Category: Health

“Cochrane Reviews Are Often Referred to as Gold Standard Evidence in Medicine”

The credibility of Cochrane reviews matters. One of their most important reviews, that I cite in my in-progress work on clinical trials, suggests that results of randomized double-blind clinical trials, usually agree with results of observational studies on the same topic. This matters a lot, because observational studies can give us more and quicker actionable results, saving lives.

(p. A23) Cochrane reviews are often referred to as gold standard evidence in medicine because they aggregate results from many randomized trials to reach an overall conclusion — a great method for evaluating drugs, for example, which often are subjected to rigorous but small trials. Combining their results can lead to more confident conclusions.

. . .

. . . what we learn from the Cochrane review is that, especially before the pandemic, distributing masks didn’t lead people to wear them, which is why their effect on transmission couldn’t be confidently evaluated.

For the full commentary, see:

Zeynep Tufekci. “In Fact, the Science Is Clear That Masks Work.” The New York Times (Saturday, March 11, 2023): A23.

(Note: ellipses added.)

(Note: the online version of the commentary has the date March 10, 2023, and has the title “Here’s Why the Science Is Clear That Masks Work.”)

To Force Use of Organic Farming, Government Banned Chemical Fertilizers; A Ban Which “Devastated” Crops and “Destroyed the Farmers”

(p. A6) GALENBINDUNUWEWA, Sri Lanka—For more than half a century, Pahatha Mellange Jayaappu has tilled the field on his modest farm in Sri Lanka’s agricultural heartland, unswayed by recurrent political and economic turmoil.

Now the 71-year-old is just trying to eke out enough of a harvest to feed his family after an abrupt ban on chemical fertilizers last year devastated his crops. He says he has given up on planting for profit.

“We have lived through armed insurrections and bad government policies,” Mr. Jayaappu said. “This is the worst year I’ve ever seen. They have destroyed the farmers.”

Many Sri Lankans aren’t getting enough to eat, and farmers and agricultural experts say the food shortages are set to worsen. The government reversed the ban in November and promised fresh supplies of chemical fertilizers, but farmers said many received only a small amount, and too late for the current growing season.

. . .

The ban on imports of agricultural chemicals took effect in May 2021, and the rice harvest the following March was down 40%, according to government data. Prices soared. Sri Lanka, which had been largely self-sufficient in rice, was forced to use some of its fast-dwindling foreign reserves to import the key staple. Other crops, like tea, an important foreign-exchange earner, have also suffered. In May, the country defaulted on its external debt.

. . .

Mr. Wickremesinghe was installed by Parliament last month after his predecessor, Gotabaya Rajapaksa, fled the country and resigned in the face of mass protests over fuel shortages and food prices.  . . .

Mr. Rajapaksa billed the ban as a nationwide shift to organic farming, but agricultural experts say that requires a yearslong transition. Opposition lawmakers said cutting off imports of fertilizer, which the government heavily subsidizes for farmers, was a shortsighted attempt to hold on to foreign reserves.

. . .

Farmers complained that the organic fertilizers that came on the market after the ban took effect were poor quality, full of material that wasn’t fully decomposed. And the haste of the ban left insufficient time to make their own compost, or learn how to farm organically.

For the full story, see:

Shan Li and Philip Wen. “Sri Lanka’s Farmers Struggle to Survive.” The Wall Street Journal (Saturday, August 20, 2022): A6.

(Note: ellipses added.)

(Note: the online version of the story was updated Aug. 19, 2022, and has the title “Sri Lanka’s Farmers Struggle to Feed the Country—and Themselves.”)

Experienced Nurses Can Be Disciplined If They Use Hunches from Clinical Observations to Override AI Protocols

(p. A1) Melissa Beebe, an oncology nurse, relies on her observation skills to make life-or-death decisions. A sleepy patient with dilated pupils could have had a hemorrhagic stroke. An elderly patient with foul-smelling breath could have an abdominal obstruction.

So when an alert said her patient in the oncology unit of UC Davis Medical Center had sepsis, she was sure it was wrong. “I’ve been working with cancer patients for 15 years so I know a septic patient when I see one,” she said. “I knew this patient wasn’t septic.”

The alert correlates elevated white blood cell count with septic infection. It wouldn’t take into account that this particular patient had leukemia, which can cause similar blood counts. The algorithm, which was based on artificial intelligence, triggers the alert when it detects patterns that match previous patients with sepsis. The algorithm didn’t explain (p. A9) its decision.

Hospital rules require nurses to follow protocols when a patient is flagged for sepsis. While Beebe can override the AI model if she gets doctor approval, she said she faces disciplinary action if she’s wrong. So she followed orders and drew blood from the patient, even though that could expose him to infection and run up his bill. “When an algorithm says, ‘Your patient looks septic,’ I can’t know why. I just have to do it,” said Beebe, who is a representative of the California Nurses Association union at the hospital.

As she suspected, the algorithm was wrong. “I’m not demonizing technology,” she said. “But I feel moral distress when I know the right thing to do and I can’t do it.”

. . .

In a survey of 1,042 registered nurses published this month by National Nurses United, a union, 24% of respondents said they had been prompted by a clinical algorithm to make choices they believed “were not in the best interest of patients based on their clinical judgment and scope of practice” about issues such as patient care and staffing.” Of those, 17% said they were permitted to override the decision, while 31% weren’t allowed and 34% said they needed doctor or supervisor’s permission.

. . .

Jeff Breslin, a registered nurse at Sparrow Hospital in Lansing, Mich., has been working at the Level 1 trauma center since 1995. He helps train new nurses and students on what signs to look for to assess and treat a critically ill or severely injured patient quickly.

“You get to a point in the profession where you can walk into a patient’s room, look at them and know this patient is in trouble,” he said. While their vital signs might be normal, “there are thousands of things we need to take into account,” he said. “Does he exhibit signs of confusion, difficulty breathing, a feeling of impending doom, or that something isn’t right?”

. . .

Nurses often describe their ability to sense a patient’s deterioration in emotional terms. “Nurses call it a ‘hunch,’ ” said Cato, the University of Pennsylvania professor who is also a data scientist and former nurse. “It’s something that causes them to increase surveillance of the patient.”

. . .

At UC Davis earlier this spring, Beebe, the oncology nurse, was treating a patient suffering from a bone cancer called myeloid leukemia. The condition fills the bones with cancer cells, “they’re almost swelling with cancer,” she said, causing excruciating pain. Seeing the patient wince, Beebe called his doctor to lobby for a stronger, longer-lasting pain killer. He agreed and prescribed one, which was scheduled to begin five hours later.

To bridge the gap, Beebe wanted to give the patient oxycodone. “I tell them, ‘Anytime you’re in pain, don’t keep quiet. I want to know.’ There’s a trust that builds,” she said.

When she started in oncology, nurses could give patients pain medication at their discretion, based on patient symptoms, within a doctor’s parameters. They gave up authority when the hospital changed its policies and adopted a tool that automated medication administration with bar-code scanners a few years ago.

In its statement, UC Davis said the medication tool exists as a second-check to help prevent human error. “Any nurse who doesn’t believe they are acting in the patient’s best interests…has an ethical and professional obligation to escalate those concerns immediately,” the hospital said.

Before giving the oxycodone, Beebe scanned the bar code. The system denied permission, adhering to the doctor’s earlier instructions to begin the longer-acting pain meds five hours later. “The computer doesn’t know the patient is in out-of-control pain,” she said.

Still, she didn’t act. “I know if I give the medication, I’m technically giving medication without an order and I can be disciplined,” she said. She watched her patient grimace in pain while she held the pain pill in her hand.

For the full story, see:

Lisa Bannon. “Nurses Clash With AI Over Patient Care.” The Wall Street Journal (Friday, June 16, 2023): A1 & A9.

(Note: ellipses added.)

(Note: the online version of the story has the date June 15, 2023, and has the title “When AI Overrules the Nurses Caring for You.”)

Lister Used Data, Results, and Amiability to Convince Physicians to Sterilize Hands, Scalpels, and Wounds

(p. C6) What was the most dangerous place in the vast territories of the British Empire in the 19th century? Was it the savage savannas of Zululand? Perhaps the frozen wastes of the Northwest Passage, or the treacherous high passes of the Hindu Kush?

To judge from “The Butchering Art,” a fine and long overdue biography of the great physician Joseph Lister by Lindsey Fitzharris, the answer might be a much more domestic corner of empire: the Victorian teaching hospital.

. . .

Infection rates plummeted when Lister used carbolic acid to wash hands and scalpels, to dress wounds, and to sterilize sutures. He even sprayed it into the air of the operating room. But other physicians were skeptical and bitterly resisted the notion that their sloppy and unhygienic practices were the cause of so many deaths.

. . .

Lister won over his opponents, not with bile and rhetoric but with a relentless focus on data and results, coupled with his innate amiability. He paid particular attention to audiences of medical students, perhaps anticipating Max Planck’s observation that bitter disciples of old dogmas are never won over by new theories, they simply die off and are replaced by a new generation.

The modesty and compassion of Lister would have been remarkable in any man, let alone a surgeon. His patients and students adored him. Lister taught his residents that “every patient, even the most degraded, should be treated with the same care and regard as though he were the Prince of Wales himself.” After he drained a young girl’s knee abscess, the girl showed him her doll, which was missing a leg. As Ms. Fitzharris writes, “The girl fumbled around under her pillow and—much to Lister’s amusement—produced the severed limb.” Lister called for needle and thread and “stitched the limb back onto the doll and with quiet delight handed it back to the little girl.”

For the full review, see:

John J. Ross. “BOOKSHELF; The Butchering Art.” The Wall Street Journal (Saturday, Oct. 14, 2017): C6.

(Note: ellipses added.)

(Note: the online version of the review has the date Oct. 13, 2017, and has the title “BOOKSHELF; Review: ‘The Butchering Art’ Resurrects Joseph Lister.”)

The book under review is:

Fitzharris, Lindsey. The Butchering Art: Joseph Lister’s Quest to Transform the Grisly World of Victorian Medicine. New York: Farrar, Straus and Giroux, 2017.

The reviewer repeats the plausible but debunked view of Planck that old scientists do not change their views. The debunking occurs in:

Diamond, Arthur M., Jr. “Age and the Acceptance of Cliometrics.” Journal of Economic History 40, no. 4 (Dec. 1980): 838-41.

Hull, David L. , Peter D. Tessner, and Arthur M. Diamond, Jr. “Planck’s Principle: Do Younger Scientists Accept New Scientific Ideas with Greater Alacrity Than Older Scientists?” Science 202 (Nov. 17, 1978): 717-23.

Stimulant Ephedrine Was Known and Used in Bronze Age

Ephedrine currently has a variety of medical uses, including as a decongestant.

(p. A4) Bronze Age humans have been credited with a number of civilizational advancements: the invention of irrigation, the wheel, writing systems and the ability to forge weapons and tools from the durable metal that lends the era its name.

Now, strands of human hair discovered in an ancient burial cave in Spain suggest another novelty: a proclivity for consuming psychoactive drugs.

. . .

The findings, published Thursday [April 6, 2023] in Scientific Reports of the journal Nature, provide the first direct evidence that ancient Europeans consumed psychoactive drugs much like their pre-Columbian brethren in Mesoamerica, the researchers said.

Elisa Guerra-Doce, the lead author of the study, said researchers were stunned by the results, especially because the cave interiors yielded no detectable signs of the drugs’ presence. A chemical analysis of the hair revealed evidence of three alkaloid substances known to produce altered states of consciousness: ephedrine, atropine and scopolamine.

The compounds themselves are produced by flora native to Minorca. Atropine and scopolamine, powerful hallucinogens, can be found in plants in the nightshade family, among them mandrake, henbane and thorn apple. Ephedrine, a stimulant, can be extracted from joint pine.

“These findings are so singular,” said Ms. Guerra-Doce, an expert in the anthropology of intoxication at the University of Valladolid in Spain. “Sometimes when people think about drugs, they think it’s a modern practice. These results tell a different story.”

. . .

The three compounds have a long history of human use. Ephedrine is a stimulant that provides bursts of energy and mental clarity, and it can stave off sleepiness. Atropine and scopolamine are powerful deliriants that can produce hallucinations and out-of-body experiences.

For the full story, see:

Andrew Jacobs. “Scientists See Bronze Age In New Light: It Was Trippy.” The New York Times (Friday, April 7, 2023): A4.

(Note: ellipses, and bracketed date, added.)

(Note: the online version of the story has the date April 6, 2023, and has the title “Tripping in the Bronze Age.”)

The academic paper mentioned in the passage quoted above is:

Guerra-Doce, E., C. Rihuete-Herrada, R. Micó, R. Risch, V. Lull, and H. M. Niemeyer. “Direct Evidence of the Use of Multiple Drugs in Bronze Age Menorca (Western Mediterranean) from Human Hair Analysis.” Scientific Reports 13, no. 1 (April 6, 2023): article #4782.

“Flowers Never Bend, With the Rainfall”

Sometimes when I am in a dark mood I wonder how you keep moving forward when you do not know how much time is left. Some seek an answer in religion. I am more open to a kind of stoicism combined with the other gift of Prometheus: blind hope.

(p. 3) A few months into treatment, I realized that Josh might not make it to the next spring, when we would normally visit my extended family in Greece. I told Dr. Sara that I would like to take my husband to Greece, because he might not get the chance again.

. . .

My diary reminds me that while we were there, I asked Josh what he would do differently in life. “Not get cancer,” he said.

. . .

As for me, I kept hearing the lyrics to a Simon and Garfunkel song in my head: “So, I’ll continue to continue to pretend, my life will never end, and flowers never bend, with the rainfall.” It was my soundtrack.

For the full commentary, see:

Anemona Hartocollis. “My Husband’s Doctor, Onscreen.” The New York Times, SundayStyles Section (Sunday, November 20, 2022): 1-3.

(Note: the online version of the commentary was updated June 20, 2023 [sic], and has the title “Cancer, My Husband’s Doctor, and Catherine Deneuve.”)

Some High Performers Find Ways to Avoid Accumulating Microstresses

(p. C5) Have you had days that exhaust you extraordinarily without any particular reason why?

. . .

There’s a common but little-understood reason for that exhaustion. We call it “microstress”—brief, frequent moments of everyday tension that accumulate and impede us even though we don’t register them.

. . .

One study published in the journal Biological Psychology in 2015 found that exposure to social stress within two hours of a meal leads your body to metabolize the food in a way that adds 104 calories on average. “If this happens daily, that’s 11 pounds gained per year,” noted Lisa Feldman Barrett, a psychology professor at Northeastern University and author of “Seven and a Half Lessons About the Brain.”

. . .

In our research, we observed that some of the high performers—a small subset that we came to call the “Ten Percenters”—were much better at coping with microstress than the rest of those we studied, and perhaps than the rest of us, too. What do they do differently?

. . .

. . ., they’re better at removing themselves from interactions that generate microstress in their lives, whether or not they realize the dynamic. Ten Percenters are more likely to shape these interactions by dealing with simmering disagreements head-on or by limiting such contacts.

. . .

Our Ten Percenters were also thoughtful about not creating the kinds of conditions that cause microstress for others. Think about what happens—to both of you—when you push your child too hard on their grades and it comes back in the form of a rebellious attitude. Or the stress you may create as a manager by unnecessarily shifting expectations. Stopping this cycle helps to prevent microstress from boomeranging back on us.

For the full essay, see:

Rob Cross and Karen Dillon. “Combating the ‘Microstress’ That Causes Burnout.” The Wall Street Journal (Saturday, April 22, 2023): C5.

(Note: ellipses added.)

(Note: the online version of the essay has the date April 21, 2023, and has the same title as the print version.)

The essay quoted above is adapted from Cross and Dillon’s book:

Cross, Rob, and Karen Dillon. The Microstress Effect: How Little Things Pile Up and Create Big Problems—and What to Do About It. Boston, MA: Harvard Business Review Press, 2023.

Betting on Elections Is a Form of Free Speech

(p. A17) The Commodity Futures Trading Commission has moved to shut down PredictIt, an online marketplace for futures contracts on the outcomes of political events, effective Feb. 15, 2023. This is a blow to investors in these contracts, such as those on the presidential election of 2024, who are left uncertain as to how their positions will be unwound. And it’s a blow to the public at large, because political futures have proven to have better predictive power than polls.

. . .

. . . in early 2020, . . . PredictIt listed a contract on whether the World Health Organization would declare Covid-19 a pandemic. According to John Phillips, chief executive of Aristotle, the firm that operates PredictIt, the CFTC telephoned to complain about that contract, saying it was in poor taste. The contract had already expired.

. . .

If investors can express their opinions on the future prices of corn and pork bellies, surely the First Amendment also protects their ability to do the same on elections and other political matters. It’s a matter of free speech that you can put your money where your mouth is.

For the full commentary, see:

Donald Luskin. “The Feds Don’t Want You Betting on Elections.” The Wall Street Journal (Wednesday, Nov. 2, 2022): A17.

(Note: ellipses added.)

(Note: the online version of the commentary has the date November 1, 2022, and has the same title as the print version.)

Open Is Good (Hearts, Minds, Societies, and Windows)

Windows are liberating. The person in the room can decide how much air and light to let in. So I have never liked when central planners who control buildings omitted windows that could be opened. Other things equal, let people choose. Florence Nightingale wanted open windows, partly based on the mistaken miasma theory of disease. John Snow famously and courageously showed that cholera was caused by bad water, not bad air, thereby jump-starting the process of experts rejecting the miasma theory. But although the miasma theory was not universally applicable (some bad things spread in ways other than the air) and was wrong in some details (what was bad about some of the air was not the air itself, but the pathogens in the air), some of the actions that had been taken on the basis of miasma theory had positive effects. Ventilation was good because the air did sometimes have something bad in it–bacteria and viruses. Closing up buildings kept the bad inside to spread and infect. So now, fortunately, we are back to recognizing that ventilation has important good effects. In the meantime less harm would have been done if our buildings and our other rules had allowed more individual liberty to choose (windows that could be opened), and less centrally planned mandates (windows sealed closed).

(p. D1) One of the paramount lessons of the Covid-19 pandemic is that fresh air matters. Although officials were initially reluctant to acknowledge that the coronavirus was airborne, it soon became clear that the virus spread easily through the air indoors. As the pandemic raged on, experts began urging building operators to crank up their ventilation systems and Americans to keep their windows open. The message: A well-ventilated building could be a bulwark (p. D5) against disease.

It was not a novel idea. More than a century ago, when infectious diseases ravaged cities in the United States and Europe, public health reformers preached the power of good ventilation, and open-air homes, hospitals and schools sprang up in New York, London and other locales on both sides of the Atlantic.

But over the last century, society lost hold of that idea. Scientific advances turned pathogens into problems that could be solved at the individual, biomedical level, with medicines and vaccines, rather than through infrastructure or societal change. Skylines became crowded with air-conditioned towers. An energy crisis encouraged engineers to seal structures tightly. And by the time the coronavirus arrived, Americans were spending their days in schools, offices and homes that could barely breathe.

. . .

Germ theory had not yet gained widespread acceptance; instead, the longstanding theory of miasma held that disease was the result of “bad air.” So sanitary reformers began calling for an overhaul of urban spaces, including improvements in ventilation. “An abundant supply of fresh air, at a proper temperature, is the first requisite of health in every place,” the Citizens’ Association of New York wrote in a report published in 1865.

. . .

Similar reforms were also underway in hospitals thanks, in part, to the crusading work of Florence Nightingale, the British nurse who was stationed at a filthy military hospital during the Crimean War in 1854. The nurse, who believed in the healing power of “air from without,” helped popularize pavilion-style hospitals, which featured long, narrow wards with a row of large, open windows running along each wall.

. . .

Ventilation rates fell and then plummeted further during the energy crisis of the 1970s, when buildings were sealed even more tightly. “In fact,” said James Lo, an architectural engineer at Drexel University, “a lot of effort pre-Covid is to try to reduce the amount of ventilation because people don’t want to spend the energy.”

. . .

In the United States today, the American Society of Heating, Refrigerating and Air-Conditioning Engineers, or ASHRAE, sets widely used indoor air quality standards and specifies minimum ventilation rates. In practice, these rates typically govern how buildings are designed, rather than how they are operated day to day, and many structures deliver less fresh air than they were designed to provide, experts said.

The standards define acceptable indoor air quality as air that does not have “harmful” levels of “known contaminants,” and with which at least 80 percent of occupants are satisfied. But infectious disease is not a focus.

“It says nothing about, ‘Does this level of air quality protect you from risk of infection when the seasonal flu is going around, or when there’s a novel epidemic disease, like Covid?’” said William Bahnfleth, an architectural engineer at Penn State University and the chairman of the epidemic task force at ASHRAE.

For the full story, see:

Emily Anthes. “The New War on Bad Air.” The New York Times (Tuesday, June 20 [sic], 2023): D1 & D5.

(Note: ellipses added.)

(Note: the online version of the story was updated June 23, 2023, and has the same title as the print version.)

Roughly 5,000 New Species Found in Clarion Clipperton Zone of Pacific Ocean

(p. B3) Researchers from the Natural History Museum London analyzed samples of bottom-dwelling animals collected on expeditions to the 2.3 million-square-mile area, known as the Clarion Clipperton Zone, which lies halfway between Hawaii and Mexico. Of the 5,578 species found in the zone, between 88% and 92% are new to science, according to the paper, published Thursday [May 24, 2024] in the journal Current Biology.

. . .

Adrian Glover, an author of the study and merit researcher at the museum, spent several months at sea collecting samples earlier this year.

. . .

“It doesn’t rival coral reefs or rainforests for diversity,” Glover said. “But it is actually higher than soft sediments along the continental shelf, which is just totally bizarre.”

Glover said new marine invertebrates are valuable because they can contain unusual chemical compounds that could potentially be turned into anticancer, antifungal or antiviral drugs.

For the full story, see:

Eric Niiler. “New Species Discovered Deep in Pacific.” The Wall Street Journal (Friday, May 25, 2023): B3.

(Note: ellipses, and bracketed date, added.)

(Note: the online version of the story was updated May 25, 2023, and has the title “Thousands of New Species Discovered in Ocean Area Targeted by Deep-Sea Miners.”)

The academic paper summarized above is:

Rabone, Muriel, Joris H. Wiethase, Erik Simon-Lledo´, Aidan M. Emery, Daniel O.B. Jones, Thomas G. Dahlgren, Guadalupe Bribiesca-Contreras, Helena Wiklund, Tammy Horton, and Adrian G. Glover. “How Many Metazoan Species Live in the World’s Largest Mineral Exploration Region?” Current Biology 33, no. 12 (June 19, 2023): 2383–96.

Much of Pandemic Funding to Improve Ventilation in Schools “Is Sitting Untouched in Most States”

(p. 1) As the next presidential election gathers steam, extended school closures and remote learning have become a centerpiece of the Republican argument that the pandemic was mishandled, the subject of repeated hearings in the House of Representatives and a barrage of academic papers on learning loss and mental health disorders among children.

But scientists who study viral transmission see another lesson in the pandemic school closures: Had the indoor air been cleaner (p. 16) and safer, they may have been avoidable. The coronavirus is an airborne threat, and the incidence of Covid was about 40 percent lower in schools that improved air quality, one study found.

The average American school building is about 50 years old. According to a 2020 analysis by the Government Accountability Office, about 41 percent of school districts needed to update or replace the heating, ventilation and air-conditioning systems in at least half of their schools, about 36,000 buildings in all.

There have never been more resources available for the task: nearly $200 billion, from an array of pandemic-related measures, including the American Rescue Plan Act. Another $350 billion was allotted to state and local governments, some of which could be used to improve ventilation in schools.

“It’s a once-in-a-generation opportunity to fix decades of neglect of our school building infrastructure,” said Joseph Allen, director of the Healthy Buildings program at the Harvard T.H. Chan School of Public Health.

Schoolchildren are heading back to classrooms by the tens of millions now, yet much of the funding for such improvements is sitting untouched in most states.

Among the reasons: a lack of clear federal guidance on cleaning indoor air, no senior administration official designated to oversee such a campaign, few experts to help the schools spend the funds wisely, supply chain delays for new equipment, and insufficient staff to maintain improvements that are made.

Some school officials simply may not know that the funds are available. “I cannot believe the amount of money that is still unspent,” Dr. Allen said. “It’s really frustrating.”

For the full story, see:

Apoorva Mandavilli. “Bad Ventilation Remains Threat To U.S. Students.” The New York Times, First Section (Sunday, Aug. 27, 2023): 1 & 16.

(Note: the online version of the story was updated Aug. 28, 2023, and has the title “Covid Closed the Nation’s Schools. Cleaner Air Can Keep Them Open.”)