analyze them. The device is not as fast as the GeneXpert, but it can examine the genetics of virtually any organism, including tuberculosis. The hospital's machine, which was purchased with money from a government research grant, has never been used. "The hospital has had this for months," Mannan said. "But nobody knows how it works." We were standing at the door of the virology lab, where the new P.C.R. Cobas TaqMan 48, made by Roche and sold for roughly fifty thousand dollars, was resting on a shelf, still wrapped in its shipping material.
How could that be? I was staring at a machine that could alter, even save, the lives of scores of the people who were sitting nearby in the gathering heat. Mannan said nothing, though his anger was palpable.
[...] "It's a nice lab," Mannan said when we left. "Beautiful, actually. But if the doctors used it properly that would interfere with their private practice."
I asked what he meant.
"It is simple," he said. "If patients are treated at the hospital, they won't need to pay for anything else."
Hospitals routinely sell foreskins collected from newborn circumcisions to companies for thousands of dollars. These companies use them for 1) making expensive skin cream, 2) cosmetic testing, and 3) skin grafts for burn victims.
So with those foreskins, or more accurately, the fibroblasts from the cells of the foreskin, collagen can be lab-created, and where do you put collagen? On your face! Penis wrinkle cream, anyone? Oprah's beloved SkinMedica product? Yup! Foreskins! One foreskin can be used for decades to grow thousands of fibroblasts.
The debate is essentially over and the final word is in: vaccines do not cause autism. The results of a rigorous study conducted over several years were just announced and they confirmed the results of several past studies.
Basically, the final two groups that were studied consisted of 256 children with ASD [autism spectrum disorders] and 752 matched controls. One very interesting aspect that looks as though it were almost certainly placed into the experimental design based on concerns of anti-vaccine advocates like Sallie Bernard is a group of children who underwent regression. Basically, the study examined whether there was a correlation between ASD and TCV [thimerosal-containing vaccines, i.e. mercury-containing vaccines] exposure. It also examined two subsets of ASD, autistic disorder (AD) and ASD with regression, looking for any indication whether TCVs were associated with any of them. Regression was defined as:
"the subset of case-children with ASD who reported loss of previously acquired language skills after acquisition."
Also, when adding up total thimerosal exposure, the investigators also included any thimerosal exposure that might have come prenatally from maternal receipt of flu vaccines during pregnancy, as well as immunoglobulins, tetanus toxoids, and diphtheria-tetanus. In other words, investigators tried to factor in all the various ideas for how TCVs might contribute to autism when designing this study.
So what did the investigators find? I think you probably know the answer to that question. They found nothing. Nada. Zip. There wasn't even a hint of a correlation between TCV exposure and either ASD, AD, or ASD with regression:
"There were no findings of increased risk for any of the 3 ASD outcomes. The adjusted odds ratios (95% confidence intervals) for ASD associated with a 2-SD increase in ethylmercury exposure were 1.12 (0.83-1.51) for prenatal exposure, 0.88 (0.62-1.26) for exposure from birth to 1 month, 0.60 (0.36-0.99) for exposure from birth to 7 months, and 0.60 (0.32- 0.97) for exposure from birth to 20 months."
The last result is a bit of an anomaly in that it implies that exposure to TCVs from birth to 1 month and birth to 7 months actually protects against ASD. The authors quite rightly comment on this result thusly:
"In the covariate adjusted models, we found that an increase in ethylmercury exposure in 2 of the 4 exposure time periods evaluated was associated with decreased risk of each of the 3 ASD outcomes. We are not aware of a biological mechanism that would lead to this result."
So get your kids (and yourselves) vaccinated and save them & their playmates from this whooping cough bullshit, which is actually killing actual kids and not, you know, magically infecting them with autism. Vaccination is one of the greatest human discoveries ever -- yes, Kanye, OF ALL TIME -- has saved countless lives, and has made countless more lives significantly better. So: Buck. Up.
Rates of breast cancer and melanoma in humans are on the rise and appear to favor the left side of the body. A suspected cause is that the box springs in our beds act as antennas to focus the EM radiation from FM radio and broadcast television directly into the left sides of our bodies. No, really:
Electromagnetic waves resonate on a half-wavelength antenna to create a standing wave with a peak at the middle of the antenna and a node at each end, just as when a string stretched between two points is plucked at the center. In the U.S. bed frames and box springs are made of metal, and the length of a bed is exactly half the wavelength of FM and TV transmissions that have been broadcasting since the late 1940s.
Update: So, you know when you run across something about some current scientific theory or hypothesis on a blog or in a magazine or newspaper or even in a scientific journal, there's a fair chance that whatever the article says is misleading, misstated, or even incorrect. That's just how it is and if you didn't know, now you do. Take this stuff with a grain of salt. It's why I use phrases like "suspected cause" instead of something like "box springs and FM radio proven to cause cancer".
I don't post things like this because I think they're right, I post them because I think they are interesting. The geometry of TV signals and box springs causing cancer on the left sides of people's bodies in Western countries...that's a clever bit of hypothesizing, right or wrong.
In this case, an organization I know nothing about (Vetenskap och Folkbildning from Sweden) says that Olle Johansson, one of the researchers who came up with the box spring hypothesis, is a quack. In fact, he was "Misleader of the year" in 2004. What does this mean in terms of his work on box springs and cancer? I have no idea. All I know is that on one side you've got Olle Johansson, Scientific American, and the peer-reviewed journal (Pathophysiology) in which Johansson's hypothesis was published. And on the other side, there's Vetenskap och Folkbildning, a number of commenters on the SciAm post, and a bunch of people in my inbox. Who's right? Who knows. It's a fine opportunity to remain skeptical. (thx, tom)
When Jane McGonigal got a concussion last year, her recovery was taking longer than expected and she got discouraged. Then she decided to make her recovery process into a game called SuperBetter.
SuperBetter is a superhero-themed game that turns getting better in multi-player adventure. It's designed to help anyone recovering from an injury, or coping with a chronic condition, get better, sooner - with more fun, and with less pain and misery, along the way.
The game starts with five missions. You're encouraged to do at least one mission a day, so that you've successfully completed them all in less than a week. Of course, you can move through them even faster if you feel up to it.
McGonigal recently gave a short talk about SuperBetter:
A great article on gender and children and the tough choices parents have to make when their children show signs of being transgender.
A recent medical innovation holds out the promise that this might be the first generation of transsexuals who can live inconspicuously. About three years ago, physicians in the U.S. started treating transgender children with puberty blockers, drugs originally intended to halt precocious puberty. The blockers put teens in a state of suspended development. They prevent boys from growing facial and body hair and an Adam's apple, or developing a deep voice or any of the other physical characteristics that a male-to-female transsexual would later spend tens of thousands of dollars to reverse. They allow girls to grow taller, and prevent them from getting breasts or a period.
Scientists have developed a gel that rebuilds teeth. It could replace drilling & filling as the treatment of choice for cavities.
The gel or thin film contains a peptide known as MSH, or melanocyte-stimulating hormone. Previous experiments, reported in the Proceedings of the National Academy of Sciences, showed that MSH encourages bone regeneration.
Bone and teeth are fairly similar, so the French scientists reasoned that if the MSH were applied to teeth, it should help healing as well.
To test their theory, the French scientists applied either a film or gel, both of which contained MSH, to cavity-filled mice teeth. After about one month, the cavities had disappeared, said Benkirane-Jessel.
Scientists are working on two fronts toward a cure for AIDS: 1) neutralizing HIV in the human body so that regular medication is unnecessary, and 2) eradicating all traces of HIV in the body.
Human immune-system stem cells are transplanted into pups bred from these mice when they are two days old, and over the next few months, those cells mature and diversify into a working immune system. Then the mice are infected with HIV, which attacks the immune cells. But before transplanting the original human cells, the researchers introduce an enzyme that interferes with the gene for a protein the virus needs to stage the attack. This modification makes a small percentage of the mature immune cells highly resistant to HIV, and because the virus kills the cells it can infect, the modified cells are the only ones that survive over time. Thus, the HIV soon runs out of targets. If this strategy works, the virus will quickly become harmless and the mice will effectively be cured.
Here's what the New Yorker writer and doctor told the graduating class of the Stanford School of Medicine.
Half the words you now routinely use you did not know existed when you started: words like arterial-blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.
O.K., I made that last one up. But the velluvial matrix sounds like something you should know about, doesn't it? And that's the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about.
Since I graduated from medical school, my family and friends have had their share of medical issues, just as you and your family will. And, inevitably, they turn to the medical graduate in the house for advice and explanation.
I remember one time when a friend came with a question. "You're a doctor now," he said. "So tell me: where exactly is the solar plexus?"
I was stumped. The information was not anywhere in the textbooks.
"I don't know," I finally confessed.
"What kind of doctor are you?" he said.
Maciej Ceglowski tells the story of how the cure for scurvy was discovered, lost, and finally redsicovered, but not before it disrupted Robert Falcon Scott's 1911 expedition to reach the South Pole.
This is a good example of how the very ubiquity of vitamin C made it hard to identify. Though scurvy was always associated with a lack of greens, fresh meat contains adequate amounts of vitamin C, with particularly high concentrations in the organ meats that explorers considered a delicacy. Eat a bear liver every few weeks and scurvy will be the least of your problems.
But unless you already understand and believe in the vitamin model of nutrition, the notion of a trace substance that exists both in fresh limes and bear kidneys, but is absent from a cask of lime juice because you happened to prepare it in a copper vessel, begins to sound pretty contrived.
A pair of companies have developed a bio-printer that works just like a regular 3-D printer but instead of using polymer, it uses human tissue to print out skin, blood vessels, and livers.
To start with, only simple tissues, such as skin, muscle and short stretches of blood vessels, will be made, says Keith Murphy, Organovo's chief executive, and these will be for research purposes. Mr Murphy says, however, that the company expects that within five years, once clinical trials are complete, the printers will produce blood vessels for use as grafts in bypass surgery. With more research it should be possible to produce bigger, more complex body parts. Because the machines have the ability to make branched tubes, the technology could, for example, be used to create the networks of blood vessels needed to sustain larger printed organs, like kidneys, livers and hearts.
Some scientists have developed a promising method for targeting and destroying individual cancer cells without harming the tissue around them. Tiny (like nano tiny) gold-plated iron-nickel discs are attached to cancer-seeking antibodies. The antibodies attach themselves to the cancer cells and when an alternating magnetic field is applied, the metal nano-discs vibrate and literally shake the cancer cells to death.
Since the antibodies are attracted only to brain cancer cells, the process leaves surrounding healthy cells unharmed. This makes them unlike traditional cancer treatment methods, such as chemotherapy and radiation, which negatively affect both cancer and normal healthy cells.
In 1961, surgeon Leonid Rogozov was the only physician stationed on an isolated 12-man Soviet base in Antarctica when he developed appendicitis. He had to remove his appendix himself.
"I didn't permit myself to think about anything other than the task at hand. It was necessary to steel myself, steel myself firmly and grit my teeth. In the event that I lost consciousness, I'd given Sasha Artemev a syringe and shown him how to give me an injection. I chose a position half sitting. I explained to Zinovy Teplinsky how to hold the mirror. My poor assistants! At the last minute I looked over at them: they stood there in their surgical whites, whiter than white themselves. I was scared too. But when I picked up the needle with the novocaine and gave myself the first injection, somehow I automatically switched into operating mode, and from that point on I didn't notice anything else.
To ensure it had enough eggs to meet pandemic-level demand, the government invested more than $44 million in the program over five years; more than 35 farms are now involved in this feathered Manhattan Project. No signs advertise the farms' involvement in the program, and visits from the outside world are discouraged. The government won't disclose where the farms are located, and the farmers are told to keep quiet about their work -- not even the neighbors are to know.
These don't exactly sound like free-range operations:
After nine months of service, [the chickens] are typically euthanized because they can no longer lay "optimal eggs," Mr. Robinson said. "They've served their government," he said.
Whoa, I had no idea that giving birth at home without a doctor or midwife was a thing that people were doing now.
After giving birth to her first baby in the hospital, Schoenborn, 31, chose to have her next four children at home -- by herself. Although her husband was in the house during the births, he didn't help with the deliveries.
"My hospital births were very managed," says Schoenborn. "I wanted privacy and to be free of internal exams. I wanted to give birth in an upright position and they want you to lie down. I feel birth is an instinctive process and in the hospital they treat women like they're broken and birth like an illness."
The most striking feature of the H1N1 flu vaccine manufacturing process is the 1,200,000,000 chicken eggs required to make the 3 billion doses of vaccine that may be required worldwide. There are entire chicken farms in the US and around the world dedicated to producing eggs for the purpose of incubating influenza viruses for use in vaccines. No wonder it takes six months from start to finish. But we'll get to that in a minute.
The most commonly used process for manufacturing an influenza vaccine was developed in the 1940s -- one of its co-inventors was Jonas Salk, who would go on to develop the polio vaccine -- and has remained basically unchanged since then. The process is coordinated by the World Health Organization and begins with the detection of a new virus (or rather one that differs significantly from those already going around); in this instance, the Pandemic H1N1/09 virus. Once the pandemic strain has been identified and isolated, it is mixed with a standard laboratory virus through a technique called genetic reassortment, the purpose of which is to create a hybrid virus (also called the "reference virus strain") with the pandemic strain's surface antigens and the lab strain's core components (which allows the virus to grow really well in chicken eggs). Then the hybrid is tested to make sure that it grows well, is safe, and produces the proper antigen response. This takes about six to nine weeks.
[Quick definitional pause. Antigen: "An antigen is any substance that causes your immune system to produce antibodies against it. An antigen may be a foreign substance from the environment such as chemicals, bacteria, viruses, or pollen. An antigen may also be formed within the body, as with bacterial toxins or tissue cells." So, when the H1N1 vaccine gets inside your body, the pandemic strain's surface antigens will produce antibodies against it.]
At roughly the same time, a parallel effort to produce what are referred to as reference reagents is undertaken. The deliverable here is a standardized kit provided to vaccine manufacturers so that they can test how much virus they are making and how effective it is. This process serves to standardize vaccine doses across manufacturers and takes four months to complete. WHO notes that this part of the process is "often a bottleneck to the overall timeline for manufacturers to generate the vaccine".
Once the reference virus strain is produced, it is sent to pharmaceutical companies (Novartis, Sanofi Pasteur, etc.) for large-scale production of the vaccine. The companies fine-tune the virus to increase yields and produce seed virus banks that will be used in the bulk production.
And this is where the 1.2 billion chicken eggs come in. A portion of the seed virus is injected into each 9- to 12-day old fertilized egg. The virus incubates in the egg white for two to three days and is then separated from the egg.
For the shot vaccine, the virus is sterilized so that it won't make anyone sick. This is the magic part of the vaccine: it's got the pandemic virus antigens that make your body produce the antibodies to fight the virus but the virus is inactive so it won't make you ill. For the nasal spray vaccine, the virus is left alive and attenuated to survive only in the nose and not the warmer lungs; it'll infect you enough to produce antibodies but not enough to make you sick. Either way, the surface antigens are separated out and purified to produce the active ingredient in the vaccine. Each batch of antigen takes about two weeks to produce. With enough laboratory space and chicken eggs, the companies can crank out an infinite amount of purified antigens, but those resources are limited in practice.
[Side note. You may have noticed that the H1N1 vaccine has been difficult to find in some places around the US. The vaccine manufacturers have said that the Pandemic H1N1/09 virus when combined with the standard laboratory virus does not grow as fast in the eggs as they anticipated. The batches of antigens from each egg have been smaller than expected, up to five or even ten times smaller in some cases. Hence the slow rollout of the vaccine.]
The purified antigen is then tested against the aforementioned reference reagents once they are ready. The antigen is diluted to the required concentration and placed into properly labelled vials or syringes. Further testing is performed to make sure the vaccine won't make anyone ill, to confirm the correct concentration, and for general safety. At this point clinical testing in humans is required in western Europe but not in the United States. Finally, each company's vaccine has to be approved by the appropriate regulatory body in each country -- that's the FDA in the case of the US -- and then the vaccine is distributed to medical facilities around the country.
The process of inoculation against diseases like smallpox has been known for at least 1200 years. An 8th-century Indian book contains a how-to chapter on smallpox inoculations. Chinese use of the technique dates back to the first millennium as well. The technique was imported to Europe via the Ottoman Empire in 1721 and reached America at about the same time.
The practice is documented in America as early as 1721, when Zabdiel Boylston, at the urging of Cotton Mather, successfully inoculated two slaves and his own son. Mather, a prominent Boston minister, had heard a description of the African practice of inoculation from his Sudanese slave, Onesimus, in 1706, but had been previously unable to convince local physicians to attempt the procedure. Following this initial success, Boylston began performing inoculations throughout Boston, despite much controversy and at least one attempt upon his life. The effectiveness of the procedure was proven when, of the nearly three hundred people Boylston inoculated during the outbreak, only six died, whereas the mortality rate among those who contracted the disease naturally was one in six.
It is inadvertently affirmed in the Christian countries of Europe that the English are fools and madmen. Fools, because they give their children the small-pox to prevent their catching it; and madmen, because they wantonly communicate a certain and dreadful distemper to their children, merely to prevent an uncertain evil. The English, on the other side, call the rest of the Europeans cowardly and unnatural. Cowardly, because they are afraid of putting their children to a little pain; unnatural, because they expose them to die one time or other of the small-pox. But that the reader may be able to judge whether the English or those who differ from them in opinion are in the right, here follows the history of the famed innoculation, which is mentioned with so much dread in France.
Wired has a long piece by Amy Wallace about the anti-science anti-vaccine crowd.
Ah, risk. It is the idea that fuels the anti-vaccine movement -- that parents should be allowed to opt out, because it is their right to evaluate risk for their own children. It is also the idea that underlies the CDC's vaccination schedule -- that the risk to public health is too great to allow individuals, one by one, to make decisions that will impact their communities. (The concept of herd immunity is key here: It holds that, in diseases passed from person to person, it is more difficult to maintain a chain of infection when large numbers of a population are immune.)
Update: I am on Team Tom Scocca on this issue:
Anti-vaccine activists are degenerate idiots who deserve to get polio and live out their days in iron lungs while Child Protective Services takes away their children to be properly raised. Or tetanus. Get lockjaw and shut up and die. What's the point of living in 21st-century America if not to avoid dying of stupid, easily preventable disease?
Ordinarily I wouldn't question others' parenting choices. But the problem is literally one of live or don't live. While that parent chose not to vaccinate her child for what she likely considers well-founded reasons, she is putting other children at risk. In this instance, the child at risk was my son. He has leukemia.
Update: Ben Goldacre on anti-vaccine scares as a cultural thing, not a science thing:
There's something very interesting about vaccine scares. These are cultural products. They're not about evidence. If vaccine scares were about genuine scientific evidence showing that a vaccine caused a disease, then the vaccine scares would happen all around the world at exactly the same time, because information can disseminate itself around the world very rapidly these days. But what you find is that vaccine scares actually respect cultural and national boundaries.
(via lined and unlined)
Should you vaccinate your kids against the swine flu this winter? Will it even work against the H1N1 virus? Or will it even be available? Maybe we should be focused on a much simplier solution: keeping our hands clean.
Using soap and water or a sanitizer virtually eliminated the presence of the [H1N1] virus [in an Australian study].
Update: I've gotten a few emails so a clarification: vaccines are obviously not bad. Vaccinate your kids against the H1N1 virus when a vaccine becomes available if you feel that's the right thing to do. It's just that in the United States people often emphasize the quick fix over something that can be effective but requires a change in behavior. Much of what you hear about the damn swine flu is people being infected, the deaths, the coming vaccine, and how to protect our precious children from THE KILLER VIRUS THAT KILLS PEOPLE SO LET'S PANIC!! I thought it was important to call out something common sensical, unsexy, and effective like hand washing.
Update: I give up. Don't wash your hands. It is completely ineffective and has never saved anyone from anything. Get vaccinated and stay inside. When you do go outside, wear a surgical mask and try not to go near other people.
Harvard Magazine has a nice profile of surgeon and writer Atul Gawande that talks about, among other things, his constant state of flow.
Gawande had seen that part of the man's colon was ischemic -- dead and gangrenous -- and had ceased to move waste out of the body. He wasn't sure about the cause, but suspected a blood clot. One thing was clear: without immediate surgery, the colon would rupture.
After examining the patient, Gawande conferred with the resident in the corridor outside the man's room. He went through a familiar and well-practiced set of actions that he seemed to do without thinking: slipping his ring finger into his mouth to moisten it, working his wedding band off, unbuckling his watchband, threading it through the ring, and refastening it, all the while carrying on a conversation about stopping the patient's anti-clotting medication and getting a vascular surgeon to assist.
Scientists are gradually coming to the conclusion that exposure to organophosphate pesticides increases the risk of Parkinson's disease.
Taken together, 30-plus years of research add up to an increasingly persuasive conclusion: exposure to pesticides and other toxins increases the risk of Parkinson's disease, and we are only now beginning to wrestle with the true scope of the damage.
At six, Hannah Clark received a heart transplant...but they kept the second heart in her chest as well. Ten years later, her new heart failed and they were able to remove it because her old heart had mended itself in the meantime.
For the first few months, the new heart did nearly all the work, but this "rest" gave Hannah's own heart a chance to begin recovery. By the time of the second heart was finally removed, Hannah's heart was doing virtually all the work itself.
It's amazing what doctors can entice the human body to do.
I've got two follow-ups to share with you regarding Atul Gawande's New Yorker piece about healthcare costs in the US (kottke.org post). In the Wall Street Journal, Abraham Verghese argues that in order for a healthcare reform plan to be successful, it has to include cost cutting.
I recently came on a phrase in an article in the journal "Annals of Internal Medicine" about an axiom of medical economics: a dollar spent on medical care is a dollar of income for someone. I have been reciting this as a mantra ever since. It may be the single most important fact about health care in America that you or I need to know. It means that all of us -- doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others -- are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not? -- it's hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman's plan and scuttled Hillary Clinton's proposal.
In Gawande's example, what Verghese is saying is that you can't just make McAllen's healthcare system adopt an El Paso type of system without a whole lot of pain.
Gawande addressed some of the criticisms of his article on the New Yorker site. One of the major criticisms was that McAllen's higher costs were associated with higher levels of poverty and unhealthiness:
As I noted in the piece, McAllen is indeed in the poorest county in the country, with a relatively unhealthy population and the problems of being a border city. They have a very low physician supply. The struggles the people and medical community face there are huge. But they are just as huge in El Paso -- its residents are barely less poor or unhealthy or under-supplied with physicians than McAllen, and certainly not enough so to account for the enormous cost differences. The population in McAllen also has more hospital beds than four out of five American cities.
On Friday, Atul Gawande gave the commencement address at the University of Chicago Pritzker School of Medicine. The address touched on some of the same themes as his recent piece on the differing costs of healthcare across the US. He began with an anecdote about how observation of well-nourished children in poor Vietnamese villages led to village-wide improvments in curbing malnutrition.
The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children's mothers were breaking with the locally accepted wisdom in all sorts of ways -- feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children's rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to.
And I don't know why, but I've always thought of surgery as primarily a cerebral pursuit; a great surgeon is so because he's clever and smart. A short passage from Gawande's address reveals that perhaps that's not the case:
In surgery, for instance, I know that I have more I can learn in mastering the operations I do. So what does a surgeon like me do? We look to those who are unusually successful -- the positive deviants. We watch them operate and learn their tricks, the moves they make that we can take home.
So surgeons learn surgery in the same way that kids learn Kobe Bryant's post moves from SportsCenter highlights?
From the Effects Measure blog:
Influenza is a virus full of mystery and surprises. The more we study it the more complicated it becomes. Remember the adage: "If you've seen one flu pandemic, you've seen one flu pandemic."
This reminds me of the first line of Anna Karenina:
Happy families are all alike; every unhappy family is unhappy in its own way.
(via david archer)
Bone is a springy and salty wonder that is proving much more functional within the human body than originally thought.
The skeleton is a multipurpose organ, offering a ready source of calcium for an array of biochemical tasks, and housing the marrow where blood cells are born. Yet above all the skeleton allows us to locomote, which means it gets banged up and kicked around. Paradoxically, it copes with the abuse and resists breaking apart in a major way by microcracking constantly. "Bone microcracks, that's what it does," Dr. Ritchie said. "That's how stresses are relieved." [...] But like all forms of health care, bone repair doesn't come cheap, and maintaining skeletal integrity consumes maybe 40 percent of our average caloric budget.
The article leads off with the story of Harry Eastlack, whose body repaired itself with bone-building cells no matter what the injury, essentially giving him a not-so-Wolverine-like second skeleton. Here's a photo I found of Eastlack's skeleton, which is housed at the Mutter Museum of the College of Physicians.
Since I don't use Adderall or Provigil, it took me a few days to get through this New Yorker article about neuroenhancing drugs. The main takeaway? Like cosmetic body modification in the 80s, mind modification through prescription chemical means is already commonplace for some and will soon be for many.
Chatterjee worries about cosmetic neurology, but he thinks that it will eventually become as acceptable as cosmetic surgery has; in fact, with neuroenhancement it's harder to argue that it's frivolous. As he notes in a 2007 paper, "Many sectors of society have winner-take-all conditions in which small advantages produce disproportionate rewards." At school and at work, the usefulness of being "smarter," needing less sleep, and learning more quickly are all "abundantly clear." In the near future, he predicts, some neurologists will refashion themselves as "quality-of-life consultants," whose role will be "to provide information while abrogating final responsibility for these decisions to patients." The demand is certainly there: from an aging population that won't put up with memory loss; from overwrought parents bent on giving their children every possible edge; from anxious employees in an efficiency-obsessed, BlackBerry-equipped office culture, where work never really ends.
The article is full of wonderful vocabulary. Like the "worried well": those people who are healthy but go to the doctor anyway to see if they can be made more healthy somehow. Being concerned about how good you've got it and attempting to do something about it seems to be another one of those uniquely American phenomena caused by an overabundance of free time & disposable income and the desire to overachieve. See also the impoverished wealthy, the dumb educated, and fat fit.
Karrie Karahalios created a program that interprets conversations and generates real-time visual feedback. A social mirror of sorts.
The "clock" shows the progress of the talk. Three times a second, a color bar pops up showing who was speaking. The louder the speech, the longer the bar. Interruptions are shown as overlapping color bars. Every minute, a new circle of bars is rendered in a visual record akin to the rings of tree trunk.
Referred to as a "conversation clock," it's already been tested with kids with low-functioning autism, teaching them to vocalize. One speech specialist thinks it can help kids with Asperger's, who tend to dominate conversations, learn not to "monologue" so much.
Marriage counselors are also using it to teach your husband how to shut up for five minutes.
Eno is an antacid produced by GlaxoSmithKline. It's globally distributed, mainly across South America, India, and the Middle East, and it's available as sachets and tablets in both Lemon and an ambiguous "Regular" flavor.
Ogilvy & Mather produced a stunning print advertisement for the company, featuring a gun made of food. Quite an improvement over Eno's commercial from the 80s, although if the packets made me seem as effervescent as the actor, perhaps I'd take some on my down days.
He said that public health measures like cleaning up contaminated water and food have saved the lives of countless children, but they "also eliminated exposure to many organisms that are probably good for us." "Children raised in an ultraclean environment," he added, "are not being exposed to organisms that help them develop appropriate immune regulatory circuits."
One of the decisions we made even before Ollie was born was that he was going to be a dirty kid. We wash our hands often with non-antibacterial soap and water, especially after being on the subway, but otherwise don't worry about it much. I can count on one hand how many times I've used the antibacterial hand sanitizer that seemingly comes bundled with toddlers these days.
Update: See also The Germ-Phobic Mommies.
During the 2007-2008 flu season, an early version of Google Flu Trends was used to share results each week with the Epidemiology and Prevention Branch of the Influenza Division at CDC. Across each of the nine surveillance regions of the United States, we were able to accurately estimate current flu levels one to two weeks faster than published CDC reports.
In a small but intriguing study from the University of Illinois medical school, doctors and students maintained close to the ideal number of chest compressions doing CPR while listening to the catchy, sung-in-falsetto tune from the 1977 movie "Saturday Night Fever."
Due to a hand tremor, musician Eddie Adcock was having trouble playing the banjo. During the surgery to fix the problem, the doctors had Adcock play his banjo to isolate the problem in his brain and then they made the repair. Video here. (via delicious ghost)
Ten people who have unusual medical conditions, including the woman who can't stop orgasming, the woman who is allergic to cell phones and microwaves, and the boy who can't sleep.
I try not to miss any of Atul Gawande's New Yorker articles, but his piece on itching from this week's issue is possibly the most interesting thing I've read in the magazine in a long time. He begins by focusing on a specific patient for whom compulsive itching has become a very serious problem. (Warning, this quote is pretty disturbing...but don't let it deter you from reading the article.)
...the itching was so torturous, and the area so numb, that her scratching began to go through the skin. At a later office visit, her doctor found a silver-dollar-size patch of scalp where skin had been replaced by scab. M. tried bandaging her head, wearing caps to bed. But her fingernails would always find a way to her flesh, especially while she slept.
One morning, after she was awakened by her bedside alarm, she sat up and, she recalled, "this fluid came down my face, this greenish liquid." She pressed a square of gauze to her head and went to see her doctor again. M. showed the doctor the fluid on the dressing. The doctor looked closely at the wound. She shined a light on it and in M.'s eyes. Then she walked out of the room and called an ambulance. Only in the Emergency Department at Massachusetts General Hospital, after the doctors started swarming, and one told her she needed surgery now, did M. learn what had happened. She had scratched through her skull during the night -- and all the way into her brain.
From there, Gawande pulls out to tell us about itching/scratching (the two are inseparable), then about a recent theory of how our brains perceive the world ("visual perception is more than ninety per cent memory and less than ten per cent sensory nerve signals"), and finally about a fascinating therapy initially developed for those who experience phantom limb pain called mirror treatment.
Among them is an experiment that Ramachandran performed with volunteers who had phantom pain in an amputated arm. They put their surviving arm through a hole in the side of a box with a mirror inside, so that, peering through the open top, they would see their arm and its mirror image, as if they had two arms. Ramachandran then asked them to move both their intact arm and, in their mind, their phantom arm-to pretend that they were conducting an orchestra, say. The patients had the sense that they had two arms again. Even though they knew it was an illusion, it provided immediate relief. People who for years had been unable to unclench their phantom fist suddenly felt their hand open; phantom arms in painfully contorted positions could relax. With daily use of the mirror box over weeks, patients sensed their phantom limbs actually shrink into their stumps and, in several instances, completely vanish. Researchers at Walter Reed Army Medical Center recently published the results of a randomized trial of mirror therapy for soldiers with phantom-limb pain, showing dramatic success.
Crazy! Gawande documents and speculates about other applications of this treatment, including using virtual reality representations instead of mirrors and utilizing multiple mirrors for treatment of M.'s itchy scalp. Anyway, read the whole thing...highly recommended.
The "Jumping Frenchmen of Maine" were described by George Beard in 1878. They had an excessive startle response, sometimes with echolalia, echopraxia, or forced obedience. In 1885, Gilles de la Tourette concluded that "jumping" was similar to the syndrome that now bears his name. Direct observations of jumpers have been scarce. We studied eight jumpers from the Because region of Quebec. In our opinion, this phenomenon is not a neurologic disease, but can be explained in psychological terms as operant conditioned behavior. Our cases were related to specific conditions in lumber camps in the 19th and the beginning of the 20th century.
Doctors and researchers are investigating the source of a new disease caused by aerosolized pig brains.
Their working hypothesis is that the harvesting technique -- known as "blowing brains" on the floor -- produces aerosols of brain matter. Once inhaled, the material prompts the immune system to produce antibodies that attack the pig brain compounds, but apparently also attack the body's own nerve tissue because it is so similar.
(via frontal cortex)
Dr. Jay Parkinson M.D. emailed in to tell me about his new medical practice in Williamsburg. He's got no office (housecalls only), takes appointment requests via SMS, email, or IM, handles some follow-ups over video chat, and specializes in the 18-40 age group without traditional health insurance. The goal, states Parkinson, is to "mix the service of an old-time, small town doctor with the latest technology to keep you and your bank account healthy".
To give you an idea of how the practice operates, here's a recap of his first day on the job:
Yesterday went quite well and I was very happy with the amount of money I kept out of the hands of companies that attempt to take advantage of how difficult it is to find prices for medications and healthcare services. For example, the first patient I saw needed a medication that Walgreens offered for $60. I called my tried and true Williamsburg mom-and-pop pharmacy only a few blocks from Walgreens and talked to Arthur the Pharmacist who said he sells it for $15. "Thanks Arthur." "No thank you Jay." The way it should be done.
My second patient was getting a certain medication for years every month by mail from Walgreens that costs $63 per month. I knew where she could get the same medication for $42 a month. I just saved her $252 per year. After she made her $200 down payment on my services via PayPal, her monthly fee for my services is now only $17 a month. But I just saved her $21 a month on her monthly mail order medication. She's essentially getting the rest of the year of my services for free. Not bad.
Sounds fantastic. If only every doctor was this much of an advocate for his patients.
Update: The WSJ Health blog has a short interview with Parkinson, followed by a lengthy comment thread.
Oscar the cat lives at the Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. According to an article in the New England Journal of Medicine, Oscar possesses a peculiar talent...he knows when the residents there are going to die and curls up with them for comfort before they pass.
Making his way back up the hallway, Oscar arrives at Room 313. The door is open, and he proceeds inside. Mrs. K. is resting peacefully in her bed, her breathing steady but shallow. She is surrounded by photographs of her grandchildren and one from her wedding day. Despite these keepsakes, she is alone. Oscar jumps onto her bed and again sniffs the air. He pauses to consider the situation, and then turns around twice before curling up beside Mrs. K.
One hour passes. Oscar waits. A nurse walks into the room to check on her patient. She pauses to note Oscar's presence. Concerned, she hurriedly leaves the room and returns to her desk. She grabs Mrs. K.'s chart off the medical-records rack and begins to make phone calls.
Within a half hour the family starts to arrive. Chairs are brought into the room, where the relatives begin their vigil. The priest is called to deliver last rites. And still, Oscar has not budged, instead purring and gently nuzzling Mrs. K. A young grandson asks his mother, "What is the cat doing here?" The mother, fighting back tears, tells him, "He is here to help Grandma get to heaven." Thirty minutes later, Mrs. K. takes her last earthly breath. With this, Oscar sits up, looks around, then departs the room so quietly that the grieving family barely notices.
For some, the hospital is a place to go to get sick, not to get healthy. At the Veterans Affairs hospital in Pittsburgh, they're cutting down on diseases passing from patient to patient by testing arriving patients for drug-resistant bacteria, more careful use of equipment, and careful isolation of the most sick. A surgical unit in the hospital has cut their infection rate by 78% since 2001.
A company called Lifeforce has received FDA approval to store white blood cells for people as a "back-up copy of your immune system". The idea is that those pre-diseased cells could be reproduced in the lab and infused back into your body when needed to fight off infection or deal with the aftermath of chemotherapy.
How doctors make their decisions is being studied in the hopes of making medical care better. "Doctors can also make mistakes when their judgments about a patient are unconsciously influenced by the symptoms and illnesses of patients they have just seen. Many common infections tend to occur in epidemics, afflicting large numbers of people in a single community at the same time; after a doctor sees six patients with, say, the flu, it is common to assume that the seventh patient who complains of similar symptoms is suffering from the same disease."
The Ghost Map is a book about:
- a bacterium
- the human body
- a geographical map
- a man
- a working friendship
- a household
- a city government
- a neighborhood
- a waste management system1
- an epidemic
- a city
- human civilization
You hooked yet? Well, you should be. As the narrative unfolds around the 1854 London cholera epidemic, author Steven Johnson weaves all of these social, geographical, and biological structures/webs/networks into a scientific parable for the contemporary world. The book is at its best when it zooms among these different scales in a Powers of Ten-like fashion (something Johnson calls The Long Zoom), demonstrating the interplay between them: the way the geography of a neighborhood affected the spread of a virus, how ideas spreading within a social context are like an epidemic, or the comparison between the organism of the city and the geography of a bacterial colony within the human colon. None of this is surprising if you've read anything about emergence, complexity, or social scale invariance, but Johnson effectively demonstrates how tightly coupled the development of (as well as our understanding of) viral epidemics and large cities were across all of these scales.
The other main theme I saw in the book is how inherently messy science is. Unlike many biographies, The Ghost Map doesn't try to tie everything up into a nice little package to make a better story. The cholera epidemic and its resolution was sloppy; there was no aha! moment where everyone involved understood what was going on and knew what had to be done. But the scientific method applied by John Snow to the situation was solid and as more evidence became available over the years, his theory of and solution to cholera epidemics were revealed as actual fact. Johnson reminds us that that's how science works most of the time; science is a process, not a set of facts and theories. During the recent debate in the US over evolution and intelligent design, I felt a reluctance on the part of scientists to admit to this messiness because it would give an opening to their detractors: "haha, so you admit you don't know what's going on at all!" Which is unfortunate, because science is powerful in its nuance and rough edges (in some ways, science is what happens at the margins) in helping us understand ourselves and the world we live in.
Atul Gawande on the rise in Cesarean deliveries in the US, which soon may become safer than natural childbirth: "We are losing our connection to yet another natural process of life. And we are seeing the waning of the art of childbirth. The skill required to bring a child in trouble safely through a vaginal delivery, however unevenly distributed, has been nurtured over centuries. In the medical mainstream, it will soon be lost."
The hygiene hypothesis of allergies "argues that exposure to more natural environments such as farms early in life helps train the body to respond appropriately to harmless microbes and pollen". Could also be called the "let your kids eat dirt hypothesis". Somewhat related story: my dad had allergies when he was a kid but then got stung by a bunch of bees one day and boom, no more allergies.
Michael Crichton on the sad state of patents in the US, particularly those related to medicine. "Any doctor who reads a patient's test results and even thinks of vitamin deficiency infringes the [homocysteine/B-12] patent. A federal circuit court held that mere thinking violates the patent."
Want to learn how to be a doctor? Check out these surgery videos on Google Video.
So, it's day five of my cold. Last night, I was down to only two out of my five senses. My sense of taste and smell left the scene sometime on Saturday. On Sunday, I had salad and fruit for lunch because I figured if I can't taste anything, I might as well eat healthy. Trying to smell or taste strongly aromatic substances like wine or scented shower gel produces a sensation not unlike that of tasting or smelling something, except there's no smell or taste. It's the weirdest thing...I don't even know how to properly describe it. It's like there's a ghost of a taste and when I think too hard about trying to really taste it, it's gone. It'll be a relief when I finally decongest and can enjoy food again.
And then yesterday while driving, we went from sea level up to around 600 ft of elevation, which caused the pressure to build up in my head enough to affect my hearing. By 4pm, everything was kind muffled and I was asking Meg speak up repeatedly. I could just barely hear the hum of the highway under the car. Last night at dinner, I couldn't taste anything, smell anything, hear anything, and my voice was so gravelly from my cold (and probably way too loud from overcompensating for the hearing loss) that listening to me was probably not very pleasant. My ears finally popped somewhat this morning and I can hear ok again, but smell and taste are still missing. Come back, guys, I miss you!
 After a bit of research this AM, I've determined that what I have is a cold and not the flu.
 I remember reading a book or article once that mentioned a person who lost their sense of taste and when it would briefly return, that person would drop whatever they were doing and go eat a great meal. Anyone know where that story is from?
Scientists have found a probable carrier for the ebola virus: fruit bats. According to the WHO, ebola causes death in "50-90% of all clinically ill cases".
In the five years since the sequencing of the human genome, "much of the data have little immediately useful meaning, and the research has produced only a trickle of medicine". And where medical science has failed, hucksters have filled the gap.
Gelf Magazine says "a new study uses shoddy stats to hold the movie industry responsible for society's poor health choice". "But even if we disregard the fact that people don't necessarily take their public-health cues from films like Scary Movie and Rambo: First Blood Part II, the study has serious flaws that undermine even its tenuous claim on our attention".
Among laparoscopic surgeons, those who have played video games in the past are significantly faster and less error-prone in a surgical training exercise than those who have never gamed. Even better were those who are current gamers...they realized 30% gains in speed and accuracy over their non-gaming counterparts.
Laurie sends along an account of the week she spent in a psych ward. She says she's "trying to publicize it in order to remove some of the stigma of mental illness". Reminds me of Heather's accounts of her psych ward stay last year.
Making sense of the appendix, the one in your body, not the one in books. "Perhaps the appendix lifted the odds that our ancestors could resist childhood diseases and live to childbearing years."
The science of Lance Armstrong. Between 1992 and 1999, he increased his muscle efficiency by 8 percent, a gain previously thought to be impossible.
I was somewhat disappointed in the 2003 edition of this collection, especially after enjoying so much the last three editions. Perhaps Oliver Sacks and I disagree on what makes science writing good. The two best articles were 1491 by Charles Mann about what the Americas were like before Columbus landed and the effect of the European arrival:
In North America, Indian torches had their biggest impact on the Midwestern prairie, much or most of which was created and maintained by fire. Millennia of exuberant burning shaped the plains into vast buffalo farms. When Indian societies disintegrated, forest invaded savannah in Wisconsin, Illinois, Kansas, Nebraska, and the Texas Hill Country. Is it possible that the Indians changed the Americas more than the invading Europeans did? "The answer is probably yes for most regions for the next 250 years or so" after Columbus, William Denevan wrote, "and for some regions right up to the present time."
and Atul Gawande's The Learning Curve, an article on how doctors need to learn on the job (while potentially making costly mistakes) in order to become more effective overall:
In medicine, there has long been a conflict betwenn the imperative to give patients the best possible care and the need to provide novices with expericne. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think that patients actually benefit from teaching. But there is no avoiding those first few unsteady times a young physician tries to put in a central line, removes a breast cancer, or sew together two segments of colon. No matter how many protections are in place, on average these cases go less well with the novice than with someone experienced.
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