Sunday, December 18, 2011

Plague, Yersinia pestis

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A draft genome of Yersinia pestis from victims of the Black Death maps the genome from the plague of 1347-8. Researchers obtained DNA from the teeth of plague victims buried in a mass grave in East Smithfield, (originally the Churchyard of the Holly Trinity) near the Tower of London. [1]

Alexander Yersin linked Y. pestis to bubonic plague in 1894. However, controversy and doubt exist over the identity of the plague organism in part because today’s plague does not match the virulence of the Black Death that ravaged Europe in the 1300s. The sequencing by an improved technique (molecular capture assay) apparently establishes that the organism of the Black Death is the same as today’s plague with minor differences.

The bubonic plague existed in Asia with appearances in the Middle East and the Justinian plague in Rome and Constantinople in 541-542. Hippocrates describes a plague in Athens in 430-426 BC. Sanskrit tablets describe plague in Asia as early as 600 BC. Jewish physicians even associated plague with rats in the Tara also about 600 BC. Neither ancient plague, nor modern plague, 19th century to the present time manifested the virulence and devastation of the Black Death of 1347.

The diversity of today’s plague in China suggests that the Far East may have been the reservoir with appearances in Europe carried down the Silk Road and through the Mediterranean by rats aboard ship. The configuration of large Phoenician trading ships may have further enabled the spread[2]

Doubters question whether the plague prior to 1347 was even the same organism. One researcher suggests that the ancient plague in Athens was Salmonella.[3] A look to the history of clinical medicine could end the controversy at least from a practical standpoint. The clinical acumen of Hippocrates in 450 BC was sufficient to distinguish Typhoid from the plague as well as small pox, malaria and TB.[4] There may be historical confusion and laboratory doubt but the clinical picture of plague was and is so distinctive that physicians of that day should not have confused plague with other infections.

The issue of virulence in the case of the Black Death seems explainable by the minor differences in the genome then and now. It would be interesting to see which changes correlated with the change in virulence. With its rapid spread, Y. pestis had an ideal environment in which to evolve taking advantage of weaknesses in the host population. With that evolution, came increased virulence, which shortened the duration between onset and death. The shorter time of infectiousness inhibited the further spread of the epidemic. Thus, the epidemic faded away. Furthermore, the population at risk diminishes as those most susceptible to the infection die off leaving those with minor expositors and resulting mobilized immune systems -- and those with genetic resistance to the disease in the first place -- in greater numbers relative to the further spread of the disease.

One might further speculate that faced with a diminished population, it was to the organism's advantage to devolve into a less virulent form in order to give greater expositor to others and thus a greater chance of continuing its presence and preserving its DNA. I would suppose that process of devolving to be the mechanism of dormancy in China or elsewhere in East Asia.

I do not think that it would have been essential that Y. pestis devolve along the exact genetic lines that it used in achieving greater virulence. The change in strategy might explain the dichotomy in the sequencing of today’s Y. pestis DNA with that of ancient DNA. [5]

My epidemiology professor speculated that the Black Death Y. pestis achieved a level of virulence in which it spread pneumatically, thus the name pneumonic plague. One might further imagine that with a pneumonic form, the cyanosis would turn the victim black in death.

If indeed the above considerations proves relevant, it would not be surprising to find today's Y. pestis devolved to a less virulent form than the Black Death which so devastated Europe.


http://www.nature.com/nature/journal/v478/n7370/full/478465a.html



[1] Kirstin Bos et al, Nature,478, 27Oct 2011, p 506
[2] conjecture
[3] Edward C. Holmes, Nature, 478, p465
[4] Hippocrates’ medical text
[5] Further conjecture, but clinically objective

Sunday, November 13, 2011

Cloud Computing for Medical Record

http://blogs.ft.com/fttechhub/#axzz1dch1Vyjh                        
How will cloud computing accommodate confidentiality and permissions to use the data for data mining?
Assuming it can, the thing most needed is a linked database containing a complete and continuously updated list of every disease and syndrome known to man. Thus any provisional diagnosis or problem could in real time list every related entity (differential diagnosis) meeting the same of similar basic criteria. The inaccuracy of initial diagnosis remains an ongoing problem in US medicine, 15-17% missed or wrong diagnosis by current studies. A statistically derived differential diagnosis would go a long way towards inducing the clinician to look for possible error or deeper consideration. |

Monday, November 7, 2011

Extended Care

Share | For the geriatric generation a nursing home becomes a self fulfilling prophecy. The level of inactivity results in rapid loss of muscle mass, and CNS function. If the patients is not vegetative to start with, they soon will be. There is a clear connection between the physical demand and intellectual engagement of independent living/survival and CNS capacity. The same can be said for a care taker wherein the patient becomes dependent and bedridden.

I remember a family concerned over the old man burning himself up in his home. He had started two fires by accident, extinguishing both without help. The family was worried and felt guilt. They insisted on a nursing home. They placed him in one and then another facility. He hated them both. They sold his house. The old man was vegetative within the year. The loss of familiar surroundings and the demands of daily living amounted to an insurmountable loss for this old man. He was not alone.

Far too many seniors get put away at enormous cost -- and abandonment. This phenomena sadly occurs in America far more than in any other culture. Furthermore, the insurance industry enshrines the practice with advertising and nursing home coverage. Medicare furthers the concept as does the option of medicaid. The corruption of medicaid in this matter is a story in itself.

In other cultures the old man or woman is honored with respect engagement and ongoing responsibilities, far beyond the basic needs of living. The grand parent or great grand parent remains in the family as a stabilizing influence, baby sitter, house sitter, dog sitter, gofer, watchdog wood cutter, gardner and venerated source of wisdom. These demands preclude atrophy of both brain and body. There is no wonder why the life expectancy in the US is so much lower than in much of the rest of the world. According to a CIA study in 2010 America comes in 37th. We are number one in cost however.

Sunday, October 9, 2011

FGM Female Genital Mutilation

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I am a physician outraged by the continuing genital mutilation of children in the US. Children born in the US are citizens of the US whether their parents are or not. Those children like it or not are protected by our laws and our customs not those of the immigrant. If the immigrant family obtains US citizenship, then that family has pledged allegiance to our flag and our laws. If citizenship is not the case, then such an illegal act of child abuse/assault justifies and demands immediate deportation.
I encountered only one of these cases of genital mutilation in my practice and that was enough. An adolescent Egyptian girl with dysuria had a large distended blader. I could not examine her without her aunt in the room. What we saw was unimaginable. Fortunately, the aunt was supportive. The patient had multiple urethroplasties with a fair outcome.  

We have a heavy burden of African and Middle East immigrants, most of who came here to escape violence in their own country. Committing more violence while here, is unacceptable. Some immigrants seek citizenship others not. In either case, justice prevails. The problem is the secretive nature of the act and the immigrants’ commitment to their own cultural tradition.

Eventually a physician will examine these children. The clear duty is to the child, not the family. The law demands that the physician report the crime to the police and child welfare.
 
Excuses given:
·         Custom and tradition: Communities that practice FGM maintain their customs and preserve their cultural identity by continuing the practice.
·         Women’s sexuality: In some societies, FGM espiers to control womens sexuality by reducing their sexual fulfillment.
·         Religion: While religious duty is commonly cited as a justification for the practice of FGM, it is important to note that FGM is a cultural, not religious, practice. In fact, while Jews, Christians, Muslims, and other indigenous religions in Africa, practice FGM, none of these religions requires it.

There is no room for dancing around some concept of other cultures or political correctness. The life altering and life threatening complications for these girls who have yet not a voice in the matter are far too great.

 At the request of HHS, the Centers for Disease Control and Prevention (CDC) undertook a study to determine the prevalence of FGM in the United States. Using data from the 1990 U.S. Census, along with country-specific prevalence data on FGM, the CDC estimated that in 1990, there were approximately 168,000 girls and women living in the United States with or at risk for FGM. This estimate has to be a gross under-estimate given that every female infant born to some of these communities is at risk. The United Kingdom estimated 200,000 in their country alone.
In my view, immigration has gotten too far ahead of cultural evolution.


    

Thursday, October 6, 2011

Microscope

ZEISS
I cannot imagine what it is  like to practice medicine without a microscope. Boy does that date me. Our clinic ran a lab, that is before small clinical labs were virtually eliminated by regulation. From my experience with hospital labs, it is a good idea to look over your urine, gram stains and blood smears. OK, things are more efficient now. You don't have time to stick your nose in the lab. The computer-screen images everything you need including x-rays. Sure, if you are in the Mayo Clinic. What about rural health. Wherever you go for an outdoor lifestyle there won't be that kind of support.

Enter super-microscopy, a field not yet adapted for small office use but what potential. With a small library of fluorescent dyes, one could diagnose a wide array of infectious and parasitic diseases. Who knows, with weather change, we could be looking for malaria.  Some fluoroscopy techniques yield super-microscopy imaging with traditional light microscopes and filters. This is not a costly thing.

Traditional light microscopes with wave lengths of between 350 and 750 nm become blurry right at the cell wall or edge of microbes, 200 nm. With fluorescent dyes that respond to a much narrower range of wavelength the image sharpens up to a resolution around 20 nm. That tenfold improvement in resolution is a real big deal for clinical use.

Commercial interests will work away from that goal of clinical use, however, because large scale clinic use of fluro-microscopy would threaten the high profit margins of hospital and commercial laboratories' revenue stream.

I wouldn't hang my shingle without one.

Wednesday, September 28, 2011

Rick Perry Stem Cells

http://www.nature.com/news/2011/110920/full/477377a.html
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The US Food and Drug Administration is clamping down on unapproved stem cell treatments. Stem Cell clinics circumvent restrictions on unproven uses by administrating treatments outside the country. Texas may go a step further. Governor Rick Perry promotes Texas stem cell research and treatment as a commercial benefit to Texas. Governor Perry received a treatment himself for low back pain. Treatments are promoted for a wide variety of applications and threaten to unleash a new wave of quackery.  

Some human trials have resulted in unfortunate outcomes and the scientific community and the FDA demand caution. Governor Perry, however, challenges that caution continuing to promote commercialization.

Romance and intrigue pepper the long 4,500 year history of medicine. Starting with Hippocrates, the science and high standards of the profession have waged a dynamic struggle between objectivity (inductive reasoning) and philosophical belief systems. (deductive reasoning at best) Old beliefs conflicted with direct evidence. Clerical and political leaders conflicted with Scientific medicine. The first physician to describe the blood flow through the lung, Michael Servetus, was burned at the stake with all his books by order of the Inquisition and the insistence of Calvin.

The political part has not changed much. Politicians should stay ouut of medical care, but leave decisions involving patients to the medical schools, the CDC, research and credible professional societies --- putting patient safety and care above all else.

Monday, August 29, 2011

Hippocratic Method

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Hippocrates (460-370)
Medical schools give early instruction to students in the proper manner in which to interview and examine their first patients. Textbooks stress listening skills, objectivity, and using one’s mind and senses as precision instruments of analysis. These words might very well have come from Hippocrates two thousand four hundred and fifty years ago.

Hippocrates was the first to treat medicine as a science. Early Hellenic physicians were essentially surgeons or sophists dealing with external injuries, leaving the rest to the Gods. Hippocrates dissociated medicine from mythology and rituals. He brought together the loose medical knowledge in medical schools where he taught, systematizing that knowledge into his teachings and text.  He, furthermore, gave physicians their highest moral inspiration.

The Hippocratic method came to entail the studied bedside manner and inductive reasoning that characterize the best internists and clinicians today. The art consisted of clinical inspection, observation, a flexible and critical mind-set, and a continuous search for a source of error. Hippocrates insisted upon a careful systematic thorough examination of the patient with consideration of facial appearance, pulse, temperature, respirations, palpation, urine, sputum, feces, pain and movement. He insisted on transparency, honesty and non-judgmental impersonal objectivity. This bedside method, distinctive of all true clinicians from Sydenham to Osler, formed the basis of scientific medicine.

Professionally, Hippocrates stressed the dignity of the physician and respect of the patient including confidentiality and trust. That simple axiom, 2450 years ago, brought honor and privilege to the medical profession for centuries to come. As such, Hippocrates remains the father of Internal medicine.  His accuracy in description of disease with few changes and few additions would serve in current medical texts. Physicians continued the use of his texts -- especially on malaria and tuberculosis -- up through the 18th century.  The Hippocratic method fell out of common use after Hippocrates’s death but revived in the 17th century.

Hippocrates’s aphorism on diabetes, based on tasting the patient’s urine for sugar and his treatment with a diet of red meat and sour wine struck me as amazing. Hippocrates practice and teachings were at the height of Athenian democracy. He was contemporary to Sophocles, Plato, and Socrates. Never before or since has there been so much genius in so little time and space.
   

Tuesday, August 23, 2011

Armed Forces Institute of Pathology

Share | Who was the genius who decided to close the AFIP as an "obscure little agency" with no current military relevance?  http://www.nature.com/news/2011/110817/full/476270a.html Nature476, 270-272 (2011)

Announced in 2005 as part of an armed forces budget cut, AFIP will close its doors 15 September. The AFIP budget was only 93 million, yet its value to clinical medicine world wide was and is beyond calculation. AFIP would be nearing its 150th anniversary, founded by General Wm. Hammond in 1862.

AFIP with pathology specimens including: 55 million slides, 31 million paraffin blocks and 500,000 wet specimens and some 800 expert employees with the most advanced equipment for the analysis and identification of submitted tissue; acted as a backup and final arbitrator of difficult medical diagnosis. AFIP received more than 50,000 requests for second opinion each year, making changes or additions to over half of these. The diagnostic capabilities were greater than even the teaching hospitals, and the AFIP was recognised world wide in this regard.

For example as given by Alison Mccook's article in Nature, two high-grade lymphomas can be difficult to distinguish using the usual staining techniques. AFIP, however can distinguish these two using molecular and immunohistochemical techniques that most hospitals lack. The two lymphomas have very different treatments. Treating the wrong diagnosis could result in the patients death. There are many such cases with critical need for a correct diagnosis.

Given that 15% of diagnoses are wrong in the first place and as many as 50% are found inadequate or wrong at autopsy, the loss of AFIP, which provided a low cost backup for us all, amounts to an international tragedy. 

Once again, persons given the high level and studied responsibility for making decisions effecting clinical medicine, who do not know anything about medicine create more problems than they solve.

In the course of my clinical years, I sent specimens to AFIP maybe only two times, but each was critical to the patient, and the answer made a difference. What I remember them mostly for, however, was the tray of some 200 microscope slides depicting various pathologies sent on loan for study at little or no cost -- as a student, priceless.

Friday, July 8, 2011

Clinical Decision Support (CDS), a Lawyer’s View

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Michael Greenberg and Susan Ridgely, two lawyers from Rand Health, publish in this week’s JAMA, Clinical Decision Support and Malpractice Risk.[1] The plaintiff attorneys have it both ways. If the CDS suggests too many potential drug interactions for a new prescription and the physician ignores the lessor risks, he or she exposes himself or herself to a potential lawsuit. If on the other hand the software vender limits the number of risks on whatever basis the vendor too assumes greater risk. If the clinician withholds the medicine based on minimal risk of drug interaction, and the patient suffers, who knows, this too may be a potential tort.
The article goes on to suggest that an expert consensus further endorsed by the Office of the National Coordinator (ONC), Medicare and Medicaid, may provide a safe harbor for CDS.
My interest in CDS involves diagnosis rather than treatment and there may be a risk to the differential diagnosis as well. I would think that listing all of the possibilities for diagnosing patient problems would demonstrate the consideration of the items on the list. Furthermore, considering multiple possibilities reduces the likelihood of being wrong. Indeed, if the initial diagnosis does prove wrong, the list serves as evidence of having at least considered the right answer and rejecting that option for whatever stated reason.
Here too the issue arises of how long to make the list. With every conceivable possibility included, one runs the probability of exasperating clinicians into ignoring the entire list. Here again malpractice risks result from either too long a list or too short a one. A statistical appraisal of the list, however, might improve the odds.  An expert consensus and bureaucratic endorsement may be problematic too in keeping pace with the rapid and accelerating changes in medical knowledge and understanding.
Electronic health records hold a promise of future excellence once the systems evolve. In the meantime, expect a difficult transition. As long as computers remember and do statistics, while clinicians think and integrate information, we should be all right. Computers should be good at remembering those lists that we memorized in medical school. (Let us not make them longer)


[1] Clinical Decision Support and Malpractice Risk JAMA, Vol. 306, No.1, page 90, 6 July 2011


Tuesday, June 28, 2011

Diagnostic Support in Electronic Patient Records

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Given that American medicine now ranks at some 35th or 36th in longevity and infant mortality, and at best 15% of diagnoses are wrong, some form of clinical diagnostic decision support seems warranted. Autopsy went out of fashion for many reasons. It was once the final arbitrator of quality medicine and arguably lead to both modern scientific medicine and the high quality of our medical schools. Electronic records offer some hope of restoring a measure of that quality support.
Within the electronic patient record, a differential diagnostic listing covering all of the possibilities might give the patient greater assurance that: over confidence, snap diagnosis or more conveniently reimbursable diagnosis, will not lead to some unfortunate outcome. With a sufficient differential diagnostic listing, the physician will likely consider the person’s true condition, even the rare ones.
Problem oriented charting went a long way to meet the need for considering all of the patient’s problems. It introduced a level of broader consideration of both subjective and objective findings before offering an assessment and finally a diagnosis. However, this list of problems, symptoms and findings with a considered assessment may point to many underlying possibilities.
Listing all of these possibilities in a statistically weighted manner supports a considerably higher confidence and probability of accuracy in the final diagnosis. Treatment protocols offer little, if the clinician makes the wrong diagnosis.
The best of physicians realize that medicine is an art and diagnosis often allusive. They will welcome a diagnostic tool if they find it accurate and useful. Sir William Osler at Hopkins challenged his students to look deeply for underlying diagnosis when considering a number of superficial problems. He did the same in his classical textbook, Principals and Practice of Medicine in 1892.

Wednesday, June 15, 2011

Quantum Biology

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The ongoing revolution in medical science, molecular biology, may in time give way to a yet smaller and far more complex scale of quantum biology. Coherence, entanglement and "spooky behavior at a distance" may once again re-define medical science.

Even now, evidence of quantum physics emerges in plant photosynthesis and the shore-birds ability to navigate by the Earth's magnetic field.

Did you ever wonder how the Golden Plover Chicks can navigate from Alaska to Fiji alone long-after their parents make the journey.

The Fijian language expresses foolishness by the phrase, "looking for the eggs of the Golden Plover." Such foolishness might evolve an undreamed of future.

http://www.nature.com/news/2011/110615/full/474272a.html?WT.ec_id=NATURE-20110616

Thursday, May 5, 2011

Book Review John E. Wennberg's Tracking Medicine

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Book Review


John Wennberg’s book, Tracking Medicine, a researcher’s quest to understand health care, challenges anyone interested in health information technology or the Affordable Health Care Act to a `must read.` Wenneberg spent 40 years applying statistical analysis to the care given in various U.S. locations. Wennberg discovered an extreme variation in the manner and quantity of medical services rendered. He applied the science of epidemiology and statistics to understand these differences. What he found was a fundamental contradiction in the patterns of medical practice. These contradictions surprise and shock the medical establishment and others who believed that for healthcare more is better.
Patient satisfaction, outcome and longevity -- even in some teaching centers – proved inversely related to the intensity of medical, surgical and hospital services. Furthermore, Wennberg found that the greater the capacity of the facility and number of specialists per capita, the greater the intensity of care. Intriguingly, he found that providers were completely unaware of this variation. Present day Certificates of Need, required for expanding the number of hospital beds -- and in large measure many other provisions in the Affordable Health Care Act – indeed reflect much of Wennberg’s research.
Wennberg together with the Dartmouth Institute of Health Policy and Clinical Practice proposed four policies to improve clinical medicine and quality. They suggested:
1.      Organized local systems
2.      Decreasing overtreatment by shared decision making between patient and doctor
3.      Strengthening the science of health care delivery
4.      Constraining undisciplined growth in health care capacity
Variation Capacity and Outcome
Striking variations in the frequency of certain surgeries occurred in adjacent communities.  Tonsillectomies, prostatectomies and hysterectomies varied by large factors. The surgical rate varied in proportion to the number of beds and or surgeons per population. Wennberg called this phenomena “supply sensitive care.” A consistent and validated inverse relationship existed between the oversupply of providers versus patient satisfaction and outcome. Chronic disease appeared to be the greatest problem wherein institutions provided high cost acute care -- Wennberg called it “rescue care” – while neglecting lower cost managed care by primary care physicians, patient involvement and patient education. An even greater expense associated with intensity of care, based on capacity appeared to place terminally ill patients in ICU often against their wishes but with the same terminal outcome.
Communities with a high number of specialists per capita experienced worse outcomes than populations with a constrained availability of care. This statistically validated phenomenon flew in the face of conventional wisdom and the belief that American hospitals are best and more is better. Controversial, to say the least, and argued by some of the most respected medical centers, the striking variation in treatment, the relation of excess care to capacity, and the surprising inverse relation of more care to poor outcome and poor patient satisfaction, remains a valid and highly reproducible statistic.
Reasons to reform:
1.      Over reliance on rescue care
2.      Acute care hospitals for chronic illness
3.      Excessive capacity per population
4.      The establishment of more skilled nursing facilities, outpatient, and home care has not reduced inpatient use, ICU, and a high tech death.
5.      Over use will not go away – getting worse
6.      Not just Medicare but private fee for service as well
7.      Organized care does not reduce the over use of ICU
8.      Cross market subsidy of insurance premiums; that is, low use areas of care pay equally with high use populations in effect subsidizes unnecessary care.
9.      Increased co-pay in high use areas a burden on patients in these areas of overuse
10.  Overuse equates to decreased life expectancy for the patient
Wennberg makes the point that organized care with shared savings may be able to “rationalize the black box of supply sensitive care.” He advocated practice and hospital networks, but cautions that cost may not always decrease with decreased capacity due to cost shifting. He suggests that the major cost to Medicare and other insurance stems from ICU care for terminal patients. Wennberg believes that encouraging a patient’s fully informed participation in medical decisions puts the brakes on overtreatment and is the way to reign in excessive and sometimes harmful care. Such participation, however, calls for a radical change in the culture of doctor patient interaction.
Wennberg’s final list of remedies
1.      Fully informed participation of patient in decision
2.      Constrain spending on supply sensitive care
3.      Constrain preference sensitive surgery
4.      Decrease the number of doctors, specialists and hospital capacity.
5.      Adjust insurance premiums by local area spending
6.      Feedback of information about practice variation, tracking both the variation and outcome
Wennberg particularly likes the provision in the Patient Protection and Affordable Care Act of 3/2010 specifying an Innovation Center within Centers for Medicare and Medicaid. His final suggestion cautions not to train primary care physicians in centers failing to limit overuse and patient choice if the primary care physicians are to become skilled in coordinating care.
John E. Wennberg, M.D.  Peggy Y. Thomson Professor (Chair) for the Evaluative Clinical Sciences, Professor of Community and Family Medicine (Epidemiology) and of Medicine Department of Community and Family Medicine and The Dartmouth Institute for Health Policy and Clinical Practice[1] Educated Mc Gill University, MD 1961 Johns Hopkins School of Hygiene and Public Health, MPH 1966
------------------------------------
This book makes a huge contribution to our understanding of the problems with US medical care. The statistics speak for themselves. They fly in the face of conventional wisdom of providers, well-meaning planners and patients’ families many of whom take exception to some of the end of life research, proposed in the Affordable Care Act.
I am not a statistician, but I was a primary care clinician and manager of an efficient primary care clinic. I managed other physicians and consultants, -- not an easy task -- and I wrestled with the contentious changes that took place in the late 80s and early 90s. As such and with considerable time to think it over, I suggest that many more problems plague our health care delivery system, problems that need validation and in some case adjudication. While I am enthusiastic about reform and much of the good in the plan, I am not at all certain that the Affordable Health Care Act solves all of these problems.
For example, let me list some of the problems that seem largely overlooked:
1.      The US ranks embarrassingly low in all measure of public health statistics among industrialized nations. The U.S. ranks 37th in Life Expectancy and 46th in Infant Mortality[2] Why might that be an important issue for the CIA?
2.      We pay little attention to European health care systems all of which seem to be out performing our own
3.      The well-established routine of increasing usual and customary fees to an ever higher and higher level to offset the discounted reimbursements, to both hospitals and physicians
4.      The uninsured receiving all of their health care in the emergency room, because the ER cannot refuse care – widely acknowledged to be the most expensive form of medical delivery.
5.      Hospital charges spiraling higher and higher due to the above
6.      HMOs requiring referral only to the HMO listed specialists who are much less qualified, as a rule, than specialists referred to by the primary care doctor and who due to their abilities do not need the problems of contracting with an HMO.
7.      The extreme discrepancy between primary care reimbursement and specialist reimbursement, which has lead to a dearth of primary care physicians and an overabundance of specialists
8.      The very high liability insurance premium paid in advance by all providers but especially by the high risk surgical specialties
9.      The difficulty for treating physicians to access current medical terminology, criteria of diagnosis etc at the time of patient contact
10.  The expense of journals, CME and even Internet access to current medical journal articles
11.  The increased competitive capacity and less scientific medicine engendered by patients migration to alternative medicine, alternative practitioners, autonomous physician extenders etc. decisions often based on the attraction of lower cost and in some cases a desire to return to nature. (Natural childbirth at home without anti natal care might be an example)
12.  The abuses of drug companies: outrageously high prices -- semi-fraudulent re-patenting of popular drugs, who’s patent is expiring, in order to extend their high prices and keep these products out of the generic drug market
13.  The failure of insurance companies to provide a demand side restraint on healthcare coast thus enriching their own revenue with ever higher premiums
14.  The characterization of medicine as a business and a free market rather than as a profession and a critical infrastructure
15.  Using the  threat of antitrust action, Health and Human Services and Hospital administrators, CEOs ended the local medical societies ability to censure its members and hold accountable member’s behavior both in and out of the hospital.
16.  The loss of medical society input in hospital staff credentialing and privileges
17.  Medical conditions, which fall outside the prevue of the specialist or between specialties leads to missed diagnosies.
18.  The inaccuracy of reported medical diagnosis, thus a corruption of the data base leading to erroneous statistical analysis and attempts to draw conclusions from insurance reports
19.  Misdiagnosis resulting in protracted illness or worse
20.  The requirement for a qualifying diagnosis to justify a laboratory test
21.  Excessive CAT scans may be in part economically motivated and driven by malpractice law suits while sadly delivering excessive radiation exposure
22.  The C-section rate and a continuing high hysterectomy rate
23.  The poor distribution of physicians in relation to population Physicians migrate to attractive geographic locations with per capita income and amenities
24.  General lack of Clinical Pathological Conferences, CPC or Morbidity and Mortality, M&M conferences, (except in major teaching hospitals and medical schools)
25.  Rare or nonexistent autopsies We once judged hospitals by their autopsy rate. The autopsy and the CPC accounted for much of our past glory of U.S. scientific medicine. The risk of lawsuits based on autopsy and CPCs, although protected in theory, may be a factor.
26.  Does not address the patient’s unhealthy attitude towards self-care whilst demanding a pill or a procedure to bail him or her out of an unsustainable life style
27.  Government takes a punitive rather than educational approach to regulation of the system
Greed dominates the healthcare economy, not so much by mainstream providers as by an opportunistic periphery, a tsunami of players entering the Health Care industry to take advantage of its commercialization. Health Care is not a Free Market! It is a profession and vital U.S. infrastructure. Opportunists view the health care industry as free money from Medicare and by much of the enabling health insurance industry, free money that comes out of the taxpayer’s pocket, as a hidden tax on employers, or persons seeking to protect themselves with individual health insurance.
The Patient Protection & Affordable Health Care Act strives to eliminate many of the insurance abuses. However, we continue to interdict access to the big dollars by policing access but the core issue is no different from the flow of illegal drugs from Mexico and South America. The drug producing countries are not the problem – America’s appetite for illegal drugs is the problem. In medicine, all of the above crises are indicative of the greed and mentality of entitlement that drives them.
Punitive efforts to curtail overtreatment and abuses of the system paradoxically enable and promote the greed by gaming around the regulations. Solving any of these problems requires a change in both the culture of Medicaine and the culture of Regulation – in favor of graduate education, information technology and a commitment to excellence. A public option by the states, run by the state’s medical schools in partnership with Public health with salaried physicians run in competition with traditional fee-for-service may be the best way to get there. A serious look at European Health Care systems may tell us what works. I suspect it will require a major reeducation of our population in healthy life styles. Infant mortality will be a useful barometer to measure progress.
“The commission — created by President Obama to address America’s fiscal challenges — predicted that, by 2035, federal outlays for Medicare, Medicaid, the Children’s Health Insurance Program, and the health insurance exchange subsidies will account for 10 percent of U.S. gross domestic product (GDP), up from 6 percent in 2010…. If historical rates of growth continue, U.S. spending on health care from all sectors… will surpass 20 percent of GDP within five years and eat up the entire GDP by 2082…something… dramatic will have to happen between now and then…”[3]

Saturday, March 19, 2011

Watson

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In 2005, Nico Schlaefer, a grad student at Carnegie Mellon University, built a statistical query system and wrote a thesis he called Statistical Thought Expansion later named Ephyra. IBM was impressed. Nico worked three summers on Watson. He is now a PhD candidate at CM and an IBM PhD Fellow.
In the Tourette syndrome example given below, Watson was unable to answer until they included more of the symptoms and signs in the database. Q & A as done with Watson seems analogues to Clinical Data & Differential Diagnosis. To make Watsons job easier, enter clinical data in a relational database in simple consistent terms. Likewise, list the sum total of medical diagnostic information in the same simple consistent terms. The relational database can correlate and list the match ups as diagnostic possibilities. A statistical program -- and here is where Watson comes in -- can list the probility of each. Furthermore, a statistical program can conduct an ongoing adjustment to the probable diagnosis based on realtime outcome as determined by subsequent information.
This is not to say that the computer makes the diagnosis, but it does give, at a glance, all of the possibilities. In fact quite the reverse, the statistical program improves its selections and statistics based on the clinician’s evolving and final diagnosis.
In practice, this computer directed diagnostics can be done on an off the shelf database program. Watson may be too hard to move around, and I imagine that the off the shelf database on the clinician’s own computer will be a bit less expensive. The important aspect, however, is still the statistical application. I guess that the articles about the development of Watson do not divulge all of the statistical mechanism, which makes up the AI of Watsons prenominal performance.
Simplicity, however, is the thing that works best with clinicians, and I would bet that there is already a simple statistical application that will function with a relational database. Schlaefer describes source expansion, and for us that source is medical information, all of it -- in simple database terms with criteria of diagnosis.
Found in Probably Irrelevant, from an interview. “Information Retrieval in IBM’s Watson: An interview with Nico Schlaefer,”  Posted on March 17th, 2011 by Jon Elsas
“Nico Schlaefer: Here is a question for which source expansion helped:
What is the name of the rare neurological disease with symptoms such as: involuntary movements (tics), swearing, and incoherent vocalizations (grunts, shouts, etc.)?
This is a question from the TREC 8 evaluation [pdf], but if written as a statement (”This rare neurological disease has symptoms such as …”) I think it could also pass as a Jeopardy! question. The answer is “Tourette syndrome”.
We first tried to answer this question using Wikipedia as a source, and there is indeed an article about “Tourette syndrome” in our copy of Wikipedia, but unfortunately it doesn’t mention most of the keywords in the question and Watson wasn’t able to get the answer. We then expanded Wikipedia, and “Tourette syndrome” was one of the topics that was automatically selected. The expanded article contains the following text passages which, by the way, all come from different websites:
·         Rare neurological disease that causes repetitive motor and vocal tics
·         The first symptoms usually are involuntary movements (tics) of the face, arms, limbs or trunk.
·         Tourette’s syndrome (TS) is a neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics.
·         The person afflicted may also swear or shout strange words, grunt, bark or make other loud sounds.
These passages jointly almost perfectly cover the question keywords. I think the only content word that is not in there is “incoherent”. This made it very easy for Watson to find the answer.”