KOLAHUN

THE ILLUSION OF CONTROL

 
My favorite button on the keyboard: CONTROL.

When you ESC, you escape. When you DELETE, you delete. When you RETURN, you return. And if you’ve ever CAPS LOCK, you know you'VE caps lockED.  But what happens when you CONTROL?  Nothing. You have no more control over the computer than you did before. But the need to control is real and so are placebo buttons on city streets, elevators, computers and cars designed to convince you that you have control over streets, elevator, etc., when you really don’t.  

The illusion of control is the tendency to believe that one has control over events that they actually have no demonstrable evidence of influence.  Being out of control can be distressing to some people. When asked “heads or tales”, people feel more distress if forced to choose AFTER the coin is tossed, even though the outcome is the same as if they answered before. People tend to throw dice harder when they desire high numbers even though the force of the throw doesn’t change the odds. Pushing the following buttons only feeds our illusion of control and our need for more of it:

Don't Believe the Hype (yet)

Here we go again.  Here comes another pharmaceutical sponsored study with a lot of hype and no benefit.  This time it's for a new anti-cholesterol medicine.  The NEJM just published a study, paid for by the drug manufacturer, Merck, which concludes that:

Treatment with anacetrapib had robust effects on LDL and HDL cholesterol, had an acceptable side-effect profile, and, within the limits of the power of this study, did not result in the adverse cardiovascular effects observed with torcetrapib. (Funded by Merck Research Laboratories; ClinicalTrials.gov number, NCT00685776.)

It's unclear why this was an 'early release' by the NEJM editors.  The study shows that against placebo, the drug reduces LDL.  It's not an outcome study.  In fact, there was essentially no difference in negative cardiac outcomes for each wing (2.0% in the trial and 2.6% in the placebo).  They barely demonstrated that against sugar-pills, this drug doesn't do harm.

What's the hype?  Why publish an 'early release'?  Is the drug going to be available next week?  Have we not learned the lessons of Vioxx and Avandia FDA recalls?  In fact, in the Avandia case, a major part of the story was the deceipt of the NEJM itself by pharmaceutical researchers. It makes little sense to hype this uncorroborated study for a drug with no proven benefit which might be unavailable to a vast group of patients because of cost.  It's far better in these leading medical journals to hype those studies which validate (or invalidate) existing highly common but inadequately researched study medications than to chase the newest studies which have no immediate clinical utility.

'Democracies' Don't Ensure Good Public Health

Joe Amon, writing recently in Foreign Policy, mistakenly relates two unrelated concepts: the strength of a country's public health and that country's governance type.  He postulates that Haiti's governance type increased its of having a cholera epidemic:

In short, because disease and democracy often work in opposite directions: vulnerable populations and inadequate government action create both the conditions for cholera epidemics to emerge and to become unmanageable. 

Cholera epidemics stem from the same basic cause: poor people living in crowded and unsanitary conditions, with inefficient public health monitoring and limited health care. Cholera is a bacterial infection caused by the ingestion of fecally contaminated water or food. When an outbreak starts, it gains momentum fast.

But another cause is government denial and cover-up. Governments don't want to admit the failure of health-care or surveillance systems, and they are afraid of the trade and travel sanctions that may result from a large outbreak. But inaction leads to larger epidemics: Treating a few cases of cholera with oral rehydration salts or intravenous fluids is relatively straightforward, managing hundreds or thousands of cases is not. With prompt and proper treatment, less than 1 percent of those infected die. Without a fast response, death rates of five percent or more are not unheard of.

Um...Haiti is a democratic country!  It's even got a President and an Assembly.  Perhaps he means, a liberal democracy - the type of government we generally mean when we generically use the term 'democracy'.  A country with a strong constitution, individual liberties, limited government and fair elections.

But even if we ascribe that to him, does his argument still stand the test of reality?  For example, there are four cholera epidemics going on right now -

• Nigeria - which is a corrupt democracy, but had an orderly transition of Presidential power after when Yar'Adua died and Goodluck Jonathan took over
• Pakistan - another terrible democracy, but still a nominal democracy
• Haiti - see above
• Papau New Guinea - which seems to be a stable parliamentary democracy.

So...no.  All of these countries have some type of democratic governments.  Nigeria is a lower middle income country with a strong history of corruption and a high level of income inequality.  Pakistan is very similar.  Haiti and Papau New Guinea are both democratic states which are just too poor - but there's not a recent history of political instability in either country.

Conversely, we can come up with at least one example of a state with a respected tradition of liberal democracy and see how it failed completely during an emergency.  In 2005, the US, which has had stable democratic governance for 200+ years (only interrupted in the 19th century by the Civil War), responded incredibly poorly when a hurricane hit one of its 50 most populous city.  The disenfranchised during Katrina were the poor, who had little means of escaping the oncoming tempest.  But there's little reason to doubt the governance and electoral process of New Orleans, Louisiana or the US.

Perhaps we can find common themes in these cases.  Mr. Amon agrees that poverty is a unifying causation.  There's no doubt that cholera follows poverty.  Even in middle-income countries, the areas of cholera find the pockets of poverty in the inequality.  Moreover, perhaps the attention to public health itself is a determinent.  The four countries mentioned above have a long history of poor public health infrastructure.  The US, for its part, spends a lot of money on a dysynchronous health system.  The parts may function on their own, but the lack of uniform public health governance limits the overall resiliancy of the system. 

At the least, however, we should be able to agree that 'democracy' itself is not a derminant for or against the onset of cholera.

Truck Driver Health

Having recently driven from Chicago to Louisiana, I began thinking of the wholy unhealthy lifestyle that truck drivers subject themselves to.  There are about 3.5 million truck drivers in the US.  And of those who carry loads mainly drive on interstate highway syste, the road offers very little in healthy lifestyle options.  They get very little exercise during their trips.  Food options mainly consist of fast food and convenience stores at fuel stations.  Truck stops notoriously have previously reputed to harbor easy access to drugs and unsafe hetero/homosexual prostitution.  The trucks themselves can be enviornmentally toxic. 

And all that doesn't even mention the basic worry of accidents.  There's not much within the brief search I've done that addresses this within google or pubmed.  While it's true that truck driver licensure ensures basic health requirements and scheduled illicit drug testing, I might be persuaded to accept the claim that truck drivers constitute a 'vulnerable population'. 

To get to that point, however, does anyone know good resources on the health of truck drivers, any epidemiology studies or other good resources on this subject?

 

UPDATE: Just found this link:

Some 200 medical researchers, doctors, regulators, trucking executives and others spent two and a half days in Baltimore this week talking about truck and bus drivers. From the blizzard of studies, statistics and analyses came a short message to the trucking industry: Invest in health.

It has long been understood that truck driving - particularly long-haul driving - is a physically demanding and risky occupation. Moreover, long hours, hard labor and on-the-road living make it hard for drivers to take care of their health.

 

Dr. Sun Yat-sen (1866 - 1925)

For your reading pleasure, the Physician and Surgeon's Almanac for November 12, 2010.

Born Sun Dixiang in Cuiheng, China in the southern province of Guangdong, his brother lived in Hawaiian and, when Dixiang was old enough, he join him there, so that he could attend school and learn English. It was there that Sun converted to Christianity and was baptized. 

He returned to China and attended medical school. In Hong Kong, Dr. Sun practiced medicine from 1892 to 1894, but felt his work was too boring and his life, too traditional.

He joined a revolutionary group whose goal was to bring constitutional government to imperial China, and because of such activities, he was forced to leave the country in 1895 and live in exile.

On October 10, 1911 a rebellion against the Qing Dynasty ended the monarchy and Sun returned home from the United States and was elected the first President of the Republic of China.

Forget Your ABC's in Saving Lives

Children learn ABCs to start literacy education.  Medical students re-capitulate this response this every time they are asked a difficult 'pimp' question by their professors.  When they don't know the immediate treatment of, say, a hyponatremic seizure*, they revert to the infallible response a child may use..."ABC".  In this case, however, they mean 'Airway, Breathing, Circulation,' the initial resuscitation of any sick person as taught by the American Heart Association for over 40 years. 

Recently, however, the American Heart Association re-arranged the letters according to the latest physiologic evidence:

 

The 2010 AHA Guidelines for CPR and ECC recommend a change in the BLS sequence of steps from A-B-C (Airway, Breathing, Chest compressions) to C-A-B (Chest compressions, Airway, Breathing) for adults, children, and infants (excluding the newly born; see Neonatal Resuscitation section). This fundamental change in CPR sequence will require reeducation of everyone who has ever learned CPR, but the consensus of the authors and experts involved in the creation of the 2010 AHA Guidelines for CPR and ECC is that the benefit will justify the effort.

 

Until I read the evidence myself, I'll presumptively accept the well-reputed AHA.  However, It will be a radical change for the public to learn and remember the re-ordering of the the well-versed alphabet.  And, on a more frivilous note, it'll perhaps incite palpatations in those medical students using outdated heuristics. 

Too bad for them. 

 

*The appropriate treatment being 3% normal saline.

TB - Treating the Patient and the Disease

Modern allopathic medicines treat 'diseases'.  If you have hypertension, you get a medicine - and possibly some adjunct advice about diet or exercise.  If you have diabetes, you get injections to bring your sugars down - and more adjunct advice about diet or exercise.  The traditional 'non-traditional' fields of health care emphasize other aspects of individual well-being apart from the disease itself.

For example, herbalists may help someone with hypertension who has sleep difficulties or gastro-intestinal problems as a way to counter the body's response to those negative stimuli - which culminates in high blood pressure.

A recent study published in the allopathic journal CHEST, showed how these two modalities can be used together synergistic-ally. 

 

The team conducted a prospective randomized controlled trial using a Guduchi preparation called tinocordin. The study involved 100 patients with sputum-positive pulmonary tuberculosis admitted to a tertiary care teaching hospital between January 1999 and April 2000. One group was randomized to receive antitubercular drugs, including rifampicin, isoniazid, ethambutol, and pyrazinamide. The other group received the same antitubercular treatment plus 500 mg tinocordin 3 times per day for the first 2 months of treatment.

The researchers followed patients at 15, 30, and 60 days, assessing them for clinical improvement, weight gain, radiologic improvement, hematologic parameters, sputum conversion, and adverse effects. Patient outcomes were deemed satisfactory after 2 months if they achieved sputum conversion, clinical improvement of greater than 80%, and radiologic improvement greater than 50%.

At 15, 30, and 60 days, clinical improvement was 23%, 48%, and 73%, respectively, in the study group, and 16%, 31%, and 57%, respectively, in the control group. The differences were statistically significant.

In the study group, mean radiologic improvement at 30 days was 26.1% and at 60 days was 55.5%; in the control group, it was 23.24% at 30 days and 46.96% at 60 days (P < .05 at 60 days).

Sputum conversion at 15, 30, and 60 days was achieved by 46%, 74%, and 90% of the study group, respectively; it was achieved by 22%, 58%, and 76% of the control group, respectively (P < .001).

At 2 months, 69.56% of patients in study group had a satisfactory response, compared with 30.61% of the control group. Adverse effects (11%) included constipation (2.17%), rash and itching (4.34%), and increased frequency of micturation (4.34%).

 

The novelty of this treatments bucks the 'more is better' paradigm of allopathic medicine which, while showing profound improvements in some interventions, is limited by its own monolithic modality.  HIV treatment improved with the use of triple-therapy and combining two types of anti-malarial medicines reduced resistance.  However, they were all arrows from the same quiver.  Usage of different modalities, however, such as herbal therapy, along with conventional treatment potentially compounds the available ways to make people healthier. 

New (low-tech) v. New (high-tech) Test for Tb?

Within the last few months, there have been two stark improvements in the diagnosis of Tb.  Just to put it in perspective, Tb kills over 1,400,000 people around the world, ranking 7th amongst all causes.  The most common and simple way to diagnose Tb in a field setting is by light microscopy.  However, this process misses Tb in patients who don't have the mycobacterium in their sputum.  Moreover, this method can't test resistance pattern for the emergent MDR-TB. 

Andrew Miller, an undergraduate student from Texas, invented the New (cheap) method.  He constructed a portable, highly functioning microscope which costs $240, with a casing produced by a 3D printer (see below).  The lighting would come from a top-mounted LED light, obviating need for electricity.  This microscope has yet  to be field tested.

 

 

Meanwhile, the New (expensive) model consists of a field-level PCR machine with ready made reagents which can be used by quickly trained technicians.  The GeneXpert System adds value by self-enclosed PCR testing and by reporting Rifampin resistance.  Of course, the machine needs a stable power source, appropriate ambient conditions and maintenance - all of which can currently only be provided at, and have been validated in, reference laboratories. 

 

For those of you who have worked in resource limited settings, which one would you have preferred to have?  Please, leave any answers in the comment section.

Do We Need The Name AIDS?

In the Jamaica Observer, 'ER' asks a pertinent question:

 

Dear Eve,

I am still not clear on the difference between HIV and AIDS. I think that as a person gets AIDS they will soon die, and some people are telling me that this is not so. Who is right?

ER - still confused

 

The response is the standard answer in the form of, well...HIV is the virus that attacks your immune system and  when your immune system is weak you get AIDS...and so forth.  The medical community has definitions for this weak immune system - usually when the CD4 count falls below 350 or 200.  But all these definitions are changing! 

Patients with HIV started treatment if the CD4 was below 200 or if they had an opportunistic illness.  Now, most of the recent literature indicates we should start treatment if their CD4 falls below 350 or even 500.  But if they do, then they may never get AIDS! The obvious patient question:  so why am I taking medications for a disease I don't have?

We should message HIV like we do diabetes.  You have it.  At some point you will need medications.  In the meanwhile, here's how to protect yourself and others and keep yourself healthy.  Plus, morphing these two terms into one makes messaging in our twitter world much more effective.