Diabetes Screening

Share | The Greeks, Asclepions of Hippocrates's time, screened for diabetes by taste. An alternative method was accomplished by poring the patient's urine on the ground and observing whether or not the urine attracted ants. The taste-test was said to have greater sensitivity while the ante-test offered greater specificity. It might be interesting to compare the sensitivity and specificity of the ante-test and the taste-test with today's fasting blood sugar and one hour glucose challenge test.

Medical Education, medical information

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Educators do not seem much interested in the clinical viewpoint of medical education, so here it is anyway. Medical education equates to the delivery of medical information -- much more than it is possible to teach.  Medical schools should be obligated to provide current medical information from the first year of medical school and throughout the life of the graduating physician --- Current forms of accessing medical information, CME or GME are completely inadequate and obsolete, locked up in copyright, cost and limited by the distribution of the printed text.

Currently there is no real-time source for the total sum of medical knowledge and the leading edge of information growth. Physicians and students alike need such a source that is up-to-date, real time, 24/7. That source should contain it all, terminology and diagnostic criteria as currently understood by the medical school and the specialties.[1] Every medical school should provide total medical terminology, information and current knowledge for every one of their student, residents, graduate and physicians under their employ at no cost by secure 24/7 online access.

Given such a source of current medical information, indexing the relational database could offer an ongoing differential list of diagnostic possibilities for each-and-every sign, symptom and laboratory finding. Despite advances in medical science, missed diagnosis continues to plague the profession. A correct and timely diagnosis seems more likely with instant access to lists of all the possibilities, criteria for diagnosis and brief summary. Statistical analysis of those lists should be ongoing and real-time offering simple probabilities for both single positives and combinations. This statistical process will be essential for assimilating genomic data and applying it to personal medical care.

Information technology offers an unlimited repository of knowledge accessible through a relational database. The computer never forgets. It lends itself to statistical analysis, but it does not think.  Thinking is the job of the student and the physician. That critical clinical thinking and the basic sciences remain the educational challenges of the medical school. Medical information is so vast and so rapidly changing, however, that it has long since grown beyond the capacity of any one physician to learn and forget much less to remember.

Today in the real world the physician is met with time constraints, productivity demands and repetition, all of which discourage discovery and lead to missed diagnosis. Diseases and treatments fall into familiar patterns. A hundred and fifty, or so, conditions fall easily into a recurring pattern of diagnoses. A one-page encounter form can cover the needed ICD codes required for insurance. That recurring pattern, however, erodes away the physicians heard earned clinical acumen. We often overlook rare disease possibilities and there are so many of them with new discoveries all the time. Additionally, increasing numbers of Immigrants bring in problems common to their home country but only now cropping up here in the US.

Physicians keep up to date with expensive seminars and long hours reading expensive journals at home but nonetheless slowly fall behind. The older a physician grows, the greater the clinical judgment but the more he or she forgets. The content shrinks.

Traveling to a conference or accessing journals presents problems of time and money for a rural physician. A limitless source of medical information at the fingertips would help. The generalist must fill the gaps between specialties and cover a broad spectrum of medical challenges. A total medical information system would help met that need. Proprietary systems like Epocrates provide some of the needed medical information. None of the proprietary systems, however, list everything, nor do they have the ability to stay current. Furthermore, marketing and often greed motivate the content; they emphasize drugs and treatment more than diagnosis. Medical schools need to provide an umbilical cord for the student and to the lifetime of the graduate physician regardless of the specialty. We have an obligation in medical education to lead the way and to a pursuit of excellence.

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[1] A word of caution, often overlooked by non-clinical educators, information should be limited to medical students and graduate MDs --- those with the ability, education and dedication to care for patients. Providing that information to various assistants and alternative providers will cut off the supply and even the existence of Primary Care Physicians. Another mandate that should go without saying but today is often ignored; physicians must all freely exchange information techniques and knowledge between one another.

 

Gestational Diabetes Screening, who’s “Best Evidence”

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The National Institutes of Health consensus panel has determined that the one-step screening test for gestational diabetes results in greater numbers of positive outcomes than the traditional two-step method. The one-step requires a 3-hour glucose tolerance test. The traditional method specifies screening with a non-fasting glucose challenge testing at one hour. Only the positives then go on to the 3-hour GTT. The one-step approach results in 15% to 20% positives, whereas the traditional two-step protocol results in only 5% to 6% positives.[1] The panel concluded that the current data do not indicate whether the one-step protocol improves outcome or diagnostic accuracy.

From the data, one might wonder if the non-fasting screen misses significant numbers resulting in fewer diagnoses of gestational diabetes – a matter of sensitivity. Alternatively, the 3-hour test may lack specificity resulting in false positives. Looking further in the literature,[2] O’Shea and O’Connor in Ireland argue in favor of an HbA1c in the second trimester.    The American College of Obstetrics and Gynecology recommends screening by history, risk factors or the non-fasting 50g glucose challenge.[3] The US Preventive Services Task Force argues that there is insufficient evidence for or against anti-natal screening for diabetes. Mayo Clinic states that history and risk factor screening may be sufficient for women under 25.[4]

Obviously, the increasing obesity among young women poses a threat. Hospitals have broadly adopted the one-step approach. One wonders if the hospitals favor the more expensive option with higher numbers of positive results for business reasons. You might conversely ask if the US Preventive Services Task Force leans in the opposite direction for reasons of cost containment.

There is nonetheless a consensus that the definitive test for gestational diabetes is the 3-hour GTT with proven correlation to outcome. Is this not an argument in favor of professional judgment in selecting when to do the GTT rather than elusive best evidence? --- Who's best evidence and who’s viewpoint?

 

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[1] http://tinyurl/c642s5e

[2] www.ncbi.nlm.nih.gov/pubmed/22838107

[3]http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/Screening%20and%20Diagnosis%20of%20Gestational%20Diabetes%20Mellitus.aspx

[4] http://www.mayoclinic.com/health/gestational-diabetes/DS00316/DSECTION=tests-and-diagnosis

The Flexner Report 100 years Later

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178858
Thomas P. Duffy

Best Evidence, `for whom the bell tolls`

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Best evidence begs a number of questions: How do you define best? Best for whom?  Whose evidence? To whom does it apply? Where geographically and environmentally does it apply? Any slogan applied often enough and long enough becomes a cliché.  `Best evidence` applies to treatment, not to diagnosis. Without the right diagnosis, best evidence for treatment would seem irrelevant. That, however, is not the way we practice medicine today. Speed is everything. Diagnosis comes secondary to treatment, to the specialty at hand and secondary to the CMS requirement for tests and procedures – even for insurance reimbursement. Sorry, but the delivery of healthcare in the average hospital clinical complex has become more of a business than an application of the art, the science and the humanity of medicine.` Best evidence` runs the risk of becoming a tool for achieving the highest economic return for drug companies, insurance companies and hospitals. `Best evidence` can become a tool for subordinating the provider to administrative requirements, rather than limiting over treatment or the mistreatment for which it is intended.

For example: A 76yo WM retired truck driver seeks advice from a seemingly competent clinician in a large healthcare complex about his recurring bronchitis sometimes leading to pneumonia. He presently has only some loose rhonchi on physical exam, but does have a history of hay fever as a child and a smoking history of 20 pack-a-day-years, having stopped when he was 54. The clinician, limited for time, listens to the chest through his shirt, observes that the machine BP was normal taken by an aid, notes that the immunization history is out of date and that the patient has not had a colonoscopy. The provider dutifully fills in the check marks on the hand-held computer-record ordering a colonoscopy, immunizations, a video for smoking cessation and a TB skin test. The patient indicates that he has had BCG and has a mildly positive reaction. The provider then deletes the TB skin test and orders a CAT scan of the chest. The patient asks for something to stop the recurrent infections. The clinician then explains briefly and adds a video about misuse of antibiotics and the development of resistant strains. The CAT scan comes back questionable for a suspicious mass near the mediastinum. A repeat CAT is ordered for a month later. The repeat shows no change, maybe a bit better. Colonoscopy was negative; immunizations are updated.  All of the boxes on the electronic health record are checked appropriately fulfilling all of the tenants of `best evidence.` The clinician updates the problem list and expresses the opinion that it may be an old TB walled off in a lymph node requiring no further action, come back in a year. The patient ended up in the emergency room a month later with pneumonia.

Now in truth, the patient does have elevated blood pressure and a chronic allergic bronchitis together with aspiration, which has lead to recurrent bouts of debilitating bronchitis and pneumonia --- in this case, an emergency department admission a month later. A PCR for tuberculosis taken later as a requirement for a government job was negative for TB.

Later still, a kindly old internist practicing from his home does a complete history, system review and physical on our patient. He notes a Grade I murmur of aortic insufficiency at the cardiac base, indeed rhonchi and some wheezing in both lung fields, and an elevated BP. The physician places his patient on Lisinopril and defying the video’s newfound wisdom, adds prophylactic penicillin. The physician further steps outside of guidelines ordering basic lab including renal. His expectations of negative results are confirmed. A Holter monitor shows good BP control. A cardiac eco-scan shows good output. The internist asks the patient to return in one month for follow-up.

Not so exceptionally, this case illustrates a contrast between the urge to standardize care and the traditional physician driven care of the past. This is an actual case with some modifications for simplicity. If you were to view the regimented care as promoted by `best evidence`  from a cost basis or from an outcome basis, the kindly old internist wins every time. Why is that, when we know so much more today than we did and science is so advanced? Well, that is just the point. Science is advancing so fast that any standardized protocol becomes obsolete before it is printed. Furthermore, it applies to an arbitrary population not to an individual patient. It applies to an environment and location unrelated to the case at hand. Best evidence guidelines have the potential to serve the author of the guidelines rather than the patient for which they are intended. For example: a drug company for use of its patented high margin product, a hospital for its utilization of high priced procedures, an insurance company for its higher volume or a clinic for limiting its liability or the government attempting to  limit the cost of care -- all at the expense of the patient. Even more specifically `best evidence` may not apply to your patients own individual genetic makeup and his or her own proclivity for disease or reaction to treatment. Lastly, no treatment guideline can be valid in the face of missed or wrong diagnosis.

 

 

 

Autopsies

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http://www.pbs.org/wgbh/pages/frontline/criminal-justice/post-mortem/without-autopsies-hospitals-bury-their-mistakes/
Marshall Allen ProPublica "without autopsies hospitals bury their mistakes"

"A half-century ago, an autopsy would have been routine. Autopsies, sometimes called the ultimate medical audit, were an integral part of American health care, performed on roughly half of all patients who died in hospitals. Today, data from the Centers for Disease Control and Prevention show, they are conducted on about 5 percent of such patients." Frontline and ProPublica, Marshall Allen 12/15/2011

A number of factors contributed to inadequate diagnosis and to the declining ranking of American Medicine internationally -- not the least of which was the abandonment of hospital autopsies. 

Marie Francois Bichat (1771-1802) Paris, over the door to his pathology lab, Bichat wrote, "Death Comes to the Aid of the Living." 

The insurance does't pay. The hospital doesn't want it. Relatives are reluctant. The providers are afraid of liability, but X-ray conference and excessive use of the CAT scan does not come close to replacing the autopsy. Many diagnosis can only be confirmed or established at autopsy. It is the only way to conduct a meaningful CPC. Furthermore, there is no way to program a computer to offer decision support without confirming the data.  Insurance, Medicare and the Joint Commission should demand it and stop pussy footing around quality, missed diagnosis, and bad outcomes. Historically the autopsy represented one of the greatest breakthroughs in the advancement on medical knowledge.Asking for it was a challenge. That was my job as an intern. Hospitals were ranked by their autopsy rate so the pressure was on. If we could achieve consensus, we might require authorization for autopsy as a requirement for admission and regain some of our lost sense of academic excellence.

Radiation in Space Tourism (public)

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On February 27, 2013, the Inspiration Mars Foundation held a press conference in the National Press Club to announce the plan of the foundation to launch a mission to Mars in 2018. Philanthropist Dennis Tito is going to totally fund the foundation ($100 million) initially. Tito voiced his intention to send a flight to Mars on January 5, 2018 when Mars moves close to Earth in favorable alignment. Stating that the technology is already in place and that the issues that need to be overcome are only the requirements of a 72 week trip. He acknowledges the psychological and physical challenges for the humans involved, but with perhaps an underestimation of the radiation issue.
 

Technology may not be the number one obstacle to a safe flight to Mars. The cosmic radiation along the way may exceed the level of human tolerance. Looking beyond Mars and our Solar System, the deleterious challenges of radiation and the limitations of shielding will be even greater. Avoiding the radiation, shielding or engineering humans to withstand radiation offer the only alternatives. The first choice of avoiding the radiation may prove the only safe one.

A version of “Avatar” the movie, may offer the only presently feasible way for humans to live in the cosmos beyond. Aside from the movie, we are making rapid strides along these lines with Drones and other robotic applications. Soon we may launch unmanned fighter planes. Think of experiencing a visit to a distant planet or solar system in virtual reality while controlling the vision, hearing and movement of a life like robot.

Lag-time will be an obstacle. Quantum entanglement and the quantum computer may resolve that issue. The traveler might live in a lifelike replica of the space vehicle and operate a control module not unlike the Da Vinci surgical robot. Can we build a true human Avatar? More easily, I think, than meeting the challenge of shielding or adapting to the radiation. The braging rights might not be as great but the financial model might be more sustainable and expandable to flights beyond. Are we ready to invite a couple to forfit their DNA to science? We will probably get volunteers, but they should know the risks -- and the certain cost.

This is an aviation venture; that pioneering spirit is in our DNA, but before we get to hyper-drive and genetically modified humans, avatars might be a more efficient way to go.

 

http://www.astrobio.net/exclusive/1901/resisting-radiation

http://online.wsj.com/article/SB10001424127887323384604578328631778830030.html http://nasawatch.com/archives/2013/02/dennis-tito-to.html http://inspirationmars.org/ http://inspirationmars.org/Inspiration%20Mars%20Press%20Release.pdf http://www.marssociety.org/