Tuesday, June 13, 2017

Health Care

There will never be an agreement, so what we ned is health care for Democrats in one system and healthcare for Republicans in another. Then both parties can have exactly what they want. In a perfict world, the two systems would turn out to be the same.

Sunday, May 28, 2017

Cocktail

A team from Harvard and MIT formulated a cocktail of small molecules to treat hearing loss. Ingrediants not specified, the cocktail, fed to mice and cochlear cells in vitro, stimulates cochlear stem cells and the growth of functioning hair cells. The only problem may be the question of the growth factoron other  epithelial stem cells. 
OK, so do you want to look like a gurilla withgood hearing or stick with your Phonak hearing aids, no volenteers?
Cell Reports 2017 zFeb 21; 18: 1917

A second, possibly more practicle cocktail, reported in 
Proc Natl Acad Sci USA 2017 Mar 28; 114:3509
Proved a dietary supplement highly effective in preventing the post. partum blues. The cocktail comprised of 2 gm tryptophan, 10 gm tyyrosine and bluebarry juice qsad, given day 3, 4, 5 after delivery effectively mitigated the post partum elevated mono amine oxidase (MAO-A) levels. The small study was so dramatically successful as to hope for more serious later post partum depression benefits.


Thursday, April 27, 2017

Female Genital Mutilation (FGM)

"According to reports, several young Somali girls were brought from Minnesota, one of twenty-four states that have passed legislation to make female genital mutilation (FGM) illegal according to state laws, to Michigan, one of twenty-six states in which FGM has not been made illegal in state law, where Dr. Nagarwala, with assistance from Mrs. Attar, performed the procedure outlawed by federal law in a medical office owned by Dr. Attar.

“Since 1996, there have been specific federal criminal penalties for performing FGM/C in the United States on anyone under 18 years old, including fines, up to 5 years in prison, or both. In 2013, Congress amended the federal statute related to FGM/C to criminalize the knowing transportation of a girl under 18 years old from the United States for the purpose of performing FGM/C abroad—often referred to as ‘vacation cutting,’ ” according to the June 2016 Government Accountability Office’s report Female Genital Mutilation/Cutting.

The current federal statute, which codifies both the 1996 law and the 2013 law can be seen here at U.S. Code Title 18  Part I  Chapter 7  § 116 – Female genital mutilation.

Surprisingly, neither the 1996 federal law that outlawed FGM, nor the 2013 federal law that outlawed “vacation cutting” requires health care providers to report known or suspected instances of FGM to local, state, or federal health authorities or law enforcement. Current federal law criminalizes the practice of FGM, but does not specifically require reporting on it, though health care providers are obligated to report instances of child abuse, a category in which FGM falls.

With this paucity of reporting data, two recent studies, one by the Population Reference Bureau (PRB), another by the Centers for Disease Control (CDC), have used demographic analysis to estimate that the number of women who have “undergone” FGM or are “at risk of the procedure” in the United States exceeds 500,000.

“Female genital mutilation/cutting (FGM/C), involving partial or total removal of the external genitals of girls and women for religious, cultural, or other nonmedical reasons, has devastating immediate and long-term health and social effects, especially related to childbirth,” the Population Reference Bureau (PRB), a non-profit research organized funded in part by the Bill & Melissa Gates Foundation, reported in February 2016.

“In 2013, there were up to 507,000 U.S. women and girls who had undergone FGM/C or were at risk of the procedure, according to PRB’s data analysis. This figure is more than twice the number of women and girls estimated to be at risk in 2000 (228,000). The rapid increase in women and girls at risk reflects an increase in immigration to the United States, rather than an increase in the share of women and girls at risk of being cut. The estimated U.S. population at risk of FGM/C is calculated by applying country- and age-specific FGM/C prevalence rates to the number of U.S. women and girls with ties to those countries,” PRB reported.

PRB’s “at risk” estimates were based on demographic analysis, rather than actual reported incidents of FGM in the United States.

They made the common sense assumption that young girls raised in immigrant households where the country of origin is one where the FGM incidence has been documented to be high are “at risk” since those cultural practices are not left in the home country by the family but are likely to continue in the United States.

“Just three sending countries—Egypt, Ethiopia, and Somalia—accounted for 55 percent of all U.S. women and girls at risk in 2013 (see Table 1). These three countries stand out because they have a combination of high FGM/C prevalence rates and a relatively large number of immigrants to the United States. The FGM/C prevalence rate for women and girls ages 15 to 49 is 91 percent in Egypt, 74 percent in Ethiopia, and 98 percent in Somalia. About 97 percent of U.S. women and girls at risk were from African countries, while just 3 percent were from Asia (Iraq and Yemen),” PRB explained.

“FGM/C has gained attention in the United States in part because of the rising number of immigrants from countries where FGM/C is prevalent, especially sub-Saharan Africa. Between 2000 and 2013, the foreign-born population from Africa more than doubled, from 881,000 to 1.8 million,” the PRB report added:

This type of violence against women violates women’s human rights. There are more than 3 million girls, the majority in sub-Saharan Africa, who are at risk of cutting/mutilation each year. In Djibouti, Guinea, and Somalia, nine in 10 girls ages 15 to 19 have been subjected to FGM/C. Some countries in Africa have recently outlawed the practice, including Guinea-Bissau, but progress in eliminating the harmful traditional practice has been slow.1 Although FGM/C is most prevalent in sub-Saharan Africa, global migration patterns have increased the risk of FGM/C among women and girls living in developed countries, including the United States.

“CDC published a report in 2016 estimating that 513,000 women and girls in the United States were at risk of or may have been subjected to FGM/C in 2012,” according to the June 2016 Government Accountability Office’s report Female Genital Mutilation/Cutting. The CDC report found the virtually the same results PRB found using 2013 data:

While subject to certain limitations, this represents a substantial increase—about threefold—from CDC’s prior estimate of 168,000, which was based on 1990 data.CDC attributed this increase to a sharp rise in recent decades in the U.S. population originating from countries where FGM/C is commonly practiced, and noted that the increase occurred despite FGM/C prevalence not increasing or seemingly falling in many of these countries.

“In the report for the 2012 estimate, the authors said that until scientifically valid data are collected, the approach used provides the best available information on the potential levels of FGM/C,” GAO wrote:

CDC and others have acknowledged that collecting more scientifically valid data would be difficult due, in part, to the cultural and legal sensitivity of the
information needed. International efforts to collect data on the actual occurrence of FGM/C have faced similar challenges. Starting in October
2015, however, the United Kingdom began requiring health care providers in England to report through a nationwide database any instance of FGM/C described to them or discovered during physical exams. (emphasis added)

Recent press reports indicate that the methodologies used in both the CDC report and the PRB report are supported by at least one instance where health care providers actually tracked the incidence of  FGM among recent immigrants to the United States from a country in which it is a very common cultural practice.

“In Phoenix, Arizona, a staggering 98 percent of Somali women being treated at the Refugee Women’s Health Clinic have been circumcised, founder Dr. Crista Johnson said. She estimates the Somali community is at least 12,000-strong,” NBC News reported in 2014.

But the work by the Refugee Women’s Health Clinic in Phoenix accurately reporting on the incidence of FGM among recent immigrants to the United States is the exception in a public health system that is not required to specifically report suspected or actual incidents of FGM by law in most jurisdictions and is reluctant to do so for a variety of ideological and institutional reasons.

“Despite the fact that FGM in all forms has been explicitly illegal in the United States since 1996, legislation criminalizing the practice has not been comprehensively implemented or enforced, and community members, social service providers and law enforcement officials often fail to identify, report or investigate incidents of FGM,” Sanctuary for Families reported in 2013:

Anecdotal evidence indicates that female genital mutilation also continues to be performed within the United States. Typically, FGM in the U.S. is carried out by traditional practitioners who operate covertly and illegally. When U.S. health care providers carry out the procedure, they frequently come from countries where the practice is prevalent, and they operate on girls from their own communities at the request of a child’s parents.

“Some states have enacted laws specifically criminalizing FGM/C, while other states may pursue FGM/C offenses under other related statutes, such as child abuse laws,”  according to the June 2016 Government Accountability Office’s report Female Genital Mutilation/Cutting:

In some instances, states require that an occurrence of FGM/C be reported.

DOJ indicates that two states, Illinois and Tennessee, have mandatory reporting for FGM/C.

All states have mandatory reporting laws governing child abuse, which may apply to reporting FGM/C depending on the relevant circumstances and particular statutory requirements.

Some state laws address other areas of FGM/C, such as provisions prohibiting “vacation cutting” or provisions for community education and outreach.

“Local law enforcement and child protection officials told us that immigrant communities may underreport due to cultural norms, victims’ reluctance to betray their community or family members, and concern about potential effects on their immigration status and that of their family members. In addition, although many professionals who may be in contact with girls at risk for FGM/C are mandatory reporters (e.g., health care, school, and child care officials), they may be uncertain about whether FGM/C should be reported,” according to the Government Accountability Office’s June 2016 report Female Genital Mutilation/Cutting:

For example, health care providers we spoke with stated that they may not report instances of girls being at risk of or subjected to FGM/C due to uncertainty about mandatory reporting requirements (e.g., if FGM/C occurred before arriving in the United States), or because they prefer to counsel parents on the consequences of FGM/C to change parents’ position on the issue.

School officials we spoke with had little or no experience encountering FGM/C among their students, in general, and school officials may not be certain of what actions are appropriate when they encounter suspicions of FGM/C, which can affect reporting. For example, an official from a nongovernmental organization that works with Somali women said teachers contacted them for guidance on dealing with suspicions of vacation cutting.

In addition, a former school psychologist who now works with a national organization told us about an instance when school officials had suspicions of vacation cutting that was not
reported.

However, they did not confirm these suspicions with the student or her family, out of concern that she would be pulled out of school and her home environment would be disrupted. Without clear evidence that FGM/C had occurred, the officials decided to provide the student with general support for trauma.

States’ mandatory reporting requirements vary across jurisdictions, are dependent on the relevant facts and circumstances, and would be subject to some level of interpretation by
the reporting official. These factors can make it challenging to determine the appropriate course of action when encountering potential instances or risks of FGM/C on minors

The public health establishment–at the federal, state, and county levels–has been reluctant to look for and report on female genital mutilation (FGM) data, just as it has been reluctant to report on the incidence of latent and active tuberculosis (TB) among resettled refugees.

An example of this reluctance when it comes to reporting on active TB among refugees is the hidden blockbuster discovered by Breitbart News in January that 1,565 refugees have been “diagnosed with active TB since 2012, three times more than previously reported.”

Many state government health departments that report active TB among refugees make the data very difficult to find.

Other state government health departments simply fail to fully report active TB among refugees, and many county governments, particularly those in urban areas controlled by Democrats, refuse to comply with the public health reporting requirements of the Refugee Act of 1980, particularly with regards to latent TB.

Public data on the incidence of FGM–which occurs almost exclusively among the immigrant population arriving from Africa, the Middle East, and the Near East–is far more difficult to obtain than public data on the incidence of active TB.

Every state has had very clear reporting standards about the incidence of active TB among the entire population for well over half a century–in many states for more than a century.

Such is not the case with FGM, because the barbaric practice was virtually unknown in the United States until the significant upswing over the past several decades in the arrival of immigrants from countries where it is has been a common practice for centuries.

“I think it’s more than mere reluctance,” an attorney familiar with the refugee resettlement program tells Breitbart News about the reluctance of public health officials to obtain and report data on FGM.

“I think it’s a deliberate, ideological approach of moral equivalency, meaning that just about anything multiculturalism dishes out, should be respected and accepted – and the PC bureaucracy backs them up,” the attorney says.

“Public health and medical care in general, is not supposed to be a judgment, and because FGM has been made illegal in the U.S. with individual states even passing their own laws, it’s made it easier for public health departments to opt out of addressing it, leaving it instead to law enforcement agencies,” the attorney adds.

"If there is any doubt, just look at the annual refugee health reports like the one for Texas that has extensive data about health issues related to arriving refugees; they report on STDS but there is nothing about FGM, a condition that for many women who have been mutilated, brings life-long medical issues,” the attorney concludes.

The 2014 Refugee Health Report issued by the state of Texas, for instance reports, extensively on the rates of syphilis for refugees over the age of 15, but includes no data on FGM.

Refugee health reports for the states of CaliforniaUtahArizonaMinnesotaIndiana, and Florida follow a similar pattern.

The Centers for Disease Control’s (CDC) guidelines to medical professionals responsible for conducting the initial domestic medical screenings of refugees arriving in the United States for resettlement by the federal government specifically recommend genital examinations, which would clearly identify arriving refugees who are FGM victims. However, a significant number of those screeners may not be following those recommendations, or may delay the examinations indefinitely based on language in the guidelines that states “[i]n refugees who previously experienced trauma (e.g., sexual assault victims), the anal and genital examination may be postponed until the refugee establishes a trusting relationship with a provider.”

That apparent failure misses key information that could help stop the spread of the barbaric practice in the United States, as adult women arriving in the country who are already victims of FGM are likely to be in family situations where their daughters are at risk of being subjected to the same abuse in this country.

Common sense suggests that the PRB’s and CDC’s estimates of the number of girls in the United States at risk for FGM is likely to be very close to the true incidence of FGM in this country today.

The public health establishment’s long record of hiding and obscuring data that accurately reflects the true public health status of immigrants and refugees, however, appears to be one of the major stumbling blocks in identifying and eradicating this barbaric practice in the United States, as is the lack of specificity in the underlying federal and state statutes."

Coppied in block from Britbart because their link does not work and this problem rises to the level of an epidemic conspiricy of sexual assault and the message is urgent likewise. The origional article may be from the Detroit Free Press.

I'm licensed in Michigan and my Interpritation of Michigan State law requires reporting of sexual assault on a minor. I once saw a case of FGM in Colorado. The young girl was unable to urinate and in extreem pain. her Aunt brought her in without consent of the parents. I was able to catheterize and get her to a gynachologist for a more lasting repair. The case was reeported. Parental consent gives way to   Sexual assault and life threatening circumstances ind injury, indeed.

Mutilization does not fully charactorize the disfigurement I encountered. If this FGM is religion, such a religion is savage and uncivilized.

Saturday, January 28, 2017

Demonetize Medicine

Fashions come and go. Medicine despite our scientific origins engages in the same, some internal some externally imposed. Capitalization and industrialization promised a health care system where in current industrial management technologies would lower cost, increase productivity and improve outcome. Corporations, mergers, and healthcare providers compet for space at the seemingly unlimited healthcare feeding trough. The art, compassion and excellence of an Aescelapian medical profession gave way to greed to put it bluntly. Industrial medicine monetized every aspect of healthcare raising prices to the point of deminishing returns at the bottom line, unbundling and championing a new class of supper administrators with salaries in the millions. As a result, US medicine, for a time, the  world's leading profession, now ranks near the bottom of the 37 countries comprising the Organization for Economic Cooperation and Developement (OECD) and their metrics for ranking health care. We have the highest underlying cost structure, the most obscene prices and the worst outcomes, reference the Global Burden of Disease (GBD).

We are in the midst of replacing a structure who's heart was in the right place but still did not cover everyone, was a fiat progressive tax system to itself and had the effect of a blank check for procedures, Perscription drugs, hospitals and any other organization with a pretext of healthcare. Politics, burocracy and external forces rather than professional, medical and academic drive the change as well as the outcry to maintain the status quo.

Disruptive change in the form of genomics, artificial Inteligence, imminaging and hand held or bedside diagnostic tools in the hands of the primary care physician may demonetize much of the burden. However, there remains the challenge of removing layer upon layer of administrative waste, a system of corporate medicine favoring the bottom line over patient care we need a return to basic education, excellence and especially continuing medical education (CME).

If I was the Zar, I would run a public system through medical schools, state by state, open to everyone, salaries only with incentives, and run it in competition with private insurance based fee for service. We are playing catchup, so there is nothing wrong with looking at European systems that produce better outcomes at much lower cost. Demonetize the greed.

Saturday, January 7, 2017

Stethescope, a Lost Art


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February is the 235th birthday of Rene' Laennec, the French physician who in 1816 attempting to listen more carefully to the chest of a young woman suffering heart disease and unable to place his ear on her chest due to her sex and obesity, ruled up the paper chart to listen through the tube. The acoustics worked so well that Laennec developed a wooden tube for routine use.

Laennec was born February 17th 1781 in Brittany. His mother died of TB when he was 5. At age 12 he studied medicine with an uncle at the University in Nantes. A good student, Rene' wrote poetry, learned English, German, studied Greek, Later in 1799 at the University of Pari, Laennec reintroduced the art of percussion as described earlier, 1761, by Leopold Auenberger, a cellist, physician and friend of Motzart. In 1816 Laennec developed his acoustic tube and explored its further subtelities for diagnosis. Laennec published his classic text De Auscultation Mediate 1819, a notable reference even today. Laennec worked as a chest physician, lecturer and professor at the College de France 1822-23; he treated TB patients at the Hospital de la Charite'.

Laennec was said to have had TB, possibly since childhood; he died in 1826, at age 45, having made one of the greatest contributions to the art of medicine -- the same year Chopin published his Polonaise in London.

Tuesday, January 3, 2017

Brain Mets or Psych?

An advanced cancer patient refusing treatment, presents all sorts of problems for family and providers. Compound this with bizarre psychiatric symptoms and contrary behavior and you have legal and ethical challenges as well. The first thing one does is order a psych consult, a tenuous diagnosis, even commitment, in the extreme, restraints. This Perspective Articlre in NEJM describes such a dilemma. Dec 8 375 2220-2221 DOI 10.1056/NEJp 1612129

My first rotation as a junior medical student -- UMichMed '60 in "Old Main," a 2000 bed hospital with 20 bed wards -- was "Blue Female" 2nd floor east, exclusively advanced breast cancer. Each ward had its own personality, largely driven by the nursing staff and the patients themselves. Blue. Female's was one of mutual support and suprising spirit; they shared in one another's condition, complications, prognosis and listened through the curtains to one another's daily rounds. Despite turnover and a frequent empty bed, you could feel the strength and moral.

Not infrequently, however one or two would become recalcitrant, atgumentive and display bizarre ideation. Residents and young professors, new to Blue Female, would invariably order a psych consult and speculate over which psych diagnosis. We did not have MRI, but everyone in the ward knew the problem was metastice to brain, even the ward clerk who did not rotate. We did not need an MRI or for that matter a psychiatrist who usually failed to figure it out.

Not long ago, I listened to an ethicist presentation of an almost identical case to the one in the NEJ. The case involved court orders for treatment and, early on, a court ordered confinement for psychiatric care and family guilt. No one thought to order an MRI.

Sadly we have losst the beauty of bedside teaching, supportive wards when support is needed the most and that's not to mention autopsy which would indeed figure it out, without the family having to say, she went crazy in the end.

Wednesday, October 12, 2016

Patient Care

Historical evidence suggests that the three measures of quality patient care we're infant mortality, bedside teaching and autopsy rate. We once ranked hospitals on these three considerations. We can blame politics/greed, misplaced confidentiality and stupidity respectively for their decline. Thr Global Burden of Disease statistics confirms, with the US at near the bottom in every category. Some of the poor outcome is behavioral and environmental, but dumbing down medical education to met the lower standards is not a solution. Furthermore, where we once lead in compulsive public health, today it's hard to find.