KOLAHUN

Logistics (Wednesdays) - Hospitals Are Focal Parts of Cities

At its apex, the Simpsons did a remarkable job of satirizing the reality of America.  But one fundamental fallacy of the show was the (nuclear)-factory-as-the-economic-engine of a community.  In reality, as the USA prospered through the second half of the 20th century, industrial jobs were outsourced to developing countries and the US began specializing in the service sectors.  These included the financial sector, the software sector and, crucially, the health sector.

Nowadays, a large percentage of jobs in any community belongs in the health field.  On an aggregate level, it's been well publicized that US health-care related costs comprise about 15% of the national income.  But on a more specific level, we can see from this Forbes.com list how influential these jobs are in large communities:  

Atlanta, Ga.

1. Home Depot: 1,180 job openings

2. WellStar Health System: 1,013 job openings

3. Northside Hospital: 759 job openings

4. Pizza Hut: 753 job openings

5. Emory University: 648 job openings

Boston, Mass.

1. Staples: 1,250 job openings

2. Massachusetts General Hospital: 1,048 job openings

3. Liberty Mutual: 829 job openings

4. Harvard University: 753 job openings

5. Kindred Healthcare: 700 job openings

Chicago, Ill.

1. Accenture: 918 job openings

2. Pizza Hut: 815 job openings

3. Sears: 696 job openings

4. HCR Manor Care: 680 job openings

5. Taco Bell: 613 job openings

Dallas – Fort. Worth, Texas

1. Texas Health Resources: 1,623 job openings

2. HCA: 1,219 job openings

3. Baylor Health Care: 979 job openings

4. Pizza Hut: 921 job openings

5. Methodist Health Systems: 704 job openings

In these randomly selected large markets, at least one of the top five employers is a health facility, while in the Dallas/Ft. Worth area, four of the top five are.  These examples go on across the country:  Johns Hopkins in Baltimore, UCSF in San Francisco, the Texas Medical Center in Houston and in New Orleans, Tulane Hospital and Ochsner Health Systems.  

But it's not just the US where health related employers are a focal point of growth.  As money is spent on development in Africa, a large percentage goes to health expenditures.  And in India, scores of not-for-profit and for-profit companies are racing to build hospitals, both for domestic consumption and for medical tourism (they even have a conference just on how-to-build-hospitals in India).  

As technology accelerates and the complexity of health structures grows the construction/consulting industry that envelops it also grows.  The quaint notion of a hospital with a certain number of medical beds + more surgical beds + some examining rooms has given way to highly complex mini-cities.  These self-contained locals now have their own energy sources, sanitation systems, HVAC (heating/ventilation/AC) complexes, information systems, high-volume laundromats, restaurant/grocery-store/catering businesses and, of course, the focal medical parts which include the clinics/ORs/ERs/radiology/lab/pharmacy/patient beds/etc.

As an end-punctuation, here are some links you can use to find more information on hospital construction:

• A conference in India
• A primer on how to think about building your own hospital
• A much more indepth site on how to build a hospital, with lots of technical manuals
• More technical manuals
• An expensive book summarizing 5 different symposia presentations

 

 

 

Games in medicine (Tuesdays) - Disappointing Evidence

Pets.com became the poster-child of the internet bubble in the late 1990s when, within a year, it went from a celebrated IPO to...a liquidated, bankrupt company. A lot had to do with the inability to deliver on hopes of reducing logistical/storage costs of bulky goods as it just wasn't feasible to deliver cat litter on the cheap.  The concept may have looked good on paper, but reality imposed higher and quicker costs than anticipated.  And eventually the bubble burst.  (And yet the internet still survives!)

 

Gaming in Medicine seems to be at a similar embroyonic stage.  Good ideas come by each day.  For example, multiple researchers view the Nintendo WII as a natural aide for rehabilation purposes - for recovery after ACL surgeries, for improving balance among nursing home residents, or for creating a virtual reality for post-stroke patients.  But so far, the evidence in published trials haven't been very positive.  

The conclusion from a Cochrane review reports the following:

"We found limited evidence that the use of virtual reality and interactive video gaming may be beneficial in improving arm function and ADL function when compared with the same dose of conventional therapy. There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on grip strength or gait speed. It is unclear at present which characteristics of virtual reality are most important and it is unknown whether effects are sustained in the longer term. Furthermore, there are currently very few studies evaluating the use of commercial gaming consoles (such as the Nintendo Wii)."

Perhaps the concept itself of using virtual reality modules or interactive gaming itself is flawed...but unlikely.  More probably, we still haven't figured out the right levers to pull on these machines to accomodate the intersection of diseases and patients best.  Much like the internet didn't just fold after the bubble burst (and people had to go back to the store to buy cat litter) in the 90s, gaming will likely be prominent in medicine in the next few decades.  It'll just take retooling and then refining of the tools.  

(Meanwhile, don't bet your retirement portfolio on these companies/products yet.)  

 

Human Resources (Thursday) - Task Shifting

 

The table to the left shows the despair some countries suffered in providing sufficient clinician capital for the HIV pandemic*.  In Malawi, for example, there were over 7000 HIV+ patients per doctor, while in Moçambique, there were over 6800 HIV+ patients for each doctor.  The ratios were better, but still unacceptable, for the number of patients per nurse.  (For comparison, see the rations in the USA and UK at the bottom of the table.)

The explosion of thirty years of a simmering pandemic exacerbated the push/pull dynamics of the health care brain-drain in these countries.  Countries tried numerous strategies, including incentivizing native clinicians, attracting foreign ones and quite creatively, 'task-shifting' - the concept that in areas of need, important tasks are handled by less formally trained staff.

The need for task-shifting is represented in the above table.  For example, the initiation of anti-retroviral medicine is essentially a physician's role here in the US.  But emulating this restriction in either Malawi or Moçambique is a fool's errand - there just aren't enough hours in a day to treat all the patients.  And so through protocols, close supervision and available referrals for consultations, nurses can diagnose HIV and start medications.  Meanwhile, for patients with more complicated illnesses, physician assistants (aka clinical officers) take over management.  And if the physician assistant needs assistance, there's the potential of referring the patient to the consultant physician.  

How well does task-shifting work?  Here's the punch-line from a 2010 review:

We found 2960 articles, of which 84 were included in the core review. 51 reported outcomes, including research from 10 countries in sub-Saharan Africa. The most common intervention studied was the delegation of tasks (especially initiating and monitoring [HIV medications]) from doctors to nurses and other non-physician clinicians. Five studies showed increased access to HAART through expanded clinical capacity; two concluded task shifting is cost effective; 9 showed staff equal or better quality of care; studies on non-physician clinician agreement with physician decisions was mixed, with the majority showing good agreement.

Yet the conceit of 'task-shifting' isn't simply a desperation of circumstance.  It's the belief that the number of talented clinicians isn't exactly equal to the exact number of doctors.  If there are 500 physicians in Malawi, it's not the case that there are only 500 people capable of doing a doctor's work.  Especially in countries with destroyed/fledgling/non-existent educational systems, there are lots more individuals who could have been and want to be doctors.  Utilizing these individuals isn't just necessary, it's elegant.  

 

*2004 WHO data, published in the New England Journal of Medicine 

Logistics (Wednesdays) - Cholera, Where Logisticians Save Lives

The second metaphorical stomach-punch to the Haitian people after the devastating earthquake in January, 2010 was the cholera epidemic.  Starting in October of that year, cholera preyed on the dense concentration of displaced Haitians in camps and affected 250,000 people while killing over 4,000.  While it's true that overall, the international response was substandard and inadequate, there were some people (and organizations) who provided effective care.  

It may be surprising to learn, however, that the most consequential of these people were not doctors or nurses.  Rather, they were the logisticians - the handy-men and handy-women of NGOs who are responsible for building, fixing, buying, supplying and pretty much doing everything that's not actually medical.  They're determinant in any health endeavor, whether it be in a modern Western hospital (e.g. guys who fix the internet for the electronic health system) or in a field project in a disaster.  Yet, it's in a cholera epidemic that a logistician's value reaches the apex.  

Cholera kills patients in a simple but brutal way - it dehydrates them.  An adult can lose up to 20 liters of fluid each day - and if this isn't replaced quickly, she dies.  Antibiotics are of limited benefit and there's no type of surgery that's curative.  Simply to live, a patient with cholera needs to replace each liter of fluid lost.  That's it.  

Thinking of it like this, it's actually pretty easy to medically treat ONE patient with cholera.  Just keep giving her oral re-hydration solution until she's better.  If she's too weak or is vomiting, then simply give her replacement fluids intravenously.  The problem isn't treating one patient.  

It's that cholera frequently explodes into an epidemic, where there are hundreds, then thousands and then hundreds-of-thousands of affected patients.  It's at this point that the power of logistics comes in.  Logistic guys (and gals!) set up tents for patients, import potable water, and fire up generators for lights.  They dilute different concentrations of chlorine - for mixing oral re-hydration solution, for cleaning hands and feet and for neutralizing the diarrhea-waste.  They truck around to different water points to ensure containment of dirty water and ferry around bags of IV fluid.  

And while they don't sit there with any one patient, they dramatically affect the lot of every patient.  

Games in Medicine (Tuesdays) - The Malaria Game

To the right is a picture of our laboratory technician, Fofana, in Kolahun, Liberia in 2006.  As you can see, he's using a microscope that microbiologists in the 1600s would be proud of: an indirect sunlight powered light source.  In the last decade, we've made some advances in the diagnosis of this intra-cellular parasite which claims almost 3 million lives annually.  There are now rapid tests which can detect the most dangerous form, plasmodium falciparum.  Even more recently, there are rapid tests which can detect the other three types, including the rapidly more virulent plasmodium vivax form of malaria.  

Yet, due to the immunologic-based nature of these rapid tests, there are many false results.  In clinical situations where a clinician strongly suspects a patient has malaria but this isn't confirmed by the rapid test, the default test is to do a 'blood smear': spread some of the patient's blood on a slide and look for the malaria parasites under a microscope, much like Fofana is doing in the above picture.  Of course, each step in examining a 'blood smear' entails possible errors: poor slide preparation, inadequate light and most frequently, human error in analyzing the slide.  Especially with 'task shifting' and the (proper) use of technicians in lieu of unavailable microbiologists in rural settings, this last type of error gets expanded.

A potential solution comes from UCLA in the form of a crowdsourcing game, spearheaded by Aydogan Ozcan and Sam Mavandadi.  Using camera-phones with adaptors, it's now easy to upload pictures of the 'blood smears'.  Then using, the power of the many, Ozcan and Mavandadi propose to release the pictures to legions of gamers over the internet.  In their initial study, they found pretty good concordance rates between beginners and experts.  As we've seen with these types of crowd-sourcing success, the key lies in the fact that while an individual may be wrong frequently, there is wisdom in groups.

The caveats mainly deal the practical implementation of the project rather than the concept.  In a busy clinic of a hundred children getting tested for malaria, can you do this crowd-sourcing in real-time?  Is there sufficient bandwidth to upload the pictures?  What happens when the electricity goes down?  These are not insurmountable obstacles.  And in some areas, especially urban ones, this might be a way to improve the proficiency of the technicians, who may not get as much continuing education as they'd like in the first place.  

Meanwhile, try the game itself.  It's fun.  And you can pretend to be a microbiologist diagnosing malaria! 

 

 

Point-of-Care (Mondays): Peritoneal Dialysis After Earthquakes?

Earthquakes give no warning.  And when they occur in urban areas, they can easily kill thousands of people.  Within just the last ten years, the 2004 Sumatra, Indonesia 9.1 earthquake killed over 225,000, while infamously, the 2010 Haiti 7.0 earthquake killed more than 300,000 people.  Other large ones in the last decade each taken dozens of lives (Sichuan, China 2008, Pakistan 2005, Iran, 2003).  Deaths occur mainly through immediate surgical trauma - from falling buildings, collapsing houses and crumbling streets.

But a secondary cause of death follows the immediacy of the fallen cement.  In the subsequent few days and weeks, crush injuries to limbs muscle cause a medical condition called rhabdomyolysis.  Here, lysed muscle tissue release electrolytes and heme products causing untenable electrolyte abnormalities and kidney failure, respectively.  A way to diagnose this would be to look at the urine - if there is evidence of 'heme' (parts of a blood and muscle cells) in a simple urine dipstick test, without any red blood cells in the urine, then there's a high probability of rhabdomyolysis.  The more sophisticated way is to use a point-of-care Istat machine which can measure electrolyte and renal function

The first steps in treating rhabdomyolysis involves alkalinization of the blood (and urine) by giving sodium bicarbonate and administring intravenous (IV) hydration.  In many of the less serious cases, alkaline should neutralize the effects of the electrolytes and IV hydration should improve kidney function.  However, in some cases, the kidneys need to be temporarily replaced - i.e. the patient needs dialysis.  

There are two ways to dialyze patients.  The more common method we think of is hemodialysis - where through a special IV, a patient's blood is withdrawn, filtered through a special machine and then put back into the body.  This method, however, requires the special IV access and large machines (along with electricity).  Medicines Sans Frontieres (MSF, aka Doctors Without Borders) teamed up a few years ago with the Renal Disaster Relief Task Force - an international group of kidney doctors, nurses and technicians.  In conjunction, they provide the dialysis machines, the human capital and the logistic resources to earthquake stricken areas.  After the 2010 Haiti earthquake, they published a brief synopsis of their activities in the Lancet, which can be freely accessed here.  

But might there be a more efficient way to dialyze the victims?  In addition to hemodialysis, there's a another' method of dialysis called 'peritoneal dialysis'.  Here, instead of taking blood out to be 'washed' by an external machine, dialysis is performed 'naturally' within a patient's abdomen.  A surgeon inserts a catheter into a patient's abdomen and then fluid is pumped through the catheter.  While walking around, the membranes and fluid in the abdomen filter the electrolytes.  Every 5 hours, the patient replaces the fluid and thus the abdomen functions as the body's replacement kidney.  This is continued indefinitely for those whose kidneys have failed, or in the case of rhabdomyolysis, until the kidneys resume proper function.  

Peritoneal dialysis seems much simpler in areas where machines, technicians and electricity are limited.  Yet it seems to be under-utilized.  For example, in the Marmara, Turkey earthquake of 1999, of the 477 victims who needed dialysis, only 8 were given peritoneal dialysis.  It's unclear why this is so.  Are there logistic or co-morbid reasons to offer hemodialysis over peritoneal?  Is it operator dependant?  With the invevitability of future earthquakes, hopefully we can answer these questions and provide this secondary prevention mortality.  

For any real number x

For any real number x, where e is the base of the natural logarithm, i is the imaginary unit, and cos and sin are the trigonometric functions cosine and sine respectively, with the argument x given in radians.

 

Joseph Lister, 1st Baron Lister, M.D. (1827 - 1910)

It was Friedlieb Runge who discovered creosote, a chemical compound with anti-decomposition properties, widely used in the industrializing countries in the railway and shipping business since it protected the wood on train tracks and boats from rotting. It was also used for treating sewage, because it reduced the odor, although people were not exactly sure how.

Joseph Lister, a surgeon at the University of Glasgow, born on this day in 1827, suspected that chemical compounds such as creosote, could be used to combat skin wound decomposition, as well.

In an 1867 series of articles in The Lancet, entitled: "On a new method of treating compound fracture, abscess, etc.: with observation on the conditions of suppuration", Lister described the use of carbolic acid solution as a means to reduce the incidence of gangrene in surgical wounds. Lister applied a bandage dressing of carbolic acid onto the wound of a boy who had an open leg fracture. After four days, no infection had developed, and after a total of six weeks the bone healed without infection or decomposition. This was considered a remarkable achievement.

Moses Ben Maimonides, M.D. (1135 - 1204)

And now, the Physician and Surgeon's Almanac for March 30.

Moses Ben Maimon, also called Rambam, or by his Arabic name Abū ʿImran Mūsā ibn Maymūn ibn ʿUbayd Allāh  born on March 30, 1135. As a member of the Jewish community of Córdoba, in Islamic Spain, young Moses studied Judaic studies and science and showed remarkable talent in both areas.

When fanatical Islam forced many in the Jewish community to leave Córdoba , the Maimons moved from country to country, from Morocco to Palestine and then to Egypt. All  the while, Moses continued his studies in his favorite subjects, rabbinics and Greek philosophy, and added medicine to them.

 

When his younger brother, a prosperous jewelry merchant died in a shipwreck, taking the entire family fortune with him, Moses was left to support his family. Unable to afford a living on a Rabbi’s income, Moses turned to medicine and became a practicing physician. So successful in private practice and medical education, he later became the court physician to Saladin, the great military leader and Sultan of Egypt and Syria . At the same time he became famous as Maimonides, one of the greatest legal thinkers and philosophers in the history of Judaism and the world.

"What Is Mothra?", asked Sarah Singer.

Gatheer 'round children. Gather 'round...

Mothra (モスラ Mosura) is

#1 – Awesome!

#2 - A 1961 Japanese Kaiju (monster) film from Toho Studios, directed by genre regular Ishirō Honda with special effects by Eiji Tsuburaya.

#3 – More entertaining, funnier and magical, compared to Godzilla movies.

Executive Order 9066

On this day in 1942, President Roosevelt signed the executive order that lead to the forced internment of American citizens based on their ancestral country of origin. Japanese, German and Italian American citizens across the nation were relocated to internment camps as the United States readied itself for war against the Axis Powers in World War II.

Hans Asperger, M.D. (1906 - 1980)

Alas, gentle reader, the Physician and Surgeon’s Almanac for February 18^th.

Born in Hausbrunn, Austria on this day in 1906, Hans Asperger, a pediatrician and psychiatrist.

As a boy, young Hans enjoyed spending time alone, he had difficulty making friends and with the few he did have, he frequently bored them with his obsessive knowledge of poetry.

Incomplete Reporting in New Orleans

There's a Times-Picayune article from Feb 3rd by Bill Barrow which describes the slashing of medical and mental health services across the LSU run medical system and, of particular interest to me, in New Orleans:

• Eliminating the 20-bed chemical detox unit: $841,632.
• Closing nine inpatient psychiatric beds on the DePaul Hospital campus, leaving 29 open: $663,007.
• Closing 10 mental health beds in the emergency department, leaving 10 open: $853,673.
• Closing four general emergency department beds, leaving 40: $1.43 million.
• Closing 24 medical/surgical beds: $1 million.
• Cutting additional personnel across all departments: $4.94 million.
• Scaling back treatment for state prisoners: $2 million.
• Cutting professional services contracts with Tulane physicians/professors: $2.29 million.

 

My first reaction is that these are brutal.  The LSU system primarily is the medical safety net for indigent patients and so necessarily, any cuts will disproportionately affect...the indigent.  And specifically, the indigent who have mental health illnesses.  Less detoxing for poor people.  Fewer ER psych beds.  And fewer overall ER and med-surg beds in the LSU (aka "University") hospital.  

Maybe all these patients will be ok.  Maybe this is the slap of hard-reality in the face they need to overcome...drug addictions...and heart attacks.  Or maybe, they'll just move elsewhere were services for indigent patients is better.  The likelihood is that there will just be more mass suffering for those without resources.  

But one point in this article which irks me more is the question of proportion.  These cuts seem brutal.  But what's the overall budget for the LSU hospitals and the state government?  Are there other cuts in the state budget as severe?  How are these cuts in relation to corporate tax cuts within Louisiana?  

20 years ago, to answer these proportionality questions, one would have to go to a library.  But I can do it now just by opening another tab and googling the answers.  It would be quite helpful, though, for the reporters on these beats who have access to these public databases to link to them in the stories.  Or if their editors don't want out-linking from their sites, then perhaps links to other stories within their own paper?  

It seems that one reason for the polarization of the electorate is that we've become more reactionary.  LSU hospital slashing!  Deep medicaid cuts!  Corporate executive pay rises!  But reporters can help reduce this with the simple tools of the internet and giving context to their stories.   

 

The "Others", Revisited

In 2009, we reported on a San Francisco real estate company's neighborhood map being suggestive of the City's attitude toward its declining African American communities by coloring them gray and replacing the proper names of black neighborhoods with the word "other".

Apparently, someone at corporate saw fit to make a change...

Welcome back to the City, OMI and BVHP....but lower Pacific Heights and Hayes Valley where the Fillmore, "Harlem of the West" should be.

 

2009

2011 

Anton Pavlovich Chekhov, M.D. (1860 -1908)

"Medicine is my lawful wife, and literature is my mistress. When I get fed up with one, I spend the night with the other. Though it is irregular, it is less boring this way, and besides, neither of them loses anything through my infidelity." 

A quote by Dr. Anton Pavlovich Chekhov, born on this day in 1860, in the small town of Taganrog, Ukraine. He described his childhood as not having one. His father was abusive to him, his siblings and his mother and at the age of sixteen, his bankrupt father left him behind to manage the family's failing finances in Taganrog while he, himself, moved to Moscow.

With his father hoping to avoid debtors' prison and his mother emotionally broken, Chekhov put himself through school, by working odd jobs and sending money to his family in Moscow. In 1879, he was accepted to Moscow University's school of medicine.

He made little money as a physician, often treating people for free; a habit that continued well into his success as a author and dramatist. Two years after completing medical school, he began coughing blood, but he hid this from others as he pursued medicine and writing.

$75 Per Speeding Ticket

In full disclosure, I've spent hundreds of dollars in fines levied by the NOLA traffic cameras, mostly going a bit over 30mph where the speed limit is 25mph.  My emotional response:  it's fucking annoying.  

More analytically, however, there are two competing interests.  First, do these cameras REDUCE traffic accidents?  Who knows...but anecdotally, they have made me and my neighbor drive slower.  So logically, they probably work.

Second, however, is the question of justice?  Are they being implemented fairly?  To that, I'd say NO.  As per the article, the cameras are placed in somewhat devious ways:

A visit to the hardest-working traffic camera in town makes plain the reason for its success -- and why it has many motorists hopping mad. The camera is positioned about a block down from where Henry Clay, one of New Orleans' smoother streets, widens dramatically into a broad boulevard. The sidewalk on the avenue's uptown side is lined by a tall brick wall, reducing the odds that, say, a child might suddenly run into the street.

In short, drivers judge the street as one where they can safely travel at perhaps 35 mph. But the speed limit is 25 mph. At 31 mph, the camera trips, and a $75 ticket is issued. At 35 mph, the fine jumps to $110.

Plus, the delay in actually receiving the ticket in the mail leaves a latency period where the punitive ticket doesn't change driving behavior - because you haven't gotten the ticket yet!  If you got a ticket by an actual cop, you're much more likely to drive slower for the next few weeks.  But with a camera, you get the ticket in the mail in a couple of weeks, blissfully and ignorantly driving the same in the meanwhile.  

Finally, I'm going to search to see whether the City audits the collections and releases where the funds have been allocated.  Hopefully, this isn't a money-grab to cover under-funded accounts.  

 

10

There are only 10 types of people in the world: those who understand binary, and those who don't.

Clinical Diagnosis of HIV in neonates?

Jaspen et al attempt to find clinical clues which may herald HIV infection in exposed neonates in South Africa:

417 HIV-infected and 125 HIV-exposed, uninfected infants, median age 46 days (IQR 38-55), were included. The median CD4 percentage in HIV-infected infants was 34 (IQR 28-41)%. HIV-infected infants had lower weight-for-age, more lymphadenopathy, oral thrush, and hepatomegaly than exposed uninfected infants (Adjusted Odds Ratio 0.51, 8.8, 5.6 and 23.5 respectively; p<0.001 for all). Sensitivity of individual signs was low (<20%) but specificity high (98-100%). If any one of oral thrush, hepatomegaly, splenomegaly, lymphadenopathy, diaper dermatitis, weight <50th centile are present, sensitivity for HIV infection amongst HIV-exposed infants was 86%. These algorithms performed similarly when used to predict severe immune suppression.

Neonatal HIV can be notoriously hard to diagnose.  In the developed world, we screen patients of all ages for HIV with a rapid, anti-body test, but then confirm it with a more advanced PCR test.  In neonates, however, because they get maternal antibodies in utero and through breast milk, the anti-body tests could be a 'false-positive' - i.e. the test says positive, but it's actually false because it's detecting the mother's transmitted anti-bodies.  So the general strategy in the developed world is to skip the preliminary (less costly) antibody test and go directly to the (more expensive) PCR test.

This strategy fails in the undeveloped world where the (more expensive) PCR tests aren't available.  The two prevailing strategies are a) look for very much cheaper antibody tests and b) look for ways to clinically screen patients and then refer only the higher suspicion ones to get the more expensive tests (as Jaspen et al have done).

Strategy A is the preferred way and some money is being spent on that.  My preference would be that more money be spent on that.  In the meanwhile, those nurses/house officers/doctors have to 'get through the day' with whatever tools they have.  And if they find that more lymphadenopthy can increase the clinical probability that a neonate has HIV, they may feel more confident sending that mother and baby by bus over many kilometers to a more sophisticated testing and treating center.  

It's suboptimal.  But until we get better and cheaper tests, it's the prudent field level strategy.  

Dominos in North Korea

The headlines of the major international news sites and newspapers blared the death of Kim Jong Il today.  He died 2 days ago, but the news was left out of public consumption, presumably to maintain order and choreograph the unveiling of his son.  Good riddance.  

The man was a mass murderer who promoted the deaths of millions of his country's men, women and children.  In the 90s, he ruled during a terrible famine.  He set up labor and death camps.  Death could only have been too kind to him.

And now the question remains - what of the North Koreans? Or simply the 'Koreans' as they were known before the bifurcation of the peninsula at the start of the Korean War in 1950.  They live in fear, in isolation, in brainwashing and in hunger.  The vested international actors are South Korea, China, Japan, the US and Russia.  

China's going through economic hardships themselves, if one were to believe the warnings of Paul Krugman (and I generally do).  The South Koreans have prospered since the 1960s and do they really want the burden of unification that the West Germans went through?  The US is mired in multiple wars across the world and has little interest in this time of divided government and a realpolitik president in getting involved in another conflict or country rebuilding.  Russia seems to be cash-heavy, but is undergoing its own version of public outcry against a kleptocarcy.  

So who's got the incentive to do anything but maintain the status quo and let the hermit kingdom continue?  Meaning, onward continue the silenced suffering of the (North) Koreans.  

Vox Arborum

I had a sneaking suspicion that tree population was linked to voter turnout in the City.

I soon found out, since Golden Gate Park is not a voting precinct, trees living there cannot vote.

Something must be done!

 

Horto in Urbs

The Perversion of Oncology Economics

In an insidiuously chilling editorial in the NEJM, the intersection of micro- and macro-economics of oncolgy is explained.  Oncology through the 20th century consisted of using available poisons to hurt cancer cells (bad guys) quicker than other body cells (good guys).  Given the obvious potential to seriously harm patients, only few physicians did so.  This anachronistic process led to these few physicians 'selling' chemotherapy medicines out of their office.  

Towards the end of the 20th century, this vending became incredibly profitable as cancer medications became more expensive (and as people stopped dying of communicable diseases with better public health, vaccines and antibiotics).  But as the rate of medical costs soar, medical payers (CMS and private insurers) have begun focusing on decreasing oncology care costs.  And so we now end up with a non-sustainable system.

But what's the actual problem?  Greedy pharmaceuticals - not really, as they're not humanitarians, they're capitalists.  The governmentn - well, for anyone to the left of Rick Perry...perhaps.  But what exactly is the government supposed to do - pay more for medicines when it doesn't need to?  

No, I'd say the fault lies in the fundamental pay scheme of modern American medicine which emphasizes pay-for-service rather than pay-for-outcome.  Here's a model of how it would work, per the NEJM article:

One solution is adopting clinical pathways for which practices are paid disease-management fees that are not based on chemotherapy sales. For instance, one large oncology group has developed care pathways specifying preferred drug combinations and sequences — for example, allowing only a few first-line, mostly generic regimens for patients with non–small-cell lung cancer, as compared with the 16 possible drugs and many more combinations included in National Comprehensive Cancer Network pathways. This approach has been shown to result in equal or better survival, less use of chemotherapy near the end of life, and 35% lower costs than usual care.

"The Plural of Anecdote is not Data"

Nancy Pelosi channeled the above phrase from an unknown source in the political sphere.  But in the sphere of medicine, sometimes clinicians are confronted with the case that, in fact, no data exist and all that's left to help guide decisions are the plural of anecdote, whatever that may be called.

Here's a NEJM article in which pediatricians Stanford confront the problem.  Of note, among the various fields in medicine, few are as poorly researched as pediatrics:

Without clear evidence to guide us and needing to make a decision swiftly, we turned to a new approach, using the data captured in our institution's electronic medical record (EMR) and an innovative research data warehouse.

They simply did a quick case-control study withing their own institution's database, found some apparently north-star-ish advice and made a clinical treatment decision.  Luckily for the patient and them, the situation worked out for the best.  They then conclude grandiosely:

Our case is but one example of a situation in which the existing literature is insufficient to guide the clinical care of a patient. But it illustrates a novel process that is likely to become much more standard with the widespread adoption of EMRs and more sophisticated informatics tools. Although many other groups have highlighted the secondary use of EMR data for clinical research,2,3 we have now seen how the same approach can be used to guide real-time clinical decisions. The rapid electronic chart review and analysis were not only feasible, but also more helpful and accurate than physician recollection and pooled colleague opinion. Such real-time availability of data to guide decision making has already transformed other industries,4 and the growing prevalence of EMRs along with the development of sophisticated tools for real-time analysis of identified data sets will no doubt advance the use of this data-driven approach to health care delivery. We look forward to a future in which health information systems help physicians learn from every patient at every visit and close the feedback loop for clinical decision making in real time. (Emphasis added)

These authors have identified a fundamental problem in clinical analysis - the volume of perplexing clinical questions supersedes the available volume of decent studies answering them.  In this case, most clinicians revert to, what worked yesterday, or the day before.  And clinicians with longer memories can go back even further.  And those special clinicians with higher computing power can even figure out mental matrices in which they subdivide patients based on comparative characteristics.  

But, of course, what these Stanford pediatricians have done is outsourced the mental computing to a local computer which does the hard work.  And good for them and their patients.  Perhaps the epidemiologists can figure out how to synthesize these datum to produce meaningful statements, similar to meta-analyses.  

But clinicians shouldn't fool themselves or their patients into accepting that this is 'optimal' medicine.  It's not.  It's second best.  Nor is this a problem if clinicians de-throne themselves from the alter of deities and begin to explain to patients the uncertainty in diagnoses and treatments.  

Take Two Twitters and Call Me in the Morning

Chorbev et. al describe in the Journal of Telemedicine and Applications a plausible model for improved diabetes through group share.  They set up a platform where:

We have developed a healthcare social network that provides methods for distance learning; opportunities for creation of virtual self-help groups where patients can get information and establish interactions among each other in order to exchange important healthcare-related information; discussion forums; patient-to-healthcare specialist communication. The mission of our virtual community is to increase the independence of people with diabetes, self-management, empower them to take care of themselves, make their everyday activities easier, enrich their medical knowledge, and improve their health condition, make them more productive, and improve their communication with other patients with similar diagnoses.

On one hand, one of the flaws with this is that this network captures those who already are invested in improving their care - the self-selection bias.  If you're online and have the choice between TMZ (Humpdashian!) versus your HbA1C, even with marginal costs, the uninterested patient will choose Humpdashian.  But on the other hand, the Gladwell understanding of the social network model, would argue that given the low cost of interaction (send some emails, perhaps check your sugars more often or take your insulin more regularly), even with low motivation, the participation of these patients should be high.  So while each patient doesn't have to do so much, the fact that many are doing a bit improves substantially the median health outcome.

More systematically, the Gladwell argument discounts the power of networks to find answers.  The beginning examples of chaos theory generally use the patterns of birds or fish as the analogy to describe the complex patterns developed without hierarchy:

Chaos theory looks at how very simple things can generate very complex outcomes that could not be predicted by just looking at the parts by themselves.
 
You may have noticed the wonderful swirling patterns of birds flying together in the sky or fish schooling in the oceans. At first glance we would think the birds would have to be rather intelligent to work out how to fly in formation like that. We would probably also assume there must be a 'bird in charge' giving  instructions to all the others. 

Research into swarms has shown, however, that all that is required is for each bird to maintain the distance between itself and its neighbours and fly in the average direction of its neighbours. From this alone the wonderful, swirling, complex patterns the birds or fish make are seen. Simple rules can generate complex behaviours that just seem to emerge out of nowhere. While each individual agent does not need much intelligence, the is swarm intelligence which resides with the collective.

And this is the argument put forth by the social network as improved health model.  It's actually the feature (rather than the bug) of this model that it's non-hierarchical.  In this way, simple modifications to the program or to the rules set forth to the patients can have large, cascading effects.  And done well, these can still be inexpensive in cost to the patients (effort) and to society ($$).  

GORT,

KLAATU

BARADA

NIKTO

The Ministry of Information

“more power to the misinformed”

 

Do Protocols Make Dumber Clinicians?

There's a lot of push-back from clinicians arguing that patients are individuals and can't be pegged into uniform clinical protocols.  This argument necessarily invokes the straw-man in the guise of the 'physicians don't have control anymore' lament.  I readily counter with the refrain that common things occur commonly and that most patients do fall within the parameters of protocols.  Most patients with DKA need insulin, fluids and potassium.  Most patients with community acquired pneumonia improve with empirically chosen antibiotics.  

But the more important part of the rebuttal is that for the exceptional patients who don't conform, the clinician still has the choice to change treatment.  As of yet, there's no one arguing that when justified, a clinician still doesn't have final decision making authority.  Not insurance companies.  Not the government.  And not the egg-head proponents of protocolized medicine.  

More defensively against protocols is the argument that they make trainees stupider.  It's perplexing why this should be so.  Currently, it's probably the case that trainees have too many models to study - each attending teaches a different method.  Consolidating these should simplify the majority of cases, allow trainees to understand the basics and, as there are always exceptions, enable them to treat these non-conforming clinical quandaries.  

This just published JAMA retrospective study on how well Critical Care fellows fared on their Board exams gives some initial evidence that, in fact, protocols don't make them dumber.  The study divided up the fellows based on how many protocols were in place in their institution and then compared how they performed in relevant sections of the boards.  What they found was that there was no difference in clinical knowledge between programs with a high number of protocols and those with a low number of protocols.  

Results Ninety of 129 programs (70%) responded to the survey. Seventy-seven programs (86%) had protocols for ventilation liberation, 66 (73%) for sedation management, and 54 (60%) for lung-protective ventilation at the time of the survey. Eighty-eight (98%) of these programs had trainees who completed the ABIM Critical Care Medicine Certification Examination, totaling 553 examinees. Of these 88 programs, 27 (31%) had 0 protocols, 19 (22%) had 1 protocol, 24 (27%) had 2 protocols, and 18 (20%) had 3 protocols for at least 3 years. Forty-two programs (48%) were classified as high intensity and 46 (52%) as low intensity, with 304 trainees (55%) and 249 trainees (45%), respectively. In bivariable analysis, no difference in mean scores was observed in high-intensity (497; 95% CI, 486-507) vs low-intensity programs (497; 95% CI, 485-509). Mean difference was 0 (95% CI, –16 to 16), with a positive value indicating a higher score in the high-intensity group. In multivariable analyses, no association of training was observed in a high-intensity program with mechanical ventilation score (adjusted mean difference, −5.36; 95% CI, –20.7 to 10.0).

Conclusion Among first-time ABIM Critical Care Medicine Certification Examination examinees, training in a high-intensity ventilator protocol environment compared with a low-intensity environment was not associated with worse performance on examination questions about mechanical ventilation management.

 

 

Gleevec, India, Patents and the Fate of Affordable Medications

An important editorial by Dr. Druker - one of the key investigators of Gleevec [imatinib] - and how a legal case in India may affect the affordability of generic medications across the world.  The argument in India centers around how much modification a pharmaceutical needs to make in order to be granted a full new patent on the modification.  

The Indian law states should have the following characteristic (paraphrased from an MSF editorial):  "a new form of a known medicine can only be patented if it is not obvious and shows significantly improved therapeutic efficacy over existing medicines"  Novartis, Gleevec's manufacturer, contends that smaller changes are material and should be granted full patent privileges.  

I agree with Dr. Druker on this:

However, the price at which imatinib has been offered for sale by Novartis around the world has caused me considerable discomfort. Pharmaceutical companies that have invested in the development of medicines should achieve a return on their investments. But this does not mean the abuse of these exclusive rights by excessive prices and seeking patents over minor changes to extend monopoly prices. This goes against the spirit of the patent system and is not justified given the vital investments made by the public sector over decades that make the discovery of these medicines possible.

Public institutions around the world have continuously played a critical role in the research that leads to vital new medicines reaching the market. Without access medical research becomes a luxury good. Most of my colleagues would be very uncomfortable if we felt that this would be the result of our decades ofeffort.

 

Water-world - India and Bangladesh

According to this Al-Jazeera article, a recent signing between India and Bangladesh resolved many land-border issues:

India and Bangladesh have signed a raft of agreements during a visit to Dhaka by Manmohan Singh, India's prime minister, including one to resolve long-running border disputes.The South Asian neighbours concluded a land boundary agreement on Tuesday to demarcate their 4,000km shared border and sort out 162 "enclaves" - small pockets of one country's territory surrounded by the other."Both of our countries have now demarcated the entire land boundary and have resolved the status of enclaves," Singh said at a ceremony with his Bangladeshi counterpart, Sheikh Hasina, in Dhaka.

But what may be the key graf in this story isn't the above headline but rather the unresolved disputes left over water access between the two countries.  The 1996 Ganges water sharing treaty - already in peril due to political and economic tensions - is possibly being tested by the changes in climate change leading to a conflict between asymmetric partners:

A review of current literature on the Ganges reveals that the issue of majo r concern is the quantity of water available to the mega-city of Kolkata and to southwestern Bangladesh, both of which rely on the Ganges water for short- and long-term needs. However, there is evidence that theunderlying causes of water quantity problems are of po

litical and economic nature, both in the conditions that had lead to the construction and implementation of the Farakka Barrage itself, as well as those precluding a fair and workable long-term water sharing agreement. Politically and militarily, India is by far the stronger of the two nations, and wishes to not only maintain its dominance but also enhance it; these factors are reinforced by India's advantageous terms of trade, economic growth, and position as the upper riparian state. Any future effort to resolve the ongoing dispute between India and Bangladesh must address these underlying variables to be successful in the long run.

 

HIV Pre-exposure Prophylaxis and the Underground Economy

Recent large trials have shown some positive evidence that pre-exposure prophylaxis for HIV works.  The first was the iPrEx trial showing it worked in men who have sex with women.  Then we have the HTPN 052 trial showing it works in preventing transmission from one HIV+ partner to his/her HIV- partner in heterosexual couples.  

As these positive results have seeped into the mainstream press, inevitably, there's been a run on anti-retrovirals, as reported here by marketwatch:

The State of Florida Agency for Health Care Administration (AHCA) recently sent out an alert to Florida health care providers and pharmacies notifying them of stricter requirements for incoming pharmacy claims for HIV/AIDS medications. AHCA informed AHF that the change is in response to an increase in demand for Truvada for use as a prevention pill by HIV-negative individuals and the fraudulent prescriptions that are appearing as a result.

 And while the state of Florida is absolutely right to maintain legitimacy and control over prescription medicines, there's a larger story here.  What we see here is an excess of demand for HIV medications over the supply.  Good.  This reflects the fear that HIV- negative individuals have of being infected with the virus and the hope they are clinging to that pre-exposure prophylaxis works.  We want these individuals to take care for themselves and in doing so reduce the overall transmission of the disease.  We've been working on this for 30 years!

The stated fear of opponents of wide-spread pre-exposure prophylaxis is that it will lead to more promiscuous behavior - which should perhaps be called the bare-back theory.  And that used improperly, the virus will soon find resistance to the medications, making them less efficacious in other patients.  But there are still lots more positive benefits to pre-exposure prophylaxis medications than negative ones.  In vulnerable sex workers.  In stable discordant couples - both heterosexual and homosexual.  There are lots of people who would benefit.  

The CDC has started the discussion on the proper use of pre-exposure prophylaxis (see below).  Admittedly however, there are political and scientific motives for not forcibly pushing these yet.  But as we fill in the knowledge gaps, the right way to use this modality will be the same as birth control and condoms and other preventive measures - emphasis on the risk of improper use while encouragement on proper application.

 

Toothpaste out of the Tube - Hospitalists

Over the past ten years, the care of general internal medicine patients has specialized to 'hospitalists'.  These are doctors who are general doctors who 'specialize' in taking care of patients while in the hospital.  This has happened because:

1. clinic work has gotten so busy, practitioners don't have time to go see his/her patients in the hospital
2. hospital care of patients has gotten more complicated with dozens of new drugs and testing modalities
3. clinicians want the 'shift-work' benefits associated with hospitalist care

With that in mind, here's a study showing that there's not much financial benefit to the use of hospitalists:

Results:

In propensity score analysis, hospital length of stay was 0.64 day less among patients receiving hospitalist care. Hospital charges were $282 lower, whereas Medicare costs in the 30 days after discharge were $332 higher (P < 0.001 for both). Patients cared for by hospitalists were less likely to be discharged to home (odds ratio, 0.82 [95% CI, 0.78 to 0.86]) and were more likely to have emergency department visits (odds ratio, 1.18 [CI, 1.12 to 1.24]) and readmissions (odds ratio, 1.08 [CI, 1.02 to 1.14]) after discharge. They also had fewer visits with their primary care physician and more nursing facility visits after discharge.

Limitation:

Observational studies are subject to selection bias.

Conclusion:

Decreased length of stay and hospital costs associated with hospitalist care are offset by higher medical utilization and costs after discharge.

Primary Funding Source:

National Institute on Aging and National Cancer Institute.

 

This is sobering news for the use of hospitalists.  But, as with the toothpaste analogy, it's unlikely we're going to go back to a system where internists become generalists and decide to re-learn the care of complex hospital patients in addition to taking care of their clinic patients.  So this implies that we have to figure out why that secondary cost - the 30day ER re-visit - is high.  

Are patients let out of the hospital too early by hospitalists who don't know enough about the patients?  Do hospitalists understand post-hospital care sufficiently?  Is there appropriate return to the primary care physician?  Are there enough appointment slots in clinics for hospital follow-up patients?