KOLAHUN

Games in medicine (Tuesdays) - The Cold Future of the Virtual World?

"Progress" frequently gets interrupted by a variant of the status quo bias, wherin a person's preference is for the present circumstances in lieu of a potentially more rewarding state of change in the future.  Early on, people bemoaned the rise of Facebook as a narcissistic exercise, but now there are almost one billion users.  Similarly, there were criticisms of ebook readers (though lots of people now use a kindle or ipad), of energy efficient cars (until gas prices spiked) and of the tethering effect of cell phones (even though now there's near universal acceptance).

So when a new technology is presented, we need to be aware of our own aversion to change when determining the cost-benefit analysis of implementation.  In the following study, for example, I was disturbed by the artificiality promoted:  

Wii Tennis Play for Low-Income African American Adolescents’ Energy Expenditure
Staiano Amanda E., Calvert Sandra L.

Exergames, which are video games that require gross motor activity, are popular activities that produce energy expenditure. Seventy-four 
low-income African American 12- to 18-year-old adolescents were randomly assigned to a 30-minute condition: 1) solitary Wii tennis 
exergame play against virtual peers; 2) social Wii tennis exergame play against a real peer; or 3) control group with sedentary computer 
activity. Adolescents were tested for caloric expenditure after exposure to treatment conditions as well as on a tennis court using Actical 
accelerometers. Adolescents who played the  social exergame against a peer expended significantly more energy than those who played 
alone. Both exergame groups expended more energy than the control group. Adolescents who played the  social exergame also expended 
comparable calories to actual tennis court play during a simulated lesson. Exergames, then, could promote physical activity,  thereby 
becoming a tool to combat the obesity crisis that is affecting many youth. 

The idea that we'd take kids out of natural parks and force them to play tennis with a wii controller in a dank living room contrasted quite negatively with recent images of Roger Federer winning his 17th Wimbeldon on lush grass.  My own childhood involved spending hours playing (and mostly losing) tennis with friends in Chicago-area parks.  I'm quite nostalgic for the outdoors, for the authentic sound of the tennis ball hitting the racket, for the bike ride to and from the courts.  

But, of course, it's easy to remember fondly the springs and summers in Chicago.  Meanwhile, the winters were unbearable and the rackets stayed zipped up in cases for months on end.  Would I have played indoors with my friends for three more months a year?  

Moreover, those Chicago suburbs were safe.  Parents would allow 10 year-olds to bike around from home to friends to parks.  Nowadays, including the world of 'low income African Americans' in the above study, parents are more worried about the dangers of leaving their children unattended.  They'd likely be more comfortable having a group of children play in their living room, even if there are some inauthenticities and inefficiencies as a second best option, if the first best option entailed sufficient danger/risk.  

 This isn't a nihilistic endorsement of all 'progress'.  Glenn Greenwald recently showed the dangers of the 'bug splat' mentality video game violence in drone attacks.  Rather, it's the realization that novel ideas (such as substituting wii tennis for real tennis) shouldn't be indiscriminately dismissed simply out of a sense of nostalgia.  

 

Point-of-Care (Mondays): Tb testing revisited

The main point of any test is to arrive at the right diagnosis with the least effort.  In a car analogy, for example, to know how much gas is left in the tank, the most accurate method would be to actually open up the tank and look in it.  That's obviously quite cumbersome, so car manufacturers invented a guage.  It's a good approximation, but especially at the lower end, it's not very refined.  

Similarly, in diagnosing human diseases, one of the most accurate diagnostic tools is an autopsy.  But again...it's quite cumbersome (not to mention counterproductive).  So the medical world comes up with with diagnostic tests.  Using these tests, it's possible to understand if some pathology is going on inside a body without cutting it.  

In pulmonary Tuberculosis (Tb), the most (non-autopsy) test involves doing a bronchosopy and then culturing the sample.  But in much of the developing world, these are cost- and time-prohibitive.  So there's a constant search for simpler tests which give the answer to the simple question: does this patient have Tb or not.  Recent advances using the GeneXpert have added welcome high end technology solutions in resource-poor settings.  Yet this machine still needs an electric source and some well trained technicians.  

Perhaps coming to the rescue is a urine antigen test produced by Determine.  The initial results are promising, but not yet ready for clinical integration (see the linked for the appropriate statistical analysis - but basically, while the test has a high median LR of 14 and a very high LR in pt's with CD4<50, the data come from only one study in a trial-setting).  If further studies validate the effectiveness of the Determine TB-LAM strip, this could be prove to be a significant improvement in the arsenal of non-invasive diagnostic tests of Tb.